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NURS 2310
Unit 13
Anxiety and Somatoform
Disorders
Key Terms
Anxiety = Apprehension, tension, or
uneasiness from anticipation of
unknown/unrecognized danger; considered
pathological when social and/or occupational
functioning is affected
Stress = Mental/emotional/physical strain
experienced in response to stimuli from the
external or internal environment
Somatization = the expression of
psychological needs in the form of physical
symptoms; possibly related to repressed
anxiety
Panic = A sudden overwhelming feeling of
terror or impending doom; usually
accompanied by behavioral, cognitive, and
physiological signs/symptoms considered to
be outside the norm
Hysteria = Characterized by recurrent
multiple somatic complaints that are
unexplained by organic pathology, and is
thought to be associated with repressed
anxiety
Dissociation = The splitting off of clusters
of mental contents from conscious
awareness
Amnesia = A pathologic loss of memory of
an experience or specific period of time;
emotional, dissociative, or organic in nature
Phobia = An excessive or unreasonable fear
cued by the presence or anticipation of a
specific object or situation, exposure to
which provokes an immediate anxiety
response; the phobic stimulus is avoided or
endured with marked distress
Types of Anxiety and
Anxiety-Related Disorders
Panic Disorder
Recurrent panic attacks that cause intense
apprehension, fear, or terror
Associated w/feelings of impending doom
Accompanied by intense physical
discomfort
Panic attacks usually last only minutes, but
symptoms of depression are common due
to unpredictable nature of occurrence
Average age at onset is late 20s
Characterized by periods of remission and
exacerbation
Diagnostic Criteria for Panic Disorder include
the presence of at least 4 of the following:
– palpitations, pounding heart, or accelerated heart
rate
– sweating - parasthesias
– trembling or shaking - chills or hot flashes
– sensations of shortness of breath or smothering
– feeling of choking
– chest pain or discomfort
– nausea or abdominal distress
– feeling dizzy, unsteady, lightheaded, or faint
– derealization or depersonalization
– fear of losing control or going crazy
– fear of dying
Generalized Anxiety Disorder
Chronic, unrealistic, and excessive worry that
causes clinically significant distress or
impairment in social/occupational functioning
Numerous somatic complaints and symptoms
of depression are common; exacerbations are
stress-related
Other symptoms include restlessness,
fatigue, irritability, difficulty concentrating,
muscle tension and sleep disturbances
May begin in childhood/adolescence
Diagnosed after 6 months of symptoms
Phobias
Includes agoraphobia, social phobia (or
social anxiety disorder), and specific phobia
Agoraphobia
Fear of being in places/situations from
which one can’t escape, or in which help
might not be available if panic symptoms
should occur
Onset in the 20s or 30s; persists for many
years
Impairment can be severe and cause the
individual to be confined to his/her home
Social Phobia
Excessive fear of situations in which a
person might do something embarrassing or
be evaluated negatively by others
Extreme concerns about being exposed to
possible scrutiny by others
Fear of social or performance situations in
which embarrassment may occur
Onset of symptoms often begins in late
childhood or early adolescence and runs a
chronic, sometimes lifelong, course
Impairment interferes with functioning
Specific Phobia
A marked, persistent, and excessive or
unreasonable fear when in the presence of,
or when anticipating an encounter with, a
specific object or situation
Frequently occur concurrently with other
anxiety disorders
Exposure to the phobic stimulus produces
overwhelming symptoms of panic, including
palpitations, sweating, dizziness, and
difficulty breathing
Individual recognizes that fear is excessive,
but powerless to change it
Obsessive-Compulsive Disorder
Obsessions = unwanted, intrusive, persistent
ideas, thoughts, impulses, or images that
cause marked anxiety or distress
Compulsions = unwanted, repetitive behavior
patterns or mental acts such as praying or
counting that are intended to reduce anxiety
Obsessive-Compulsive Disorder = recurrent
obsessions/compulsions severe enough to
cause significant distress or impairment;
individual recognizes behavior as excessive,
but is compelled to continue due to the relief
from discomfort that it provides; usually
begins in adolescence or early adulthood
Body Dysmorphic Disorder
Exaggerated belief that the body is
deformed or defective in some specific way
Most common complaints involve imagined
or slight flaws of the face or head
Trichotillomania
(Hair-Pulling Disorder)
The recurrent pulling out of one’s hair from
the scalp, eyebrows, and eyelashes
Impulse preceded by increasing tension; the
act produces sense of release or gratification
Usually begins in childhood
Trauma-Related Disorders
Includes post-traumatic stress disorder
(PTSD) and acute stress disorder
Post-Traumatic Stress Disorder
Develops following exposure to an extreme
traumatic stressor involving a threat to the
physical integrity of self or others
Symptoms may begin within 3 months after
the trauma or may be delayed; diagnosis
occurs after symptoms that cause significant
interference w/functioning have been
present for at least 1 month
PTSD (cont’d)
Individual re-experiences the traumatic
event via intrusive recollections/nightmares;
may not recall every aspect of the trauma
Involves either a sustained high level of
anxiety/arousal or a general numbing of
responsiveness; may lead to depression
and/or substance abuse
Acute Stress Disorder
Symptomology is the same as for PTSD, but
symptoms resolve within 1 month of the
precipitating trauma
Adjustment Disorder
A maladaptive reaction to an identifiable
stressor that results in the development of
clinically significant emotional or behavioral
symptoms that impair social/occupational
functioning or are in excess of expected
reaction to the stressor
Occurs within 3 months after onset of
stressor and persists for no longer than 6
months after stressor or its consequences
have ended
Manifested as depression, anxiety, acting-
out behaviors or a combination thereof
Somatic Symptom Disorders
Includes somatic symptom disorder, illness
anxiety disorder, conversion disorder, and
factitious disorder (previously known as
Munchausen syndrome)
May involve primary or secondary gains
– In primary gain, the physical symptoms allow
the individual to avoid some unpleasant activity
or difficult situation about which he or she is
anxious
– Secondary gain involves the promotion of
emotional support or attention the individual
might not otherwise receive
Somatic Symptom Disorder
Characterized by multiple physical
symptoms that have no medical explanation
Associated with psychological distress and
long-term seeking of assistance from
health-care professionals
Symptoms may be vague, dramatized, or
exaggerated in their presentation
Illness Anxiety Disorder
Unrealistic or inaccurate interpretation of
physical symptoms that results in excessive
preoccupation about having a serious illness
Illness Anxiety Disorder (cont’d)
Fear becomes persistent and disabling in
spite of reassurances that no organic
pathology can be found
History of doctor-shopping due to presumed
misdiagnosis
Conversion Disorder
Emotional distress expressed through loss
of (or change in) body function for which
there is no apparent physical cause
Symptoms may occur suddenly following a
stressful experience
Factitious Disorder
The conscious, intentional feigning of
physical and/or psychological symptoms on
oneself or another person (i.e. by proxy) in
order to receive emotional care and support
May involve self-infliction of painful injuries,
injection or insertion of contaminated
substances, manipulation of medical
assessment instruments, and/or improper
use of medication
Dissociative Disorders
Includes dissociative amnesia, dissociative
identity disorder (or multiple personality
disorder), and depersonalization-
derealization disorder
Dissociative Amnesia
Inability to recall important personal
information; may be specific to a trauma or
series of traumatic experiences
Usually follows severe psychosocial stress,
and recovery is often abrupt and complete
Dissociative Identity Disorder
Characterized by the existence of two or
more unique personalities in a single
individual
Only one personality is evident at any given
moment, and only one is dominant most of
the time over the course of the disorder
Transition from one personality to another
may be sudden or gradual, and may be
dramatic
Symptomology causes clinically significant
distress or functional impairment
Depersonalization-Derealization
Disorder
Depersonalization = a disturbance in the
perception of oneself
Derealization = an alteration in the
perception of the external environment
Depersonalization-Derealization Disorder =
characterized by a temporary change in the
quality of self-awareness
– Involves change in body image and feelings of
unreality or detachment from the environment
– Diagnosis made upon functional impairment
Treatment Modalities
Individual psychotherapy
– Eye movement desensitization and
reprocessing (EMDR)
Group/family therapy
Psychopharmacology
Medications used to Treat
Anxiety Disorders
Most commonly treated with anti-anxiety
agents and sedative-hypnotics
– Depress subcortical levels in the limbic system
– CNS depression ranges from mild sedation to
coma
Classes of anti-anxiety agents include
antihistamines, benzodiazepines, and
miscellaneous agents
– Buspirone (Buspar) does not depress the CNS
10-day to 2-week onset
Does not build tolerance or dependence
Sedative-hypnotics include barbiturates,
benzodiazepines, and miscellaneous agents
*Anti-anxiety agents:
Antihistamines
– Hydroxyzine (Atarax, Vistaril)
Benzodiazepines
– Alprazolam (Xanax)
– Chlordiazepoxide (Librium)
– Clonazepam (Klonopin)
– Clorazepate (Tranxene)
– Diazepam (Valium)
– Lorazepam (Ativan)
Miscellaneous agents
– Buspirone (Buspar)
Anti-Anxiety Agents (cont’d)
Efficacy may vary
– Alcohol, narcotics, barbiturates, antipsychotics,
and antidepressants increases effects
– Nicotine and caffeine decreases effects
Common side effects include drowsiness,
confusion, and lethargy
Abrupt withdrawal can be life-threatening
– Insomnia
– Increased anxiety
– Vomiting
– Tremors, convulsions, and delirium
*Sedative-hypnotics:
Barbiturates
– Secobarbital (Seconal)
Benzodiazepines
– Flurazepam (Dalmane)
– Temazepam (Restoril)
– Triazolam (Halcion)
Miscellaneous Agents
– Chloral Hydrate (Noctec)
– Zaleplon (Sonata)
– Zolpidem (Ambien)
– Eczopiclone (Lunesta)
Sedative-Hypnotic Agents (cont’d)
Short-term use
Chronic use may induce tolerance and
physical/psychological dependence
Additive effect on CNS depression with
alcohol, antihistamines, antidepressants, or
other CNS depressants
Watch for decreased effectiveness of other
medications metabolized by the liver
Nursing Process
Assessment
– Gather information about client’s mood and
level of anxiety, thoughts to harm self/others
Diagnosis
– Risk for self-directed violence R/T anxiety-
related depression
– Imbalanced nutrition, less than body
requirements R/T lack of interest in food
– Disturbed sleep pattern R/T anxiety
– Anxiety R/T panic disorder
– Social isolation R/T agoraphobia
Planning
– Care plan
– Concept map
Implementation
– Establish trust
– Provide for safety
– Perform risk assessment
– Administer scheduled and PRN medications
Evaluation
– Mental health/psychiatric assessment tool
– Review safety plan/contract
– Assess for medication side effects