ANXIETY DISORDERS

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ANXIETY DISORDERS
A. Perez-Millan, ARNP MSN
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INTRODUCTION

• Stress is.
• Anxiety is.
• Fear is.
• Defense mechanisms
• Coping mechanisms

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Psychobiology of Anxiety
Threat Information enters the brain
Pathway
Cortex Limbic System
(Center of emotions) Amygdala (Recognizes
threat)
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Psychobiology of Anxiety (continued)
Hypotalamus Pituitary gland Adrenal Cortex
(cortisol) Sympatho-Adrenal Medulla (epinephrine,
nor-epinephrine)
Fight or flight
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COPING WITH STRESS AND ANXIETY
EFFECTIVE MEDIATION
Anxiety Return to usual
coping
RELIEF BEHAVIORS
STRESS
ANXIETY
Psychological Physical Social

• Defense Mechanisms Coping Mechanisms
  Social/Cultural/Spiritual Support systems

INEFFECTIVE MEDIATION
Anxiety Physical
Psychological
Illness

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Anxiety Disorders (cont.)

• Epidemiological statistics
• Anxiety disorders most common type of all
  psychiatric illnesses.
• More common in women than men
• Occur in children from social minorities.
• Poverty a factor.
• Produces considerable functional impairment and
  distress.

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Anxiety is pathological if

• The response is disproportionate to the severity
  of the threat.
• The response continues beyond the existence of
  the threat.
• Functioning is impaired.

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Application of Nursing Process

• Panic disorder (P.D.) assessment
• Characterized by recurrent panic attacks, onset
  of which are unpredictable, and manifested by
  intense apprehension, fear, or terror, often
  associated with feelings of impending doom and
  accompanied by intense physical discomfort.
  (Townsend, p 515)

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Application of Nursing Process (cont.)

• Panic disorder with agoraphobia
• Assessment
• Characterized by same symptoms characteristic of
  panic disorder.
• In addition, affected person experiences a fear
  of being in places or situations from which
  escape might be difficult (or embarrassing) or in
  which help might not be available in the event
  that a panic attack should occur.

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Application of Nursing Process (cont.)

• Generalized anxiety disorder (G.A.D.)
• Assessment
• Characterized by chronic,
• unrealistic, and excessive
• anxiety and worry.

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Etiology

• Panic and generalized anxiety disorders
• Psychodynamic theory
• Ineffective use of ego defense mechanisms.
• Cognitive Theory
• Distorted thinking results in maladaptive
  behaviors and emotional disorders.

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Etiology (cont.)

• Panic and generalized anxiety disorders (cont.)
• Biological aspects
• Genetics
• Neuroanatomical
• Biochemical
• Neurochemical
• Medical conditions

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Nursing Diagnosis

• Panic level of anxiety related to real or
  perceived threat to biological integrity or
  self-concept.
• Powerlessness related to impaired
• cognition.

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Client Objectives- Outcomes

• The client
• Is able to recognize signs of anxiety and
  intervene so that it does not reach panic levels.
• Uses adaptive coping mechanisms to prevent panic
  anxiety when stressful situations occur.
• Performs activities of daily living independently

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Client Objectives- Outcomes (cont.)

• The client (cont.)
• Is able to maintain anxiety at a manageable
  level.
• Is able to participate in decision-making,
  thereby maintaining control over life situation.
• Verbalizes acceptance of life situations over
  which he or she has no control.

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Planning/ImplementationPanic and Generalized
Anxiety Disorder

• Nursing intervention is aimed at relief of acute
  panic symptoms.
• The nurse also works at assisting the client to
  take control of his or her own life situation and
  to accept those situations over which he or she
  has no control.

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Phobias

• Agoraphobia without history
• of Panic Disorder
• Assessment
• Fear of being in places or
  situations
• from which escape might be difficult
• or in which help might not be
  available if an attack or panic-like
  symptoms should occur.

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Phobias (cont.)

• Social phobia
• Assessment
• Excessive fear of situations in which the
  affected person might do something embarrassing
  or be evaluated negatively by other.

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Phobias (cont.)

• Specific phobia
• Assessment
• Marked, persistent, and excessive or unreasonable
  fear when in the presence of, or when
  anticipating, an encounter with a specific object
  or situation.

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Phobias (cont.)

• Specific phobia assessment
• Animal type
• Natural environment type
• Blood-injection-injury type
• Situational type
• Other type

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Phobias (cont.)

• Predisposing factors for phobias
• Psychoanalytical theory
• Unconscious fears are expressed
• in a symbolic manner .
• Learning theory Fears are
• conditioned responses.
• Early experiences

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Phobias (cont.)

• Cognitive theory
• Anxiety is the result of anxiety-inducing
  self-talk.
• Negative self-statements
• Irrational beliefs
• Biological aspects
• Temperament
• Innate fears

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Nursing Diagnosis

• Fear related to causing embarrassment to self in
  front of another, to being in a place from which
  one is unable to escape, or to a specific
  stimulus.
• Social isolation related to fears of being in a
  place from which one is unable to escape.

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Objectives- Outcomes

• The client
• Is able to functions in the presence of the
  phobic object or situation.
• Uses coping mechanisms to maintain anxiety at a
  manageable level.
• Voluntarily attends group activities and
  interacts with peers.

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Objectives- Outcomes

• The client (cont.)
• Discusses feelings that may have contributed to
  irrational fears.
• Verbalizes a future plan of action to deal with
  the phobic object or situation.

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Planning/ImplementationPhobias

• Nursing intervention is aimed at decreasing the
  clients fear and increasing his or her ability
  to function in the presence of the phobic
  stimulus.

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Obsessive-Compulsive Disorder (OCD)

• Assessment data
• Recurrent obsessions or compulsions that are
  severe enough to be time-consuming and cause
  severe distress or significant
• impairment.

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Obsessive-Compulsive Disorder (OCD) (cont.)

• Obsessions Unwanted, intrusive, persistent ideas
  or thoughts.
• Compulsions Unwanted repetitive actions to
  reduce anxiety.
• Rituals Repetitive actions that a person must do
  over and over to decrease anxiety.

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Obsessive-Compulsive Disorder (OCD) (cont.)

• Predisposing factors to OCD
• Psychoanalytical theory
• A weak ego.
• Regression to the pre-oedipal phase of
  development.

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Obsessive-Compulsive Disorder (OCD) (cont.)

• Predisposing factors to OCD (cont.)
• Learning theory
• Conditioned response to a traumatic event.
• Biological theory.
• Neuroanatomy
• Abnormalities in basal ganglia and
  orbital-frontal cortex of the brain.
• Biochemical
• Decreased serotonin. (5-HT)

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Obsessive-Compulsive Disorder (OCD) (cont.)
Diagnosis

• Ineffective coping related to underdeveloped
  ego, possible biochemical changes.
• Ineffective role performance related to need to
  perform rituals

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Obsessive-Compulsive Disorder (OCD) (cont.)
Outcomes

• The client
• Is able to maintain anxiety at a manageable
  level.
• Verbalizes understanding of relationship between
  anxiety and ritualistic behavior.
• Identifies situations that produce anxiety and
  result in rituals.

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Obsessive-Compulsive Disorder (OCD) (cont.)
Outcomes (cont.)

• The client (cont.)
• Able to use more adaptive coping strategies to
  deal with stress. (thought stopping, relaxation
  techniques, and physical exercise)
• Is able to perform ADLs role-related
  responsibilities without the need for ritualistic
  behaviors.

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Planning/Implementation Obsessive- Compulsive
Disorder

• Nursing intervention is aimed at helping the
  client maintain his or her anxiety at a
  manageable level without using ritualistic
  behavior.
• The focus is in the the development of more
  adaptive methods of coping with anxiety. Never
  interrupt a ritual!

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Post-traumatic Stress Disorder

• Assessment
• Development of symptoms after exposure to an
  extreme traumatic situation involving a threat
  to the safety of self or others.
• Re-experiencing the traumatic event, maintaining
  a high level of anxiety, and a general numbing of
  responsiveness.
• Intrusive recollections or nightmares of the
  event are common. Flashbacks

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Post-traumatic Stress Disorder (cont.)
Predisposing factors

• Psychosocial theory- Severity of the trauma.
• Learning theory- Negative reinforcement
• Cognitive theory- Extreme sense of helplessness.
• Biological aspects- Addiction to the trauma

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Post-traumatic Stress Disorder (cont.) Diagnosis

• Post-trauma syndrome related to distressing event
  outside the range of usual human experience.
• Dysfunctional grieving related to loss of self
  or other actual or perceived losses incurred
  during or after the event.

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Post-traumatic Stress Disorder (cont.) Outcomes

• The client (cont.)
• Can identify goals for future and demonstrate
  adaptive coping strategies.
• Includes significant others in the recovery
  process and willingly accepts their support.
• Verbalizes no ideas or intent of self-harm.

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Post-traumatic Stress Disorder (cont.) Outcomes
(Cont.)

• The client (cont.)
• Identifies community resources for assistance in
  times of stress.
• Gets enough sleep to avoid risk of injury.
• Has worked through feelings of survivors guilt.
• Attends support group.

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Post-traumatic Stress Disorder (cont.)
Planning/Implementation

• Nursing intervention id aimed at
• Reassurance of safety.
• Decrease in maladaptive symptoms (e.g.
  nightmares)
• Demonstration of more adaptive coping strategies.
• Adaptive progression through the grief process.

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Anxiety Disorder due to General Medical
Condition

• Assessment
• Symptoms of this disorder are
• judged to be the direct
• physiological
• consequence of
• a general medical
• condition.

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Substance-Induced Anxiety Disorder

• Assessment (cont.)
• Prominent anxiety
• symptoms that
• are judged to be
• due to the direct
• physiological effects
• of a substance.

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Substance-Induced Anxiety Disorder

• Assessment (cont.)
• Prominent anxiety symptoms that are judged to be
  due to the direct physiological effects of a
  substance.

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EVALUATION

• Reassessment is conducted to determine whether
  nursing actions have been successful in achieving
  the objectives of care.

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Client/Family Education

• Nature of the illness
• What is anxiety?
• What might it be related to?
• What is OCD?
• What is PTSD?
• Symptoms of anxiety disorders

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Client/Family Education (cont.)

• Management of the illness
• Medication management
• Possible adverse effect
• Length of time to take effect
• What to expect from the medication
• Stress management
• Teach ways to interrupt escalating anxiety.
• Teach relaxation techniques.

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Client/Family Education (cont.)

• Support services
• Crisis hotline
• Support groups
• Individual psychotherapy

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Treatment Modalities

• Individual psychotherapy
• Group/family therapy
• Cognitive therapy
• Behavior therapy
• Systematic desensitization
• Implosion therapy

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Treatment Modalities (cont.)
Psychopharmacology

• Panic and generalized anxiety disorder
• Anxiolytics (Benzodiazepines, Buspirone)
• Antidepressants
• Beta Blockers
• Phobic disorders
• Anxiolytics (Benzodiazepines, Buspirone)
• Antidepressants
• Beta Blockers

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Treatment Modalities (cont.)
Psychopharmacology

• OCD
• Antidepressants
• PTSD
• Antidepressants
• Anxiolytics (Benzodiazepines, Buspirone)
• Beta Blockers