1. ANXIETY DISORDERS

2. WHAT IS ANXIETY?  SUBJECTIVE EXPERIENCE OF DISCOMFORT IN RESPONSE TO AN ACTUAL OR PERCEIVED THREAT OR LOSS (“STRESSOR”)  THREAT MAY BE EXTERNAL OR INTERNAL  ANXIETY MAY PERSIST EVEN AFTER THREAT IS GONE

3. WHAT IS ANXIETY, cont’d  PERCEPTION OF THREAT DEPENDS ON THE INDIVIDUAL  SOMATIC COMPONENT: AUTONOMIC (SYMPATHETIC) NERVOUS SYSTEM ACTIVATION

4.    Acute Stress: Activation of the Hypothalamic-Pituitary-Adrenal Axis Release of dopamine and serotonin Release of endogenous opiates Increased TSH

5. Physiology of Anxiety: Activation of Sympathetic N.S. Somatic Symptoms: Dry mouth Palpitations, chest tightness or chest pain Tachypnea, breathlessness Nausea, constipation or diarrhea  Energy Muscle tension, restlessness Urinary retention, or incontinence 

6. Levels of Anxiety  Mild ( Stage 1 )  Moderate ( Stage 2 )  Severe ( Stage 3 )  Panic (Stage 4)

7. Mild Anxiety  Increased alertness  Broad field of perception  Enhances learning and performance

8. Moderate Anxiety  Perceptual field narrows  Tunes out stimuli  Focused on one task  Decreased attention span   Problem solving ability

9. Severe Anxiety  Narrow or distorted perception and cognition  Flight of ideas  Physical symptoms problematic  Behavior directed toward relief of discomfort

10. Panic  Disorganized and irrational  Overwhelmed, out of control  May become violent, hysterical, or immobilized “Fight, Flight or Freeze”

11. Nursing Interventions for Anxiety: Some Guidelines Table 9-1: Interventions for Levels of Anxiety, p. 87  Assess level of anxiety via objective, subjective data  Assess client’s coping methods and effectiveness  Planning: can source of client’s stress/anxiety be managed or not?  Client teaching: will not be effective if anxiety is severe or panic level OK for moderate anxiety if it is simple and step-by-step

12. ANXIETY DISORDERS  WHEN ANXIETY INTERFERES WITH FUNCTIONING AND SELF-CARE  MOST ARE CHRONIC, BUT MAY BE IN RESPONSE TO ACUTE SITUATION  CHALLENGING TO TREAT/MANAGE

13. ANXIETY DISORDERS NIMH 2009: Anxiety disorders more prevalent than mood disorders (40 million) 18.1% of US population over age 17 First episode by age 21.5 Co-occurrence with depression and substance abuse Common to have more than one anxiety disorder

14. UNDERSTANDING ANXIETY: Primary Gain  Behaviors directed toward relief of the anxiety, e.g. Excessive activities and tasks Avoiding the thing(s) that cause the anxiety Using medications to relieve physiologic discomfort  Using mood altering substances

15. UNDERSTANDING ANXIETY: Secondary Gain  Refers to attention or benefit the person gets from the illness  Can become more important than relieving the anxiety Decreases motivation to get well Others take care of individual  Complicates treatment

16. Axis 1 Anxiety Disorders Generalized Anxiety Disorder (GAD) Panic Disorder with Agoraphobia without Agoraphobia Obsessive-Compulsive Disorder (OCD) Phobias Somatoform Disorders

17. Acute and Post-Traumatic Stress Disorders and Dissociative Disorders Not in this Module: Will be covered with Violence, Abuse and Trauma - Module 8

18. Etiology/Theories of Anxiety Disorders  Biological Theories Defects in Brain Chemistry-- Person over-responds to stimuli  Neurotransmitter dysregulation  Altered # of benzodiazepine receptors

19. Genetic Theory  Some disorders clearly run in families: e.g. panic, OCD  Inherited trait for shyness has been discovered

20. Psychoanalytic/ Psychodynamic Theories  Result of conflict between instincts and values  Use of Defense Mechanisms to deal with anxiety: Repression Displacement Conversion

21. Interpersonal Theory  Anxiety is caused by threat to self-esteem, security or self-control

22. Generalized Anxiety Disorder (GAD)  Most common type  Cognitive and physical symptoms  Chronic and excessive worry ( > 6 months)  Worry is habitual, cannot be controlled  Causes impairment

23. http://www.youtube.com/watch?v=U6QuNjlHsHw&feature=related

24. Interventions for GAD Goal: to assist the client to develop adaptive coping responses  Assess for level of anxiety = moderate to severe  Reduce level of anxiety  Identify and describe feelings  Assist to identify causes of feelings

26. Milieu Management for GAD  Calm environment  Cognitive Behavioral Therapy (CBT) Corrects faulty assumptions If you change, others will change  Recreational activities Relaxation  Groups: assertiveness, expressive arts, etc.

27. Panic Disorder  Recurring, sudden, intense feelings of  Apprehension  Terror  Impending doom  Losing control  Going crazy  Somatic Symptoms Heart Attack Dying  Recurrent  May or may not be situational If situational, will avoid places or situations that trigger symptoms  Peaks within 10 minutes

28. http://www.freefuninaustin.com/2011/09/half-price-texas-jumping-beans.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+FreeFunInAustin+%28Free+Fun+in+Austin%29 Panic DO

29. Scenario: Situational Panic An office worker experienced episodes of dizziness, nausea and a fear of losing emotional control in front of his boss and co-workers whenever the whole staff was together. He started calling in sick or skipping staff meetings.

30. Panic Disorder: Complications  Over time, the fear of situational panic attacks may cause the person to severely restrict activities  agoraphobia

31. Scenario, cont’d: Panic Disorder with Agoraphobia The office worker was fired for missing too much work. He had difficulty finding a new job, because he would often become panicked when on an interview. Eventually he stopped going out to interviews at all. “I never know when I’ll have an attack and it is easier to just not put myself through that.”

32. Etiology of Panic Disorder  Psychological Life stresses  Separation and disruption of attachment in childhood  Biological Heredity Hyperactivity of Interaction of Cognitive-- Sympathetic NS--Endocrine Systems  Catastrophic thinking (“what if”) triggers the physiological response

33. Panic Disorder: Interaction of Cognitive–ANS–HPA Axis

34. Nurse-Client Relationship and Milieu Management: Acute Phase of Panic Disorder  Communication: Similar to panic level anxiety, stay with them, reassure that they are safe  Calm environment,  stimulation  Assess for suicidal ideation: 1 in 5 are suicidal  Use touch carefully  PRN Medications: alprazolam/Xanax, lorazepam/Ativan

35. Nurse-Client Relationship  Client teaching: improvement often follows  You are not crazy  Recognize and address triggers  Recognize symptoms  Meds. can help When is the best time to teach these clients?

36. Milieu Outpatient Tx  Relaxation Exercises Stretching Yoga Soft music  Gross motor activities Walking Jogging Basketball  Cognitive Restructuring  Reinterpreting beliefs  Meeting fears  Giving options

37. Panic Disorder: Medications  Serotonin Reuptake Inhibitors Long-Term treatment Long-Term treatment  Calcium channel blockers and beta adrenergic blockers: reduce ANS symptoms  Benzodiazepines Immediate effects Immediate effects

38. Obsessive-Compulsive Disorder (OCD)  Obsessions Recurrent and persistent thoughts, ideas, impulses  Compulsions Repetitive behaviors  Performed in a particular manner (ritual)  Response to obsession  Prevent discomfort  “Neutralize” anxiety

39. http://www.youtube.com/watch?v=44DCWslbsNM&feature=related http://www.youtube.com/watch?v=Rn1OYlYzgm8&feature=related OCD

40. OCD: Associated Signs and Symptoms  Depression, low self-esteem  Increased anxiety when resist their compulsions  Strong need to control  Rituals interfere with normal routines and relationships  Magical thinking  Beliefs that thinking equals doing

41. OCD Nurse-Client Relationship  Assist to meet basic needs  Allow structured time to perform rituals  Explain expectations  Identify feelings--connect to behaviors  Introduce new activities slowly  Reinforce and recognize positives

42. Milieu Outpatient  Relaxation Exercises  Stress management  Recreational and Social skills  CBT and Thought- Stopping

43. OCD: Medications  Antidepressants Tricyclic Antidepresants Tricyclic Antidepresants  clomipramine (Anafranil) SSRIs SSRIs  fluoxetine (Prozac)  paroxetine (Paxil)

44. Phobias/DSM IV  Marked and specific fear that is excessive and unreasonable, cued by the presence or anticipation of object.  Person recognizes fear as unreasonable  Situation or object is avoided

45. Phobias -Continued  Agoraphobia without Panic Disorder : a fear of being in public places  Social Phobia : e.g. fear of being humiliated in public, fear of stumbling while dancing, choking while eating, etc.  Specific phobia : fear of a specific object or situation; animals, heights, flying etc.

46. Comparison of Panic Disorder and Specific Phobia The office worker who often experiences episodes of panic when there is heated debate and arguing during staff meetings The office worker who is terrified of being inside enclosed spaces with no windows

47. Treatment for Phobias  Outpatient is most common  Behavior therapy: systematic desensitization- like Fear of Flying groups  Nurse-client relationship and milieu Interventions are very similar to GAD

48. Medications  No effect on avoidant behaviors  SSRIs Reduce anxiety and depression Reduce anxiety and depression

49. Somatoform Disorders  Anxiety is relieved by developing physical symptoms for which no known organic cause or physiologic mechanism can be determined.  Somatization Disorder  Pain Disorder  Hypochondriasis  Conversion Disorder

50. Somatoform Disorders: Overview  Client expresses psychological conflict through symptoms  Client is not in control of symptoms and complaints  See general practitioners, not mental health professionals  Repression of feelings, conflicts, and unacceptable impulses  Denial of psychological problems  Individuals are dependent and needy

51. 1) Somatization Disorder  Recurrent frequent somatic complaints for years  Complaints change over time  Onset prior to 30 years old  See many physicians  May have unnecessary surgical procedures  Impairment  Etiology Chronic emotional abuse Unable to verbalize anger

52. 2) Pain Disorder  Severe Pain in one or more areas Significant distress and impairment Location or complaint does not change “Doctor Shoppers” Pain may allow secondary gain  Avoidance, e.g. Does not have to go to work  Frequently use pain medication If has a physiologic disorder, the amount of pain is out of proportion

53. 3) Hypochondriasis  Worry about having a serious illness despite no medical evidence  Misinterpretation of bodily symptoms  Check for reassurance from doctors and friends

54. 4) Conversion Disorder  Sudden onset of deficit or alteration in voluntary motor or sensory function  Conflicts or stressors proceed symptoms  Symptoms characteristically suggest a neurological disorder: Paralysis, blindness, or seizures Paralysis, blindness, or seizures  May show little concern or anxiety  Theory is: anxiety is “replaced” by the physical symptom

55. Nurse-Client Relationship and Management of Somatoform Disorders  Always rule out the physical  Show acceptance and empathy; do not challenge or force insight  Encourage identification, appropriate expression of emotions  Teach adaptive coping e.g. assertiveness skills

56. Critical Thinking  A soldier, who received notice of deployment to Afghanistan, suddenly developed numbness and weakness in both lower extremities. After a medical admission for diagnostic testing, no physiologic cause was found, and the client was transferred to the mental health unit.  Critique each statement by the nurse; suggesting any alternatives.

57. CRITICAL THINKING A) “The doctors have not found anything wrong with you. You should try to get up and walk.” B) “ I notice you were supposed to go overseas. Did that upset you?” C) “As part of your stay here we would like you to attend a stress management group. You probably have some stress you are not aware of.”

58. MEDICATIONS FOR ANXIETY

59. BENZODIAZEPINES (BZDs)  CNS Depressants  Compete for GABA receptors; decrease response of excitatory neurons  Tolerance, dependence are problems  Cause dizziness, somnolence, confusion  Best for short-term use  Shorter acting BZDs PRN for episodes of anxiety or panic: clonazepam (Klonopin) lorazepam (Ativan)

60. NON-BENZODIAZEPINE  First line agent: buspirone (BuSpar)  Binds to serotonin and dopamine receptors  No CNS depression  No abuse potential documented  May have paradoxical effects (increased anxiety, depression, insomnia, etc.)  May not be fully effective for 3-6 weeks  May cause EPS

61. NON-BENZODIAZEPINES: ANTIHISTAMINES  Very sedating  No addiction potential  May be used long-term  Examples: diphenhydramine (Benadryl) hydroxyzine (Vistaril)

62. ANTIDEPRESSANTS  Useful in treatment of panic (with or without agoraphobia), obsessional thinking  Low abuse potential  SSRI’s: first line drugs due to low sedation

63. ANTIDEPRESSANTS, CONT’D  SSRI’s and SNRI’s: fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) fluvoxamine (Luvox): best for OCD  venlafaxine (Effexor) duloxetine (Cymbalta)

64. Antidepressants for Anxiety, cont’d  Tricyclics (TCAs) Clomipramine (Anafranil)—for OCD

65. MISCELLANEOUS  propranolol (Inderal)-Beta adrenergic blocker and clonidine (Catapres)-Alpha 2 agonist Decrease autonomic symptoms in panic : e.g. tachycardia, muscle tremors  gabapentin (Neurontin)  For OCD and social phobias

66. GENERAL GUIDELINES FOR USE OF ANTIANXIETY AGENTS  Sedation potentiates falls, accidents  Cautious use in elderly, renal, liver problems  Do not combine with other CNS depressants or alcohol  Paradoxical effects common: esp. with BZDs, buspirone, and some antidepressants  Don’t stop benzodiazepine therapy abruptly