Anxiety DisordersAnxiety Disorders

PrevalencePrevalence

Anxiety Disorders more prevalent Anxiety Disorders more prevalent than mood disorders- 18 %than mood disorders- 18 %

Primary gainPrimary gain: the individuals desire : the individuals desire to relieve the anxiety to feel betterto relieve the anxiety to feel better

Secondary gainSecondary gain: refers to attention : refers to attention and support the person gets from the and support the person gets from the illnessillness

Primary GainPrimary Gain The individual’s desire to relieve the The individual’s desire to relieve the

anxietyanxiety– Physical symptomsPhysical symptoms

Stomach Ache Stomach Ache Inability to walkInability to walk

– ObsessionsObsessions– CompulsionsCompulsions

CleansCleans ExerciseExercise

– FearsFears Cannot driveCannot drive

– WorryWorry– IsolationIsolation

Secondary GainSecondary Gain

Attention or benefit Attention or benefit – Health Care ProvidersHealth Care Providers– Spouse does moreSpouse does more– Children take care of younger siblingsChildren take care of younger siblings

Can become more important Can become more important than relieving the anxietythan relieving the anxiety

– Decreases motivation to get wellDecreases motivation to get well– Others take care of individualOthers take care of individual

Complicates treatmentComplicates treatment

Axis 1 Anxiety DisordersAxis 1 Anxiety Disorders

1.1. Generalized Anxiety Disorder (GAD)Generalized Anxiety Disorder (GAD)

2.2. Panic DisorderPanic Disorder with Agoraphobiawith Agoraphobia

without Agoraphobiawithout Agoraphobia

3.3. PhobiasPhobias

4.4. Somatoform DisordersSomatoform Disorders

Etiology of Anxiety DisordersEtiology of Anxiety Disorders

Biological and GeneticBiological and Genetic– Defects in Brain Chemistry; Person over Defects in Brain Chemistry; Person over

responds to Stimuli responds to Stimuli – Inherited trait for shyness has been Inherited trait for shyness has been

discovered discovered – Brazelton; believes in the biological Brazelton; believes in the biological

basis of temperamentbasis of temperament

PsychoanalyticPsychoanalytic

Result of conflict in valuesResult of conflict in values Client is often perfectionist and Client is often perfectionist and

drivendriven Defense mechanismsDefense mechanisms

– RepressionRepression– DisplacementDisplacement– Conversion Conversion

Generalized Anxiety DisorderGeneralized Anxiety Disorder(GAD)(GAD)

Cognitive and Physical SymptomsCognitive and Physical Symptoms– Worry; unable to focusWorry; unable to focus– Dry mouth, stomach acheDry mouth, stomach ache

Anxiety or worry is chronic and excessiveAnxiety or worry is chronic and excessive Significant DistressSignificant Distress Worry is debilitating and habitualWorry is debilitating and habitual

– Focus changesFocus changes Causes impairmentCauses impairment

– Interpersonal or socialInterpersonal or social– OccupationalOccupational– Sense of helplessnessSense of helplessness– DepressionDepression– Chemical dependencyChemical dependency

Generalized Anxiety DisorderGeneralized Anxiety Disorder Excessive worry occurring more often than Excessive worry occurring more often than

not for 6 monthsnot for 6 months Person cannot control the worryPerson cannot control the worry Anxiety and worry are evident and three Anxiety and worry are evident and three

or more of the following:or more of the following:– RestlessnessRestlessness– FatigueFatigue– IrritabilityIrritability– Decreased ability to concentrateDecreased ability to concentrate– Muscle tensionMuscle tension– Disturbed sleepDisturbed sleep

Interventions for GADInterventions for GAD Goal is to assist the client to develop adaptive Goal is to assist the client to develop adaptive

coping responsescoping responses Assess for level of anxiety: moderate to severeAssess for level of anxiety: moderate to severe Reduce level of AnxietyReduce level of Anxiety

– Must occur prior to problem solvingMust occur prior to problem solving– Promotes trustPromotes trust

Acceptance of feelingsAcceptance of feelings Acknowledgment of discomfortAcknowledgment of discomfort

Identify and describe feelings Identify and describe feelings (repression; displacement)(repression; displacement) Assist to identify causes of feelingsAssist to identify causes of feelings

Milieu Management for GADMilieu Management for GAD Calm environmentCalm environment Cognitive Behavioral TherapyCognitive Behavioral Therapy

– Corrects faulty assumptionsCorrects faulty assumptions– If you change others will changeIf you change others will change

Recreational activities Recreational activities – Relaxation exercises or tapesRelaxation exercises or tapes

GroupsGroups– Stress ManagementStress Management– Problem solvingProblem solving– Self esteemSelf esteem– AssertivenessAssertiveness– Goal settingGoal setting

MedicationMedication

Serotonin Reuptake InhibitorsSerotonin Reuptake Inhibitors– Long-Term treatmentLong-Term treatment

Serotonin and Norepinephrine Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)Reuptake Inhibitors (SNRI)– Long-Term treatmentLong-Term treatment

Buspirone (Buspar)Buspirone (Buspar)– Nonaddicting non-benzodiazepineNonaddicting non-benzodiazepine

BenzodiazepineBenzodiazepine– Immediate effectImmediate effect

Four Symptoms for Diagnosis of Four Symptoms for Diagnosis of Panic DisorderPanic Disorder

Chest painChest pain ChokingChoking DizzinessDizziness DyspneaDyspnea Fear of going crazyFear of going crazy Fear of dyingFear of dying SweatingSweating PalpitationsPalpitations Trembling and shakingTrembling and shaking NauseaNausea Hot flashes and chillsHot flashes and chills

EtiologyEtiology PsychologicalPsychological

– Life stressesLife stresses Separation and disruption Separation and disruption of attachment in childhoodof attachment in childhood

BiologicalBiological– Heredity Heredity – 3 systems3 systems

Cognitive (catastrophic thinking “what if”)Cognitive (catastrophic thinking “what if”)– Triggers physiologyTriggers physiology

Nervous SystemNervous System– Sympathetic (flight fight response)Sympathetic (flight fight response)– Respiratory, cardiovascular, gastrointestinal, neuromuscularRespiratory, cardiovascular, gastrointestinal, neuromuscular

Endocrine SystemEndocrine System– Andrenal cortex (cortisol)Andrenal cortex (cortisol)

Libido, insomnia, anxietyLibido, insomnia, anxiety– Adrenal Medulla (epinephrine)Adrenal Medulla (epinephrine)

AnxietyAnxiety

The Nurse Patient Relationship: The Nurse Patient Relationship: Acute PhaseAcute Phase

Communication: Similar to panic level Communication: Similar to panic level anxiety, reassure that they are safeanxiety, reassure that they are safe– Have client breath with you (set the pace)Have client breath with you (set the pace)

Keep stimulation downKeep stimulation down Assess for suicidal ideation: 1 in 5 are Assess for suicidal ideation: 1 in 5 are

suicidalsuicidal Use touch carefullyUse touch carefully PRN Medications: Xanax, AtivanPRN Medications: Xanax, Ativan

The Nurse Patient The Nurse Patient RelationshipRelationship

and Panic Disorderand Panic Disorder

Teaching: give client a handout on Panic Teaching: give client a handout on Panic DisorderDisorder – Client need to know there is a diagnosisClient need to know there is a diagnosis– They are not “crazy”They are not “crazy”– SymptomsSymptoms– Medications that can helpMedications that can help

When clients learn about the diagnosis they When clients learn about the diagnosis they usually improveusually improve

Interventions and MilieuInterventions and Milieu

Cognitive restructuringCognitive restructuring Reinterpret their Reinterpret their

beliefs regarding the beliefs regarding the danger of the eventdanger of the event

Identify feelingsIdentify feelings Identify triggersIdentify triggers Avoidance makes it Avoidance makes it

worseworse Meeting FearsMeeting Fears

– What is the worst that What is the worst that can happen?can happen?

– What will I doWhat will I do– OptionsOptions

Recognize bodily Recognize bodily sensations and sensations and symptoms of anxietysymptoms of anxiety

Relaxation ExercisesRelaxation Exercises– StretchingStretching– YogaYoga– Soft musicSoft music

Gross motor activitiesGross motor activities– Walking Walking – JoggingJogging– BasketballBasketball

Panic DisorderPanic Disorder

Recurring, Recurring, sudden sudden intense intense feelings offeelings ofApprehensionApprehensionTerrorTerror Impending doom Impending doom Loosing controlLoosing controlGoing crazyGoing crazy

Somatic SymptomsSomatic Symptoms– Heart AttackHeart Attack– DyingDying

Can happen in the middle Can happen in the middle of the nightof the night– fearful and exhausted.fearful and exhausted.

SituationalSituational– Often recur in the same Often recur in the same

placeplace– Can occur with Can occur with

anticipationanticipation– Avoid places or situationsAvoid places or situations

Peaks within 10 minutesPeaks within 10 minutes

MedicationMedication

Serotonin Reuptake InhibitorsSerotonin Reuptake Inhibitors– Long-Term treatmentLong-Term treatment

BenzodiazepineBenzodiazepine– Immediate effectImmediate effect

Obsessive Compulsive DisorderObsessive Compulsive Disorder ObsessionsObsessions

– Recurrent and PersistentRecurrent and Persistent ThoughtsThoughts IdeasIdeas ImpulsesImpulses ImagesImages Experienced as intrusive and senselessExperienced as intrusive and senseless

CompulsionsCompulsions– Repetitive behaviorsRepetitive behaviors

Performed in a particular mannerPerformed in a particular manner Response to obsessionResponse to obsession Prevent discomfortPrevent discomfort Neutralize anxietyNeutralize anxiety

OCDOCD DepressionDepression

– Low self-esteemLow self-esteem– Rigid thinkingRigid thinking– Unable to RelaxUnable to Relax

Increase anxiety when they resist the compulsionIncrease anxiety when they resist the compulsion Need to controlNeed to control

– ThemselvesThemselves– OthersOthers– environmentenvironment

Interferes with normal routineInterferes with normal routine– Time-consumingTime-consuming

Interferes with relationshipsInterferes with relationships– Not enough time to relate to othersNot enough time to relate to others– Magical thinkingMagical thinking

Believes thinking equals doingBelieves thinking equals doing

OCDOCDNurse-Patient RelationshipNurse-Patient Relationship

Assist to meet Basic NeedsAssist to meet Basic Needs Allow time to perform ritualsAllow time to perform rituals

– Work to limitWork to limit Explain expectation routines and changes Explain expectation routines and changes Identify feelingsIdentify feelings Connect feeling to behaviorsConnect feeling to behaviors Reinforce and recognize positive Reinforce and recognize positive

non-ritualistic behaviorsnon-ritualistic behaviors

OCD and MilieuOCD and Milieu

Relaxation ExercisesRelaxation Exercises Stress managementStress management Recreational and Social SkillsRecreational and Social Skills Cognitive Behavior TherapyCognitive Behavior Therapy

– OutpatientOutpatient– Contact feared stimuliContact feared stimuli– Limit the ritualsLimit the rituals– 7-week exposure and response 7-week exposure and response

prevention therapyprevention therapy

OCDOCDMedicationMedication

AntidepressantsAntidepressants– Tricyclic AntidepresantsTricyclic Antidepresants

Clomipramine (Anafranil)Clomipramine (Anafranil)

– SSRIsSSRIsFluoxetine (Prozac)Fluoxetine (Prozac)Paroxetine (Paxil)Paroxetine (Paxil)

Phobias/DSM IVPhobias/DSM IV

Marked and Marked and specificspecific fear that is excessive and fear that is excessive and unreasonable cued by the presence or unreasonable cued by the presence or anticipation of object.anticipation of object.

Person recognizes fear as unreasonablePerson recognizes fear as unreasonable Situation or object avoidedSituation or object avoided

– AnimalAnimal– Natural environment; heightsNatural environment; heights– Blood/injectionBlood/injection– Situational/elevators Situational/elevators

Phobias-ContinuedPhobias-Continued

Agoraphobia without Panic disorder: Agoraphobia without Panic disorder: a fear of being in public placesa fear of being in public places

Social phobia: fear of being Social phobia: fear of being humiliated in public, fear of humiliated in public, fear of stumbling while dancing, choking stumbling while dancing, choking while eatingwhile eating

Specific phobia: fear of a specific Specific phobia: fear of a specific object or situation; animals, heigth, object or situation; animals, heigth, flyingflying

Treatment for PhobiasTreatment for Phobias

Outpatient is most commonOutpatient is most common Behavior therapy: systematic Behavior therapy: systematic

desensitization; like Fear of Flying desensitization; like Fear of Flying groupsgroups

Nurse patient relationship Nurse patient relationship – Interventions are very similar to GADInterventions are very similar to GAD

InterventionsInterventions

MedicationsMedications– No effect on avoidant behaviorsNo effect on avoidant behaviors– SSRIsSSRIs

Reduce anxiety and depressionReduce anxiety and depressionBlock PanicBlock Panic

MilieuMilieu– Cognitive Behavioral TherapyCognitive Behavioral Therapy

Somatoform DisordersSomatoform Disorders

Anxiety is relieved by developing Anxiety is relieved by developing physical physical symptomssymptoms for which for which no knownno known organic organic causcause or physiologic mechanism can be e or physiologic mechanism can be identifiedidentified

Somatization DisorderSomatization Disorder Conversion DisorderConversion Disorder Pain DisorderPain Disorder HypochondriasisHypochondriasis

Somatoform DisordersSomatoform Disorders

Client expresses psychological conflict Client expresses psychological conflict through symptomsthrough symptoms

Client is not in control of symptoms and Client is not in control of symptoms and complaintscomplaints

See general practitioners not mental See general practitioners not mental health professionalshealth professionals

Repression of feelings, conflicts, and Repression of feelings, conflicts, and unacceptable impulsesunacceptable impulses

Denial of psychological problemsDenial of psychological problems Individuals are dependent and needyIndividuals are dependent and needy

Somatization DisorderSomatization Disorder Recurrent frequent somatic complaints for yearsRecurrent frequent somatic complaints for years Complaints change over timeComplaints change over time No physiological causeNo physiological cause Onset prior to 30years oldOnset prior to 30years old See many physiciansSee many physicians May have unnecessary May have unnecessary

surgical proceduressurgical procedures ImpairmentImpairment

– Social functioningSocial functioning– Occupational functioningOccupational functioning

EtiologyEtiology– Chronic emotional abuseChronic emotional abuse– Unable to verbalize angerUnable to verbalize anger

Helped by having them talk about experiences and feelingsHelped by having them talk about experiences and feelings

Pain DisorderPain Disorder

Severe Pain in one or more areasSevere Pain in one or more areas– Significant distress and impairmentSignificant distress and impairment– Location or complaint does not changeLocation or complaint does not change

Unlike somatization disorderUnlike somatization disorder

– No organic basisNo organic basis– Doctor ShoppersDoctor Shoppers– Pain may allows secondary gainPain may allows secondary gain

AvoidanceAvoidance– Does not have to go to workDoes not have to go to work

Pain medicationPain medication

– Sometime there is a physiologic disorderSometime there is a physiologic disorder The amount of pain is out of proportionThe amount of pain is out of proportion

HypochondriasisHypochondriasis

Worry they have a serious illness Worry they have a serious illness despite no medical evidencedespite no medical evidence

Misinterpretation of bodily Misinterpretation of bodily symptomssymptoms

Check for reassurance from doctors Check for reassurance from doctors and friendsand friends

Conversion DisorderConversion Disorder Suggests a Neurological ConditionSuggests a Neurological Condition

– Deficit or alteration in voluntary motor or Deficit or alteration in voluntary motor or sensory functionsensory function

Psychological factors that proceed Psychological factors that proceed symptomssymptoms– ConflictsConflicts– StressorsStressors

SymptomsSymptoms– ParalysisParalysis– BlindnessBlindness– seizuresseizures

Conversion Disorder:Conversion Disorder:

Primary GainPrimary Gain– Alleviation of anxietyAlleviation of anxiety– Conflict kept out of consciousnessConflict kept out of consciousness

Secondary GainSecondary Gain– Response of others to the illnessResponse of others to the illness– Can prolong symptomsCan prolong symptoms

Somatoform DisordersSomatoform Disorders

The Clients can develop a health problem The Clients can develop a health problem just like anyone elsejust like anyone else

Be carefulBe careful Always rule out the physicalAlways rule out the physical

READ:READ:

““Conversion Disorder and the Nursing Conversion Disorder and the Nursing Student”Student”

MEDICATIONS FOR MEDICATIONS FOR ANXIETYANXIETY

BENZODIAZEPINESBENZODIAZEPINES

CNS DepressantsCNS Depressants Compete for GABA receptors; decrease Compete for GABA receptors; decrease

response of excitatory neuronsresponse of excitatory neurons Tolerance, dependence are problemsTolerance, dependence are problems Cause dizziness, somnolence, confusionCause dizziness, somnolence, confusion Best for short-term useBest for short-term use Shorter acting benzodiazepines Shorter acting benzodiazepines

– PRN for episodes of anxiety or panic: PRN for episodes of anxiety or panic: clonazepam (Klonipin)clonazepam (Klonipin)

alprazolam (Ativan)alprazolam (Ativan)

NON-BENZODIAZEPINESNON-BENZODIAZEPINES

First line agent: buspirone (BuSpar)First line agent: buspirone (BuSpar) Binds to serotonin and dopamine Binds to serotonin and dopamine

receptorsreceptors No CNS depressionNo CNS depression No abuse potential documentedNo abuse potential documented May have paradoxical effects (increased May have paradoxical effects (increased

anxiety, depression, insomnia, etc.)anxiety, depression, insomnia, etc.) May not be fully effective for 3-6 weeksMay not be fully effective for 3-6 weeks May cause EPSMay cause EPS

NON-BENZODIAZEPINES: NON-BENZODIAZEPINES: ANTIHISTAMINESANTIHISTAMINES

Very sedatingVery sedating No addiction potentialNo addiction potential May be used long-termMay be used long-term Examples: Examples:

– diphenhydramine (Benadryl)diphenhydramine (Benadryl)– hydroxyzine (Vistaril)hydroxyzine (Vistaril)

ANTIDEPRESSANTSANTIDEPRESSANTS

Useful in treatment of panic (with or Useful in treatment of panic (with or without agoraphobia), obsessional without agoraphobia), obsessional thinkingthinking

Low abuse potentialLow abuse potential SSRI’s: first line drugs due to low SSRI’s: first line drugs due to low

sedationsedation

ANTIDEPRESSANTS, CONT’DANTIDEPRESSANTS, CONT’D Selective Serotonin Re-uptake Inhibitors Selective Serotonin Re-uptake Inhibitors

fluoxetine (Prozac)fluoxetine (Prozac)sertraline (Zoloft)sertraline (Zoloft)paroxetine (Paxil)paroxetine (Paxil)citalopram (Celexa)citalopram (Celexa)escitalopram (Lexapro) escitalopram (Lexapro) fluvoxamine (Luvox): best for OCDfluvoxamine (Luvox): best for OCD

Tricyclics: Tricyclics: clomipramine (Anafranil): for OCDclomipramine (Anafranil): for OCD

MISCELLANEOUSMISCELLANEOUS Clonidine (Catapres) and Propranolol Clonidine (Catapres) and Propranolol

(Inderal) (Inderal) – Decreases autonomic symptoms in Decreases autonomic symptoms in

panic : tachycardia, muscle tremorspanic : tachycardia, muscle tremors

Gabapentin (Neurontin)Gabapentin (Neurontin)For OCD and social phobiasFor OCD and social phobias

GENERAL GUIDELINES FOR GENERAL GUIDELINES FOR USE OF ANTIANXIETY AGENTSUSE OF ANTIANXIETY AGENTS

Sedation increases falls, accidentsSedation increases falls, accidents Cautious use in elderly, renal, liver Cautious use in elderly, renal, liver

problemsproblems Do not combine with other CNS Do not combine with other CNS

depressants or alcoholdepressants or alcohol Paradoxical effects common: esp. with Paradoxical effects common: esp. with

benzodiazapines, buspirone, some benzodiazapines, buspirone, some antidepressantsantidepressants