PSYCHIATRIC
NURSING
ANXIETY DISORDERS
Chapter 18
S
Objectives
S Define anxiety and differentiate it from other terms (stress,
fear, etc.).
S Describe various types of anxiety disorders.
S Identify etiological factors in the development of anxiety
disorders.
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Theories: Anxiety
Disorders
S Biological changes in the brain
S Noradrenergic system is sensitive to
norepinephrine; locus ceruleus is involved in
precipitating panic attacks.
S Dopamine system involved in pathophysiology of
OCD.
S GABA dysfunction affects development of panic
disorder.
Theories: Anxiety
Disorders (cont'd)
S Abnormal control of glutamate plays role in
anxiety disorders.
S Hormonal changes in pregnant women affect
certain anxiety disorders.
S Lactic acid may precipitate anxiety.
S Caffeine and nicotine may trigger panic attacks.
Theories: Anxiety
Disorders (cont'd)
S Genetic theories: strong evidence for familial or
genetic predisposition for anxiety disorders
Theories: Anxiety
Disorders (cont'd)
S Psychosocial theories: in psychoanalytic theory,
anxiety is viewed as sign of psychologic conflict;
anxiety is the outcome of repressing forbidden
impulses
Theories: Anxiety
Disorders (cont'd)
S Behavioral theory
S Anxiety is a learned response that can be unlearned.
S Compulsive behavior is a maladaptive attempt to
alleviate anxiety.
S Behavior modification teaches new ways to behave.
Theories: Anxiety
Disorders (cont'd)
S Humanistic theories:
S Environmental stressors, biological factors, and
intrapsychic fears cannot be dealt with separately
but rather as they interact with one another.
S Treatment approaches are integrative.
Anxiety
S A universal experience
S A normal response that usually helps cope with
threatening situations
S Anxiety disorders are characterized by anxiety so
disabling as to adversely affect day-to-day
functioning
S Affects all age groups
Anxiety (cont'd)
S Anxiety disorders are most common of mental
illnesses
S All anxiety disorders have in common excessive,
irrational fear and dread
S Anxiety is either a dominant disturbance or an
avoidance behavior
S Free-floating anxiety is unrelated to a specific
stimulus
Anxiety Disorders
S Individuals face anxiety on a daily basis.
S It is a necessary force for survival & provides motivation for
achievement.
S Anxiety is used interchangeably with stress, however, they are
not the same.
S stressor is an external pressure that is brought to bear on the
individual.
S Anxiety is the subjective emotional response to that stressor.
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Anxiety Disorders
• Anxiety: a vague diffuse apprehension that is associated with
feelings of uncertainty and helplessness.
•
Stress: a state of disequilibrium that occurs when there is a
disharmony between demands occurring within an
individual’s internal or external environment and his/her
ability to cope with those demands.
• Fear: the intellectual appraisal of a threatening stimuli. It’s a
cognitive process.
• Anxiety is the emotional response to that appraisal.
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Anxiety Disorders
S
Anxiety disorders are the most common of all psychiatric
illnesses and may result in a considerable functional
impairment.
S
More common in women (girls) than in men (boys) by 2:1.
S
More common in low socioeconomic and minority.
S
Familial predisposition to anxiety disorders.
S
Anxiety is usually considered a normal reaction to a realistic
danger or threat to biological integrity or self-concept.
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Anxiety Disorders
S
Anxiety considered abnormal if persists even when
danger or threat is no longer present.
S
Anxiety is considered abnormal if:
1.
It is out of proportion to the situation that is creating
it.
2.
It interferes with social, occupational, or other
important areas of functioning.
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Anxiety (cont'd)
S Dissociation
S Emotional numbing
S Impaired social relationships
S Separates emotions from behaviors
S Consciousness, memory, identity, and/or perceptions
of the environment are impaired.
Common Themes
S Anxiety disorders and dissociative identity
disorder originate in childhood.
S Major common theme = disabling anxiety
S Other common features: personality and mood
changes, distorted perceptions, inability to
concentrate, memory impairment, defense
mechanisms
Common Themes (cont'd)
S Both anxiety and dissociative disorders may have
underlying comorbid illnesses like depression or
substance abuse.
S Both disorders profoundly affect quality of life.
Common Themes (cont'd)
S Psychotropic medications and teaching adaptive
coping are mainstays of treatment.
S A holistic approach is best for caring for these
clients.
1. Panic disorder
S This disorder is characterized by recurrent panic attacks, with
unpredictable onset, and manifested by intense fear, or terror,
often associated with feelings of impending doom and
accompanied by intense physical discomfort. (ongoing worry
about having another attack).
S At least four of the following 13 symptoms must be present to
identify the presence of panic disorder. If fewer than four
symptoms are present, the individual is diagnosed as having a
limited-symptom attack.
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Panic disorder
S
Symptoms:
1. Palpitation, pounding heart, or accelerated heart rate.
2. Sweating
3. Trembling or shaking
4. Sensation of shortness of breath or smothering
(suffocating)
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
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Panic disorder
S
S
Symptoms continue
9. Derealization (feelings of unreality) or
depersonalization (being detached from self)
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesis (numbness or tingling sensations)
13. Chills or hot flashes
The attacks usually last minutes or, more rarely, hours.
Symptoms of depression are common.
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Panic disorders
S The average age of onset of panic disorder is the late
20s.
S Frequency and severity varied (some people may have
a moderate attacks weekly; others may have less sever
attacks several times a weeks.
S Panic disorder may/may not be accompanied by
agoraphobia.
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2. Generalized anxiety disorder (GAD)
S
Characterized by chronic, unrealistic, and excessive anxiety
and worry. Symptoms should exist for 6 months or longer, with
no organic cause (caffeine intoxication, hyperthyroidism).
S
GAD symptoms (7 symptoms) must occurred more days than
not for at least 6 months and cause clinically significant distress
or impairment in functions.
S
These symptoms are:
1. Excessive anxiety & worry,
2. Restlessness or feeling on edge,
3. Being easily fatigued,
4. Difficulty concentrating (mind going blank),
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Generalized anxiety disorder (GAD)
5.
6.
7.
Irritability,
muscle tension, &
sleep disturbance (difficulty falling asleep,
unsatisfied sleep)
S
Depression symptoms and somatic complaints may
combine this disorder.
S
Onset is more common after 20 although the disorder
may start in childhood or adolescent.
S
GAD tends to be chronic.
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Generalized anxiety disorder (GAD)
S There are many etiological implications for panic
disorder and GAD:
S Psychodynamic theory: inability of the ego to
intervene with conflicts between id and superego,
producing anxiety.
S Cognitive theory: faulty thinking patterns precede
maladaptive behaviors and emotional disorders
leading to disturbance in feeling and behavior.
Distorted thinking produce irrational appraisal.
S Biological aspects: genetics
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Generalized anxiety disorder (GAD)
S Neuroanatomical: pathological changes in the temporal
lobes, particularly hippocampus.
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Generalized anxiety disorder (GAD)
S Biochemical: abnormal elevation of blood lactate.
S Neurochemical: involvement of the neurotransmitter
norepinephrine.
S Medical conditions: abnormality in hypothalamicpituitary-adrenal & hypothalamic-pituitary-thyroid axes;
acute MI, substance intoxication, hypoglycemia, caffeine
intoxication, mitral valve prolapse..
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3. Phobias
1.
Agoraphobia with panic disorder
* Characterized by symptoms of panic disorder and the individual
experiences a fear of being in places or situations from which
escape might be difficult or in which help might not be
available in the event that a panic attack should occur.
Example: being outside the home alone.
2. Agoraphobia without history of panic disorder
Less common than no 1
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Phobias
3. Social phobia: excessive fear of situations in which a person
might do something embarrassing or be evaluated negatively by
others.
S The individual may has extreme concern and fears any
situation where social embarrassment may happen.
S Examples (eating or speaking in public place, fear of use public
toilets, fear of writing in the presence of others, saying thing
infront of people, answering a question, etc.)
S Exposure to the phobia situation usually produce feeling of
anxiety, sweating, tachycardia and dyspnea).
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Phobias
S Onset often begins in the late childhood or early adolescence
and runs chronic, sometimes lifelong.
4. Specific phobia (simple phobia): marked, persistent,
excessive or unreasonable fear in the presence of, or in
anticipating an encounter with, a specific object or situation.
S Specific phobias frequently come with other anxiety
disorders, but they are rarely the focus of clinical attention
in these situations.
S The phobic person may be no more anxious until exposed to
the phobic object or situation.
S Upon exposure, or even when the individual thinks about
the phobic object, symptoms appear (palpitation, sweating,
dizziness, difficult breathing,30etc.).
Phobias
S Individuals invariably recognize that the fear is
excessive or unreasonable but powerless to change.
S It may occur at any age. Those begin in childhood
often disappear without treatment.
S Women more than men.
S The disorder is common among general
population, however, people seldom seek treatment
until the phobia interferes with their ability to
function.
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Phobias
S There are 5 subtypes of the most common specific phobias:
 Animal type (fear of animal or insect),
 Natural-environment type (object/situation that occur in the
natural environment such as height, storms, water),
 Blood-injection-injury type (seeing blood, having injection,
having any invasive medical procedure),
 Situational type (fear of specific situation such as elevators,
flight, driving, transportation)
 Other type (all others irrational fears such as fear of
contracting a serious illness)
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Etiological implications for phobias
1.
Psychoanalytical theory: Oedipal complex (opposite-sex
parent) and castration anxiety (fears aggression from same-sex
parent). To protect themselves these children repress this fear
from the father and displace it onto something safer which
becomes the phobic stimulus. (the phobic stimulus becomes
the symbol of the father but the child does not realize this).
2.
Learning theory: a stressful stimulus produces the
‘‘unconditioned’’ response to fear. When the stressful stimulus
repeated with a harmless object, the harmless object alone
produce the fear. This become phobia when the individual
avoids harmless objects to escape fear.
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Etiological implications for phobias
S Phobia may also acquired by direct learning or modeling (a
mother who exhibits fear toward an object will provide a
model for the child who may also develop a phobia of same
object).
3. Cognitive theory: faulty cognition/thinking such as negative
self-statements and irrational beliefs. Some individual
engage in a negative and irrational thinking that produce
anxiety reaction. The individual begins to seek out
avoidance to prevent the anxiety, and phobias result.
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Etiological implications for phobias
4.
Biological aspects:
1. Temperament: a 4 years old boy afraid of dogs
and by age of 5 he overcomes his fear and used to
play with dogs. Then, when he is 20, he is bitten
by a dog and developed a dog phobia.
2. Life experiences: some researchers believe that
phobias are symbolic of original anxietyproducing situations/subjects that have been
repressed. (a child who is punished by locked in a
room will develop phobia of closed places, a child
who falls down stairs develops phobia of high
places.
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4. Obsessive-compulsive disorder (OCD)
OCD is characterized by recurrent obsessions (unwanted ideas)
or compulsions (repetitive behavior to reduce anxiety) that
are severe enough to be time-consuming or to cause marked
distress or significant impairment.
Etiological implications:
1. Psychoanalytical theory: weak, underdeveloped egos;
regression to earlier developmental stage
2. Learning theory: conditioned response to traumatic event
3. Biological aspects: brain abnormalities, high serotonin
secretion
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5. Posttraumatic stress disorder
S
PTSD is the development of characteristic symptoms
following exposure to an extreme traumatic stressor involving
a personal threat to physical integrity or physical integrity of
others.
S
The symptoms may be occur after learning about unexpected
or violent death, serious harm, or threat of injury or death of
a family member or close person.
S
PTSD is not related to common experiences. Examples
(being kidnapped, being tortured, surviving sever automobile
accident, etc.)
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Posttraumatic stress disorder
S
Symptoms: high level of anxiety, nightmares, symptoms of
depression, symptoms should be present for more than one
month ( otherwise called acute stress disorder).
S
Etiological implications: Psychosocial theories,
learning and cognitive theories
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6. Anxiety disorder due to a general
medical condition
S Symptoms as direct physiological consequence of a general
medical condition. Examples:
 Endocrine conditions (hypo and hyperthyroidism, hypoglycemia)
 Cardiovascular conditions (congestive heart failure, pulmonary
embolism)
 Respiratory condition (COPD, pneumonia)
 Metabolic conditions (B12 deficiency
 Neurological conditions (encephalitis)
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7. Substance-induced anxiety disorder
S Symptoms are due to direct physiological effects of a
substance (drug, toxin exposure).
S They symptoms may occur during substance
withdrawal.
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Treatment modalities for anxiety
disorders
S Individual psychotherapy
S Cognitive therapy
S Behavioral therapy
S Group and family therapy
S Psychopharmacology
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Your Assessment Approach:
The Client with an Anxiety
Disorder
S Physiological Assessment
S How often do you experience palpitations?
S Psychological Assessment
S Do you feel sad and/or hopeless?
Your Assessment Approach:
The Client with an Anxiety
Disorder
S Cognitive Assessment
S Do you think about the same things over and over?
S
[More at Your Assessment Approach: Anxiety Disorder]
S
Your Assessment
Approach:
The Client with Panic
Attack
To determine the psychological effects of panic on
your client, ask:
S How do you feel right now?
S When did you start feeling this way?
S
Your Assessment
Approach:
The Client with Panic
Attack
To determine the somatic effects of panic on your
client, ask:
S Are you having chest pains or shortness of breath?
S Have you felt dizzy or faint?
S
[More at Your Assessment Approach: Panic Attack]
Your Assessment
Approach:
The Client with PTSD
S Questions to help assess PTSD
S When was the last time you struck out in anger?
S How would you describe your mood right now?
Happy? Sad? Depressed?
S How much time do you spend thinking the same
thing over and over?
Your Assessment
Approach:
The Client with PTSD
S Questions to help assess PTSD
S How do you sleep at night? Any nightmares or
repetitive dreams?
S
[More at Your Assessment Approach: PTSD]
Comprehensive
Assessment (cont'd)
S Conduct a history and physical exam.
S Gather subjective and objective information.
S Interview family member(s) if possible.
Comprehensive
Assessment (cont'd)
S Complete psychosocial assessment to discover
source of anxiety.
S Differentiate between anxiety and depression.
S Evaluate sleep and sleep quality.
Comprehensive
Assessment (cont'd)
S Complete suicide and homicide assessment.
S Major focuses for a client with dissociative
disorder are identity, memory, and consciousness.
Plan of Care for Anxiety
S Mild to moderate anxiety
S Use a calm, quiet approach
S Observe client’s verbal/nonverbal behavior
S Encourage client to verbalize feelings
Plan of Care for Anxiety
(cont'd)
S Mild to moderate anxiety
S Teach relaxation techniques (meditation, guided
imagery, etc.) when anxiety is mild
S Simple physical activities often help reduce anxiety
S Develop goal-oriented contract
Plan of Care for Anxiety
(cont'd)
S Severe to panic levels of anxiety:
S First priority is to reduce anxiety to tolerable levels.
S Stay with the client.
S Provide a safe and supportive milieu.
S Use a firm voice and short, simple sentences.
Plan of Care for Anxiety
(cont'd)
S Severe to panic levels of anxiety:
S Place client in quieter, smaller, less stimulating
environment; focus the client’s diffuse energy on
repetitive task or tiring task.
S Administer antianxiety medication if ordered.
Client/Family Education
S Medications used to treat anxiety disorders
include benzodiazepines, tricyclics, Selective
serotonin reuptake inhibitors SSRIs and Serotonin and
norepinephrine reuptake inhibitors SNRIs, lithium,
beta blockers, alpha-adrenergic antagonists,
atypical antipsychotics, and neuroleptics.
S Teach about medication indications, side effects,
and drug–drug interactions.
Client/Family Education
(cont'd)
S Teaching about medications
S Drowsiness is a common side effect.
S Do not drink alcohol while taking.
S Drink decaffeinated beverages.
S Do not take other medications or adjust dosage in
any way without consulting health care provider.
Client/Family Education
(cont'd)
S Nonpharmacologic measures comprise effective
coping skills:
S CBT techniques (desensitization (in which panic or
other undesirable emotional response to a given stimulus is
reduced or extinguished, especially by repeated exposure to
that stimulus), reciprocal inhibition (describes the
process of muscles on one side of a joint relaxing to
accommodate contraction on the other side of that joint).,
cognitive restructuring)
S Relaxation training
S Individual or group therapy
S Exercise and nutrition
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Personal Challenges
S Anxiety is contagious.
S The nurse may be impatient and irritated by
somatic complaints.
S It is important to identify the source of one’s own
anxiety and consistently role-model adaptive
behavior.
Personal Challenges
(cont'd)
S A client’s avoidance mechanism can be
challenging to staff.
S Some nurses feel overwhelmed and helpless in
the face of clients’ pain and catharsis.
S Ready answers are more likely to interfere with
client’s communication.
THANK YOU
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