Download Types of Anxiety Disorders

Types of Anxiety Disorders
 Situational anxiety: anxiety experienced by people faced with a stressful environment
o Beneficial because it motivates people to accomplish tasks in a prompt
manner; May be intense
o Patients often learn coping mechanisms
o Generalized anxiety disorder (GAD) difficult to control, excessive anxiety
that lasts 6 months or more
 Focuses on a variety of life events or activities, and interferes with
normal day-to-day functions
 Most common; most frequently encountered by the nurse
 Symptoms = restlessness, fatigues, muscle tension, nervousness,
inability to focus or concentrate, overwhelming sense of dread,
sleep disturbances, elevated BP, heart palpitations, respiratory
change, dry mouth, abdominal cramping, diarrhea, urinary urgency
 Women are slightly more likely to experience GAD
o Panic disorder: characterized by an intense feeling of immediate
apprehension, fearfulness, terror, or impending doom, accompanied by
increase autonomic nervous system activity
o Phobias: fearful feelings attached to situations or objects
 Common phobias include fear of snakes, spiders, crowds, and
heights
 Social anxiety = fear of crowds
 Performance anxiety: performers may experience feelings of dread,
nervousness, or apprehension before a performance
 Phobias compel a patient to avoid the fearful stimulus entirely to
the point that his or her behavior is unnatural
o Obsessive-compulsive disorder (OCD): an unnatural behavior, that
involves recurrent, intrusive thoughts or repetitive behaviors that interfere
with normal activities or relationships
 Fear of germs or repetitive hand washing
o Post-traumatic stress disorder (PTSD): a type of situational anxiety that
develops in response to re-experiencing a previous life event
 Traumatic life events such as war, physical or sexual abuse, natural
disasters, or murder may lead to a sense of helplessness and reexperiencing of the event
Specific Regions of the Brain Responsible for Anxiety and Wakefulness
 Limbic system: an area in the middle of the brain responsible for emotional
expression, learning and memory
o Signals routed through the limbic system ultimately connect with the
hypothalamus
o Anxiety, fear, anger, aggression, remorse, depression, sexual drive, and
euphoria
 Hypothalamus – an important center responsible for unconscious response to extreme
stress such as high BP, elevated respiratory rate, and dilated pupils
 Responses associated with fight-or-flight response
o Connects with the reticular formation
o reticular formation: a network of neurons found along the entire length of
the brainstem
 stimulation causes heightened alertness and arousal
 inhibition causes general drowsiness and the induction of sleep
Area responsible for Sleep and Wakefulness
 reticular activating system (RAS) – larger area in which the reticular formation is
found; connects the brainstem to the thalamus
o responsible for sleeping and wakefulness
o performs an alerting function for the entire cerebral cortex
o helps a person focus attention on individual tasks by transmitting
information to higher brain centers
 if signals are prevented from passing through the RAS, no emotion-related signals are
sent to the brain, resulting in a reduction in general brain activity
Anxiety Management through Pharmacologic
 most productive way to manage stress = anxiolytics
 stress is often a symptom of an underlying disorder
 more productive to treat the cause of anxiety rather than just the symptoms with
medication
 Anxiolytics: drugs having the ability to relieve anxiety; provide treatment for phobias,
PTSD, GAD, OCD, and panic attacks
o Antidepressants
o CNS depressants (drugs for seizures)
o Emotional & mood disorder drugs
o Antihypertensive drugs
o Antidysrhythmic drugs
Indication for the need of pharmacotherapy in patient with anxiety
 Assess intensity and duration of symptoms
 Identify precipitating factors
 Identify coping mechanisms
 Assess for sleep disorders
 Obtain a drug history
o Hypersensitivity
o Use of alcohol & other CNS depressants
o Drug abuse & dependence
 Use caution for certain clients
o Those who are elderly
o Those with suicidal potential
o Those with impaired renal or liver function
Table 14.1 Stages of Sleep
Stage
Description
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NREM Stage 1
NREM Stage 2
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NREM Stage 3
NREM Stage 4
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REM Sleep
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At the onset of sleep, the patient is in a stage of
drowsiness for about 1 to 7 minutes
patient can be easily awakened
lasts for about 4% to 5% of total sleep time.
The patient can still be easily awakened
This stage constitutes the greatest amount of
total sleep time, 45% to 55%.
The patient may move into or out of a deeper
sleep
HR & BP fall
GI activity rises
lasts for about 4% to 6% of total sleep time.
The deepest stage of sleep, 12% to 15% of total
sleep time
nightmares occur in children
Sleepwalking is also a common behavior for
this stage
HR & BP remain low
GI activity remains high.
This stage is characterized by eye movement
and a loss of muscle tone
Eye movement occurs in burst of activity.
Dreaming takes place in this stage
The mind is very active and resembles a normal
waking state.
Treating Anxiety & Insomnia with CNS Agents
 Have an ability to reduce anxiety symptoms by altering levels of norepinephrine and
serotonin
 Restoration of neurotransmitter imbalances may reduce symptoms associated with
depression, panic, OCD, and phobia
 Typical antidepressants
o Tricyclic antidepressants (TCAs)
o Selective serotonin reuptake inhibitors (SSRIs)
o Monoamine oxidase inhibitors (MAOIs)
 Categorized into 2 classes = Benzodiazepines & Barbiturates
 Other CNS depressants that have a calming effect in the body include the opioids and
ethyl alcohol
 Should be viewed as a continuum ranging from relaxation to sedation, to the
induction of sleep and anesthesia
 Coma and death are the end stages of CNS depression
 Can cause physical or psychological dependence
 Sedatives: medications that depress the CNS because of their ability to sedate or
relax a patient
 Hypnotics: at higher does, sedatives are called hypnotics because of their high ability
to induce sleep
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Sedative-Hypnotic: term used to describe a drug with the ability to produce a calming
effect at lower doses and the ability to induce sleep at high doses
Tranquilizer: an older term, sometimes used to describe a drug that produces a calm
or tranquil effect
Withdrawal Syndrome
o for some CNS depressants can cause life threatening neurologic reactions
o fever, psychosis, seizures
o increased heart rate
o lowered blood pressure
o loss of appetite
o muscle cramps
o impairment of memory, concentration, and orientation
o abnormal sounds in the ears and blurred vision
o insomnia, agitation, anxiety, and panic
Table 14.3 SSRIs – Fluoxetine (Prozac) Adverse Effects
 Stevens-Johnson Syndrome
 Abnormal bleeding
 Extreme mania/hypomania
 Extreme psychomotor disturbances
 Suicidality (especially in children)
 Seizures
 Autonomic instability with possible rapid fluctuations of vital signs
 Severe hyperthermia
 Serotonin syndrome
Antidepressants → treat major depression and anxiety conditions including GAD, OCD,
panic, phobia, and PTSD
 Mechanism of action – increase availability of serotonin at specific postsynaptic
receptor sites located within the CNS
o Adverse Effects – dizziness, nausea, insomnia, somnolence, confusion,
seizures
 MAOIs (monoamine oxidase inhibitors)
o Avoid foods containing tyramine, a form of the amino acid tyrosine, to
avoid a hypertensive crisis
o Refrain from caffeine intake
o MAOIs potentiate the effects of insulin and other diabetic drugs
o Adverse Effects – orthostatic hypotension, headache, diarrhea
o Rarely used because of the potential for serious adverse effects
Prototype Drug Escitalopram
 Action and Uses – selective serotonin reuptake inhibitor (SSRI)
o Increases the availability of serotonin at specific postsynaptic receptor
sites located within the CNS
o Selective inhibition of serotonin reuptake results in antidepressant activity
without production of symptoms of sympathomimetics or anticholinergic
activity
o This medication is indicated for conditions of generalized anxiety and
depression
o Unlabeled uses include the treatment of panic disorder
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Drug-Drug Interactions
o Should be avoided dur to serotonin syndrome, marked by autonomic
hyperactivity, hyperthermia, rigidity, diaphoresis, and neuroleptic
malignant syndrome
o Combination with MAOIs can result in hypertensive crisis, hyperthermia,
and autonomic instability
o Will increase plasma levels of metoprolol and cometidine
o Concurrent use of alcohol and other CNS depressants may enhance CNS
depressant effects
Treating Anxiety and insomnia with benzodiazepines
 Withdrawal Effect?
 Why are they the drug of choice?
o Drug of choice for short-term treatment of insomnia caused by anxiety
o They have replaced barbiturates because of their greater safety margin
o Shorten the length of time it takes to fall asleep
o Reduce the frequency of interrupted sleep
Table 14.4 Clonazepam (Klonopin) Adverse Effects
 Acute hyperexcited states
 increased Muscle spasticity
 Hallucinations
 Renal impairment
 Congenital defects among women who are pregnant
 Respiratory impairment due to hypersalivation
 Respiratory depression
 Laryngospasm
 Cardiovascular collapse
Table 14.4 Lorazepam (Ativan) Adverse effect
 Drowsiness and sedation
 When given in higher doses or by the IV route, more severe effects may be observed
o Amnesia
o Blood pressure changes
o Weakness
o Blurred vision
o Disorientation
o Double vision
o Ataxia
o Nausea
o Sleep disturbance
o Vomiting
 Should be monitored carefully due to rapid onset of CNS effects and potential
respiratory depression with adjunctive therapies
 Drug of choice for short-term treatment of insomnia cause by anxiety
Barbiturates (Why are they not the drug of choice?)
 Drugs derived from barbituric acid
 Powerful CNS depressants prescribed for their sedative, hypnotic, and antiseizure
effects
 Rarely used because of significant adverse effects
 High Risk of psychologic and physical dependence – Schedule II drugs
 Withdrawal syndrome is extremely severe and can be fatal
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Overdose results in profound respiratory depression, hypotension, and shock
Capable of depression CNS function at all levels
Intensify the effects of GABA throughout the brain by binding to GABA receptorchloride channel molecules
o low doses = reduce anxiety and cause drowsiness
o moderate doses = inhibit seizure activity and promote sleep by inhibiting
brain impulses traveling through the limbic system & the RAS
o high doses = can induce anesthesia
tolerance can develop with repeated use
Table 14.5 Barbiturates for Sedation & Insomnia
 Adverse Effects of Antiseizure Medication
o Short acting = Respiratory depression, laryngospasm, & apnea
o Intermediate acting = agranulocytosis, angioedema, Stevens-Johnson
syndrome, respiratory depression, circulatory collapse, apnea,
laryngospasm
o Long Acting = agranulocytosis, respiratory depression, Stevens-Johnson
syndrome, exfoliative dermatitis (rare), CNS depression, coma & death
Other CNS depressants for anxiety and sleep disorders
 Chemically unrelated to either benzodiazepines or barbiturates
 Antiseizure medication valporate
 Beta blocker propanolol and Atenolol
 Drugs used mainly for insomnia therapy include the newest of all
nonbenzodiazepines CNS depressants
o Zaleplon
o Eszopiclone – used for hypnotic effects
o Zolpidem – used for hypnotic effects
 Older CNS depressants include
o Paraldehyde
o Chloral hydrate
 Buspirone and zolpidem are commonly prescribed for anxiolytic effects
 Buspirone mechanism of action is unclear
o Appears to be related to D2 dopamine receptors in the brain
o Has agonist effects on presynaptic dopamine receptors and a high affinity
for serotonin receptors
o Less likely to affects cognitive and motor performance
o Rarely interacts with other CNS depressants
o Adverse effects = dizziness, headache, drowsiness
o Dependence and withdrawal problems are less of a concern
 Zolpidem – Schedule IV controlled substance
o Limited to short-term treatment of insomnia
o Highly specific to GABA receptors
o Produces muscle relaxation and anticonvulsant effects only at doses much
higher than the hypnotic dose
o Used cautiously in patients with respiratory impairment, older adults, and
when used concurrently with other CNS depressants
o Because it is metabolized in the liver and excreted by the kidneys,
impaired liver or kidney function can increase serum drug levels
o Adverse Effects = mild nausea, dizziness, diarrhea, daytime drowsiness,
rebound insomnia may occur with discontinued use, amnesia,
sleepwalking
Prototype drug Zolpidem (Ambien)
 Adverse effects
o Daytime sedation
o Dizziness
o Confusion
o Depression
o Amnesia
o Nausea vomiting
 Drug-Drug Interaction – drug interactions include an increase in sedation when used
concurrently with other CNS depressants, including alcohol
o Phenothiazines augment CNS depression
 Herbal & Food Interaction – when taken with food, absorption is slowed
significantly, and the onset of action may be delayed
Nursing implications
 Assessment
 Potential nursing diagnoses
o Risk for injury
o Knowledge deficit related to drug therapy
o Ineffective individual coping
 Reason for the drug, Monitoring vital signs, Cautions and contraindications
 Possible drug interactions
o Completing health history
o Drug history
o Evaluation of lab reports
 Planning → client will
o Experience therapeutic effects depending on drug
o Be free of adverse effects
o Demonstrate an understanding of the drugs activity
o Accurately describe drug side effects and precautions
o Demonstrate proper self-administration technique
 Implementation
o Interventions & rationales
o Administration of drugs
o Observe for adverse effects
o Client education and discharge planning
 Evaluation
o Effectiveness of Drug therapy
o Evaluate the achievement of the goals & expected outcomes