Anxiety Disorders

RNSG 2213 Mental Health

Nursing
 Definition
• Anxiety is a normal response to
threatening situations. It becomes
pathological when it interferes with
adaptive behavior, causes physical
symptoms, or exceeds a tolerable level.
Individuals with anxiety disorders use
rigid, repetitive, and ineffective behaviors
to try to control anxiety.
 Prevalence
• Anxiety disorders are the most common of
all psychiatric disorders in the United
States, affecting up to 13.3% of the
population. People may have more that
one anxiety disorder. Anxiety disorders
and depression occur together frequently.
Other disorders include substance abuse,
somatization, and other anxiety disorders.
Women are affected more than men.
 Theories
• Genetic—anxiety disorders tend to run in
families even though no specific gene has
been identified
• Biological– research suggests that
aberrant production of a substance that
interferes with benzodiazepine binding to
receptors or altered receptor sensitivity
interfering with proper benzodiazepine
receptor function is involved.
 Theories
• Biological
– Phobias- social phobias may well be related
to noradrenergic dysfunction
– Obsessive-compulsive disorders-
neuroimaging techniques point to
orbitofrontal-limbic-basal ganglia circuit
dysfunction, whereas neurochemistry points
to serotonin dysregulation
 Theories
• Biological
– Posttraumatic stress disorder (PTSD)- a
number of theories exist, including one
suggesting that extreme stress is associated
with damaging effects to the brain
 Cultural
• Culture-bound illnesses must be
differentiated from anxiety disorders. In
some cultures, anxiety is expressed
through somatic symptoms; in other
words, cognitive symptoms predominate.
 Clinical Manifestations
• Recurrent, unexpected panic attacks of
sudden onset are a clinical symptom of
this disorder. Physical symptoms of
sympathetic arousal are accompanied by
terror, limited perceptual field, and severe
personality disorganization
 DSM-IV-TR Criteria for Anxiety
Disorders
• See Varcarolis text page 232 figure 14-2
• Anxiety Disorders
– Panic Disorder
– Phobias
– Obsessive-Compulsive Disorder (OCD)
– Generalized Anxiety Disorder (GAD)
 DSM-IV-TR Criteria for Anxiety
Disorders: Stress Related
• See Varcarolis page 238 figure 14-3
• Anxiety Disorders: Stress Related
– Posttraumatic Stress Disorder
– Acute Stress Disorder
 Panic Disorder with Agoraphobia
• Recurrent panic attacks accompanied by
fear of being in an environment or
situation from which escape might be
difficult or embarrassing or in which help
may not be available (such as being alone
outside; being home alone; traveling in a
car; bus, or plane; being on a bridge or in
an elevator)
 Simple Agoraphobia
• Fear of being in an environment or
situation from which escape might be
difficult (as listed previous slide)
• The client generally acknowledges that the
behavior is not constructive and doesn’t
really like it and will state an inability to
change the behavior.
 Phobias
• Persistent, irrational fears of a specific object,
activity, or situation that lead to a desire for
avoidance or actual avoidance of the specific
object or situation.
– Specific phobias are provoked by a specific object
(dog, or spider, etc) or situation (a storm, etc); they
are common and usually do not cause much difficulty
because people can avoid the situation/object.
– Social phobias, or social anxiety disorder, is provoked
by exposure to a social situation or a performance
situation and can cause great difficulty
Obsessive-Compulsive Disorder
• Obsessions are thoughts, impulses, or images
that persist and recur and that cannot be
dismissed from the mind (such as where are the
door keys, etc.).
• Compulsions are ritualistic behaviors that an
individual feels driven to perform to reduce
anxiety (such as checking to make sure doors
are locked repeatedly, etc.). They can be seen
separately but usually co-exist
 Generalized Anxiety Disorder
• Characterized by the presence of
excessive anxiety or worry lasting for 6
months or longer; symptoms can include
poor concentration, tension, sleep
disturbance, and restlessness
 Posttraumatic Stress Disorder
• Posttraumatic Stress Disorder (PTSD) involves
re-experiencing of a highly traumatic event
involving actual or threatened death or serious
injury to self or others to which the person
responded with intense fear or helplessness.
Symptoms usually begin within 3 months after
the traumatic incident and include flashbacks,
persistent avoidance of stimuli associated with
the trauma, numbness, or detachment, and
increased arousal.
 Acute Stress Disorder
• Occurs within 1 month after exposure to a
highly traumatic event, such as described
for PTSD. Individuals must display three
dissociative symptoms during or after the
event (numbness, detachment,
derealization, depersonalization, or
dissociative amnesia
 Substanced-Induced Anxiety
Disorder
• Symptoms of anxiety, panic attacks,
obsessions, and compulsions that develop
with the use of a substance or within a
month of stopping use
 Anxiety due to Medical Condition
• Symptoms of anxiety are sometimes the
physiological result of a medical condition
such as, cardiac dysrhythmias,
hyperthyroidism, pheochromocytoma, etc
 Assessment
• Assessment will usually involve
determining if the anxiety is from a
secondary source (medical condition) or a
primary source (anxiety disorder).
Symptoms specific to various anxiety
disorders include panic attacks, phobias,
obsessions, and compulsions
Defenses used in Anxiety Disorders
• Defense mechanisms associated with anxiety disorders
p 240 table 14-7. Preliminary screening test for anxiety
disorders p 240 box 14-1
• Hamilton Rating Scale for Anxiety p 241 table 14-8; for
example: feeling like one is going to die or having a
sense of impending doom; having narrowed perceptions
and difficulty concentrating or problem-solving; increased
vital signs, muscle tension, dilated pupils; complaints of
palpitations, urinary frequency or urgency, nausea, tight
throat; complaints of fatigue, insomnia, irritability,
disorganization
 Self-Assessment
• Nurse’s feelings may include tension or
anxiety, frustration, anger, being
overwhelmed, fatigue, desire to withdraw,
and guilt related to having negative
feelings
 Assessment Guidelines
• 1) Physical and neurological examinations will
help determine if anxiety is primary or secondary
• 2) Assess for potential for self-harm and suicide
• 3) Do a psychosocial assessment to identify
problems that should be addressed by
counseling
• 4) Note that cultural differences can affect the
way in which anxiety is manifested
 Nursing Diagnoses
• Anxiety, ineffective coping, disturbed
thought processes, chronic low self-
esteem, situational low self-esteem,
powerlessness, deficient diversional
activity, social isolation, ineffective role
performance, ineffective health
maintenance, disturbed sleep pattern, self-
care deficit, imbalanced nutrition, and
impaired skin integrity
 Outcome Criteria
• Describe the client’s state or situation that
is expected to be influenced by nursing
interventions. Examples of outcomes for
anxiety control include the following: client
will monitor intensity of anxiety, eliminate
precursors of anxiety, seek information to
reduce anxiety, plan successful coping
strategies, use relaxation techniques,
report adequate sleep, report decrease in
frequency of episodes, etc
 Planning
• Selecting interventions that can be implemented
in a community setting, since clients with anxiety
disorders are not usually hospitalized in an
inpatient psychiatric unit
• Clients with mild to moderate anxiety should be
encouraged to be involved in planning, whereas
for clients with severe anxiety, the nurse will
need to be more directive
 Intervention
• 1) identify community resources that can
off the client effective therapy
• 2) identify community support groups that
can offer the client effective therapy
• 3) assess need for intervention for families
and significant others
• 4) provide thorough teaching when
medications are used
Interventions for Anxiety Disorders
• See Varcarolis page 243 box 14-2
– Anxiety reduction
– Coping enhancement
– Hope instillation
– Self-esteem enhancement
– Simple relaxation therapy
 Interventions for Anxiety Disorders
• Anxiety reduction
• Minimizing apprehension, dread, foreboding, or uneasiness related
to an unidentified source of anticipated danger
• Coping enhancement
• Assisting a client to adapt to perceived stressors, changes, or threat
that interfere with meeting life demands and roles
• Hope instillation
• Facilitation of the development of a positive outlook in a given
situation
• Self-esteem enhancement
• Assisting a client to increase his/her personal judgment of self-worth
• Simple relaxation
• Use of techniques to encourage and elicit relaxation for the purpose
of decreasing undesirable signs and symptoms such as pain,
muscle tension, or anxiety
 Counseling
• To assist clients to improve or regain
coping abilities, counseling is often
combined with other cognitive and
behavioral therapies
 Counseling
• Cognitive therapy • Systematic
• Cognitive desensitization
restructuring • Flooding
• Cognitive-behavioral • Response prevention
therapy • Thought stopping
• Relaxation training
• Modeling
 Cognitive Therapy
• Assumes that cognitive errors made by
the client produce negative beliefs that
persist. Counseling calls for the nurse to
assist the client to identify these thoughts
and negative beliefs and to appraise the
situation realistically
 Cognitive Restructuring
• This therapy calls for the nurse to assist a client
to identify automatic negative anxiety-arousing
thoughts and negative self-talk, discover the
basis for the thoughts and to assist the client to
appraise the situation realistically and replace
automatic thoughts and negative self-talk with
realistic thinking (such as with agoraphobia-
increasing self-esteem by replacing negative
thoughts with more realistic evaluation of client’s
own abilities.
 Cognitive-Behavioral Therapy
• Uses a variety of approaches such as
psychoeducational methods, continuous
panic self-monitoring, breathing retraining,
development of anxiety management
skills, and in vivo exposure to feared
stimuli
 Relaxation Training
• Teaching muscle relaxation will result in
reduction of tension and anxiety
 Modeling
• Shows client how an individual copes
effectively and expects the client to imitate
the adaptive behavior
 Systematic Desensitization
• Gradual exposure gradually introduces the
client to a phobic object or situation in a
predetermined sequence of least to most
frightening. Teaches the client to use a
relaxation technique for anxiety
management
 Flooding (Implosion Therapy)
• Extinguishes anxiety as a conditioned
response by exposing a client to a large
amount of the stimulus he/she finds
undesirable
 Response Prevention
• The individual who would reduce anxiety
by performing a ritual is not permitted to
perform the ritual
 Thought Stopping
• A technique calling for the client to shout
“STOP” or snap a rubber band on the wrist
whenever an obsessive thought begins.
This helps the client dismiss the thought.
 Milieu
• The environment should be structured to
offer safety and predictability, should have
activities to shift the client’s focus from his
or her anxiety and symptoms, and should
provide therapeutic interactions (for
hospitalized patient)
 Self-Care Activities
• Clients with anxiety disorders can usually
meet their own basic physical needs.
Self-care activities most likely to be
affected are discussed below.
• Nutrition & fluid intake-those with OCD
who are involved with their rituals to the
exclusion of all else, nutrition & fluid intake
could be affected. Assess weight and
encourage intake.
 Self-Care Activities
• Personal hygiene & grooming—excessive
neatness, rituals associated with bathing and
grooming, indecision are common among clients
with phobias and OCD. Skin integrity may be a
problem when rituals involve washing.
• Elimination—clients with OCD may suppress
urges to void and defecate
• Sleep—anxious clients often have difficulty
sleeping. Clients with generalized anxiety
disorder (GAD), Posttraumatic stress disorder
(PTSD), and stress disorder may have
nightmares.
 Psychobiological interventions
• See Varcarolis page • Anxiolytes
246 table 14-12 – Benzodiazepines for
• Antidepressants short-term (2-4 weeks
for full effects)
– SSRIs
– TCA
• Beta blockers
– MAOI – Social anxieties and
panic disorder
– SNRI
– Antihistamines relieve
• Venlafaxine (Effexor)
symptoms of anxiety
but produces no
dependence
 Antidepressants
• Selective serotonin reuptake inhibitors (SSRIs) are the
first-line treatment for anxiety disorders (esp. treatment
of panic disorder/attacks). They are more prevalent than
the tricyclic antidepressants (TCAs) because of their
more rapid onset of action and fewer problematic side
effects. Monoamine oxidase inhibitors (MAOIs) are
reserved for treatment-resistant conditions because of
the life-threatening risks from hypertensive crisis. With
MAOIs, there are many dietary restriction as well which
can lead to difficulties for clients. Also effective for
treatment of anxiety is Venlafaxine (Effexor) which is a
serotonin-norepinephrine reuptake inhibitor (SNRI).
Medications and Psychotherapy for
Anxiety Disorders
• See Varcarolis page 245 table 14-11
– Generalized anxiety disorder
– Obsessive-compulsive disorder
– Panic disorder
– Posttraumatic stress disorder
– Social phobia or social anxiety disorder
 Client and Family Medication
Teaching: Anxiety Disorders
• See Varcarolis page 247 box 14-4
 Integrative Therapy
• Consumers are using a wide number of
herbs and dietary supplements to relieve
stress. Caution is urged because herbs
and dietary supplements are not subjected
to rigorous testing. Kava kava is one herb
that studies show may have considerable
promise as a treatment for anxiety
 Evaluation
• Identified outcomes serve as a basis for
evaluation. In general, evaluation will
focus on whether or not there is reduced
anxiety, recognition of symptoms as
anxiety-related, reduced incidence of
symptoms, performance of self-care
activities, maintenance of satisfying
interpersonal relationships, assumption of
usual roles, and use of adaptive coping
strategies