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Anxiety Disorders
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Prevalence
 Anxiety
Disorders more prevalent
than mood disorders- 18 %
 Primary gain: the individual’s actions
(symptoms) relieves the anxiety and
assists the individual 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 in 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
– Support and reassurance
– (do not dismiss level of distress)
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
– Humor
– Exercise and recreation
Groups
– Stress Management
– Problem solving
– Self esteem
– Assertiveness
– Goal setting
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
Panic Disorder with or without
Agoraphobia
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
– Clients 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
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
– Limit the rituals
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
 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 allow 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 on BB:
Transitional Phenomena: A Story of One
Nursing Student

MEDICATIONS FOR
ANXIETY
Medication

Short-term (Immediate effect)
– Benzodiazepine
 Potential
for chemical dependency
– Antihistamines

Long-term
– Buspirone (Buspar)
 Nonaddicting
non-benzodiazepine
– Serotonin Reuptake Inhibitors
– Serotonin and Norepinephrine Reuptake
Inhibitors (SNRI)
BENZODIAZEPINES

CNS Depressants
– Immediate effect




Compete for GABA
receptors; decrease
response of excitatory
neurons
Tolerance, dependence
are problems
Cause dizziness,
somnolence, confusion
Best for short-term use


Longer acting
Shorter acting
– PRN for episodes of
anxiety or panic:




clonazepam (Klonipin)
alprazolam (Xanax)
diazepam (Valium)
lorazepam (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
 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
Other Medications
 Clonidine (Catapres) and Propranolol
(Inderal)
 Decreases autonomic symptoms in
panic : tachycardia, muscle tremors
 Gabapentin (Neurontin)
 For OCD and social phobias
GENERAL GUIDELINES
•
•
•
•
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
benzodiazepines, buspirone, some
antidepressants