Irene Dunn, MA,MSN,RNC
Physiological Responses to
Anxiety
Cardiovascular System
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Palpitations
Racing heart
Increased blood
pressure
Faintness*
 Actual fainting*
 Decreased blood
pressure*
 Decreased pulse rate*
Physiological Responses to
Anxiety
Respiratory System
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Rapid breathing
Shortness of breath
Pressure on chest
 Shallow breathing
Lump in throat
 Choking sensation
 Gasping
Physiological Responses to
Anxiety
Gastrointestinal System
 Loss of appetite
 Revulsion toward
food
 Abdominal
discomfort
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Abdominal pain*
Nausea*
Heartburn
Diarrhea*
Physiological Responses to
Anxiety
Neuromuscular System
 Increased reflexes
 Startle reaction
Eyelid twitching
 Insomnia
 Tremors
 Rigidity
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Fidgeting
Pacing
Strained face
Generalized
weakness
 Wobbly legs
 Clumsy movement
Physiological Responses to
Anxiety
Skin
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Flushed
face
Localized
sweating
(palms)
Itching
 Hot and cold spells
 Pale face
 Generalized
sweating
Physiological Responses to
Anxiety
Urinary Tract
 Pressure to urinate*
 Frequent Urination*
 *Parasympathetic response
Behavioral Responses to
Anxiety
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Restlessness
Physical tension
Tremors
Startle reaction
Hypervigilance
Rapid speech
 Lack of coordination
 Accident proneness
 Interpersonal
withdrawal
 Inhibition
 Flight
 Avoidance
 Hyperventilation
Cognitive Responses to Anxiety
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Impaired attention
Poor concentration
Forgetfulness
Errors in judgment
Preoccupation
Blocking of thoughts
Decreased perceptual
filed
 Reduced creativity
 Diminished productivity
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Confusion
Self-consciousness
Loss of objectivity
Fear of losing control
Frightening visual images
Fear of injury or death
Flashbacks
Nightmares
Affective Responses to Anxiety
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Edginess
Impatience
Uneasiness
Tension
Nervousness
Fear
Fright
Shame
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Frustration
Helplessness
Alarm
Terror
Jitteriness
Jumpiness
Numbing
Guilt
Medical Disorders Associated
with Anxiety
Medical Disorders Associated
with Anxiety
Cardiovascular/Respiratory
 Asthma
 Cardiac arrhythmias
 Chronic obstructive
pulmonary disease
 Congestive heart
failure
 Coronary
insufficiency
 Hyperfynamic betaadrenergic state
 Hypertension
 Hyperventilation
syndrome
 Hypoxia, embolus,
infections
Medical Disorders Associated
with Anxiety
Endocrinology
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Carcinoid
Cushing’s syndrome
Hyperthyroidism
Hypoglycemia
Hypoparathyroidism
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Hypothyroidism
Menopause
Pheochromocytoma
Premenstrual
syndrome
Medical Disorders Associated
with Anxiety
Neurological
 Collagen vascular
 Multiple sclerosis
disease
 Organic brain
 Epilepsy
syndrome
 Huntington’s disease  Vestibular
dysfunction
 Wilson’s disease
Medical Disorders Associated
with Anxiety
Substance Related Intoxications
 Anticholinergic
drugs
 Aspirin
 Caffeine
 Cocaine
 Hallucinogens
including
phencyclidine (angle
dust)
 Steroids
 Sympathomimetics
 THC
Medical Disorders
Associated with Anxiety
Withdrawal Syndromes
 Alcohol
 Narcotics
 Sedative-hypnotics
Panic Attack Criteria
Palpitations, pounding
heart, or accelerated
heart rate
Sweating
Trembling or shaking
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 (feelings
of unreality) or
depersonalization
(being detached from
oneself)
Panic Attack Criteria
 Fear of losing control or going crazy
 Fear of dying
 Paresthesias (numbness or tingling
sensations)
 Chills or hot flashes
Obsession and Compulsion
Criteria
 Obsession
– Recurrent and persistent thoughts, impulses, or
images are experienced during the disturbance
as intrusive and inappropriate and cause
marked anxiety or distress
– The thoughts, impulses, or images are not
simply excessive worries about real-life
problems.
Obsession and Compulsion
Criteria
– The person attempts to ignore or suppress such
thoughts or impulses or to neutralize them
with some other thought or action
– The person recognizes that the obsessional
thought impulses, or images are a product of
one’s own mind.
Obsession and Compulsion
Criteria
 Compulsion
– The person feels driven to perform repetitive
behaviors (such as hand washing, ordering,
checking) or mental acts (such as praying,
counting, repeating words silently) in response
to an obsession or according to rules that must
be applied rigidly.
Obsession and Compulsion
Criteria
The behaviors or mental acts are aimed at
preventing or reducing distress or preventing
some dreaded event or situation; however,
these behaviors or mental acts either are not
connected in a realistic way with what they are
designed to neutralize or prevent or are clearly
excessive.
Differences Between Anxiety
and Depression
Anxiety
Predominantly fear or
apprehension
Difficulty falling asleep
(initial insomnia)
Phobic avoidance
behavior
Rapid pulse and
psychomotor
hyperactivity
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 Depression
Predominantly sad or
hopeless with feelings of
despair
Early morning awakening
(late insomnia) or
hypersomnia
Diurnal variation (feels
worse in the morning)
Slowed speech and
thought processes
Differences Between Anxiety
and Depression
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 Anxiety
Breathing disturbances
Tremors and palpitations
Sweating and hot or cold
spells
Faintness,
lightheadedness,
dizziness
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 Depression
Delayed response time
Psychomotor retardation
(agitation may also occur)
Loss of interest in usual
activities
Inability to experience
pleasure
Differences Between Anxiety
and Depression
 Anxiety
 Depersonalization
(feeling that one’s
environment is
strange, unreal, or
unfamiliar)
 Selective and specific
negative appraisals
that do not include all
areas of life
 Depression
 Thoughts of death or
suicide
 Negative appraisals
are pervasive, global,
and exclusive
 Sees the future as
blank and has given
up all hope
Differences Between Anxiety
and Depression
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 Depression
 Anxiety
Sees some prospects  Regards mistakes as
for the future
beyond redemption
Does not regard
 Absolute in negative
defects or mistakes
evaluations
as irrevocable
 Global view that
Uncertain in negative
nothing will turn out
evaluation
right
Predicts that only
certain events may
go badly
Summarizing the Evidence
on Anxiety Disorders
Disorder:
Generalized anxiety disorder
Treatment:
Most treatment outcome studies
have shown active treatments to be superior to
nondirective approaches, and uniformly
superior to no treatment, however; most of
these studies failed to demonstrate differential
rates of efficacy among active treatments.
Treatment: Generalized anxiety
disorder
Recent studies suggested cognitive-behavior
therapy (combining relaxation exercises and
cognitive therapy), with the goal of bring the
worry process under control, to be most
efficacious
The benzodiazepines reduced the anxiety and
worry symptoms of GAD
Buspirone appeared comparable to the
benzodiazepines in alleviating GAD symptoms
The tricyclic antidepressants have been useful in
the treatment of GAD
Disorder:
Obsessive compulsive disorder
(OCD)
 Treatment:
Cognitive-behavioral therapy
involving exposure and ritual prevention methods
reduced or eliminated the obsessions and
behavioral and mental ritual of OCD.
 Approximately 40% to 60% of OCD patients
respond to serotonergic reuptake inhibitors
(SRI’s), including clomipramine, fluvoxamine,
paroxetine, fluoxetine, and sertraline, with mean
improvement in obsessions and compulsions of
approximately 20% to 40%.
Disorder: Panic disorder
 Treatment:
situational in vivo exposure
substantially reduced symptoms of panic disorder
with agoraphobia.
 Cognitive-behavioral treatments that focused on
education about the nature of anxiety and panic
and provided some form of exposure and coping
skills acquisition significantly reduced symptoms
of panic disorder without agoraphobia
Disorder: Panic disorder
 Tricyclic antidepressants and monoamine oxidase
inhibitors reduced the number of panic attacks
and also reduced anticipatory anxiety and phobic
avoidance, although side effects cause some
patients to drop from clinical trials.
 The benzodiazepines (e.g. Alprazolam) elinated
panic attacks in 55% to 75% of patients.
Disorder: Panic disorder
 More recently, serotonin reuptake
inhibitors (SRI’s), and selective serotonin
reuptake inhibitors (SSRI’s) have produced
reductions in panic frequency, generalized
anxiety, disability and phobic avoidance.
Disorder: Posttraumatic stress
disorder
 Treatment: Monoamine oxidase
inhibitors (MAO’s) reduced intrusive
thoughts, improved sleep, and moderated
anxiety and depression in PTSD patients.
 Tricyclic antidepressants reduced intrusive
thoughts and obsessions and moderated
depression in these patients.
Disorder: Posttraumatic stress
disorder
 Selective serotonin reuptake inhibitors (SSR’s)
markedly reduced intrusive thoughts, avoidance,
and sleep problems.
 Exposure therapies (systematic desensitization,
flooding, prolonged exposure and implosive
therapy) and , to a lesser extent, anxiety
management techniques (using cognitivebehavioral strategies) reduced PTSD symptoms,
including anxiety and depression, and increased
social functioning.
Antianxiety Drugs
Benzodiazepines
 Alprazolam (Xanax)
 Chloridazepoxide
(Librium)
 Clorezepate
(Tranxene)
 Diazepam (Valium)
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Halazepam (Paxipam)
Lorazepam (Ativan)
Oxazepam (Serax)
Prazepam (Centrax)
Antianxiety Drugs
 Antihistamines
– Diphenhydramine (Benadryl)
– Hydroxyzine (Atarzx)
 Beta-Adrenergic Blocker
– Propranolol (Inderal)
 Anxiolytic
– Buspirone (BuSpar)
Antidepressant/Antianxiety
Drugs
 Citalopram (Celexa)
 Fluoxetine (Prozac)
 Fluvoxamine (Luvox)
 Paroxetine (Praxil)
 Sertraline (Zoloft)
Other Newer Antidepressants
 Mirtazepine (Remerom)
 Nefazodone (Serzone)
 Reboxetine (Vestral)
 Trazodone (Desyrel)
 Venlafaxine (Effexor)
Tricyclics
 Amitiptylene (Elavil)
 Desipramine (Norpramin)
 Clomipramine (Anafranil)
 Imipramine (Tofranil)
 Nortiptyline (Pamelor)
 MAO’s
 Phenelzine (Nardil)
Cognitive Behavioral Treatment
Strategies for Anxiety Disorders
Anxiety Reduction
 Relaxation training
 Biofeedback
 Systematic
desensitation
 Interoceptive
exposure
 Flooding
 Vestibular
desensitization training
 Response prevention
 Eyemovement
desensitization and
reprocessing (EMDR)
Cognitive Restructuring
 Monitoring thoughts
and feelings
 Questioning the
evidence
 Examining
alternatives
 Decatastrophizing
 Reframing
 Thought stopping
Learning New Behavior
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Modeling
Shaping
Token economy
Role playing
 Social skills training
 Aversion therapy
 Contingency
contracting