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Anxiety Disorders Prevalence Anxiety Disorders more prevalent than mood disorders- 18 % Primary gain: the individuals desire to relieve the anxiety to feel better Secondary gain: refers to attention and support the person gets from the illness Primary Gain The individual’s desire to relieve the anxiety – Physical symptoms Stomach Ache Inability to walk – Obsessions – Compulsions Cleans Exercise – Fears Cannot – Worry – Isolation drive Secondary Gain Attention or benefit – Health Care Providers – Spouse does more – Children take care of younger siblings Can become more important than relieving the anxiety – Decreases motivation to get well – Others take care of individual Complicates treatment Axis 1 Anxiety Disorders 1. 2. Generalized Anxiety Disorder (GAD) Panic Disorder with Agoraphobia without Agoraphobia 3. 4. Phobias Somatoform Disorders Etiology of Anxiety Disorders Biological and Genetic – Defects in Brain Chemistry; Person over responds to Stimuli – Inherited trait for shyness has been discovered – Brazelton; believes in the biological basis of temperament Psychoanalytic Result of conflict in values Client is often perfectionist and driven Defense mechanisms – Repression – Displacement – Conversion Generalized Anxiety Disorder (GAD) Cognitive and Physical Symptoms – Worry; unable to focus – Dry mouth, stomach ache Anxiety or worry is chronic and excessive Significant Distress Worry is debilitating and habitual – Focus changes Causes impairment – – – – – Interpersonal or social Occupational Sense of helplessness Depression Chemical dependency Generalized Anxiety Disorder Excessive worry occurring more often than not for 6 months Person cannot control the worry Anxiety and worry are evident and three or more of the following: – – – – – – Restlessness Fatigue Irritability Decreased ability to concentrate Muscle tension Disturbed sleep Interventions for GAD Goal is to assist the client to develop adaptive coping responses Assess for level of anxiety: moderate to severe Reduce level of Anxiety – Must occur prior to problem solving – Promotes trust Acceptance of feelings Acknowledgment of discomfort Identify and describe feelings (repression; displacement) Assist to identify causes of feelings Milieu Management for GAD Calm environment Cognitive Behavioral Therapy – Corrects faulty assumptions – If you change others will change Recreational activities – Relaxation exercises or tapes Groups – – – – – Stress Management Problem solving Self esteem Assertiveness Goal setting Medication Serotonin Reuptake Inhibitors – Long-Term treatment Serotonin and Norepinephrine Reuptake Inhibitors (SNRI) – Long-Term treatment Buspirone (Buspar) – Nonaddicting non-benzodiazepine Benzodiazepine – Immediate effect Four Symptoms for Diagnosis of Panic Disorder Chest pain Choking Dizziness Dyspnea Fear of going crazy Fear of dying Sweating Palpitations Trembling and shaking Nausea Hot flashes and chills Etiology Psychological – Life stresses Separation and disruption of attachment in childhood Biological – Heredity – 3 systems Cognitive (catastrophic thinking “what if”) – Triggers physiology Nervous System – Sympathetic (flight fight response) – Respiratory, cardiovascular, gastrointestinal, neuromuscular Endocrine System – Andrenal cortex (cortisol) Libido, insomnia, anxiety – Adrenal Medulla (epinephrine) Anxiety The Nurse Patient Relationship: Acute Phase Communication: Similar to panic level anxiety, reassure that they are safe – Have client breath with you (set the pace) Keep stimulation down Assess for suicidal ideation: 1 in 5 are suicidal Use touch carefully PRN Medications: Xanax, Ativan The Nurse Patient Relationship and Panic Disorder Teaching: give client a handout on Panic Disorder – Client need to know there is a diagnosis – They are not “crazy” – Symptoms – Medications that can help When clients learn about the diagnosis they usually improve Interventions and Milieu Cognitive restructuring Reinterpret their beliefs regarding the danger of the event Identify feelings Identify triggers Avoidance makes it worse Meeting Fears – What is the worst that can happen? – What will I do – Options Recognize bodily sensations and symptoms of anxiety Relaxation Exercises – Stretching – Yoga – Soft music Gross motor activities – Walking – Jogging – Basketball Panic Disorder Recurring, sudden intense feelings of Apprehension Terror Somatic Symptoms – Heart Attack – Dying Can happen in the middle of the night – fearful and exhausted. Situational – Often recur in the same place – Can occur with anticipation – Avoid places or situations Impending doom Loosing control Going crazy Peaks within 10 minutes Medication Serotonin Reuptake Inhibitors – Long-Term treatment Benzodiazepine – Immediate effect Obsessive Compulsive Disorder Obsessions – Recurrent and Persistent Thoughts Ideas Impulses Images Experienced Compulsions as intrusive and senseless – Repetitive behaviors Performed in a particular manner Response to obsession Prevent discomfort Neutralize anxiety OCD Depression – Low self-esteem – Rigid thinking – Unable to Relax Increase anxiety when they resist the compulsion Need to control – Themselves – Others – environment Interferes with normal routine – Time-consuming Interferes with relationships – Not enough time to relate to others – Magical thinking Believes thinking equals doing OCD Nurse-Patient Relationship Assist to meet Basic Needs Allow time to perform rituals – Work to limit Explain expectation routines and changes Identify feelings Connect feeling to behaviors Reinforce and recognize positive non-ritualistic behaviors OCD and Milieu Relaxation Exercises Stress management Recreational and Social Skills Cognitive Behavior Therapy – Outpatient – Contact feared stimuli – Limit the rituals – 7-week exposure and response prevention therapy OCD Medication Antidepressants – Tricyclic Antidepresants Clomipramine (Anafranil) – SSRIs Fluoxetine (Prozac) Paroxetine (Paxil) 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 avoided – Animal – Natural environment; heights – Blood/injection – Situational/elevators Phobias-Continued Agoraphobia without Panic disorder: a fear of being in public places Social phobia: fear of being humiliated in public, fear of stumbling while dancing, choking while eating Specific phobia: fear of a specific object or situation; animals, heigth, flying Treatment for Phobias Outpatient is most common Behavior therapy: systematic desensitization; like Fear of Flying groups Nurse patient relationship – Interventions are very similar to GAD Interventions Medications – No effect on avoidant behaviors – SSRIs Reduce anxiety and depression Block Panic Milieu – Cognitive Behavioral Therapy Somatoform Disorders Anxiety is relieved by developing physical symptoms for which no known organic cause or physiologic mechanism can be identified Somatization Disorder Conversion Disorder Pain Disorder Hypochondriasis Somatoform Disorders 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 Somatization Disorder Recurrent frequent somatic complaints for years Complaints change over time No physiological cause Onset prior to 30years old See many physicians May have unnecessary surgical procedures Impairment – Social functioning – Occupational functioning Etiology – Chronic emotional abuse – Unable to verbalize anger Helped by having them talk about experiences and feelings Pain Disorder Severe Pain in one or more areas – Significant distress and impairment – Location or complaint does not change Unlike somatization disorder – No organic basis – Doctor Shoppers – Pain may allows secondary gain Avoidance – Does not have to go to work Pain medication – Sometime there is a physiologic disorder The amount of pain is out of proportion Hypochondriasis Worry they have a serious illness despite no medical evidence Misinterpretation of bodily symptoms Check for reassurance from doctors and friends Conversion Disorder Suggests a Neurological Condition – Deficit or alteration in voluntary motor or sensory function Psychological factors that proceed symptoms – Conflicts – Stressors Symptoms – Paralysis – Blindness – seizures Conversion Disorder: Primary Gain – Alleviation of anxiety – Conflict kept out of consciousness Secondary Gain – Response of others to the illness – Can prolong symptoms Somatoform Disorders The Clients can develop a health problem just like anyone else Be careful Always rule out the physical READ: “Conversion Disorder and the Nursing Student” MEDICATIONS FOR ANXIETY BENZODIAZEPINES 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 benzodiazepines – PRN for episodes of anxiety or panic: clonazepam (Klonipin) alprazolam (Ativan) NON-BENZODIAZEPINES 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 NON-BENZODIAZEPINES: ANTIHISTAMINES Very sedating No addiction potential May be used long-term Examples: – diphenhydramine (Benadryl) – hydroxyzine (Vistaril) ANTIDEPRESSANTS Useful in treatment of panic (with or without agoraphobia), obsessional thinking Low abuse potential SSRI’s: first line drugs due to low sedation ANTIDEPRESSANTS, CONT’D Selective Serotonin Re-uptake Inhibitors fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) fluvoxamine (Luvox): best for OCD Tricyclics: clomipramine (Anafranil): for OCD MISCELLANEOUS Clonidine (Catapres) and Propranolol (Inderal) – Decreases autonomic symptoms in panic : tachycardia, muscle tremors Gabapentin (Neurontin) For OCD and social phobias GENERAL GUIDELINES FOR USE OF ANTIANXIETY AGENTS Sedation increases falls, accidents Cautious use in elderly, renal, liver problems Do not combine with other CNS depressants or alcohol Paradoxical effects common: esp. with benzodiazapines, buspirone, some antidepressants