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Chapter 25 – Anxiety Disorders
Anxiety-uncomfortable feeling of apprehension / dread in
response to internal or external stimuli.
- physical, emotional, cognitive, behavioral sx
o Physical: Sweating, heart palpitations, ↑BP, ↑rr, SOB,
pacing,flushed skin, N/V/D, heartburn, etc.
o Emotional/Behavioral: Uneasy, nervous, tense, fearful, agitated,
exaggerated responses, restless, hypervigilant, etc.
o Cognitive: Unable to focus, confused, distracted, etc.
normal emotional response to anxiety
1.Physiologic arousal, fight-or-flight response, signal that an
individual is facing a threat.
2.Cognitive processes decipher the situation and decide whether
the perceived threat should be approached or avoided.
3. Coping strategies resolve the threat.
factors that determine whether anxiety is a symptom of a
mental disorder - intensity of anxiety relative to situation, trigger
for anxiety, symptom clusters that manifest anxiety.
Mild -Perceptual field widens slightly.
-observe more than before to see relationships
- Learning possible.
- aware, alert, sees, hears, grasps more than before.
-recognize and identify anxiety easily.
Moderate Perceptual field narrows slightly.
Selective inattention: not notice peripheral to immediate focus
but can do if attention directed by another observer.
-Sees, hears, and grasps less than previously.
- attend to more if directed
- sustain attention on particular focus;
-selectively inattentive to contents outside focal area.
- “I am anxious now.
Severe Perceptual field greatly reduced.
-dissociation: not notice outside current.↓ focus of attention;
-largely unable to do so when another observer suggests
-Sees, hears, grasps far less than previously.
- Attention - small area
- Inferences distorted -inadequacy of observed data.
-unaware / unable to name anxiety. Relief behaviors used.
Panic (e.g.,terror,horror,dread,uncanniness,awe)
-Perceptual field: reduced to detail usu. “blown up,”
-i.e., elaborated by distortion (exaggeration),
-focus -scattered details; speed of scattering increase.
-Massive dissociation- contents of self-system.
- threat to survival. -Learning impossible.
- “I’m in a million pieces,” “I’m gone,” “What is happening to me?”
-Perplexity, self-absorption. Feelings of unreality. Flights of ideas
/confusion.Fear. Repeats detail. Many relief behaviors automatic
(w/out thought).
-enormous energy must be used rage.pace, run, fight violently.
-dissociation contents of self-system- very rapid reorganization of
self,usually going along pathologic lines - “psychotic break” is
usually preceded by panic)
Normal anxiety - realistic intensity/ duration for situation follwd
by relief behaviors- ↓/ prevent ↑anxiety-appropriate to situation
Abnormal anxiety interferes w/ daily functioning.
Anxiety Disorders: primary sx:fear /anxiety.
- fear /anxiety excessive, out of proportion to situation.
- ability to work / interpersonal relationships - impaired.
- differentiated by situation /objects that provoke fear, anxiety, or
avoidance behavior / related cognitive thoughts.
Children: untx, sx persist - worsen.
- SI/ suicide attempts, early parenthood, subsabuse/dependence,
educ underachievement
Separation anxiety disorder - childhood.
Older Adults: ↓social fxn, ↑ somatic symptoms, ↑depressive sx
Panic Disorder
- extreme, overwhelming form of anxiety in a real/perceived lifethreatening situation.
- normal:periods of threat
-abnormal : no real physica/ psychological threat.
Panic Attacks: sudden, discrete pd of intense fear/discomfort in
few min w/significant physical discomfort/cognitive distress.
-10- 30 minutes.
Physical sx: Palpitations, chest discomfort, rapid pulse, nausea,
dizziness,sweating, paresthesia’s, trembling/shaking, suffocation
or SOB.- Similar to heart attack.
Cognitive sx: Disorganized thinking, irrational fears,
depersonalization, ↓communicate. impending doom/ death, fear
of going crazy/ out of control, desperation.
-Rec unexpected panic attacks,persistent concern having ↑ attack
- first panic attack - identifiable cause; subsequent - unexpected
Diagnostic Criteria: Recurrent unexpected panic attacks
-> 1 month after attack w/one of ff:
o Persistent concern about having another attack
o Worrying about implications of attack/ consequences, -avoid
certain places/people/things change lifestyle.
o Significant changes in behavior - fear of attacks
o agoraphobia or w/out agoraphobia.
Panic Disorder w/ Agoraphobia: most severe form of panic dx
- same symptoms of panic disorder w/fear of being in places w/c
escape is difficult /no help
Epidemiology/Risk Factors: female, middle aged, low SE status,
widowed/separated/divorced.
- Family history, substance stimulant abuse, smoking tobacco,
severe stressors.
o separation anxiety dur childhood.
o Early life traumas, hx of physical or sexual abuse, socioeconomic
or personal disadvantages, behavioral inhibition by adults.
Etiology:
1.Biologic Theories: It is highly heritable and runs in families.
2.Serotonin & Norepinephrine
NE- cardiovascular, respiratory, gastrointestinal systems.
Serotonergic neurons - central autonomic and emotional motor
3.GABA-most abundant inhibitory NT in the brain
- neurocognitive efx, ↓anxiety, sedation,↑seizure threshold.
-Abnormalities benzodiazepine–GABA–chloride ion channel
4. (HPA) Axis: activation of stress hormones, ↑anxiety /panic
5.Psychosocial Theories:
Psychodynamic: separation and loss.
Cognitive Behavioral Theory: Classic conditioning theory - learns
fear by linking adverse/ fear-provoking event w/ neutral event.
Priority Care Issues: safety.
Emergency Care: Stay w/ pt, maintain a calm demeanor/envt
Reassure patient you will not leave, and episode will pass, tell
them they are in a safe place. Give clear concise directions using
short sentences. Walk or pace w pt to an envt w/ minimal
stimulation. Administer PRN anxiolytic medications if needed.
Planning/Implementation:
o Systematic Desensitization: Exposes to a hierarchy of feared
situations from least to most feared. taught to use msrelaxation
o Implosive Therapy: therapist identifies phobic stimuli then
presents highly anxiety-provoking imagery
o Flooding: desensitize to fear assoc w anxiety-provoking
stimulus. presented w/feared objects/ situations repeatedly until
anxiety dissipates.
o Exposure Therapy: tx of choice for phobias. repeatedly exposed
to real/ simulated anxiety-provoking situations until desensitized o Cognitive Behavioral Therapy: first line trx ; used w/meds- SSRIs.
goal – help manage anxiety/ correct anxiety-provoking thoughts
through interventions
- cognitive restructuring, breathing training, psychoeducation.
o Reframing: Change situation, event, or person is viewed and
↓impact of anxiety-provoking thoughts.
o Positive Self-Talk: Involves planning / rehearsing positive coping
statements - “This is anxiety, it will pass.”, “I can handle these
symptoms.” give focal point,reduce fear when panic sx begin
Agoraphobia-Fear or anxiety triggered by about two or more
situations such as using public transportation, open spaces,
enclosed spaces, standing in line, being in a crowd, or being
outside of the home alone.
- believes something terrible might happen and escape difficult
- leads to avoidance behaviors- interferes w/ routine functioning afraid to leave the safety of the home.
- occur w/ panic disorder but is considered to be separate.
Medications:
SSRIs - fluoxetine (Prozac), sertraline (Zoloft),Imipramine(Tofranil).
Benzodiazepines - short-term tx during a panic attack. not for
long-term therapy - highly addictive.
Alprazolam (Xanax): short-term relief of anxiety , panic attacks.
- drowsiness, sedation, lethargy, fatigue,disorientation,
-rebound anxiety-anxiety that increases after the peak effects
have decreased. You must taper off.
- avoid alcohol and other OTC drugs. not stop taking meds without
talking to their doctor first. w/food. Avoiding driving a car or tasks
that require alertness.
Common Specific Phobias include:
o Agoraphobia: Fear of open spaces
o Xenophobia: Fear of strangers
o Zoophobia: Fear of animals
o Claustrophobia: Fear of closed spaces
Acrophobia: fear of heights
Agoraphobia: fear of open spaces
Ailurophobia: fear of cats
Algophobia: fear of pain
Arachnophobia: fear of spiders
Brontophobia: fear of thunder
Claustrophobia: fear of closed spaces
Cynophobia: fear of dogs
Entomophobia: fear of insects
Hematophobia: fear of blood
Microphobia: fear of germs
Nyctophobia: fear of night or dark places
Ophidiophobia: fear of snakes
Phonophobia: fear of loud noises
Photophobia: fear of light
Pyrophobia: fear of fire
Topophobia: fear of a place, like a stage
Xenophobia: fear of strangers
Zoophobia: fear of animal or animal
Generalized Anxiety Disorder- chronic, unrealistic, and excessive
anxiety and worry.
- frustrated, disgusted with life, demoralized, hopeless.
- cannot remember a time that they did not feel anxious.
-sense of ill-being and uneasiness and a fear of imminent disaster.
Clinical Course: insidious onset. chronic worriers.
-Worry is the hallmark symptom.
- affects all ages; onset in childhood and adolescence,
- mild depressive symptoms such as dysphoria.
- catastrophic thinking, - overthinking.
- highly somatic, - clusters sx-mx aches, soreness, GI ailments.
- poor sleep habits, irritability, trembling, twitching, poor
concentration, exaggerated startle response.
: -Excessive worry /anxiety for at least 6 mos
-anxiety related to several real-life activities or events.
Nursing Care: similar to panic disorder. Medications - antianxiety
agents/ antidepressants
Pharmacology:
Benzodiazepines - short-term use - alprazolam (Xanax)
SE: drowsiness, dizziness, N/V, psychological dependence, respi↓
SSRIs - paroxetine (Paxil), imipramine (Tofranil),
SNRI- venlafaxine
Buspirone (BuSpar): Commonly used - no risk for dependence.
Beta-Blockers: Clonidine (Catapres), propranolol (Inderal).
Zolpidem (Ambien): non-benzodiazepine - sleep agent.
Specific Phobia Disorder- persistent fear of clearly discernible,
circumscribed objects /situations- leads to avoidance behaviors.
Diagnostic Criteria: Unreasonable, excessive fear; immediate
anxiety response; avoidance or extreme distress; life-limiting; six
months duration; not caused by another disorder.
- focus of fear - anticipation of being harmed by phobic object.
-Anxiety is felt immediately on exposure to the phobic object and
level of anxiety is related to - proximity and degree to escape escalate to a full panic attack.
Factors that may predispose individuals to specific phobias traumatic events, unexpected panic attacks in presence of phobic
object or situation; observation of others experiencing a trauma;
or repeated exposure to information warning of dangers.
treatment of choice - exposure therapy.
- anxiolytics- short-term relief of anxiety.
Social Anxiety Disorder (Social Phobia)
- persistent fear of social or performance situations in which
embarrassment may occur.
-fear others scrutinize their behavior/ judge negatively
-diagnosed - fears related to most social situations, including
public performances and social interactions.
- low dopamine receptor binding,
- fear and avoid only one or two social situations.
- eating, writing, or speaking in public or using public bathrooms.
most common fears - public speaking, fear of meeting strangers,
eating in public, writing in public, using public restrooms, being
stared at or being the center of attention.
-Pharmacotherapy is a relatively new area of research in treating
patients with social anxiety disorder. SSRIs ,. Benzodiazepines are
Providing referrals