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Anxiety

Hear this?• There is an intense, constant fear that is

hard to describe

• It’s a sinking feeling in your stomach—almost as if someone is stalking you and you never know when those arms are going to wrap around you and drag you away.

• There’s more anxiety today, and that women, in particular, are feeling it

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Introduction

• Common in all phases of life• Most prevalent mental disorders in the U.S.• Afflicting 28.7% of the population (life span);

19.3% over a 12-month period• 1 in 4 people with an anxiety disorder is correctly

identified, diagnosed, and treated• Client’s symptoms are not primarily due to

organic factors• Stress, fear, anxiety, depression

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Types of Anxiety (DSM-IV)

• Panic disorder – acute anxiety

• Specific phobia; social phobia;

• Obsessive-compulsive disorder

• Posttraumatic stress disorder

• Generalized anxiety disorder

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Types of Anxiety (DSM-IV) –cont’d

• Acute stress disorder – immediately after the event• Anxiety disorder due to a general medical

condition• Substance-induced anxiety disorder• Others –

– Adjustment disorders featuring anxiety

– Separation anxiety

– Sleep disorder of insomnia

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Symptoms of Anxiety Disorders

• Motor tension - trembling, feeling shaky, muscle tension, muscle aches, restlessness

• Autonomic nervous system hyperactivity – shortness of breath, feeling of being smothered, heart rate↑, sweating or feel cold, clammy hands, dry mouth, dizziness,

• Hypervigilance – feeling edgy, difficulty concentrating, irritability

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Dynamics of anxiety

• Stress, coping & defense mechanism

• Theories - Freud, Sullivan, Selye

• Primary gain - desire to relieve anxiety

• Secondary gain - attention gained from others

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Process of Coping

Stressor Anxiety Neurochemical/physiological reactions

Adaptive PalliativeCoping Maladaptive Dysfunctional

What is anxiety?• Anxiety is a normal emotion which helps us

recognize real problems and solve them. In its healthy form, anxiety helps you perform at your top form when you’re adjusting to, say, a new job or a new baby

• Anxiety is not normal when it lasts days beyond a specific stressful event, or when it interferes with a person’s life

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Levels of Anxiety

• Mild +1 - slight fidgeting, alert, feeling challenged, ready for constructive action,

• Moderate +2 - irritability ↑, confidence ↓ concentrating↓, ready for protective action

• Severe +3 - hypersensitivity, distorted perceptions, ready for flight or fight,

• Panic +4 - actual flight/fight or immobilization, rage, disorganized, distorted sensory awareness

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Intervention in levels of anxiety

• Mild +1 – take as natural; benefit from it• Moderate +2 - ↓anxiety by crying,

exercising, refocusing; using medications• Severe +3 - ↓anxiety & stimuli; use simple

directions, use time out (seclusion); using medication (IM)

• Panic +4 – guide firmly, restrains if needed, using medication (IM)

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Interventions to Reduce Anxiety• Calm & quiet environment

• To identify what and how they feel

• To describe & discuss their feeling

• To identify the possible causes

• To listen carefully - assess suicidal attempt

• Do something - to release nervous energy; to discourage preoccupation with the self.

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Anxiety and other diseases

• Panic disorder occurs in 15-30% of the major depression cases

• Factitious disorder –deliberately make up the symptoms– ie. Munchausen syndrome by proxy

• Malingering – consciously create or exaggerate false symptoms to avoid work or other responsibilities

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Social Phobia –Most common anxiety disorder

• An extreme fear of being judged by others• Chr, unremitting, life long disorder. • begins around age of 13-20• Prevalence: 13.3% lifetime duration• Lead to other problems: alcohol (18.8%0, drug

abuse (13.0%), agoraphobia (44.9%)*• Paralyzed by fears that he will humiliate or

embarrass himself in front of others -> drop out from school, unemployed, no friends, …

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Panic disorder (panic attack)

• Happen unexpected or situationally bound• Spontaneous attacks of intense fear and

discomfort; may last from minutes to an hour

• Symptoms of anxiety can last for hours• S & S include heart rate ↑, chest pain, chills

or hot flushes, dizziness, SOB, fear of losing control, depersonalization

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Interventions for Panic Attack

• Stay with the pt and acknowledge the pt’s discomfort

• Maintain calm, keep the environment quiet

• Use simple direction

• Allow pts to pace or cry – to release tension

• Reassure the pt, you are in control

• Use paper bag for hyperventilation pt

generalized anxiety disorder

• Persistent, excessive and unrealistic worry that lasts for 6 months and more

• Worry for everything, irrational concerns,

• S/S: restlessness; difficulty concentrating or sleeping; irritability; fatigue; muscle tension

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Obsessive-compulsive Disorder

• Repetitive behaviors or experiencing recurrent, persistent thought

• Time consuming• Normal routine was interfered – work,

social functioning and interpersonal relationships

• Low self-esteem & self-worth →depression• Thinking process is rigid – right & wrong

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Interventions for OCD

• Physical care – food, rest, grooming• Provides pts with time to perform rituals• Explain expectations, routines, changes• Be empathic – aware of their needs to perform

rituals• Help to connect feeling and behaviors• Structure simple activities – distraction• Reinforce positive changes

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Phobic disorders

• Def: intense, irrational fear responses to an external object, activity, or situation; it causes severe distress & impair functioning

• Interventions:– Non-critical attitude– Provide activities– Physical care and comfort needs– Behavior is a method of coping

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Etiology• Cognitive theories – neg. thinking, irrational ideas• Genetics –• Biochemical factor –

– epinephrine -> nervous– Neurotransmitters – excessive serotonin,

norepinephrine, dopamine ->anxiety– GABA

• Changes in the society, value, culture, IPR,• Food, exercise

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Assessment

• Health history; physical examination• Medications – amphetamines, anticholinergics,

antihypertensive, epinephrine, OTC drugs, …• Screening – Mini International Neuropsychiatric

Interview (MINI); Liebowitz Social Anxiety Scale; Brief Social Phobia Scale; Michigan Alcoholism Screening Test…

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Treatment

• Cognitive-behavioral therapy – to reduce automatic negative perceptions and irrational beliefs,

• Relaxation training, • Behavioral approaches- ie desensitization• Pharmacotherapies – fluvoxamine (Luvox),

Prozac, Paxil, Beta-blockers, MAOIs, benzodiazepine,

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Nursing Implications

• Case finding, evaluating, and treating

• Educator – knowledge and skills to cope with anxiety

• Identifying local resources

• Document and report the anxiety disorder & advocate for treatment

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Posttraumatic Stress Disorder

• Traumatic event →PTSD and/or ASD• S & S: intense fear, horror, sense of helplessness,

dissociative symptoms• Prevalence: 50-70% - life time• PTSD can occur 10-20 years later• Denial, repression, suppression, withdrawal,

feeling of hopelessness, nightmare, illusion, depression, suicidal ideation, substance abuse

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Interventions for PTSD

• Nonjudgmental, empathic, honest• Normal reactions toward the trauma –

connections between experience & feelings• Safe verbalization of feelings – esp anger • Adaptive coping strategies – exercise,

relaxation instead of alcohol, drugs• Progressive review of the trauma event –

grieving process

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Anxiety related disorder –Somatoform disorders

(hysteria or Briquet’s syndrome)• Anxiety is expressed through physical

symptoms• Caused by an interaction of neurobiological,

psychological and familiar factors• Doctor shopping without satisfaction• Meeting needs from physical complaints

unconsciously• Different from factitious disorder -

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Anxiety related disorder – Dissociative disorders

• Anxiety is removed from conscious awareness, which helps pts to survive extreme emotional pain

• Disruption in the usually integrated functions of consciousness, memory, identity, or perception– Depersonalization disorder: outside their mind or body

– Dissociate amnesia: loss of memory

– Dissociative fugue: travel away from home & inability to remember the past, confused about identity

– Dissociative identity disorder: 2 or more identities or personality state

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Mild

Dissociative

State

Daydreaming

Moderate

DepersonalizationDisorder

Dissociative amnesia

Severe

Dissociative fugue

DID

Mohr (2009), p 461

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Anxiety related disorder –Conversion disorder

• Loss of voluntary motor or sensory functions that appears to represent physiologic pathology but, instead, relates to psychological conflict or need.

• Symptoms follow a greatly distressing event or experience to defense against intrapsychic anxiety

• La belle indifference – clients are not disturbed by their dramatic symptoms

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Anxiety related disorder –Hypochondriasis

• Clients fear that they have a serious disease despite no significant pathology or other reason for thinking so

• Hypervigilance -> misinterpret and overreact to physical signs and symptoms

• Preoccupation with bodily distress & needs for other’s attention-> disrupt social relationships

• Unaware of their anxiety or depression

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Anxiety related disorder –Body dysmorphic disorder (BDD)

• Extremely self-conscious about the imagined defect in appearance

• Thinking that others notice the imagined flaw

• Retreat from usual activities, socially isolated, decreased academic and occupational functions or even house bound

• Severe case -> suicide

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Conclusion• Diffuse apprehension – subjective, vague,

uncertainty, helplessness• Level- mild, moderate, severe, panic• Responses – physiological, behavioral, cognitive,

affective• Predisposing factors – multiple; threats to physical

integrity and self-esteem• Adaptation - coping • Anxiety is a very real and serious—yet treatable—

disorder

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Conclusion (II)

• Intervention – IPR, – self-awareness, – protecting the patient, – modifying the environment, – encouraging activity, – medication, and – learning new ways to cope with stress

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Joke

• Q: What's the difference between stress, tension and panic?

A:  Stress is when wife is pregnant, Tension is when girlfriend is pregnant, and Panic is when both are pregnant.