Mental Health Nursing II
NURS 2310
Unit 13
Anxiety and Somatoform
Disorders
Key Terms

Anxiety = Apprehension, tension, or
uneasiness from anticipation of
unknown/unrecognized danger; considered
pathological when social and/or occupational
functioning is affected
 Stress = Mental/emotional/physical strain
experienced in response to stimuli from the
external or internal environment
 Somatization = the expression of
psychological needs in the form of physical
symptoms; possibly related to repressed
anxiety

Panic = A sudden overwhelming feeling of
terror or impending doom; usually
accompanied by behavioral, cognitive, and
physiological signs/symptoms considered to
be outside the norm
 Hysteria = Characterized by recurrent
multiple somatic complaints that are
unexplained by organic pathology, and is
thought to be associated with repressed
anxiety
 Dissociation = The splitting off of clusters
of mental contents from conscious
awareness

Amnesia = A pathologic loss of memory of
an experience or specific period of time;
emotional, dissociative, or organic in nature
 Phobia = An excessive or unreasonable fear
cued by the presence or anticipation of a
specific object or situation, exposure to
which provokes an immediate anxiety
response; the phobic stimulus is avoided or
endured with marked distress
Types of Anxiety and
Anxiety-Related Disorders
Panic Disorder
Recurrent panic attacks that cause intense
apprehension, fear, or terror
 Associated w/feelings of impending doom
 Accompanied by intense physical
discomfort
 Panic attacks usually last only minutes, but
symptoms of depression are common due
to unpredictable nature of occurrence
 Average age at onset is late 20s
 Characterized by periods of remission and
exacerbation

Diagnostic Criteria for Panic Disorder include
the presence of at least 4 of the following:
– palpitations, pounding heart, or accelerated heart
rate
– sweating
- parasthesias
– trembling or shaking
- chills or hot flashes
– sensations of shortness of breath or smothering
– feeling of choking
– chest pain or discomfort
– nausea or abdominal distress
– feeling dizzy, unsteady, lightheaded, or faint
– derealization or depersonalization
– fear of losing control or going crazy
– fear of dying
Generalized Anxiety Disorder
Chronic, unrealistic, and excessive worry that
causes clinically significant distress or
impairment in social/occupational functioning
 Numerous somatic complaints and symptoms
of depression are common; exacerbations are
stress-related
 Other symptoms include restlessness,
fatigue, irritability, difficulty concentrating,
muscle tension and sleep disturbances
 May begin in childhood/adolescence
 Diagnosed after 6 months of symptoms

Phobias

Includes agoraphobia, social phobia (or
social anxiety disorder), and specific phobia
Agoraphobia
Fear of being in places/situations from
which one can’t escape, or in which help
might not be available if panic symptoms
should occur
 Onset in the 20s or 30s; persists for many
years
 Impairment can be severe and cause the
individual to be confined to his/her home

Social Phobia
Excessive fear of situations in which a
person might do something embarrassing or
be evaluated negatively by others
 Extreme concerns about being exposed to
possible scrutiny by others
 Fear of social or performance situations in
which embarrassment may occur
 Onset of symptoms often begins in late
childhood or early adolescence and runs a
chronic, sometimes lifelong, course
 Impairment interferes with functioning

Specific Phobia
A marked, persistent, and excessive or
unreasonable fear when in the presence of,
or when anticipating an encounter with, a
specific object or situation
 Frequently occur concurrently with other
anxiety disorders
 Exposure to the phobic stimulus produces
overwhelming symptoms of panic, including
palpitations, sweating, dizziness, and
difficulty breathing
 Individual recognizes that fear is excessive,
but powerless to change it

Obsessive-Compulsive Disorder

Obsessions = unwanted, intrusive, persistent
ideas, thoughts, impulses, or images that
cause marked anxiety or distress
 Compulsions = unwanted, repetitive behavior
patterns or mental acts such as praying or
counting that are intended to reduce anxiety
 Obsessive-Compulsive Disorder = recurrent
obsessions/compulsions severe enough to
cause significant distress or impairment;
individual recognizes behavior as excessive,
but is compelled to continue due to the relief
from discomfort that it provides; usually
begins in adolescence or early adulthood
Body Dysmorphic Disorder
Exaggerated belief that the body is
deformed or defective in some specific way
 Most common complaints involve imagined
or slight flaws of the face or head

Trichotillomania
(Hair-Pulling Disorder)
The recurrent pulling out of one’s hair from
the scalp, eyebrows, and eyelashes
 Impulse preceded by increasing tension; the
act produces sense of release or gratification
 Usually begins in childhood

Trauma-Related Disorders

Includes post-traumatic stress disorder
(PTSD) and acute stress disorder
Post-Traumatic Stress Disorder
Develops following exposure to an extreme
traumatic stressor involving a threat to the
physical integrity of self or others
 Symptoms may begin within 3 months after
the trauma or may be delayed; diagnosis
occurs after symptoms that cause significant
interference w/functioning have been
present for at least 1 month

PTSD (cont’d)
Individual re-experiences the traumatic
event via intrusive recollections/nightmares;
may not recall every aspect of the trauma
 Involves either a sustained high level of
anxiety/arousal or a general numbing of
responsiveness; may lead to depression
and/or substance abuse

Acute Stress Disorder

Symptomology is the same as for PTSD, but
symptoms resolve within 1 month of the
precipitating trauma
Adjustment Disorder
A maladaptive reaction to an identifiable
stressor that results in the development of
clinically significant emotional or behavioral
symptoms that impair social/occupational
functioning or are in excess of expected
reaction to the stressor
 Occurs within 3 months after onset of
stressor and persists for no longer than 6
months after stressor or its consequences
have ended
 Manifested as depression, anxiety, actingout behaviors or a combination thereof

Somatic Symptom Disorders
Includes somatic symptom disorder, illness
anxiety disorder, conversion disorder, and
factitious disorder (previously known as
Munchausen syndrome)
 May involve primary or secondary gains

– In primary gain, the physical symptoms allow
the individual to avoid some unpleasant activity
or difficult situation about which he or she is
anxious
– Secondary gain involves the promotion of
emotional support or attention the individual
might not otherwise receive
Somatic Symptom Disorder
Characterized by multiple physical
symptoms that have no medical explanation
 Associated with psychological distress and
long-term seeking of assistance from
health-care professionals
 Symptoms may be vague, dramatized, or
exaggerated in their presentation

Illness Anxiety Disorder

Unrealistic or inaccurate interpretation of
physical symptoms that results in excessive
preoccupation about having a serious illness
Illness Anxiety Disorder (cont’d)
Fear becomes persistent and disabling in
spite of reassurances that no organic
pathology can be found
 History of doctor-shopping due to presumed
misdiagnosis

Conversion Disorder
Emotional distress expressed through loss
of (or change in) body function for which
there is no apparent physical cause
 Symptoms may occur suddenly following a
stressful experience

Factitious Disorder
The conscious, intentional feigning of
physical and/or psychological symptoms on
oneself or another person (i.e. by proxy) in
order to receive emotional care and support
 May involve self-infliction of painful injuries,
injection or insertion of contaminated
substances, manipulation of medical
assessment instruments, and/or improper
use of medication

Dissociative Disorders

Includes dissociative amnesia, dissociative
identity disorder (or multiple personality
disorder), and depersonalizationderealization disorder
Dissociative Amnesia
Inability to recall important personal
information; may be specific to a trauma or
series of traumatic experiences
 Usually follows severe psychosocial stress,
and recovery is often abrupt and complete

Dissociative Identity Disorder
Characterized by the existence of two or
more unique personalities in a single
individual
 Only one personality is evident at any given
moment, and only one is dominant most of
the time over the course of the disorder
 Transition from one personality to another
may be sudden or gradual, and may be
dramatic
 Symptomology causes clinically significant
distress or functional impairment

Depersonalization-Derealization
Disorder

Depersonalization = a disturbance in the
perception of oneself
 Derealization = an alteration in the
perception of the external environment

Depersonalization-Derealization Disorder =
characterized by a temporary change in the
quality of self-awareness
– Involves change in body image and feelings of
unreality or detachment from the environment
– Diagnosis made upon functional impairment
Treatment Modalities

Individual psychotherapy
– Eye movement desensitization and
reprocessing (EMDR)

Cognitive and/or behavioral therapy
– Systematic desensitization
– Implosion therapy (flooding)

Group/family therapy

Psychopharmacology
Medications used to Treat
Anxiety Disorders

Most commonly treated with anti-anxiety
agents and sedative-hypnotics
– Depress subcortical levels in the limbic system
– CNS depression ranges from mild sedation to
coma

Classes of anti-anxiety agents include
antihistamines, benzodiazepines, and
miscellaneous agents
– Buspirone (Buspar) does not depress the CNS
 10-day to 2-week onset
 Does not build tolerance or dependence

Sedative-hypnotics include barbiturates,
benzodiazepines, and miscellaneous agents
*Anti-anxiety agents:
 Antihistamines
– Hydroxyzine (Atarax, Vistaril)

Benzodiazepines
– Alprazolam (Xanax)
– Chlordiazepoxide (Librium)
– Clonazepam (Klonopin)
– Clorazepate (Tranxene)
– Diazepam (Valium)
– Lorazepam (Ativan)

Miscellaneous agents
– Buspirone (Buspar)
Anti-Anxiety Agents (cont’d)
 Efficacy may vary
– Alcohol, narcotics, barbiturates, antipsychotics,
and antidepressants increases effects
– Nicotine and caffeine decreases effects
Common side effects include drowsiness,
confusion, and lethargy
 Abrupt withdrawal can be life-threatening

– Insomnia
– Increased anxiety
– Vomiting
– Tremors, convulsions, and delirium
*Sedative-hypnotics:
 Barbiturates
– Secobarbital (Seconal)

Benzodiazepines
– Flurazepam (Dalmane)
– Temazepam (Restoril)
– Triazolam (Halcion)

Miscellaneous Agents
– Chloral Hydrate (Noctec)
– Zaleplon (Sonata)
– Zolpidem (Ambien)
– Eczopiclone (Lunesta)
Sedative-Hypnotic Agents (cont’d)
 Short-term use
 Chronic use may induce tolerance and
physical/psychological dependence
 Additive effect on CNS depression with
alcohol, antihistamines, antidepressants, or
other CNS depressants
 Watch for decreased effectiveness of other
medications metabolized by the liver
Nursing Process

Assessment
– Gather information about client’s mood and
level of anxiety, thoughts to harm self/others

Diagnosis
– Risk for self-directed violence R/T anxietyrelated depression
– Imbalanced nutrition, less than body
requirements R/T lack of interest in food
– Disturbed sleep pattern R/T anxiety
– Anxiety R/T panic disorder
– Social isolation R/T agoraphobia

Planning
– Care plan
– Concept map

Implementation
– Establish trust
– Provide for safety
– Perform risk assessment
– Administer scheduled and PRN medications

Evaluation
– Mental health/psychiatric assessment tool
– Review safety plan/contract
– Assess for medication side effects