Anxiety

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Anxiety

• Elisa A. Mancuso RNC, MS, FNS
• Professor

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• Most common mental health problem
• 25 adults Womengtmen Age lt45
• ? Divorced/separated
• Lower socioeconomic status
• Vague apprehension and feelings of uncertainty
  helplessness
• Subjective emotional response to a stressor
• State of tension, or impending doom
• Necessary force for survival
• Mild ? Moderate ? Severe ? Panic

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Physiologic Responses

• Hormones Neurotransmitters
• Fight or Flight Response
• Depends on degree duration of anxiety
• ? Epinephrine (E) ? HR ? SV ? CO
• ? Norepinphrine (NE) ? BP
• ? Cortisone ? RR depth SOB
• ? Serotonin (5-HT)
• ? GABA

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Physiologic Responses

• Generalized Responses
• Restlessness Hyperreflexia
• Irritability Impatience
• Fainting Chest Pressure
• Palpitations Headache
• ? Diaphoresis ? Muscle tension
• ? Urination Gluconeogenesis
• ? N V Dry Mouth
• ? Libido Sexual Dysfunction

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Cognitive Responses

• Mild ()
• ? Sensory awareness ? Learning
• ? Concentration Optimal Functioning
• Moderate ()
• ? Perceptual field Impaired attention
• ? Concentration Problem Solving
• Severe ()
• Limited Perceptual field Selective inattention
• Disorganized processing Time distorted
• Panic ()
• Closed perceptual field
• ? Contact with reality
• Impaired thinking/function
• Unable to process stimuli

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Behavioral Responses

• Mild ()
• Learn new skills Alert Confident
• ? Startle reaction ? Speech Coping Skills
• Moderate ()
• ? Competitive activity ? Body position
  frequently
• Frequent topic ?s ? Defense mechanisms
• Focus on immediate events
• Severe ()
• ? Feeling of threat tremors Overload
• ? Coordination Neurosis
• Panic ()
• Total loss of control Cling to source of safety
• Helplessness Psychosis
• May strike physically or withdraw
• Completely disorganized

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Anxiety Disorders

• A group of symptoms impaired reality testing.
• Panic Disorder
• Sudden onset
• Multiple attacks
• Intense escalating apprehension
• Poor judgment, confused disoriented
• Feelings of impending doom
• Fears losing control or going insane
• Lasts 15-30 minutes or (rarely) hours

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Panic Disorder

• Intense Physical discomfort
• Palpitations Chest pain ?HR
• Dyspnea Choking/Smothering SOB
• Hyperventilation ? RR Dizziness
• Diaphoresis Chills/Hot flashes
• Tremors Shaking
• GI distress Nausea Diarrhea
• Fear of dying and/or going crazy
• Depersonalization

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Nursing Interventions

• Stay with Pt and remain calm
• Assess own level of anxiety
• Ensure safety and reassure Pt
• Pt take slow, deep breaths
• Quiet environment
• Focus on a single object in the room
• Speak in short, simple sentences
• Low, calm and soothing voice
• Encourage verbalization of concerns, feelings and
  symptoms
• Identify precipitating event
• Short term use of anxiolytics

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Generalized Anxiety Disorder

• Chronic unrealistic and excessive worry
• Regarding several events the Pt cant control
• Symptoms last gt 6 months
• Impaired social occupational functioning
• Interferes with daily life
• Symptoms
• Autonomic Hyperactivity
• Jumpiness, tremors, ? muscle tension
• ? HR ? RR
• Feeling on edge Hypervigilence
• Restlessness Irritability
• ? Concentration Mind going blank
• Easily fatigued

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Obsessive-Compulsive Disorder

• Recurrent obsessions compulsions
• ?? Time consuming
• Gradual conditioned response RT traumatic event
• Obsessions
• Unwanted intrusive, persistent images or impulses
• Recurrent thoughts of violence, contamination,
  doubt or need for specific order.
• Compulsions
• Ritualized acts of behavior to neutralize/control
  obsessions
• Touching Rearranging Opening Closing
• Washing hands Counting Checking
• Pt aware behavior is excessive, yet continues to
  engage to seek relief and ? anxiety/tension
• Interferes with usual routine
• Defense Mechanism
• Undoing
• Displacement

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OCD Nursing Interventions

• Initiate conversation as ritual is performed
• Allow behavior but set limits
• Identify behavioral cues of ? anxiety
• Present distracting stimulus
• _at_ ? frequency
• Substitute socially acceptable behavior

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Phobias

• Persistent or irrational fear of specific object,
  activity or situation that causes avoidance.
• Exposure to stimulus immediate anxiety
  response.
• Blushing, Vomiting, Humiliation, Tremors, ?HR ?BP
  ?RR
• Agoraphobia
• Fear of being alone in public place. No escape
• Social Phobia
• Fear of appearing embarrassed or evaluated
  negatively by others.
• Simple Phobia (Specific object or situation)
• Acrophobia Fear of heights
• Claustrophobia Fear of closed in places
• Mysophobia Fear of dirt, germs
• Nursing Interventions
• 1st accept Pts fear as real
• Relaxation techniques
• Behavior Modification
• Desensitization

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Post Traumatic Stress Disorder

• Extreme stressor and threat to physical
  integrity.
• Characteristic symptoms after exposure to
  traumatic life experience
• 9-11, war, earthquakes, hurricanes, airplane
  crash
• Symptoms
• Re-experiencing event (Flashback)
• Avoidance of thoughts, emotions or conversations
• Sustained ? Anxiety
• Angry Outbursts
• Hypervigilence Nightmares Sleep
  Disturbances
• Survivor Guilt Depression Substance Abuse
• Psychic Numbing Feel detached from others

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PTSD

• Nursing Interventions
• ? Environmental Stimuli
• Reorient to reality
• Reassure Pt is safe
• Encourage verbalization of event and feelings
• Facilitate grief process
• Adaptive coping techniques
• Anxiolytic meds during flashback

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Somatoform Disorders

• Physical symptoms without any organic pathology
• Womengt men
• Onset before age 30
• Somatization
• Anxiety transformed into physical illness
• No labs, diagnostic tests support DX
• Chronic course without structural ?s

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Conversion Disorder-Hysteria

• Loss or alteration in physical functioning
• Voluntary motor/sensory
• Abrupt onset after a psychological conflict
• Symptom
• Impaired sense (blind/deaf) or paralysis
• La belle indifference
• Pt demonstrates no concern for symptoms
• Defense Mechanism
• Repression
• Conversion

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Conversion Disorder-Hysteria

• Primary Gain
• Relief via repressing conflict
• Anxiety converted to symptoms
• Secondary Gain
• Sympathy, support, ?? attention
• avoid activities responsibilities
• Nursing Interventions
• Focus on ?? anxiety, NOT symptoms
• Encourage verbalization
• Identify conflicts
• ?? stress ?? relaxation
• Alternative coping skills

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Hypochondriasis

• Unrealistic preoccupation/fear of having or
  getting a serious illness
• Specific organ, bodily function or minor
  alteration
• Misinterpretation of symptoms
• Cough Lung CA
• HA Brain tumor
• Symptoms
• C/O Multiple symptoms Persist gt 6 months
• Dr. Shopping
• Demand diagnostic testing invasive procedures
• Nursing Interventions
• Review objective data, symptoms interpretation
• Set limits on whining
• ? Self-worth and resolve internal anger

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Dissociative Disorders

• Severe precipitating stressor.
• Splitting off an idea or emotion from ones
  consciousness.
• Psychological flight from anxiety
• Psychogenic Amnesia
• Sudden inability to recall important extensive
  personal information.
• Psychogenic Fugue
• Sudden unexpected travel away from home or usual
  workplace
• Begin new job, relationships (Unaware of true
  life)
• Assumes new identity
• Escapes from overwhelming stress or rejection

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Dissociative Disorders

• Multiple Personality Disorder
• Dissociative Identity Disorder (DID)
• Existence of 2 or more distinct personalities
  within an individual.
• Transition from 1 to another personality
• Sudden dramatic
• Precipitated by stress
• One personality is dominant
• Usually RT sexual child abuse.

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Dissociative Disorders

• Depersonalization Disorder
• Change in quality of self-awareness
• Feelings of unreality, ?s in body image.
• Detachment
• Sense of observing oneself
• (from outside of body)
• Not in touch with body
• No somatic sensations

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Anxiety Nursing Interventions

• 1 is Patient safety!
• Remain with Pt provide support
• Deep Breathing
• Controlled slow
• Deep regular abdominal breathing.
• Progressive muscle relaxation
• Guided imagery
• Visualize favorite place
• Embrace scenes, sounds, aromas, textures.
• Distraction
• Music, card games, reading

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Anxiety Nursing Interventions

• Journals
• ?? Self awareness
• Make entries when calm anxious every day
• Identify anxiety cues behavior responses
• Self-Help Skills
• Coping techniques Role playing Problem solving
• Assertiveness Set limits on inappropriate
  behavior
• Social Skills Group
• ? Socialization ?Self absorption
• Daily Schedule Planning
• ? Autonomy
• Support System
• Family, friends, neighbors, pets
• Nutrition
• Balanced diets NO CAFFEINE, CHOCOLATE, ETOH

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Anxiety Nursing Interventions

• CognitiveBehavioral Therapy
• Positive Reframing
• Turn negative messages into positive ones.
• Decatastrophizing
• A more realistic appraisal of situation
• Assertiveness Training
• Learn to negotiate interpersonal situations

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Anxiolytics (Anti-Anxiety) Meds

• Used short term basis lt 1 month
• Symptomatic relief only
• Potentiates GABA ?? CNS
• Caution
• Do not use ETOH or meds that ? CNS
• Do not stop med abruptly Severe Withdrawal
• CNS agitation
• ?BP ?Temp Fatal Gran Mal seizures!
• Takes 7-10 days for steady effect
• Elderly have ? hepatic ?renal function
• ?? risk for toxic effect

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Anxiolytics Meds

• Benzodiazepines
• Alprazolam (Xanax)
• Lorazepam (Ativan)
• Chlordiazepoxide (Librium)
• Diazepam (Valium)
• Clonazepam (Klonopin)
• Clorazepate (Tranxene)
• ? Risk for physical dependence tolerance
• Lipophilic cross blood-brain barrier
• Side effects
• Drowsiness Sedation
• ? Concentration Impaired memory
• Clouded Sensorium ? Coordination

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Anxiolytics Meds

• Azaspirodecanediones
• Buspirone (Buspar)
• 5-HT receptor antagonist
• Takes 2-4 weeks to be effective
• ? potential for abuse
• SE Dizziness Sedation N HA
• Propanediols
• Meprobamate (Equanil/Miltown)
• ? Thalamus Limbic system response
• Sedating Antihistamines
• Hydroxyzine (Vistaril/Atarax)
• CNS depressant effect

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Anxiolytics Meds

• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Citalopram (Celexa) Escitalopram (Lexapro)
• Fluoxetine (Prozac/ Serafem Puvules-weekly)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
• Sertraline (Zoloft)
• Only prevents 5-HT reuptake ?? 5-HT available
  ? regulation of emotions, wakefulness
• Use for OCD, GAD, Phobias
• No other neurotransmitters affected ?? E NE
• Side effects
• Anxiety Agitation Nausea Insomnia
• Sexual Dysfunction
• Akathisia (Use Propanolol)

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Anxiolytic Side Effects

• Anticholinergic
• Daytime sedation, Drowsiness, Dry mouth,
• HA, Lethargy, Ataxia, Blurred vision, N V
• Tolerance, physical psychological dependence
• Potentiates other CNS depressants
• Orthostatic Hypotension
• Blood Dyscrasias
• Abrupt Withdrawal Syndrome
• Flumazenil (Romazicon)
• Benzodiazepam antagonist
• Reverse CNS effects
• Must gradually taper down

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Defense Mechanisms

• Protect the ego cope with anxiety unconsciously
• Denial
• Refuse to acknowledge the problem
• Substance abuse
• Regression
• Return to an earlier level of development
• Holding teddy bear
• Displacement (3 way)
• Transfer feelings from 1 person, object or
  situation to less threatening person
• Angry _at_ boss ? yell _at_ kids or kick the dog
• Reaction-Formation
• Prevent unacceptable thoughts/behaviors from
  being expressed by developing opposite
  thoughts/behaviors
• Unwanted pregnancy ? New mom overprotective of
  baby

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Defense Mechanisms

• Projection (2 way)
• Unacceptable feelings/impulses are attributed to
  another person
• Im needy but claim my husband is demanding
• Repression
• Involuntary blocking of unpleasant feelings and
  experiences
• No memory of sexual abuse as a child
• Suppression
• Conscious voluntary denial of unpleasant feelings
  and experiences
• Put away NCP focus on studying for exam
• Identification
• ? Self worth by acquiring certain attributes
  characteristics of an admitted individual
• Gang members

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Defense Mechanisms

• Rationalization
• Attempting to form logical reasons to justify
  unacceptable feelings
• Not getting accepted to Harvard I didnt want to
  leave home
• Sublimation
• Substituting constructive/socially acceptable
  activity for inappropriate impulses.
• Aggressive person becomes hockey player
• Compensation
• Covering up a real or perceived weakness by
  emphasizing/excelling in another area
• Poor in sports ? Excell in chess
• Conversion
• Unconsciously transforming anxiety into a
  physical symptom
• Paralysis/Blind
• Undoing
• Symbolically negate or cancel out a previous
  intolerable action
• Man has an affair then buys his wife a new car.