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Anxiety 1 Hear this? • There is an intense, constant fear that is hard to describe • It’s a sinking feeling in your stomach— almost as if someone is stalking you and you never know when those arms are going to wrap around you and drag you away. • There’s more anxiety today, and that women, in particular, are feeling it 2 Introduction • Common in all phases of life • Most prevalent mental disorders in the U.S. • Afflicting 28.7% of the population (life span); 19.3% over a 12-month period • 1 in 4 people with an anxiety disorder is correctly identified, diagnosed, and treated • Client’s symptoms are not primarily due to organic factors • Stress, fear, anxiety, depression 3 4 Types of Anxiety (DSM-IV) • • • • • Panic disorder – acute anxiety Specific phobia; social phobia; Obsessive-compulsive disorder Posttraumatic stress disorder Generalized anxiety disorder 5 Types of Anxiety (DSM-IV) –cont’d • Acute stress disorder – immediately after the event • Anxiety disorder due to a general medical condition • Substance-induced anxiety disorder • Others – – Adjustment disorders featuring anxiety – Separation anxiety – Sleep disorder of insomnia 6 Symptoms of Anxiety Disorders • Motor tension - trembling, feeling shaky, muscle tension, muscle aches, restlessness • Autonomic nervous system hyperactivity – shortness of breath, feeling of being smothered, heart rate↑, sweating or feel cold, clammy hands, dry mouth, dizziness, • Hypervigilance – feeling edgy, difficulty concentrating, irritability 7 Dynamics of anxiety • • • • Stress, coping & defense mechanism Theories - Freud, Sullivan, Selye Primary gain - desire to relieve anxiety Secondary gain - attention gained from others 8 Process of Coping Stressor Anxiety Neurochemical/physiological reactions Coping Adaptive Palliative Maladaptive Dysfunctional 9 What is anxiety? • Anxiety is a normal emotion which helps us recognize real problems and solve them. In its healthy form, anxiety helps you perform at your top form when you’re adjusting to, say, a new job or a new baby • Anxiety is not normal when it lasts days beyond a specific stressful event, or when it interferes with a person’s life 10 Levels of Anxiety • Mild +1 - slight fidgeting, alert, feeling challenged, ready for constructive action, • Moderate +2 - irritability ↑, confidence ↓ concentrating↓, ready for protective action • Severe +3 - hypersensitivity, distorted perceptions, ready for flight or fight, • Panic +4 - actual flight/fight or immobilization, rage, disorganized, distorted sensory awareness 11 Intervention in levels of anxiety • Mild +1 – take as natural; benefit from it • Moderate +2 - ↓anxiety by crying, exercising, refocusing; using medications • Severe +3 - ↓anxiety & stimuli; use simple directions, use time out (seclusion); using medication (IM) • Panic +4 – guide firmly, restrains if needed, using medication (IM) 12 Interventions to Reduce Anxiety • • • • • • Calm & quiet environment To identify what and how they feel To describe & discuss their feeling To identify the possible causes To listen carefully - assess suicidal attempt Do something - to release nervous energy; to discourage preoccupation with the self. 13 Anxiety and other diseases • Panic disorder occurs in 15-30% of the major depression cases • Factitious disorder –deliberately make up the symptoms – ie. Munchausen syndrome by proxy • Malingering – consciously create or exaggerate false symptoms to avoid work or other responsibilities 14 Social Phobia – Most common anxiety disorder • • • • • An extreme fear of being judged by others Chr, unremitting, life long disorder. begins around age of 13-20 Prevalence: 13.3% lifetime duration Lead to other problems: alcohol (18.8%0, drug abuse (13.0%), agoraphobia (44.9%)* • Paralyzed by fears that he will humiliate or embarrass himself in front of others -> drop out from school, unemployed, no friends, … 15 Panic disorder (panic attack) • Happen unexpected or situationally bound • Spontaneous attacks of intense fear and discomfort; may last from minutes to an hour • Symptoms of anxiety can last for hours • S & S include heart rate ↑, chest pain, chills or hot flushes, dizziness, SOB, fear of losing control, depersonalization 16 Interventions for Panic Attack • Stay with the pt and acknowledge the pt’s discomfort • Maintain calm, keep the environment quiet • Use simple direction • Allow pts to pace or cry – to release tension • Reassure the pt, you are in control • Use paper bag for hyperventilation pt 17 generalized anxiety disorder • Persistent, excessive and unrealistic worry that lasts for 6 months and more • Worry for everything, irrational concerns, • S/S: restlessness; difficulty concentrating or sleeping; irritability; fatigue; muscle tension 18 Obsessive-compulsive Disorder • Repetitive behaviors or experiencing recurrent, persistent thought • Time consuming • Normal routine was interfered – work, social functioning and interpersonal relationships • Low self-esteem & self-worth →depression • Thinking process is rigid – right & wrong 19 Interventions for OCD • • • • Physical care – food, rest, grooming Provides pts with time to perform rituals Explain expectations, routines, changes Be empathic – aware of their needs to perform rituals • Help to connect feeling and behaviors • Structure simple activities – distraction • Reinforce positive changes 20 Phobic disorders • Def: intense, irrational fear responses to an external object, activity, or situation; it causes severe distress & impair functioning • Interventions: – – – – Non-critical attitude Provide activities Physical care and comfort needs Behavior is a method of coping 21 Etiology • Cognitive theories – neg. thinking, irrational ideas • Genetics – • Biochemical factor – – epinephrine -> nervous – Neurotransmitters – excessive serotonin, norepinephrine, dopamine ->anxiety – GABA • Changes in the society, value, culture, IPR, • Food, exercise 22 Assessment • Health history; physical examination • Medications – amphetamines, anticholinergics, antihypertensive, epinephrine, OTC drugs, … • Screening – Mini International Neuropsychiatric Interview (MINI); Liebowitz Social Anxiety Scale; Brief Social Phobia Scale; Michigan Alcoholism Screening Test… 23 Treatment • Cognitive-behavioral therapy – to reduce automatic negative perceptions and irrational beliefs, • Relaxation training, • Behavioral approaches- ie desensitization • Pharmacotherapies – fluvoxamine (Luvox), Prozac, Paxil, Beta-blockers, MAOIs, benzodiazepine, 24 Nursing Implications • Case finding, evaluating, and treating • Educator – knowledge and skills to cope with anxiety • Identifying local resources • Document and report the anxiety disorder & advocate for treatment 25 Posttraumatic Stress Disorder • Traumatic event →PTSD and/or ASD • S & S: intense fear, horror, sense of helplessness, dissociative symptoms • Prevalence: 50-70% - life time • PTSD can occur 10-20 years later • Denial, repression, suppression, withdrawal, feeling of hopelessness, nightmare, illusion, depression, suicidal ideation, substance abuse 26 Interventions for PTSD • Nonjudgmental, empathic, honest • Normal reactions toward the trauma – connections between experience & feelings • Safe verbalization of feelings – esp anger • Adaptive coping strategies – exercise, relaxation instead of alcohol, drugs • Progressive review of the trauma event – grieving process 27 Anxiety related disorder – Somatoform disorders (hysteria or Briquet’s syndrome) • Anxiety is expressed through physical symptoms • Caused by an interaction of neurobiological, psychological and familiar factors • Doctor shopping without satisfaction • Meeting needs from physical complaints unconsciously • Different from factitious disorder 28 Anxiety related disorder – Dissociative disorders • Anxiety is removed from conscious awareness, which helps pts to survive extreme emotional pain • Disruption in the usually integrated functions of consciousness, memory, identity, or perception – Depersonalization disorder: outside their mind or body – Dissociate amnesia: loss of memory – Dissociative fugue: travel away from home & inability to remember the past, confused about identity – Dissociative identity disorder: 2 or more identities or personality state 29 Mild Dissociative State Daydreaming Mohr (2009), p 461 Moderate Severe Depersonalization Disorder Dissociative fugue DID Dissociative amnesia 30 Anxiety related disorder – Conversion disorder • Loss of voluntary motor or sensory functions that appears to represent physiologic pathology but, instead, relates to psychological conflict or need. • Symptoms follow a greatly distressing event or experience to defense against intrapsychic anxiety • La belle indifference – clients are not disturbed by their dramatic symptoms 31 Anxiety related disorder – Hypochondriasis • Clients fear that they have a serious disease despite no significant pathology or other reason for thinking so • Hypervigilance -> misinterpret and overreact to physical signs and symptoms • Preoccupation with bodily distress & needs for other’s attention-> disrupt social relationships • Unaware of their anxiety or depression 32 Anxiety related disorder – Body dysmorphic disorder (BDD) • Extremely self-conscious about the imagined defect in appearance • Thinking that others notice the imagined flaw • Retreat from usual activities, socially isolated, decreased academic and occupational functions or even house bound • Severe case -> suicide 33 Conclusion • Diffuse apprehension – subjective, vague, uncertainty, helplessness • Level- mild, moderate, severe, panic • Responses – physiological, behavioral, cognitive, affective • Predisposing factors – multiple; threats to physical integrity and self-esteem • Adaptation - coping • Anxiety is a very real and serious—yet treatable—disorder 34 Conclusion (II) • Intervention – – – – – – – IPR, self-awareness, protecting the patient, modifying the environment, encouraging activity, medication, and learning new ways to cope with stress 35 Joke • Q: What's the difference between stress, tension and panic? A: Stress is when wife is pregnant, Tension is when girlfriend is pregnant, and Panic is when both are pregnant. 36