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Stress and Anxiety
o Stress Theories
 Conflict avoidance
 Biopsychosocial theory: SNS activation (fight/flight) Cannon, 1932
 Cause of disease due to wear/tear on body
 General adaptation syndrome (GAS) Selye, 1956
 Enlarged adrenal glands, shrinkage of thymus/spleen/lymph nodes, GI
bleeding
 Life changes Holmes & Rahe, 1967
 Social Readjustment Rating Scale: measures stress with life changes and
categorized them (mild with 30% chance of physical manifestation;
moderate 50%, high 80%)
 Stress as Transaction Lazarus, 1991
 Stress includes life changes and everyday. Process of complex interplay
among perceived demands of environment and perceived resources
 Phsychoneuroimmunology and stress
o Anxiety
 Caused by threats (internal and external)
 Differs from fear: anxiety is unconscious emotion, fear is higher level processing
cognitive response
 Mild to moderate enables effective functioning but increases alertness, narrows
perspective and attention along the anxiety continuum
 Severe anxiety can lead to inability to problem solve, focus on small/irrelevant
details
 Panic: debilitating
 Examples of physical conditions with morbid psychiatric symptoms: A fib, MI,
angina, IBS, ulcers, NVD, hypoglycemia, metabolic syndrome, psoriasis, acne,
alopecia, chronic pain, fibromyalgia, migraines, asthma, TB
 May be associated with withdrawal/intoxication from ETOH, sedatives,
anxiolytics, amphetamines, hallucinogens, caffeine, cannabis
Anxiety Disorders
o Dx
 6 months or greater
 Characterized by mixture of physiological, psychological, behavioral, and
cognitive symptoms TO EXCESS
o Assessment components
 Specific fears/phobias
 Sleep hygiene:
 Bed routine, where they sleep, napping, tv in bedroom, with kids or
significant other, activity during the day
o Neurobiological changes with prolonged anxiety
 Increased sensititivity to NE
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In PTSD, structural changes in hippocampus (can be improved with medication
and therapies)
 In OCD and PTSD changes in amygdala
 Increase in lactic acid levels in some people before a panic attack
 Involves changes in 5HT, Gaba, Glutamate, Norepi, and Cortisol
 Cortisol balance:
o Hypocortisolism: depression, motivation problems
o Hypercortisolism: OCD, panic disorders, atrophy of the
hippocampus
Generalized Anxiety Disorder (GAD) and Panic Disorder
o GAD’s prominent feature: frequent, uncontrollable worrying which can manifest as
physical symptoms
 Restlessness, irritability, fatigue, muscle tension, difficulty concentrating, sleep
disturbances
o Panic Disorder
 Recurrent panic attacks with unpredictable onset
 Lasts minutes to hours
 May or may not be accompanied with agoraphobia
 S/sx:
 Sweating, trembling, shaking, SOB, chest pain/discomfort, nausea,
dizziness, chills, hot flashes,
 derealization or depersonalization: surreal feeling of “not happening to
me” (NOT PSYCHOSIS)
 Fear of losing control/going crazy
 Fear of dying
o Theories
 Psycodynamic : ego is unable to intervene between id and superego, overuse of
ineffective ego defense mechanisms
 Cognitive: faulty/distorted or counterproductive thinking patterns result in
anxiety
o Agoraphobia
 Fear of being in places or situations from which escape might be difficult
 Not wanting to leave home or having exact routine
 Typically not socializing/interacting
 May be accompanied by panic disorder
o Pharmacologic txs
 Anxiolytics
 Antidepressants
 Antihypertensive agents
Social Anxiety Disorder (Social Phobia)
o Low self-concept and self-esteem contribute to excessive fear of doing something
embarrassing
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Specific Phobia
o Fear of objects or situations that could conceivable cause arm but the person’s rxn is
excessive, unreasonable, inappropriate
o Exposurepanic, palpitations, sweating, dizziness, difficulty breathing
o Types:
 Animals
 Nautral environment type
 Blood-injection-injury-type
 Situational type (tunnels/bridges/elevators)
 Transportation and more
o Theories:
 Psychoanalytical theory: unconscious fears may be expressed in a symbolic
manner as phobia
 Learning theory: fears are conditioned responses and thus are learned by
imposing reinforcements for certain behaviors (CONDITIONING)
 Cognitive theory: faulty cognitions, negative self-statements, irrational beliefs
 Temprament/Life experiences
o Pharmacologic Txs
 Anxiolytics
 Antidepressants
 Antihypertensives
OCD, Hoarding, Tichotillomania
o Obsessive Compulsive Disorder (OCD)
 Recurrent obsessions ( recurrent thoughts/impulses experienced as intrusive) or
compulsions (repetitive ritualistic behaviors) that is time consuming or marked
distress/significant impairment
 Person recognize they are irrational
o Body Dysmorphic Disorder (BDD)
 Exaggerated belief that body is deformed or defective in some specific way
 S/sx of depression and OCD are common
o Trichotillomania
 Recurrent pulling out of one’s own hair
 Increasing tension  release by pulling hair
o Hoarding Disorder
 Can be classified as “with excessive acquisition” if continual addition of
posessions
 Associated symptoms: perfectionism, indecisiveness, anxiety, depression,
distractibility, difficulty planning/organizing tasks
 High relapse rate
o Theories
 Psychoanalytic theory: clients with OCD have weak, underdeveloped egos
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Aggressive impulses are channeled into thoughts/behaviors that
prevent feelings of aggression from surfacing.
 Biological perspectives: genetics, abnormalities in brain structure/
neurotransmitters (5HT0
o Pharmacologic txs for OCD and BDD
 Antidepressants
o Pharmacologic tx for Trichotillomania
 Chlorpromazine (throazine)
 Amitriptiline
 Lithium
 Antidepressants: Paroxetine, Sertaline, Fluxoetine
Psychopharmacology of Anxiety Disorders
o Anxiolytics include:
 SSRIs, SNRIs
 Hydroxyzine (Vistaril)
 Benzodiazepenes
 Buspirone (BuSpar): 50/50 if effective
o SE profile of benzos/buspirone:
 Drowsiness/confusion/lethargy
 Tolerance, dependence
 Potentiates CNS depression
 Orthostatic hypotension
 Pradoxical excitement
 Delayed onset of action (with BuSpar)
Nursing care of Anxiety Disorders
o Panic Attacks
 Stay with the person, maintain calm demeanor, use short simple sentences,
move person away from stimulus, focus clients diffuse energy, administer
anxiolytics
 Observe for increased psychomotor activity, anger, withdrawal, excessive
demands, terafulness
 Connect with feelings that bring relief, triggers
o OCD
 Acknowledge person’s rationality, allow time to complete rituals. This forms
therapeutic alliance. Action takes place after ritual has taken place
 Affirming relationship is important before changing behaviors
 Gradually introduce possible new behaviors to substitute for damaging
 Do not use paraphrasing/reflecting. Why? Client understands their compulsions
are irrational
o Phobic
 Resistant to exposure/ insight oriented therapies
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Behavioral techniques work better including desensitization and cognitive
restructuring
Safety
 Counsel to avoid dangerous activities when anxiety is severe
 Move more slowly and go over instructions before undertaking new tasks/skills
o Coping skills
 Relaxation techniques (focused breating, progressive muscle relaxation)
 Sound therapy
 Boring book
 Warm liquids and warm bath
o Promoting effective thought processes and sensory perception
 Use visual aids
 Practice problem solving
 Identify misperceptions
 Help clients explore opinions in light of validated experience
Care Planning
o Common nursing dx:
 Panic anxiety, powerlessness, fear, social isolation
 Ineffective coping, ineffective role performance, disturbed body image,
ineffective impulse control
o Outcomes
 Client is able to recognize signs of escalating anxiety and intervene before
reaching panic level
 Is able to maintain anxiety at a manageable level and make independent
decisions about life situations
 Functions adaptively in presence of phobic object or situation without
experiencing panic anxiety
 Verbalizes a future plan of action for responding in the presence of the phobic
object or situation without developing panic anxiety
 Is able to maintain anxiety at a manageable level without resorting to use of
ritualistic behavior
 Demonstrates more adaptive coping strategies for dealing with anxiety than
ritualistic behaviors
 Verbalizes realistic perception of his or her appearance and expresses feelings
that reflect a positive body image
 Verbalizes and demonstrates more adaptive strategies for coping with stressful
situations
Adjustment Disorders
o Difficulties with stress rxns to more normal events
o Common
PTSD
o Rxn to extreme trauma which is likely to cause distress to anyone
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May begin within 3 months or be delayed
Symptoms include:
 Re-experiencing trauma
 Sustained high level of anxiety/arousal
 General numbing of responsiveness
 Intrusive recollections/nightmares
 Amnesia
 Depression
 Survivor’s guilt
 Substance use
 Anger/aggression
 Relationship defecits
Acute Stress Disorder
 Simmilar to PTSD, but time limited up to 1 month following trauma
Neurobiology
 Excessive stimulation of amygdala->hyperarousal
 Neuroendocrine/autonomic responses
 Cortisol
 Kindling: phenomenon where high cortisol exposure over time leads to
sensitivity of the thalamus (the stimulus processor) and EVEN GREATER
stress response
 Glutamate
 Secreted during trauma to create strong vivid memories
 NE
 Similar to cortisol, amygdala tells brainstem to increase secretion
 5HT
 Depletion
Therapy
 Cognitive therapy
 Prolonged exposure
 Group/family
 EMDR
 Psychopharmacology
Outcomes
 Pt will acknowledge the trauma and impact on life
 Demonstrate adaptive coping strategies
 Made realistic goals for the future
 Worked through feelings of survivor’s guilt
 Attends support group of individuals recovering from similar traumatic
experiences
 Verbalizes desire to put trauma in the past and progress with his or her life
Practice Problems:
Lippincott: p. 844 1-22, 23-36 p. 815, 101-137
Saunders: p. 1054: 912, 913, 918. P. 1092: 950