anxiety disorders chapter 19. concept of anxiety uncomfortable feeling of apprehension or dread ...
Post on 25-Dec-2015
220 Views
Preview:
TRANSCRIPT
Concept of Anxiety
Uncomfortable feeling of apprehension or dread
Response to internal or external stimuli
Physical, emotional, cognitive, and behavioral symptoms
Normal vs. Abnormal Intensity Cause Symptom Cluster See Table 19.1 Symptoms of Anxiety See Table 19.2 for Degrees of Anxiety (Peplau’s
model) Mild Moderate Severe Panic
Anxiety Disorders Up to 19 million of people in US Higher in women Individuals < 45 Separated, divorced Experienced childhood sexual abuse Low socioeconomic groups
Panic Extreme overwhelming form of anxiety when
individual placed in a life-threatening (or perceived) situation
Normal becomes abnormal when panic is experienced routinely or in situations that do not pose threats
Panic Disorder Experience panic in non-threatening
situations
Panic attack Discrete periods of fear or discomfort (10-30
minutes)
Physical (palpitations, rapid pulse, trembling, SOB)
Cognitive(disorganized thinking, irrational fears, fear going crazy, going to die)
Phobias: persistent, unrealistic fears (see box19.2)
Clinical Course of Panic Disorder Lifelong disorder, peaks in teenage years
and again in 30s
Chronic conditions that has several exacerbations and remissions during the course of the disease
Characterized by disabling attacks of panic that lead to other symptoms, such as phobia
Panic Attacks
Similar symptoms as heart attack, palpitation, heart racing, rapid breathing, shortness of breath (25% of ER visits for chest pain)
Types Unexpected cued
Situational cued (exposure to trigger)
Situational predisposed Diagnostic Criteria - table 19.3
With agoraphobia Without agoraphobia
Special Populations
Children
Most frequent psychiatric disorder
Often have separation anxiety and OCD
Elderly people
Very common
Epidemiology of Panic Disorder 2.9 million people
Panic disorder with agoraphobia --most severe comorbid anxiety disorders
Number of attacks
Anticipatory anxiety
Women more likely than men to experience panic disorder with agoraphobia
No difference between white and African American, Hispanic has lower
EtiologyBiological Evidence and Theories
Genetic predisposition: substantial Neuroanatomic changes
Focal areas of abnormal activity in the fear network Biochemical changes
Panicogenic substances that produce panic attacks yohimbine, fenfluamine, norepinephrin, epinephrine, sodium
lactate, and carbon dioxide Norepinephrine and locus ceruleus
Stimulate locus ceruleus, increased fear Inhibit locus ceruleus are anxiolytic Yohimbine - antagonist 2 - panicogenic
Serotonin- implicated, SSRI’s provide relief after 2-6 wks, initially, may increase anxiety
GABA- stimulation cause anxiolytic, sedating effects
Etiology (Cont.)
CRF
Neuropeptide that produces neuroendocrine, autonomic, and behavioral responses to stress
Severe stress results in an increased CRF concentrations in hippocampus, amygdala, locus ceruleus
CRF stimulations tests are conflicting
Long term use of SSRI antidepressants may inhibit release of CRF
Cholesyctokinin (CCK) -- neuropeptide
High concentrations found in cerebral cortex, amygdala, and hippocampus
Important interactions with other neurotransmitters
Carbon dioxide -- needs more study
Psychological Theories
Psychanalytic and psychodynamic theories Explain the importance of development of anxiety Commonalities of background and personality traits
Fearful or shy as a child Remembering parents as angry, critical Feelings of discomfort with aggression Long-term feelings of low self-esteem Experiencing stressful events prior to initial onset
Cognitive-behavioral theories Fear response can be learned--classical conditioning Interoceptive conditioning--pairing a somatic discomfort with
impending panic attack Catastrophic interpretation--misinterpretation of mild physical
sensations
Risk Factors Family history Substance and stimulant use or abuse Undertaking severe stressors Genetic predisposition Female gender For children
physical or sexual abuse behavioral inhibition by adults
Comorbidity More somatic complaints than general
populations
Vertigo, cardiac disease, GI disorders, asthma
Mitral valve prolapse, migraine headaches, and hypertension
Treatment
Interdisciplinary care is needed.
Priority care issues include Depression associated with panic disorder
Suicide needs to be assessed
Nursing Management: Biologic Domain
Rule out other disorders
Assessment questions Common features of panic attack. Careful review of
events prior to attack
Substance use
Sleep patterns
Physical activity
Biologic Interventions
Breathing control -- reduce hyperventilation and interrupt a panic attack. Need to practice
Nutritional planning reduce anxiety provoking substances:
caffeine, food coloring or MSG monitor symptoms after eating
Relaxation techniques (Increase physical activity) Box 19.3
Psychopharmacologic Treatment
Selective serotonin reuptake inhibitors (SSRI) Fluoxetine and sertraline -- can cause feelings of
overstimulation, slow titration Side effects -- anticholinergic, dizziness, anxiety,
nervousness, and sexual dysfunction Interact with MAOIs Fluoxetine interacts with flecainid, warfarin, phenytoin,
carbamazepine, and vinblastine Paroxetine interacts with cimetidine, decrease digoxin levels,
phobarbitol, and phenytoin Sertraline interacts with diazepan and tolbutamide, warfarin Teaching points:
Avoid over-the-counter medications Sedative effects may impede judgment while operating machinery
Psychopharmacologic Treatment
Tricylcic antidepressants Imipramine,nortriptyline and clomipramine reduce panic attacks Therapeutic effects usually occur in 3-4 weeks Single bedtime doses help deals with sedation EKG before initiation (cardiac conduction) Taper discontinuation to avoid cholinergic rebound Observe for anticholinergic effects Start at low doses and gradually increase Interacts with several medications (MAOIs, and CNS depressants) Teaching points
Take medication as prescribed Avoid OTC medications without checking first Warn about sedation, avoid operating machinery
Psychopharmacologic Treatment
Benzodiazepines Used during periods of extreme stress and for immediate
symptom release Alprazolam, lorazepam, and clonazepam Initiate benzodiazepines until antidepressants begin
working Short acting associated with rebound anxiety ( alprazolam,
lorazepam). Give in divided doses Avoid if sleep apnea Withdrawal symptoms can occur Side effects: headache, confusion, dizziness, disorientation,
sedation, and visual disturbances Interactions with TCAs, digoxin, alcohol, and other CNS
depressants. Avoid histamine blockers. Cigarette smoking increases clearance
Teaching points: avoid alcohol, sedative effects
Nursing Management:Psychlogical Assessment
Determining patterns of panic attack, symptoms, and responses
Mental status : restlessness, irritability, watchful or worried facial expression, decreased attention span, difficulty problem solving, apprehensive, or helpless,self-report scales
Suicidal assessment
Cognitive thought patterns
Self-concept
Rating scales (text box 19.6,table 19.5)
Psychological Interventions Help patient attend to and react to input other than
subjective experience (table19.7) Provide patient with information Distraction Positive self-talk “I will get through this” Panic control treatment: structured exposure to
internal sensations Exposure therapy Systematic desensitization Implosive therapy Cognitive-behavioral therapy Psychoeducation
Emergency CareInterventions for Panic Attack
Stay with the patient
Reassure that you will not leave
Give clear directions
Assist patient to an environment with minimal stimulation
Walk with the patient
Administer PRN anxiolytic medications
Obsessive-Compulsive Disorder
Severe obsessions or compulsions that interfere with life
Obsessions - unwanted thoughts, intrusive persistent thoughts, impulses or images that
cause anxiety and distress fear of contamination
Compulsions - repetitive behaviors performed in a ritualistic way that relieve anxiety
Obsessive-Compulsive Disorder
Special PopulationsOCD
Children 1%-2.3% of child and adolescent population ritualistic behaviors are typical of childhood parents begin to notice grades fall because of
decrease concentration
Elderly can occur in adulthood
OCD
2.5% lifetime prevalence of individuals
Similar rates in men and women
First-degree relatives most common
Less common in African Americans
Highly somatic
Comorbid anxiety disorders, personality disorders
EtiologyBiologic Domain
Genetic first degree relatives monozygotic twins
Neuropathologic Abnormalities in frontal cortex, limbic system, and basal
ganglia PET scans (see Ch. 18, Fig. 18-3) Increased glucose metabolism in caudate nuclei, orbitofrontal
gyri, and the cingulate gyri
Biochemical Serotonin implicated (because of SSRIs) Others probably involved
EtiologyPsychological Theories
Psychodynamic symptoms and character traits arise from
unconscious defense mechanisms: isolation, undoing, and reaction formation
not scientifically tested Behavioral
based on learning theory obsessions seen as conditioned stimuli compulsions develop to reduce obsessional
anxiety
Treatment
Interdisciplinary Staff needs to be consistent in
expectations
Priority Care Issues Suicide
Common Reponses Obsessions create anxiety and compulsions are
performed to reduce anxiety Common compulsions
washing, cleaning, checking, counting, repeating actions ordering, making confessions, and requesting assurances if sequence disturbed, person experiences anxiety
Most common obsessions fear of contamination, resulting compulsion toward handwashing
Dissociation: a breakdown in integrated functions of memory, consciousness, perception of self, environment, or sensory and motor behavior
Depersonalization: loss of sense of personality Coexists with Tourette’s Syndrome
Nursing ManagementBiologic Domain
Assess for multiple physical symptoms
Physical fears
Physical consequences of compulsions
Nutrition and sleep status
Dermatologic lesions secondary to hand washing
Head trauma
Biologic Interventions
Electroconvulsive therapy Psychosurgery Maintaining skin integrity Psychopharmacologic treatment
SSRI and TCA Antidepressants given in higher doses than for
treatment of depression Side effect monitoring a problem for those
preoccupied with somatic concerns Teaching points: medication management, do not stop
prescribed medications abruptly, avoid OTC medications, consider sedative effect
Nursing ManagementPsychological Assessment
Type and severity of obsessions and compulsions
Degree to which the OCD symptoms interfere with patient’s daily functioning
Consider using rating scales (Text Box 21.5)
Suicide assessment
Psychological Interventions
Response prevention
Thought stopping
Relaxation techniques
Cognitive restructuring
Cue Cards (Text Box 21.6)
Psychoeducation (See Psychoeducation Checklist)
Nursing Management Social Domain
Consider sociocultural factors and ability to relate to others
In hospital, unit routines carefully and clearly explained to decrease patient’s fear of unknown
Recognize significance of rituals
Assist patient in arranging schedule
Marital and family support important
Nursing Management Social interventions
Milieu interventions Personal and environmental protective
measures Family interventions
Evaluation Continuum of care
General Anxiety Disorder
Worry obsessively and interferes with life Very common -- 5% will experience it in
their life Onset gradual Comorbid psychiatric disorders, mild
depressive symptoms common Associated with alcoholism
GAD Etiology Neurochemical theories (little research)
Genetic theories (moderately inherited)
Psychological theories inaccurate assessment of environment
selective focus on negative details, distorted information, processing, and overly pessimistic view
Social theories (no specific theories) High-stress lifestyle
Multiple stressful events
Risk Factors
Unresolved conflicts
Cognitive misinterpretations
Life stressors
Genetic predisposition
Behavioral inhibition
Nursing ManagementBiologic DomainAssessment
Diet and nutrition may be hypersensitive to caffeine
Sleep patterns disturbances are common
Substance use
Nursing InterventionsBiologic Domain
Medications Buspirone (Buspar) Antidepressants
Nutrition counselingSleep hygiene
Psychosocial DomainAssessment and interventions
similar to panic disorderCognitive psychotherapy is
effective treatment of GADOutcomes include reducing
frequency and intensity of anxiety and controlling factors that contribute to anxiety
Dissociative Disorders
Dissociative amnesia
Dissociative fugue
Depersonalization disorder
Dissociative Identity Disorder
Dissociative Disorders
Failure to integrate identity, memory, and consciousness
Types Dissociative amnesia -- inability to recall Dissociative fugue -- unexpected travel away from
home Depersonalization disorder -- being detached for
one’s body Dissociative identity disorder (multiple
personality disorder) Dissociative disorder not otherwise specified
top related