Anxiety

Most common mental health problem

25 % adults Women>men Age <45 Divorced/separated Lower socioeconomic status

helplessness

Vague apprehension and feelings of uncertainty &

Subjective emotional response to a stressor

State of tension, or impending doom

Necessary force for survival

Mild Moderate Severe Panic

Physiologic Responses Hormones & Neurotransmitters

Fight or Flight Response Depends on degree & duration of anxiety

Epinephrine (E) Norepinphrine (NE) Cortisone Serotonin (5-HT) GABA

HR & SV = CO BP RR & depth = SOB

 Generalized Responses

Restlessness Irritability Fainting Palpitations Diaphoresis Urination N&V Libido

Physiologic Responses
Hyperreflexia Impatience Chest Pressure Headache Muscle tension Gluconeogenesis Dry Mouth Sexual Dysfunction

 Mild (+)

Cognitive Responses

Sensory awareness Learning Concentration = Optimal Functioning

Moderate (++)

Perceptual field Impaired attention Concentration & Problem Solving

Severe (+++)

Limited Perceptual field Disorganized processing

Selective inattention Time distorted

Panic (++++)

Closed perceptual field Contact with reality Impaired thinking/function Unable to process stimuli

 Mild (+)

Behavioral Responses
Alert & Confident Speech & Coping Skills

Learn new skills Startle reaction

Moderate (++)

Competitive activity Body position frequently Frequent topic s Defense mechanisms Focus on immediate events

Severe (+++)

Feeling of threat & tremors Coordination

Overload Neurosis

Panic (++++)

Total loss of control Cling to source of safety Helplessness Psychosis May strike physically or withdraw Completely disorganized

Anxiety Disorders
A group of symptoms & impaired reality testing.
Panic Disorder

Sudden onset Multiple attacks Intense & escalating apprehension Poor judgment, confused & disoriented Feelings of impending doom Fears losing control or going insane Lasts 15-30 minutes or (rarely) hours

Panic Disorder
Intense Physical discomfort
Palpitations Dyspnea
Chest pain HR Choking/Smothering SOB Hyperventilation RR Dizziness Diaphoresis Chills/Hot flashes Tremors & Shaking GI distress Nausea Diarrhea Fear of dying and/or going crazy Depersonalization

Nursing Interventions
Stay with Pt and remain calm
Assess own level of anxiety

Ensure safety and reassure Pt Pt take slow, deep breaths Quiet environment
Focus on a single object in the room

Speak in short, simple sentences

Low, calm and soothing voice

Encourage verbalization of concerns, feelings and

symptoms
Identify precipitating event

Short term use of anxiolytics

Generalized Anxiety Disorder

Chronic unrealistic and excessive worry
Regarding several events the Pt cant control

Symptoms last > 6 months Impaired social & occupational functioning

Interferes with daily life

Symptoms
Autonomic Hyperactivity
Jumpiness, tremors, muscle tension HR RR

Feeling on edge Restlessness Concentration Easily fatigued

Hypervigilence Irritability Mind going blank

Obsessive-Compulsive Disorder
Recurrent obsessions & compulsions Time consuming Gradual conditioned response RT traumatic event Obsessions Unwanted intrusive, persistent images or impulses Recurrent thoughts of violence, contamination, doubt or
need for specific order.

Compulsions

Ritualized acts of behavior to neutralize/control obsessions

Touching Rearranging Opening & Closing Washing hands Counting Checking Pt aware behavior is excessive, yet continues to engage to seek relief and anxiety/tension Interferes with usual routine

Defense Mechanism
Undoing Displacement

OCD Nursing Interventions

Initiate conversation as ritual is performed

Allow behavior but set limits

Identify behavioral cues of anxiety

Present distracting stimulus

@ frequency

Substitute socially acceptable behavior

Phobias
Persistent or irrational fear of specific object, activity or situation that causes avoidance.

Exposure to stimulus = immediate anxiety response. Blushing, Vomiting, Humiliation, Tremors, HR BP RR Agoraphobia Fear of being alone in public place. No escape Social Phobia Fear of appearing embarrassed or evaluated negatively by others. Simple Phobia (Specific object or situation) Acrophobia = Fear of heights Claustrophobia = Fear of closed in places Mysophobia = Fear of dirt, germs

Nursing Interventions 1st accept Pts fear as real Relaxation techniques Behavior Modification Desensitization

 Extreme stressor and threat to physical integrity.

Post Traumatic Stress Disorder

experience 9-11, war, earthquakes, hurricanes, airplane crash

Characteristic symptoms after exposure to traumatic life

Symptoms Re-experiencing event (Flashback) Avoidance of thoughts, emotions or conversations Sustained Anxiety Angry Outbursts Hypervigilence Nightmares Sleep Disturbances Survivor Guilt Depression Substance Abuse Psychic Numbing Feel detached from others

PTSD
Nursing Interventions

Environmental Stimuli Reorient to reality Reassure Pt is safe Encourage verbalization of event and feelings Facilitate grief process Adaptive coping techniques Anxiolytic meds during flashback

Physical symptoms without any organic pathology

Somatoform Disorders

Women> men

Onset before age 30

Somatization
Anxiety transformed into physical illness No labs, diagnostic tests support DX Chronic course without structural s

Conversion DisorderHysteria
Loss or alteration in physical functioning
Voluntary motor/sensory

Abrupt onset after a psychological conflict

Symptom

Impaired sense (blind/deaf) or paralysis La belle indifference

Pt demonstrates no concern for symptoms

Defense Mechanism
Repression Conversion

Conversion DisorderHysteria Primary Gain

Relief via repressing conflict Anxiety converted to symptoms

Secondary Gain
Sympathy, support, attention avoid activities & responsibilities

Nursing Interventions
Focus on anxiety, NOT symptoms Encourage verbalization
Identify conflicts stress & relaxation

Alternative coping skills

Hypochondriasis Unrealistic preoccupation/fear of having or

getting a serious illness
Cough = Lung CA HA = Brain tumor

Specific organ, bodily function or minor alteration

Misinterpretation of symptoms

Symptoms

C/O Multiple symptoms & Persist > 6 months Dr. Shopping Demand diagnostic testing & invasive procedures Review objective data, symptoms & interpretation Set limits on whining Self-worth and resolve internal anger

Nursing Interventions

 Severe precipitating stressor. Splitting off an idea or emotion from ones

consciousness.

Dissociative Disorders

Psychological flight from anxiety

Psychogenic Amnesia
information.

Sudden inability to recall important extensive personal Sudden unexpected travel away from home or usual
workplace Begin new job, relationships (Unaware of true life) Assumes new identity Escapes from overwhelming stress or rejection

Psychogenic Fugue

Dissociative Disorders Multiple Personality Disorder

Dissociative Identity Disorder (DID) Existence of 2 or more distinct personalities within an
individual. Transition from 1 to another personality Sudden & dramatic Precipitated by stress One personality is dominant Usually RT sexual child abuse.

Dissociative Disorders
Depersonalization Disorder
Change in quality of self-awareness Feelings of unreality, s in body image. Detachment

Sense of observing oneself (from outside of body) Not in touch with body No somatic sensations

Anxiety Nursing Interventions # 1 is Patient safety!

Remain with Pt & provide support Deep Breathing

Controlled slow Deep & regular abdominal breathing.

Progressive muscle relaxation Guided imagery Distraction

Visualize favorite place Embrace scenes, sounds, aromas, textures.

Music, card games, reading

 Journals

Anxiety Nursing Interventions

Self awareness Make entries when calm & anxious every day Identify anxiety cues & behavior responses + Coping techniques Assertiveness
Role playing Problem solving Set limits on inappropriate behavior

Self-Help Skills

Social Skills Group

Autonomy

Socialization = Self absorption

Daily Schedule Planning Support System Nutrition

Family, friends, neighbors, pets

Balanced diets : NO CAFFEINE, CHOCOLATE, ETOH

 CognitiveBehavioral Therapy
Positive Reframing

Anxiety Nursing Interventions

Turn negative messages into positive

ones.
Decatastrophizing

A more realistic appraisal of situation

Assertiveness Training

Learn to negotiate interpersonal

situations

Anxiolytics (Anti-Anxiety) Meds

Used short term basis < 1 month Symptomatic relief only

Potentiates GABA = CNS

Caution Do not use ETOH or meds that CNS Do not stop med abruptly = Severe Withdrawal
CNS agitation BP Temp & Fatal Gran Mal seizures!

Takes 7-10 days for steady effect Elderly have hepatic & renal function
risk for toxic effect

Anxiolytics Meds
Benzodiazepines
Alprazolam (Xanax) Lorazepam (Ativan) Chlordiazepoxide (Librium) * Diazepam (Valium) Clonazepam (Klonopin) * Clorazepate (Tranxene)

Risk for physical dependence & tolerance Lipophilic & cross blood-brain barrier

Side effects

Drowsiness Concentration Clouded Sensorium

Sedation Impaired memory Coordination

Anxiolytics Meds
Azaspirodecanediones
Buspirone (Buspar) 5-HT receptor antagonist Takes 2-4 weeks to be effective potential for abuse SE: Dizziness Sedation

N & HA

Propanediols
Meprobamate (Equanil/Miltown) Thalamus & Limbic system response

Sedating Antihistamines
Hydroxyzine (Vistaril/Atarax) CNS depressant effect

Anxiolytics Meds
Selective Serotonin Reuptake Inhibitors (SSRIs)
Citalopram (Celexa) Escitalopram (Lexapro)

Fluoxetine (Prozac/ Serafem Puvules-weekly) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft)

Only prevents 5-HT reuptake = 5-HT available regulation of emotions, wakefulness Use for OCD, GAD, Phobias No other neurotransmitters affected E & NE
Side effects: Anxiety Agitation Nausea Sexual Dysfunction Akathisia (Use Propanolol) Insomnia

Anxiolytic Side Effects

Anticholinergic: Daytime sedation, Drowsiness, Dry mouth, HA, Lethargy, Ataxia, Blurred vision, N & V Tolerance, physical & psychological dependence Potentiates other CNS depressants

Orthostatic Hypotension
Blood Dyscrasias Abrupt Withdrawal Syndrome Flumazenil (Romazicon) Benzodiazepam antagonist
Reverse CNS effects

Must gradually taper down

Protect the ego & cope with anxiety unconsciously

Defense Mechanisms

Denial

Refuse to acknowledge the problem Substance abuse

Regression

Return to an earlier level of development Holding teddy bear

Displacement (3 way)

Transfer feelings from 1 person, object or situation to less

threatening person Angry @ boss yell @ kids or kick the dog

Reaction-Formation

Prevent unacceptable thoughts/behaviors from being

expressed by developing opposite thoughts/behaviors Unwanted pregnancy New mom overprotective of baby

Defense Mechanisms
Projection (2 way)
Unacceptable feelings/impulses are attributed to another
person Im needy but claim my husband is demanding

Repression
Involuntary blocking of unpleasant feelings and experiences No memory of sexual abuse as a child

Suppression
Conscious voluntary denial of unpleasant feelings and
experiences Put away NCP & focus on studying for exam

Identification

Self worth by acquiring certain attributes &

 Rationalization Attempting to form logical reasons to justify unacceptable feelings Not getting accepted to Harvard I didnt want to leave home Sublimation Substituting constructive/socially acceptable activity for
inappropriate impulses. Aggressive person becomes hockey player

Defense Mechanisms

Compensation Covering up a real or perceived weakness by emphasizing/excelling

in another area Poor in sports Excell in chess

Conversion Unconsciously transforming anxiety into a physical symptom Paralysis/Blind