PrevalencePrevalence
Anxiety Disorders more prevalent Anxiety Disorders more prevalent than mood disorders- 18 %than mood disorders- 18 %
Primary gainPrimary gain: the individuals desire : the individuals desire to relieve the anxiety to feel betterto relieve the anxiety to feel better
Secondary gainSecondary gain: refers to attention : refers to attention and support the person gets from the and support the person gets from the illnessillness
Primary GainPrimary Gain The individual’s desire to relieve the The individual’s desire to relieve the
anxietyanxiety– Physical symptomsPhysical symptoms
Stomach Ache Stomach Ache Inability to walkInability to walk
– ObsessionsObsessions– CompulsionsCompulsions
CleansCleans ExerciseExercise
– FearsFears Cannot driveCannot drive
– WorryWorry– IsolationIsolation
Secondary GainSecondary Gain
Attention or benefit Attention or benefit – Health Care ProvidersHealth Care Providers– Spouse does moreSpouse does more– Children take care of younger siblingsChildren take care of younger siblings
Can become more important Can become more important than relieving the anxietythan relieving the anxiety
– Decreases motivation to get wellDecreases motivation to get well– Others take care of individualOthers take care of individual
Complicates treatmentComplicates treatment
Axis 1 Anxiety DisordersAxis 1 Anxiety Disorders
1.1. Generalized Anxiety Disorder (GAD)Generalized Anxiety Disorder (GAD)
2.2. Panic DisorderPanic Disorder with Agoraphobiawith Agoraphobia
without Agoraphobiawithout Agoraphobia
3.3. PhobiasPhobias
4.4. Somatoform DisordersSomatoform Disorders
Etiology of Anxiety DisordersEtiology of Anxiety Disorders
Biological and GeneticBiological and Genetic– Defects in Brain Chemistry; Person over Defects in Brain Chemistry; Person over
responds to Stimuli responds to Stimuli – Inherited trait for shyness has been Inherited trait for shyness has been
discovered discovered – Brazelton; believes in the biological Brazelton; believes in the biological
basis of temperamentbasis of temperament
PsychoanalyticPsychoanalytic
Result of conflict in valuesResult of conflict in values Client is often perfectionist and Client is often perfectionist and
drivendriven Defense mechanismsDefense mechanisms
– RepressionRepression– DisplacementDisplacement– Conversion Conversion
Generalized Anxiety DisorderGeneralized Anxiety Disorder(GAD)(GAD)
Cognitive and Physical SymptomsCognitive and Physical Symptoms– Worry; unable to focusWorry; unable to focus– Dry mouth, stomach acheDry mouth, stomach ache
Anxiety or worry is chronic and excessiveAnxiety or worry is chronic and excessive Significant DistressSignificant Distress Worry is debilitating and habitualWorry is debilitating and habitual
– Focus changesFocus changes Causes impairmentCauses impairment
– Interpersonal or socialInterpersonal or social– OccupationalOccupational– Sense of helplessnessSense of helplessness– DepressionDepression– Chemical dependencyChemical dependency
Generalized Anxiety DisorderGeneralized Anxiety Disorder Excessive worry occurring more often than Excessive worry occurring more often than
not for 6 monthsnot for 6 months Person cannot control the worryPerson cannot control the worry Anxiety and worry are evident and three Anxiety and worry are evident and three
or more of the following:or more of the following:– RestlessnessRestlessness– FatigueFatigue– IrritabilityIrritability– Decreased ability to concentrateDecreased ability to concentrate– Muscle tensionMuscle tension– Disturbed sleepDisturbed sleep
Interventions for GADInterventions for GAD Goal is to assist the client to develop adaptive Goal is to assist the client to develop adaptive
coping responsescoping responses Assess for level of anxiety: moderate to severeAssess for level of anxiety: moderate to severe Reduce level of AnxietyReduce level of Anxiety
– Must occur prior to problem solvingMust occur prior to problem solving– Promotes trustPromotes trust
Acceptance of feelingsAcceptance of feelings Acknowledgment of discomfortAcknowledgment of discomfort
Identify and describe feelings Identify and describe feelings (repression; displacement)(repression; displacement) Assist to identify causes of feelingsAssist to identify causes of feelings
Milieu Management for GADMilieu Management for GAD Calm environmentCalm environment Cognitive Behavioral TherapyCognitive Behavioral Therapy
– Corrects faulty assumptionsCorrects faulty assumptions– If you change others will changeIf you change others will change
Recreational activities Recreational activities – Relaxation exercises or tapesRelaxation exercises or tapes
GroupsGroups– Stress ManagementStress Management– Problem solvingProblem solving– Self esteemSelf esteem– AssertivenessAssertiveness– Goal settingGoal setting
MedicationMedication
Serotonin Reuptake InhibitorsSerotonin Reuptake Inhibitors– Long-Term treatmentLong-Term treatment
Serotonin and Norepinephrine Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)Reuptake Inhibitors (SNRI)– Long-Term treatmentLong-Term treatment
Buspirone (Buspar)Buspirone (Buspar)– Nonaddicting non-benzodiazepineNonaddicting non-benzodiazepine
BenzodiazepineBenzodiazepine– Immediate effectImmediate effect
Four Symptoms for Diagnosis of Four Symptoms for Diagnosis of Panic DisorderPanic Disorder
Chest painChest pain ChokingChoking DizzinessDizziness DyspneaDyspnea Fear of going crazyFear of going crazy Fear of dyingFear of dying SweatingSweating PalpitationsPalpitations Trembling and shakingTrembling and shaking NauseaNausea Hot flashes and chillsHot flashes and chills
EtiologyEtiology PsychologicalPsychological
– Life stressesLife stresses Separation and disruption Separation and disruption of attachment in childhoodof attachment in childhood
BiologicalBiological– Heredity Heredity – 3 systems3 systems
Cognitive (catastrophic thinking “what if”)Cognitive (catastrophic thinking “what if”)– Triggers physiologyTriggers physiology
Nervous SystemNervous System– Sympathetic (flight fight response)Sympathetic (flight fight response)– Respiratory, cardiovascular, gastrointestinal, neuromuscularRespiratory, cardiovascular, gastrointestinal, neuromuscular
Endocrine SystemEndocrine System– Andrenal cortex (cortisol)Andrenal cortex (cortisol)
Libido, insomnia, anxietyLibido, insomnia, anxiety– Adrenal Medulla (epinephrine)Adrenal Medulla (epinephrine)
AnxietyAnxiety
The Nurse Patient Relationship: The Nurse Patient Relationship: Acute PhaseAcute Phase
Communication: Similar to panic level Communication: Similar to panic level anxiety, reassure that they are safeanxiety, reassure that they are safe– Have client breath with you (set the pace)Have client breath with you (set the pace)
Keep stimulation downKeep stimulation down Assess for suicidal ideation: 1 in 5 are Assess for suicidal ideation: 1 in 5 are
suicidalsuicidal Use touch carefullyUse touch carefully PRN Medications: Xanax, AtivanPRN Medications: Xanax, Ativan
The Nurse Patient The Nurse Patient RelationshipRelationship
and Panic Disorderand Panic Disorder
Teaching: give client a handout on Panic Teaching: give client a handout on Panic DisorderDisorder – Client need to know there is a diagnosisClient need to know there is a diagnosis– They are not “crazy”They are not “crazy”– SymptomsSymptoms– Medications that can helpMedications that can help
When clients learn about the diagnosis they When clients learn about the diagnosis they usually improveusually improve
Interventions and MilieuInterventions and Milieu
Cognitive restructuringCognitive restructuring Reinterpret their Reinterpret their
beliefs regarding the beliefs regarding the danger of the eventdanger of the event
Identify feelingsIdentify feelings Identify triggersIdentify triggers Avoidance makes it Avoidance makes it
worseworse Meeting FearsMeeting Fears
– What is the worst that What is the worst that can happen?can happen?
– What will I doWhat will I do– OptionsOptions
Recognize bodily Recognize bodily sensations and sensations and symptoms of anxietysymptoms of anxiety
Relaxation ExercisesRelaxation Exercises– StretchingStretching– YogaYoga– Soft musicSoft music
Gross motor activitiesGross motor activities– Walking Walking – JoggingJogging– BasketballBasketball
Panic DisorderPanic Disorder
Recurring, Recurring, sudden sudden intense intense feelings offeelings ofApprehensionApprehensionTerrorTerror Impending doom Impending doom Loosing controlLoosing controlGoing crazyGoing crazy
Somatic SymptomsSomatic Symptoms– Heart AttackHeart Attack– DyingDying
Can happen in the middle Can happen in the middle of the nightof the night– fearful and exhausted.fearful and exhausted.
SituationalSituational– Often recur in the same Often recur in the same
placeplace– Can occur with Can occur with
anticipationanticipation– Avoid places or situationsAvoid places or situations
Peaks within 10 minutesPeaks within 10 minutes
MedicationMedication
Serotonin Reuptake InhibitorsSerotonin Reuptake Inhibitors– Long-Term treatmentLong-Term treatment
BenzodiazepineBenzodiazepine– Immediate effectImmediate effect
Obsessive Compulsive DisorderObsessive Compulsive Disorder ObsessionsObsessions
– Recurrent and PersistentRecurrent and Persistent ThoughtsThoughts IdeasIdeas ImpulsesImpulses ImagesImages Experienced as intrusive and senselessExperienced as intrusive and senseless
CompulsionsCompulsions– Repetitive behaviorsRepetitive behaviors
Performed in a particular mannerPerformed in a particular manner Response to obsessionResponse to obsession Prevent discomfortPrevent discomfort Neutralize anxietyNeutralize anxiety
OCDOCD DepressionDepression
– Low self-esteemLow self-esteem– Rigid thinkingRigid thinking– Unable to RelaxUnable to Relax
Increase anxiety when they resist the compulsionIncrease anxiety when they resist the compulsion Need to controlNeed to control
– ThemselvesThemselves– OthersOthers– environmentenvironment
Interferes with normal routineInterferes with normal routine– Time-consumingTime-consuming
Interferes with relationshipsInterferes with relationships– Not enough time to relate to othersNot enough time to relate to others– Magical thinkingMagical thinking
Believes thinking equals doingBelieves thinking equals doing
OCDOCDNurse-Patient RelationshipNurse-Patient Relationship
Assist to meet Basic NeedsAssist to meet Basic Needs Allow time to perform ritualsAllow time to perform rituals
– Work to limitWork to limit Explain expectation routines and changes Explain expectation routines and changes Identify feelingsIdentify feelings Connect feeling to behaviorsConnect feeling to behaviors Reinforce and recognize positive Reinforce and recognize positive
non-ritualistic behaviorsnon-ritualistic behaviors
OCD and MilieuOCD and Milieu
Relaxation ExercisesRelaxation Exercises Stress managementStress management Recreational and Social SkillsRecreational and Social Skills Cognitive Behavior TherapyCognitive Behavior Therapy
– OutpatientOutpatient– Contact feared stimuliContact feared stimuli– Limit the ritualsLimit the rituals– 7-week exposure and response 7-week exposure and response
prevention therapyprevention therapy
OCDOCDMedicationMedication
AntidepressantsAntidepressants– Tricyclic AntidepresantsTricyclic Antidepresants
Clomipramine (Anafranil)Clomipramine (Anafranil)
– SSRIsSSRIsFluoxetine (Prozac)Fluoxetine (Prozac)Paroxetine (Paxil)Paroxetine (Paxil)
Phobias/DSM IVPhobias/DSM IV
Marked and Marked and specificspecific fear that is excessive and fear that is excessive and unreasonable cued by the presence or unreasonable cued by the presence or anticipation of object.anticipation of object.
Person recognizes fear as unreasonablePerson recognizes fear as unreasonable Situation or object avoidedSituation or object avoided
– AnimalAnimal– Natural environment; heightsNatural environment; heights– Blood/injectionBlood/injection– Situational/elevators Situational/elevators
Phobias-ContinuedPhobias-Continued
Agoraphobia without Panic disorder: Agoraphobia without Panic disorder: a fear of being in public placesa fear of being in public places
Social phobia: fear of being Social phobia: fear of being humiliated in public, fear of humiliated in public, fear of stumbling while dancing, choking stumbling while dancing, choking while eatingwhile eating
Specific phobia: fear of a specific Specific phobia: fear of a specific object or situation; animals, heigth, object or situation; animals, heigth, flyingflying
Treatment for PhobiasTreatment for Phobias
Outpatient is most commonOutpatient is most common Behavior therapy: systematic Behavior therapy: systematic
desensitization; like Fear of Flying desensitization; like Fear of Flying groupsgroups
Nurse patient relationship Nurse patient relationship – Interventions are very similar to GADInterventions are very similar to GAD
InterventionsInterventions
MedicationsMedications– No effect on avoidant behaviorsNo effect on avoidant behaviors– SSRIsSSRIs
Reduce anxiety and depressionReduce anxiety and depressionBlock PanicBlock Panic
MilieuMilieu– Cognitive Behavioral TherapyCognitive Behavioral Therapy
Somatoform DisordersSomatoform Disorders
Anxiety is relieved by developing Anxiety is relieved by developing physical physical symptomssymptoms for which for which no knownno known organic organic causcause or physiologic mechanism can be e or physiologic mechanism can be identifiedidentified
Somatization DisorderSomatization Disorder Conversion DisorderConversion Disorder Pain DisorderPain Disorder HypochondriasisHypochondriasis
Somatoform DisordersSomatoform Disorders
Client expresses psychological conflict Client expresses psychological conflict through symptomsthrough symptoms
Client is not in control of symptoms and Client is not in control of symptoms and complaintscomplaints
See general practitioners not mental See general practitioners not mental health professionalshealth professionals
Repression of feelings, conflicts, and Repression of feelings, conflicts, and unacceptable impulsesunacceptable impulses
Denial of psychological problemsDenial of psychological problems Individuals are dependent and needyIndividuals are dependent and needy
Somatization DisorderSomatization Disorder Recurrent frequent somatic complaints for yearsRecurrent frequent somatic complaints for years Complaints change over timeComplaints change over time No physiological causeNo physiological cause Onset prior to 30years oldOnset prior to 30years old See many physiciansSee many physicians May have unnecessary May have unnecessary
surgical proceduressurgical procedures ImpairmentImpairment
– Social functioningSocial functioning– Occupational functioningOccupational functioning
EtiologyEtiology– Chronic emotional abuseChronic emotional abuse– Unable to verbalize angerUnable to verbalize anger
Helped by having them talk about experiences and feelingsHelped by having them talk about experiences and feelings
Pain DisorderPain Disorder
Severe Pain in one or more areasSevere Pain in one or more areas– Significant distress and impairmentSignificant distress and impairment– Location or complaint does not changeLocation or complaint does not change
Unlike somatization disorderUnlike somatization disorder
– No organic basisNo organic basis– Doctor ShoppersDoctor Shoppers– Pain may allows secondary gainPain may allows secondary gain
AvoidanceAvoidance– Does not have to go to workDoes not have to go to work
Pain medicationPain medication
– Sometime there is a physiologic disorderSometime there is a physiologic disorder The amount of pain is out of proportionThe amount of pain is out of proportion
HypochondriasisHypochondriasis
Worry they have a serious illness Worry they have a serious illness despite no medical evidencedespite no medical evidence
Misinterpretation of bodily Misinterpretation of bodily symptomssymptoms
Check for reassurance from doctors Check for reassurance from doctors and friendsand friends
Conversion DisorderConversion Disorder Suggests a Neurological ConditionSuggests a Neurological Condition
– Deficit or alteration in voluntary motor or Deficit or alteration in voluntary motor or sensory functionsensory function
Psychological factors that proceed Psychological factors that proceed symptomssymptoms– ConflictsConflicts– StressorsStressors
SymptomsSymptoms– ParalysisParalysis– BlindnessBlindness– seizuresseizures
Conversion Disorder:Conversion Disorder:
Primary GainPrimary Gain– Alleviation of anxietyAlleviation of anxiety– Conflict kept out of consciousnessConflict kept out of consciousness
Secondary GainSecondary Gain– Response of others to the illnessResponse of others to the illness– Can prolong symptomsCan prolong symptoms
Somatoform DisordersSomatoform Disorders
The Clients can develop a health problem The Clients can develop a health problem just like anyone elsejust like anyone else
Be carefulBe careful Always rule out the physicalAlways rule out the physical
READ:READ:
““Conversion Disorder and the Nursing Conversion Disorder and the Nursing Student”Student”
BENZODIAZEPINESBENZODIAZEPINES
CNS DepressantsCNS Depressants Compete for GABA receptors; decrease Compete for GABA receptors; decrease
response of excitatory neuronsresponse of excitatory neurons Tolerance, dependence are problemsTolerance, dependence are problems Cause dizziness, somnolence, confusionCause dizziness, somnolence, confusion Best for short-term useBest for short-term use Shorter acting benzodiazepines Shorter acting benzodiazepines
– PRN for episodes of anxiety or panic: PRN for episodes of anxiety or panic: clonazepam (Klonipin)clonazepam (Klonipin)
alprazolam (Ativan)alprazolam (Ativan)
NON-BENZODIAZEPINESNON-BENZODIAZEPINES
First line agent: buspirone (BuSpar)First line agent: buspirone (BuSpar) Binds to serotonin and dopamine Binds to serotonin and dopamine
receptorsreceptors No CNS depressionNo CNS depression No abuse potential documentedNo abuse potential documented May have paradoxical effects (increased May have paradoxical effects (increased
anxiety, depression, insomnia, etc.)anxiety, depression, insomnia, etc.) May not be fully effective for 3-6 weeksMay not be fully effective for 3-6 weeks May cause EPSMay cause EPS
NON-BENZODIAZEPINES: NON-BENZODIAZEPINES: ANTIHISTAMINESANTIHISTAMINES
Very sedatingVery sedating No addiction potentialNo addiction potential May be used long-termMay be used long-term Examples: Examples:
– diphenhydramine (Benadryl)diphenhydramine (Benadryl)– hydroxyzine (Vistaril)hydroxyzine (Vistaril)
ANTIDEPRESSANTSANTIDEPRESSANTS
Useful in treatment of panic (with or Useful in treatment of panic (with or without agoraphobia), obsessional without agoraphobia), obsessional thinkingthinking
Low abuse potentialLow abuse potential SSRI’s: first line drugs due to low SSRI’s: first line drugs due to low
sedationsedation
ANTIDEPRESSANTS, CONT’DANTIDEPRESSANTS, CONT’D Selective Serotonin Re-uptake Inhibitors Selective Serotonin Re-uptake Inhibitors
fluoxetine (Prozac)fluoxetine (Prozac)sertraline (Zoloft)sertraline (Zoloft)paroxetine (Paxil)paroxetine (Paxil)citalopram (Celexa)citalopram (Celexa)escitalopram (Lexapro) escitalopram (Lexapro) fluvoxamine (Luvox): best for OCDfluvoxamine (Luvox): best for OCD
Tricyclics: Tricyclics: clomipramine (Anafranil): for OCDclomipramine (Anafranil): for OCD
MISCELLANEOUSMISCELLANEOUS Clonidine (Catapres) and Propranolol Clonidine (Catapres) and Propranolol
(Inderal) (Inderal) – Decreases autonomic symptoms in Decreases autonomic symptoms in
panic : tachycardia, muscle tremorspanic : tachycardia, muscle tremors
Gabapentin (Neurontin)Gabapentin (Neurontin)For OCD and social phobiasFor OCD and social phobias
GENERAL GUIDELINES FOR GENERAL GUIDELINES FOR USE OF ANTIANXIETY AGENTSUSE OF ANTIANXIETY AGENTS
Sedation increases falls, accidentsSedation increases falls, accidents Cautious use in elderly, renal, liver Cautious use in elderly, renal, liver
problemsproblems Do not combine with other CNS Do not combine with other CNS
depressants or alcoholdepressants or alcohol Paradoxical effects common: esp. with Paradoxical effects common: esp. with
benzodiazapines, buspirone, some benzodiazapines, buspirone, some antidepressantsantidepressants
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