1. Chapter 10: Anxiety and Anxiety Disorders Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

2. 2 Anxiety  Function to warn of impending threat, conflict, or danger  State of tension, dread, or impending doom  External influences of threat  Subjective  No identifiable object  Exists on a continuum

3. 3 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. When person receives danger signal….  Fleeing  Controlling dangerous impulses  Freeze, do not act

4. 4 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Defense Mechanisms  Primary method the ego uses to manage anxiety  Unconscious  Protect ego

5. 5 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Defense Mechanisms, cont’d  Humor  Sublimation  Suppression  Displacement  Dissociation  Repression  Devaluation  Denial  Projection  Splitting of self or image of others

6. 6 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Stages of Anxiety  Mild  Moderate  Severe  Panic

7. 7 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Clinical Presentations  Panic attack  Panic disorder  Phobias  Agoraphobia  Social phobia  Posttraumatic stress disorder  Acute stress disorder  Generalized anxiety disorder  Obsessive compulsive disorder

8. 8 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Humanistic Nursing Theory  Basis: Existential theory, phenomenologic method  An interactive process:  The client calls; the nurse responds.  The nurse is a participant, fully available to the client.

9. 9 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Additional Treatment Modalities  Biologic Interventions  Pharmacologic Interventions  Psychotherapy  Behavioral therapy  Cognitive behavioral therapy  Psychologic first aid

10. 10 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Etiologic Models for Anxiety  Biologic  Genetic  Psychosocial  Psychodynamic  Social theories

11. 11 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Epidemiology  Prevalence  Age of onset  Cultural variance  Comorbidity

12. 12 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Panic Attacks  Sudden onset  Physical symptoms of anxiety  Dread/doom/fear of death  Occur with:  Panic disorder  Social phobia  Simple phobia  Posttraumatic stress disorder (PTSD)

13. 13 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Panic Disorder  Recent unexpected panic attacks  Concern (1 month) about additional attacks

14. 14 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Panic Disorder with Agoraphobia  Anxiety about being where escape is difficult  Situations avoided/endured with anxiety  Not due to effects of a medical condition/substance  Not better described by other mental disorder

15. 15 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Specific Phobia  Marked, persistent fear  Excessive and unreasonable  Cued by presence/anticipation of specific object/situation  Avoided or endured with anxiety  Distressed about having the phobia

16. 16 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Social Anxiety Disorder  Marked, persistent fear of one or more social or performance situations  Often exposes individual to scrutiny because behavior may be embarrassing  Avoided or endured with anxiety  Treated with individual therapy and serotonin selective reuptake inhibitors (SSRIs)

17. 17 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Posttraumatic Stress Disorder  Traumatic event preceding symptoms  Individual response: fear, horror, helplessness  Client often re-experiences event  Disturbing recollections  Feeling/acting as though event is reoccurring  Physiologic distress during reoccurrence  Physiologic reactivity to similar cues

18. 18 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Posttraumatic Stress Disorder, cont’d.  Avoidance of stimuli associated with the trauma  Numbing of general responsiveness  Estrangement, detachment  Restricted affect  Symptoms of increased arousal  Sleep disturbed  Irritability  Poor concentration  Exaggerated startle response

19. 19 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Acute Stress Disorder Different from PTSD:  Experiences these symptoms of dissociation: numbing, detachment, dazed, derealization, depersonalization, dissociative amnesia  Shorter time frame of development  Shorter duration of symptoms (2-30 days)  Not able to pursue a necessary task

20. 20 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Generalized Anxiety Disorder  Excessive anxiety and worry  Occurring more days than not  At least 6 months duration  Presence of three of the following: restlessness, edginess, fatigue, poor concentration, irritability, muscle tension, sleep disturbance  Anxiety and worry that interfere with normal social and occupational functioning

21. 21 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Obsessive Compulsive Disorder  Obsessions  Compulsions  Cannot be suppressed/ignored  Recognized as unwanted/unreasonable  Interferes with normal functioning  Etiology: trauma to basal ganglia/cortical connections  Treatment: SSRIs

22. 22 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment  Eating and eliminating patterns  Tics, stuttering  Eye contact  Blushing  Affect related to roles/role problems in work, finances, family, role strain

23. 23 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment, cont’d.  Culture/values  Coping strategies  Physical disability/motor dysfunction  Mental status  Orientation  Memory  Pain  Fears

24. 24 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Useful Nursing Diagnoses  Anxiety  Ineffective coping  Interrupted family processes  Fatigue  Risk-prone health behavior  Risk for loneliness  Posttrauma syndrome

25. 25 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Useful Nursing Diagnoses, cont’d.  Powerlessness  Rape-trauma syndrome  Ineffective role performance  Impaired memory  Chronic low self-esteem  Social isolation  Spiritual distress

26. 26 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Outcomes  Determined by client’s clinical manifestations  Clients will:  Demonstrate effective coping skills  Identify increasing anxiety  Identify when to call therapist  Take medications as prescribed

27. 27 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Planning  Inpatient treatment being replaced by outpatient treatment  Hospitalization: Client at risk for harm to self or others

28. 28 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Implementation  Assess own level of anxiety.  Recognize use of relief behaviors.  Teach:  To limit central nervous system (CNS) stimulants  To distinguish identifiable sources/ nonidentifiable anxiety-reducing strategies  Help build on familiar coping methods.

29. 29 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Implementation, cont’d.  Help identify support persons  Give brief, directive verbal interactions  Structure calm environment  Assess grief/depression/suicidal ideation  Teach about medication regimen

30. 30 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Treatment Modalities  Benzodiazepines  SSRIs  Fluoxetine, fluvoxamine (OCD)  Paroxetine (GAD, OCD, PTSD, social phobia, panic disorder)  Sertraline (OCD, panic disorder, PTSD)  Venlafaxine (GAD)  Clomipramine (body dysmorphic disorder)  ECT

31. 31 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Treatment Modalities, cont’d.  Psychotherapy  Behavioral therapy  Cognitive behavioral therapy

32. 32 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Evaluation  Measurable outcomes necessary  Rating scales  Hamilton Anxiety Scale  Yale-Brown Obsessive-Compulsive Scale