Anxiety Disorders

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Anxiety Disorders
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Prevalence

• Anxiety Disorders more prevalent than mood
  disorders- 18
• Primary gain the individuals desire to relieve
  the anxiety to feel better
• Secondary gain refers to attention and support
  the person gets from the illness

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Primary Gain

• The individuals desire to relieve the anxiety
• Physical symptoms
• Stomach Ache
• Inability to walk
• Obsessions
• Compulsions
• Cleans
• Exercise
• Fears
• Cannot drive
• Worry
• Isolation

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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

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Axis 1 Anxiety Disorders

• Generalized Anxiety Disorder (GAD)
• Panic Disorder
• with Agoraphobia
• without Agoraphobia
• Phobias
• Somatoform Disorders

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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

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Psychoanalytic

• Result of conflict in values
• Client is often perfectionist and driven
• Defense mechanisms
• Repression
• Displacement
• Conversion

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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

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Generalized Anxiety Disorder

• Excessive worry occurring more often than not for
  6 months
• Person cannot control the worry
• Anxiety and worry are evident and three or more
  of the following
• Restlessness
• Fatigue
• Irritability
• Decreased ability to concentrate
• Muscle tension
• Disturbed sleep

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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
• Acknowledgment of discomfort
• Identify and describe feelings
• (repression displacement)
• Assist to identify causes of feelings

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Milieu Management for GAD

• Calm environment
• Cognitive Behavioral Therapy
• Corrects faulty assumptions
• If you change others will change
• Recreational activities
• Relaxation exercises or tapes
• Groups
• Stress Management
• Problem solving
• Self esteem
• Assertiveness
• Goal setting

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Medication

• Serotonin Reuptake Inhibitors
• Long-Term treatment
• Serotonin and Norepinephrine Reuptake Inhibitors
  (SNRI)
• Long-Term treatment
• Buspirone (Buspar)
• Nonaddicting non-benzodiazepine
• Benzodiazepine
• Immediate effect

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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

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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

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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

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The Nurse Patient Relationshipand Panic Disorder

• Teaching give client a handout on Panic Disorder
  
• Client 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

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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

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Panic Disorder

• Recurring, sudden intense feelings of
• Apprehension
• Terror
• Impending doom
• Loosing control
• Going crazy

• 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
• Peaks within 10 minutes

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Medication

• Serotonin Reuptake Inhibitors
• Long-Term treatment
• Benzodiazepine
• Immediate effect

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Obsessive Compulsive Disorder

• Obsessions
• Recurrent and Persistent
• Thoughts
• Ideas
• Impulses
• Images
• Experienced as intrusive and senseless
• Compulsions
• Repetitive behaviors
• Performed in a particular manner
• Response to obsession
• Prevent discomfort
• Neutralize anxiety

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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

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OCDNurse-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

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OCD and Milieu

• Relaxation Exercises
• Stress management
• Recreational and Social Skills
• Cognitive Behavior Therapy
• Outpatient
• Contact feared stimuli
• Limit the rituals
• 7-week exposure and response prevention therapy

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OCDMedication

• Antidepressants
• Tricyclic Antidepresants
• Clomipramine (Anafranil)
• SSRIs
• Fluoxetine (Prozac)
• Paroxetine (Paxil)

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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

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Phobias-Continued

• Agoraphobia without Panic disorder a fear of
  being in public places
• 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

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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

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Interventions

• Medications
• No effect on avoidant behaviors
• SSRIs
• Reduce anxiety and depression
• Block Panic
• Milieu
• Cognitive Behavioral Therapy

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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

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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

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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

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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 allows 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

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Hypochondriasis

• Worry they have a serious illness despite no
  medical evidence
• Misinterpretation of bodily symptoms
• Check for reassurance from doctors and friends

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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

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Conversion Disorder

• Primary Gain
• Alleviation of anxiety
• Conflict kept out of consciousness
• Secondary Gain
• Response of others to the illness
• Can prolong symptoms

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Somatoform Disorders

• The Clients can develop a health problem just
  like anyone else
• Be careful
• Always rule out the physical
• READ
• Conversion Disorder and the Nursing Student

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MEDICATIONS FOR ANXIETY
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BENZODIAZEPINES

• CNS Depressants
• Compete for GABA receptors decrease response of
  excitatory neurons
• Tolerance, dependence are problems
• Cause dizziness, somnolence, confusion
• Best for short-term use
• Shorter acting benzodiazepines
• PRN for episodes of anxiety or panic clonazepam
  (Klonipin)
• alprazolam (Ativan)

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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

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NON-BENZODIAZEPINES ANTIHISTAMINES

• Very sedating
• No addiction potential
• May be used long-term
• Examples
• diphenhydramine (Benadryl)
• hydroxyzine (Vistaril)

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ANTIDEPRESSANTS

• Useful in treatment of panic (with or without
  agoraphobia), obsessional thinking
• Low abuse potential
• SSRIs first line drugs due to low sedation

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ANTIDEPRESSANTS, CONTD

• 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

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MISCELLANEOUS

• Clonidine (Catapres) and Propranolol (Inderal)
• Decreases autonomic symptoms in panic
  tachycardia, muscle tremors
• Gabapentin (Neurontin)
• For OCD and social phobias

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GENERAL GUIDELINES FOR USE OF ANTIANXIETY AGENTS

• 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
  benzodiazapines, buspirone, some antidepressants