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Chapter 8 Anxiety and Anxiety Disorders Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 1 Concept of Anxiety and Psychiatric Nursing • Anxiety – Universal human experience – Dysfunctional behavior often defends against anxiety • Legacy of Hildegard Peplau (1909-1999) – Operationally defined concept and levels of anxiety – Suggested specific nursing interventions appropriate to each of four levels of anxiety Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 2 Anxiety and Fear • Anxiety: feeling of apprehension, uneasiness, uncertainty, or dread resulting from real or perceived threat whose actual source is unknown or unrecognized • Fear: reaction to specific danger • Similarity between anxiety and fear – Physiological response to these experiences is the same (fight-or-flight response) Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 3 Types of Anxiety • Normal – Motivating force that provides energy to carry out tasks of living • Acute or state – Anxiety that is precipitated by imminent loss or change that threatens one’s security (crisis) • Chronic or trait – Anxiety that persists over time Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 4 Levels of Anxiety: Mild and Moderate • Mild – Occurs in normal everyday living – Increases perception, improves problem solving – Manifested by restlessness, irritability, mild tension-relieving behaviors Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 5 Levels of Anxiety: Mild and Moderate • Moderate – Escalation from normal experience – Decreases productivity (selective inattention) and learning – Manifested by increased heart rate, perspiration, mild somatic symptoms Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 6 Levels of Anxiety: Severe and Panic • Severe – Greatly reduced perceptual field – Learning and problem solving not possible – Manifested by erratic, uncoordinated, and impulsive behavior • Panic – Results in loss of reality focus – Markedly disturbed behavior occurs – Manifested by confusion, shouting, screaming, withdrawal Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 7 Nursing Interventions for Mild to Moderate Anxiety • Use of therapeutic communication and listening – Open-ended statements – Broad openings – Seeking clarification – Exploration • Importance of nurse remaining calm, recognizing patient’s distress Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 8 Nursing Interventions for Severe to Panic Anxiety • Reduce environmental stimuli – Remove patient to quiet area – Remain with patient • Gross motor activity to drain tension • Therapeutic communication techniques – Firm, short, and simple statements – Reinforce reality • Medications and restraints – Used only after least restrictive measures fail Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 9 Defense Mechanisms • Help protect people from painful awareness of feelings and memories that can cause overwhelming anxiety – Operate all the time – Adaptive (healthy) or maladaptive (unhealthy) • First outlined and described by Sigmund Freud and his daughter Anna Freud Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 10 Properties of Defense Mechanisms • Major means of managing conflict and affect • Relatively unconscious • Discrete from one another • Hallmarks of major psychiatric disorders • Can be reversible • Can be adaptive as well as pathological Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 11 Healthy, Intermediate, and Immature Defense Mechanisms • Healthy – Altruism, sublimation, humor, suppression • Intermediate – Repression, displacement, reaction formation, undoing, rationalization • Immature – Passive aggression, acting-out behaviors, dissociation, devaluation, idealization, splitting, projection, denial Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 12 Anxiety Disorders: General Information • Prevalence – Most prevalent lifetime psychiatric disorder • Chief characteristic – Use of rigid, repetitive, and ineffective behaviors to try and control anxiety • Comorbidity – Often occur with other psychiatric disorders as well as with medical illness • Depression, substance abuse, eating disorders Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 13 Biological Theories Related to Anxiety Disorders • Genetics – Anxiety disorders cluster in families • GABA benzodiazepine (BZA) – BZA receptors are linked to a receptor that inhibits GABA – BZA medications that bind to BZA receptors increase action of GABA and promote calm (decreased anxiety) Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 14 Biological Theories Related to Anxiety Disorders • Hypothalamus-pituitary-adrenal dysfunction – Stress response of patients with PTSD is abnormal • Brain anatomy can change as result of repeated trauma (validated by neuroimaging) Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 15 Other Theories Related to Anxiety Disorders • Learning and behavioral theory – Anxiety is a learned response from modeling from parents and/or peers • Cognitive theory – Anxiety is caused by distortions in thinking and perceiving – Cognitive-behavioral therapy yields best results in treatment of anxiety disorders Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 16 Other Theories Related to Anxiety Disorders • Cultural considerations – Sociocultural variation in symptoms of anxiety disorders noted Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 17 Panic Disorders: Panic Attack, Panic Disorder with Agoraphobia • Panic attack – Sudden onset of extreme apprehension or fear of impending doom – Fear of losing one’s mind or having a heart attack • Panic disorder with agoraphobia – Panic attacks combined with agoraphobia • Agoraphobia is fear of being in places or situations from which escape is difficult or help unavailable – Feared places avoided, restricting one’s life Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 18 Phobias • Phobia: persistent, irrational fear of specific objects, activities, or situations • Types of phobias – Specific: response to specific objects – Social: result of exposure to social situations or required performance – Agoraphobia: fear of being in places/situations from which escape is difficult or help unavailable Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 19 Obsessive-Compulsive Disorder • Obsession – Thoughts, impulses, or images that persist and recur • Ego-dystonic symptom: feels unacceptable to individual • Compulsion – Ritualistic behaviors that individual feels driven to perform • Primary gain from compulsive behavior: anxiety relief Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 20 Generalized Anxiety Disorder (GAD) • Excessive anxiety or worry about numerous things lasting at least 6 months • Common symptoms – Restlessness – Fatigue – Poor concentration – Irritability – Tension – Sleep disorders Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 21 Posttraumatic Stress Disorder (PTSD) • Reexperiencing highly traumatic event • Characterized by: – Recurrent dreams or flashbacks (dissociative experiences in which event is relived) – Avoidance of stimuli associated with trauma – Numbing of responsiveness (feeling empty) – Persistent symptoms of increased arousal (irritability, difficulty sleeping/concentrating, exaggerated startle response) Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 22 Acute Stress Disorder • Occurs within 1 month after exposure to highly traumatic event • Characterized by at least three dissociative symptoms during/after event – Subjective sense of numbing – Reduction in awareness of surroundings – Derealization – Depersonalization – Dissociative amnesia Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 23 Anxiety Caused by Medical Conditions • Direct physiological result of medical conditions such as: – Hyperthyroidism – Pulmonary embolism – Cardiac dysrhythmias • Evidence must be present in history, physical exam, or laboratory findings in order to diagnose Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 24 Nursing Process: Assessment Guidelines • Determine if anxiety is primary or secondary (due to medical condition) – Ensure sound physical/neurological exam • Use of Hamilton Rating Scale – Comprehensive data related to anxiety • Determine potential for self-harm/suicide • Perform psychosocial assessment • Determine cultural beliefs and background Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 25 Nursing Process: Diagnosis and Outcomes Identification • NANDA-International (NANDA-I) – Nursing diagnoses useful for patient with anxiety or anxiety disorder • Nursing Outcomes Classification (NOC) – Identifies desired outcomes for patients with anxiety or anxiety disorders Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 26 Considerations for Outcome Selection for Patients with Anxiety Disorders • Reflect patient values and ethical and environmental situations • Be culturally relevant • Be documented as measurable goals • Include a time estimate of expected outcomes Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 27 Nursing Process: Planning and Implementation • Planning – Select interventions that can be implemented in a community setting – Include patient in process of planning • Implementation – Follow Psychiatric–Mental Health Nursing: Scope and Standards of Practice (ANA, 2007) Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 28 Nursing Interventions for Patients with Anxiety Disorders • Identify community resources offering specialized treatments proven as effective • Identify community support groups • Use therapeutic communication, milieu therapy, promotion of self-care activities, and psychobiological and health teaching and health promotion Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 29 Nursing Interventions: Milieu Therapy • Used as part of treatment approach for patient with anxiety disorder who is hospitalized • Guiding principles – Structure daily routine – Provide daily activities to promote interaction – Provide therapeutic interactions – Include patient in decision making Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 30 Treatment for Anxiety Disorder: Cognitive-Behavioral Therapy (CBT) • Therapist teaches patient to: – Examine assumptions – Redefine fears – Restructure thinking – Make changes • Benefits of CBT – Chemical changes can occur in brain that are similar to changes occurring with medications Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 31 Treatment for Anxiety Disorders: Common Medications • BZAs: short-term treatment only – Causes dependence • Buspirone: management of anxiety disorders • Selective serotonin reuptake inhibitors (SSRIs): first-line treatment for all anxiety disorders Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 32 Treatment for Anxiety Disorders: Common Medications • Selective norepinephrine reuptake inhibitors (SNRIs): venlafaxine approved for panic disorder, GAD, and SAD • Tricyclic antidepressants (TCAs): secondand third-line treatment Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 33 Other Medications and Complementary Therapy • Other medications – ß-blockers – Antihistamines – Anticonvulsants • Complementary therapy (effectiveness unproven) – Kava kava – Valerian root – Gotu kola – St. John’s wort Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 34 Nursing Process: Evaluation • Identified outcomes: basis for evaluation – Is patient experiencing reduced anxiety? – Does patient know symptoms are anxiety related? – Does patient still display symptoms? – What newly learned behavior is displayed? – Does patient perform self-care activities? Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 35 Nursing Process: Evaluation – Does patient maintain satisfactory relationships? – Can patient resume usual roles? – Is patient compliant with medications? Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 36