Download Anxiety Disorder

Pathophysiology &
Pharmacology for Anxiety
and Sleep Disorders
1
Fight-or-Flight……or Freeze
Response
When encountering stress,
living creatures including
humans tend to react in a
means to protect themselves
through fighting, fleeing, or
freezing in
place.
2
Alarm or Acute Stress Response
• Sympathetic nervous system response
• Adrenal glands release adrenaline and increase vital signs to
enhance strength and speed.
• Pupils are dilated
• Blood is shunted away from the digestive tract and kidneys
to more essential organs.
• Corticosteroids release
• Adrenal cortex also produces corticosteroids to increase
muscle endurance and stamina and
• Decreases nonessential functions like digestion.
• They also inhibit reproduction, growth and immunity.
• Endorphin release
• Reduce sensitivity to pain and injury.
• Interact with opioid receptors in the brain to limit the perception
of pain.
3
Stress Exhaustion
Exhaustion Stage – the body does not stabilize and remains in
an alarm stage until exhaustion occurs.
Disorders that can be related to stress exhaustion:
• Sympathetic NS Effects
Headaches
Hypertension
Insomnia
Gastrointestinal upset
Anxiety disorders
• Corticosteroid Effects
Recurrent Infections
Blood sugar elevations
Exhaustion of the SNS can lead to depression
and chronic fatigue
4
Anxiety Disorders
The function of anxiety is to warn a person of an
impending threat, conflict or danger. It may be expressed
as a sense of doom, tension or dread.
 Real
 Perceived
Anxiety can become maladaptive and warn of impending
danger even when no danger actually exists. This can
eventually lead to an Anxiety Disorder
5
Levels of Anxiety
Mild anxiety – muscles tense, increased sense of
mental acuity
Examples: Meeting new people, New tasks to do
Moderate Anxiety – vital signs elevate, muscle
tension increased, may feel excited or restless,
alert, perception is narrowed and focused.
Examples: Athletic performance, Exams
6
Levels of Anxiety
Severe Anxiety – Fight, flight, or freeze, response.
Perception narrows. A sense of detachment or
dissociation can happen. Time seems to speed up or
slow down.
Example: Active Military Engagement
Panic Anxiety – Vital signs become high, perceptual
field scattered, can’t think straight, feel out of
control, may become terrified, rageful, frozen,
combative. May have memory loss for the time or
event.
Example: Automobile accident, Disaster response
7
Generalized Anxiety Disorder
• Excessive and persistent worry often over a variety
of things (or nothing at all) which impedes a
person’s ability to function well in many aspects of
life.
• Feeling of being keyed up or on edge all the time,
easily fatigues, tight muscles, sleep problems (going
to sleep), irritable and trouble concentrating.
GAD leads to health conditions such as ulcers
or hypertension due to the persistent alarm
stage of the general adaptation response.
8
Nursing Care of the Anxious Person
• Assessment:
• Level of Anxiety
• Cause of Anxiety
• Potential for Self-injury
• Nursing diagnoses
• Ineffective coping
• Anxiety
• Chronic low self-esteem
• Risk for self-injury
• Some Nursing interventions
• Relaxation training/intervention
• Teaching more effective coping skills
• Explore achievements
• Reinforce positive self-worth
• Administer medications (routine and PRN)
9
What to Do About Stress
http://www.youtube.com/watch?v=I6402QJp52M
10
Pharmacological Treatment of
Anxiety Disorders
11
3 Drug Categories
1. Anxiolytics
 Benzodiazepines
 Non-benzodiazepine – buspirone (Buspar)*
2. Antidepressants
 Selective Serotonin/Norepinephrine Reuptake
Inhibitors*
3. Miscellaneous
 Antihistamines
 Anticonvulsants*
*Will be covered in later classes
12
Benzodiazepines
• Pharmacotherapeutics
Anxiety, Insomnia, Anti-seizure, Pre-operatively
• Pharmacokinetics
Readily absorbed orally. Some are also absorbed IM
or IV. Duration depends of half-life of individual
drug. All can cause tolerance and dependency.
• Pharmacodynamics
Benzodiazepines potentiate the effects of
GABA (gamma-amino-butyric acid), a
neurotransmitter that inhibits neuronal
transmission and activity. The result is CNS
slowing and depression.
Benzodiazepines
All benzodiazepines are similar drugs and only vary in halflife and duration of action
PROTOTYPE: alprazolam (Xanax)
Side effects: Dizziness, drowsiness, sedation, altered level
of consciousness, disinhibition
Adverse events:
Tolerance, dependency, addiction, withdrawal
Potential for withdrawal-related seizures
Lowered vital signs (IV diazepam, or Valium)
Confusion/agitation/delirium
14
Non-benzodiazepine Anxiolytic
Prototype: Hydroxyzine (Vistaril, Atarax)
Pharmacotherapeutics
Wide variety of uses. Anti-allergen, anti-histamine, mild
anxiety and insomnia
Pharmacokinetics
Easily absorbed orally, IM and IV. Fairly long duration of
action (12-24 hours depending on the drug).
Pharmacodynamics
Antagonizes histamine receptor sites
Side effects
Drowsiness, Dry mouth
Adverse events
Agitation or confusion in older adults
15
Insomnia
and
Sleep Disorders
16
Sleep
• Sleep is a time of bodily rest, although the
brain remains active.
• There are two general phases of sleep:
• No rapid eye movements (NREM)
• Rapid eye movements (REM)
Sleep (cont.)
NREM stages of sleep are further divided
into:
• Stage 1—light sleep; muscles relax; brain
waves are irregular and rapid.
• Stage 2—brain waves are larger than in
stage with bursts of electrical
activity.
• Stages 3 and 4—deep sleep, with larger,
slower brain waves called delta
waves.
Sleep (cont.)
• The amount of sleep needed by a person
varies throughout the life span, with
infants requiring the most sleep and adults
requiring the least.
Sleep Disorders
Between 50 and 70 million Americans have a
sleep disorder.
Sleep disorders are seen in every area of
health care and nursing.
• Insomnia – inability to
get adequate sleep for
any reason
• Sleep apnea—
cessation of breathing
during sleep. Often
includes excessive
daytime sleepiness.
• Restless legs
syndrome (RLS) - a
neurologic movement
disorder often
associated with a sleep
complaint. Unpleasant
leg sensations and an
almost irresistible urge
to move the legs.
Sleep Disorders
• Night terrors—occur
only in children, with
periods of fright, crying,
moaning, or screaming
after a brief time asleep
• Sleepwalking—getting
up and walking about
while still asleep
• Narcolepsy—sudden
irresistible sleep attacks
of unknown origin
lasting from seconds to
minutes, two to six
times a day
Screening for Sleep Disorder
1. Do you regularly have difficulty getting to sleep or staying
asleep?
2. Do people tell you that you snore? Has anyone ever told
you that you have pauses in breathing or that you gasp for
breath when you sleep?
3. Are your legs “active” at night? Do you experience tingling,
creeping, itching, pulling, aching or other strange feelings in
your legs while sitting or lying down that cause a strong
urge to move, walk or kick your legs for relief?
4. Are you so tired when you wake up in the morning that you
cannot function normally during the day?
5. Does sleepiness and fatigue persist for more than two to
three weeks?
22
Sleep Study: Polysomnogram
A polysomnogram is done to evaluate sleep:
• This non-invasive test requires an overnight stay in
a sleep study clinic.
• A sleep technologist records multiple biological
functions during sleep, such as brain wave activity,
eye movement, muscle tone, heart rhythm and
breathing via electrodes and monitors placed on
the head, chest and legs.
• Patients may be given therapy during the course of
the study, which can include medication, oxygen or
a device called continuous positive airway pressure
therapy, or CPAP.
23
Treatment of Sleep Disorders
• Obstructive sleep apnea
• Continuous Positive Airway Pressure (CPAP) masks
that may or may not deliver oxygen can be
prescribed to use at night.
• Daytime medications to treat the excessive
sleepiness; e.g. modafinil (Provigil, Nuvigil)
• Restless Leg Syndrome
• Anticholinergic medications that reduce muscle
responses to neurological stimuli; e.g. ropinirole
(Requip) or pramipexole (Mirapex)
24
Treatment of Sleep Disorders
• Sleepwalking, Sleep Terrors
• Generally no treatment
• Narcolepsy
• Central nervous system (sympathetic) stimulants;
e.g. modafinil (Provigil) or methylphenidate
(Ritalin) during the day.
• Insomnia
• Therapy or counseling for anxiety/stress
• Alpha-adrenergic antagonists for trauma-related
insomnia, e.g. prazosin (Minipress)
• Central nervous system sedatives
25
Good Sleep Practices
Before starting medications for insomnia, individuals should be
advised to:
1. Turn off all lights in the room at night as lights stimulate
wakefulness, but get natural light during the day.
2. Do not use caffeine within 6-hours of sleep.
3. Do not use nicotine at bedtime, or at all.
4. Do not drink more than 1 alcoholic beverage at bedtime.
5. Do not eat a heavy meal at bedtime although a light snack can
help with sleep.
6. Only use the bedroom for sleep and sex – not television or videogaming. Reading may promote sleep.
7. Do not exercise vigorously within 2 hours of bedtime, but do
exercise during the day. Yoga is okay.
8. Avoid daytime napping.
9. Learn to meditate or use guided imagery at night.
26
Sleep Onset
It takes an average of 13 minutes to
actually fall asleep at night.
Don’t feel discouraged if lying awake
for 5-10 minutes!
27
Medications for Insomnia
• Melatonin – available over-thecounter. Mimics the bodies natural
responses to nighttime.
• Ramelteon (Rozerem) – prescription
melatonin receptor agonist. Stronger
than OTC types.
• Antihistamines – Diphenhydramine
(Benadryl), Hydroxyzine (Vistaril).
28
Medications for Insomnia:
Antidepressants
Prototype: trazodone (Desyrel)
• Antidepressant medication that is commonly
prescribed off-label as a sleep aid due to its
highly sedating side effects.
• No reports of long-term or serious consequences
• Side & Adverse effects:
Early morning sedation (long half-life of drug)
Occasionally patients feel restless or agitated
Rare adverse event of priapism – requires
emergency intervention
29
Benzodiazepine-Like Sedatives
Prototype: Zolpidem (Ambien)
• Commonly prescribed sedative-hypnotic
• Used PRN & not more than a few days/week.
• Produces excessive drowsiness within 30 minutes
• Do not drive or operate machinery while taking
Side & Adverse effects:

Sedation in the morning

Respiratory suppression

Rare – sleepwalking, sleep-eating, even sleepdriving have been reported!
30
Case Study Activity
Complete the Case Study, Generalized
Anxiety Disorder (see next slide) and
post answers to Assignments.
31
Case Study
Miriam Black is a 43-year-old woman referred to an
outpatient mental health center by her primary care
provider. She has complained of “persistent headaches,
nausea, fatigue, and difficulty staying asleep” for the past
several months. She is constantly worried about her
finances and paperwork at the office and finds it
increasingly difficult to concentrate at work. At times, she
feels as if her mind has gone blank.
Ms. Black’s social history includes use of tobacco at 2 packs
per day, 3-4 cups of coffee per day, and 1-2 alcohol drinks
per evening. She is employed as a research associate for a
private research company.
32
Case Study (cont’d)
Data obtained from the nursing assessment includes the
following:
Subjective: “I feel nervous most of the time.”
Objective: Vital signs: B/P 145/90, HR 105, RR 16
• Ht 5’ 4”, Wt 54.5 kg (120 lbs)
• Systems review: Loss of appetite, chronic diarrhea
The patient currently is taking alprazolam (Xanax) 1 mg PO tid.
1. How does this drug work to address Ms. Black’s generalized
distress?
2. Are there any precautions or contraindications that would
eliminate the use of this drug for Ms. Black?
3. What teaching is required for Ms. Black regarding her drug
therapy? Do you need any additional data to determine
appropriate teaching?
33
34