Chapter 17 Anxiety Disorders

Anxiety Disorders Introduction Anxiety provides the motivation for achievement, a necessary force for survival Anxiety is often used interchangeably with the word stress; however, they are not the same Stress is an external pressure that is brought to bear on an individual; anxiety is the subjective emotional response to that stressor

Anxiety Disorders (cont.) Introduction (cont.) Anxiety may be differentiated from fear in that the former is an emotional process, whereas fear is cognitive

Anxiety Disorders (cont.) Epidemiological statistics Anxiety disorders are the most common type of all psychiatric illnesses More common in women than men Minority children and children from low socioeconomic environments are at risk A familial predisposition probably exists

Anxiety Disorders (cont.) How much is too much? May be considered abnormal if Anxiety is out of proportion to the situation that is creating it Anxiety interferes with social, occupational, or other important areas of functioning

Application of the Nursing Process Panic disorder: Assessment Characterized by recurrent panic attacks, onset of which are unpredictable, and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort

Application of the Nursing Process (cont.) Panic disorder with agoraphobia Assessment Characterized by same symptoms characteristic of panic disorder In addition, affected person experiences a fear of being in places or situations from which escape might be difficult (or embarrassing) or in which help might not be available in the event that a panic attack should occur

Application of the Nursing Process (cont.) Generalized anxiety disorder Assessment Characterized by chronic, unrealistic, and excessive anxiety and worry

Etiological Implications Panic and generalized anxiety disorders Psychodynamic theory Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety S. Freud

Etiological Implications (cont.) Panic and generalized anxiety disorders (cont.) Cognitive theory Faulty, distorted, or counterproductive thinking patterns accompany or precede maladaptive behaviors and emotional disorders

Etiological Implications (cont.) Panic and generalized anxiety disorders (cont.) Biological aspects Genetics Neuroanatomical Biochemical Neurochemical Medical conditions

Diagnosis/Outcome Identification Panic Anxiety related to real or perceived threat to biological integrity or self-concept Powerlessness related to impaired cognition

Outcomes The client Is able to recognize signs of escalating anxiety Is able to intervene so that anxiety does not reach level of panic

Outcomes (cont.) The client (cont.) Is able to discuss long-term plan to prevent panic anxiety when stressful situations occur Practices techniques of relaxation daily Engages in physical exercise three times a week

Outcomes (cont.) The client (cont.) Performs activities of daily living independently Expresses satisfaction with independent functioning Is able to maintain anxiety at a manageable level without use of medication

Outcomes (cont.) The client (cont.) Is able to participate in decision-making, thereby maintaining control over life situation Verbalizes acceptance of life situations over which he or she has no control

Planning/Implementation Interventions are aimed at Maintaining anxiety at manageable level Problem-solving to increase client’s level of personal control

Evaluation Reassessment will determine whether the nursing actions have been successful in achieving the objectives of care

Phobias Agoraphobia without history of panic disorder: Assessment Fear of being in places or situations from which escape might be difficult or in which help might not be available if a limited-symptom attack or panic-like symptoms should occur

Phobias (cont.) Social phobia: Assessment Excessive fear of situations in which the person might do something embarrassing or be evaluated negatively by others

Phobias (cont.) Specific phobia: Assessment Marked, persistent, and excessive or unreasonable fear when in the presence of, or when anticipating, an encounter with a specific object or situation

Phobias (cont.) Specific phobia: Assessment (cont.) DSM-IV-TR subtypes Animal type Natural environment type Blood-injection-injury type Situational type Other type

Phobias (cont.) Etiological implications for phobias Psychoanalytical theory Unconscious fears may be expressed in a symbolic manner as phobia S. Freud

Phobias (cont.) Learning theory Learning theorists believe that fears are learned and become conditioned responses when the individual escapes panic anxiety (a negative reinforcement) by avoiding phobic stimulus

Phobias (cont.) Cognitive theory Anxiety is the product of faulty cognitions or anxiety-inducing self-instructions Negative self-statements Irrational beliefs

Phobias (cont.) Biological aspects Temperament Characteristics with which one is born that influence how he/she responds throughout life to specific situations (e.g., innate fears)

Phobias (cont.) Life experiences Early experiences may set the stage for phobic reactions later in life

Nursing Diagnosis Fear related to causing embarrassment to self in front of others, to being in a place from which one is unable to escape, or to a specific stimulus

Nursing Diagnosis (cont.) Social Isolation related to fears of being in a place from which one is unable to escape

Outcomes The client Functions adaptively in the presence of the phobic object or situation without experiencing panic anxiety

Outcomes (cont.) The client (cont.) Demonstrates techniques that can be used to maintain anxiety at a manageable level Voluntarily attends group activities and interacts with peers

Outcomes (cont.) The client (cont.) Discusses feelings that may have contributed to irrational fears Verbalizes a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety

Planning/Implementation Nursing care of the client with a phobia is aimed at Helping the client learn to function in the presence of the phobic object without experiencing panic anxiety Assisting the client to overcome fear of leaving home alone

Evaluation Reassessment is conducted to determine whether the nursing actions have been successful in achieving the objectives of care

Obsessive–Compulsive Disorder (OCD) Assessment data Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment

Obsessive–Compulsive Disorder (OCD) (cont.) Obsessions: unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress

Obsessive–Compulsive Disorder (OCD) (cont.) Compulsions: unwanted repetitive behavior patterns or mental acts that are intended to reduce anxiety, not to provide pleasure or gratification

Obsessive–Compulsive Disorder (OCD) (cont.) Etiological implications of OCD Psychoanalytical theory Clients with OCD have weak, underdeveloped egos Aggressive impulses are channeled into thoughts and behaviors that prevent the feelings of aggression from surfacing and producing intense anxiety fraught with guilt S. Freud

Obsessive–Compulsive Disorder (OCD) (cont.) Etiological implications of OCD (cont.) Learning theory Conditioned response to a traumatic event Passive avoidance Active avoidance

Obsessive–Compulsive Disorder (OCD) (cont.) Biological aspects Neurobiological disturbances may play a role Neuroanatomy Abnormalities in various regions of the brain have been implicated in the neurobiology of OCD

Obsessive–Compulsive Disorder (OCD) (cont.) Biological aspects (cont.) Physiology Electrophysiological, sleep electroencephalogram, and neuroendocrine studies have suggested that there are commonalities between depressive disorders and OCD

Obsessive–Compulsive Disorder (OCD) (cont.) Biological aspects (cont.) Biochemical Neurotransmitter serotonin may be influential in the etiology of OCD

Obsessive–Compulsive Disorder (OCD) (cont.) Diagnosis Ineffective Coping related to underdeveloped ego, punitive superego; avoidance learning, possible biochemical changes

Obsessive–Compulsive Disorder (OCD) (cont.) Diagnosis (cont.) Ineffective Role Performance related to need to perform rituals evidenced by inability to fulfill usual patterns of responsibility

Obsessive–Compulsive Disorder (OCD) (cont.) Outcomes The client Is able to maintain anxiety at a manageable level without resorting to the use of ritualistic behavior Is able to perform activities of daily living independently

Obsessive–Compulsive Disorder (OCD) (cont.) Outcomes (cont.) The client (cont.) Verbalizes understanding of relationship between anxiety and ritualistic behavior Verbalizes specific situations that in the past have provoked anxiety and resulted in seeking relief through rituals

Obsessive–Compulsive Disorder (OCD) (cont.) Outcomes (cont.) The client (cont.) Demonstrates more adaptive coping strategies to deal with stress, such as thought stopping, relaxation techniques, and physical exercise

Obsessive–Compulsive Disorder (OCD) (cont.) Outcomes (cont.) The client (cont.) Is able to resume role-related responsibilities because of decreased need for ritualistic behaviors

Planning/Implementation Nursing care of the client with OCD is aimed at Helping the client learn new, more adaptive coping strategies without resorting to obsessive–compulsive behaviors Helping the client gain independence and greater control over life situations

Evaluation Reassessment is conducted to determine whether nursing actions have been successful in achieving the objectives of care

Post-Traumatic Stress Disorder Assessment Development of characteristic symptoms following exposure to an extreme traumatic stressor involving a personal threat to physical integrity or to the physical integrity of others

Post-Traumatic Stress Disorder (cont.) Characteristic symptoms include re-experiencing the traumatic event, a sustained high level of anxiety or arousal, or a general numbing of responsiveness Intrusive recollections or nightmares of the event are common

Post-Traumatic Stress Disorder (cont.) Etiological implications Psychosocial theory The traumatic experience Severity and duration of the stressor Extent of anticipatory preparation before onset Exposure to death Numbers affected by life threat Amount of control over recurrence Location where trauma was experienced

Post-Traumatic Stress Disorder (cont.) Etiological implications (cont.) Psychosocial theory (cont.) The individual Degree of ego-strength Effectiveness of coping resources Presence of pre-existing psychopathology Outcomes of previous stressor/traumas Behavioral tendencies (temperament) Current developmental stage Demographic factors

Post-Traumatic Stress Disorder (cont.) Etiological implications (cont.) Psychosocial theory (cont.) The recovery environment Availability of social supports Cohesiveness and protective- ness of family and friends Attitudes of society regarding the experience Cultural and subcultural influences

Post-Traumatic Stress Disorder (cont.) Learning theory Negative reinforcement as behavior that leads to a reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior Avoidance behaviors Psychic numbing

Post-Traumatic Stress Disorder (cont.) Cognitive theory A person is vulnerable to post-traumatic stress disorder when fundamental beliefs are invalidated by experiencing trauma that cannot be comprehended and when a sense of helplessness and hopelessness prevail

Post-Traumatic Stress Disorder (cont.) Biological aspects It has been suggested that a person who has experienced previous trauma is more likely to develop symptoms after a stressful life event

Post-Traumatic Stress Disorder (cont.) Biological aspects (cont.) People who have suffered traumatic experiences may be more likely to become exposed to future traumas because they may be inclined to reactivate those behaviors associated with the original trauma

Post-Traumatic Stress Disorder (cont.) Biological aspects (cont.) Dysregulation of the opioid, glutamatergic, noradrenergic, serotonergic, and neuroendocrine pathways may be involved in the pathophysiology of PTSD

Post-Traumatic Stress Disorder (cont.) Diagnosis/outcome identification Post-Trauma Syndrome related to distressing event considered to be outside the range of usual human experience

Post-Traumatic Stress Disorder (cont.) Diagnosis/outcome identification (cont.) Complicated Grieving related to loss of self as perceived before the trauma or other actual or perceived losses incurred during or after the event

Post-Traumatic Stress Disorder (cont.) Outcomes The client Can acknowledge the traumatic event and the impact it has had on his or her life Is experiencing fewer flashbacks, intrusive recollections, and nightmares than he or she was on admission

Post-Traumatic Stress Disorder (cont.) Outcomes (cont.) The client (cont.) Can demonstrate adaptive coping strategies Can concentrate and has made realistic goals for the future Includes significant others in the recovery process and willingly accepts their support

Post-Traumatic Stress Disorder (cont.) Outcomes (cont.) The client (cont.) Verbalizes no ideas or intent of self-harm Has worked through feelings of survivor’s guilt Gets enough sleep to avoid risk of injury

Post-Traumatic Stress Disorder (cont.) Outcomes (cont.) The client (cont.) Verbalizes community resources from whom he or she may seek assistance in times of stress Attends support group Verbalizes desire to put the trauma in the past

Post-Traumatic Stress Disorder (cont.) Planning/implementation Nursing care of the client with PTSD is aimed at providing assistance with Integration of the trauma into his or her persona Renewing significant relationships Establishing meaningful goals for the future Progressing through the grief process Developing a sense of optimism and hope for the future

Post-Traumatic Stress Disorder (cont.) Evaluation Reassessment is conducted to determine whether nursing actions have been successful in achieving the objectives of care

Anxiety Disorder Due to General Medical Condition Assessment Symptoms of this disorder are judged to be the direct physiological consequence of a general medical condition

Substance-Induced Anxiety Disorder Assessment Prominent anxiety symptoms that are judged to be due to the direct physiological effects of a substance

Client/Family Education Nature of the illness What is anxiety? What might it be related to? What is OCD? What is PTSD? Symptoms of anxiety disorders

Client/Family Education (cont.) Management of the illness Medication management Possible adverse effect Length of time to take effect What to expect from the medication

Client/Family Education (cont.) Management of the illness (cont.) Stress management Teach ways to interrupt escalating anxiety Teach relaxation techniques

Client/Family Education (cont.) Support services Crisis hotline Support groups Individual psychotherapy

Treatment Modalities Individual psychotherapy Cognitive therapy

Treatment Modalities (cont.) Behavior therapy Systematic desensitization Implosion therapy Group/family therapy

Treatment Modalities Psychopharmacology

Anti-Anxiety Agents Indications: anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation Action: depression of the CNS Contraindications/Precautions Contraindicated in known hypersensitivity; in combination with other CNS depressants; in pregnancy and lactation, narrow-angle glaucoma, shock, and coma Caution with elderly and debilitated clients; clients with renal or hepatic dysfunction; those with a history of drug abuse or addiction, and those who are depressed or suicidal

Anti-Anxiety Agents (cont.) Interactions Increased effects when taken with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram, and with herbal depressants (e.g., kava and valerian) Decreased effects with cigarette smoking and caffeine consumption

Anti-Anxiety Agents (cont.) Monitor client for side effects Drowsiness, confusion, lethargy; tolerance; physical and psychological dependence; potentiation of other CNS depressants; aggravation of depression; orthostatic hypotension; paradoxical excitement; dry mouth; nausea and vomiting; blood dyscrasias; delayed onset (with buspirone only) Educate client/family about the drug

Panic and Generalized Anxiety Disorder Anxiolytics Antidepressants Antihypertensive agents

Phobic Disorders Anxiolytics Antidepressants Antihypertensive agents

Obsessive Compulsive Disorder (OCD) Antidepressants Post-Traumatic Stress Disorder (PTSD) Anxiolytics Antihypertensives Others