Anxiety Disorders
Anxiety Disorders
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Separation anxiety disorder
Selective Mutism
Specific phobias
Social anxiety disorder (social phobia)
Panic disorder
Agoraphobia
Generalized anxiety disorder
Specific Phobias
diagnostic criteria
• A. Marked fear or anxiety about a specific
object or situation
– Animals: cats, spiders
– Natural Environmental: heights, storms
– Blood- injection- injury: needles, invasive medical
procedures
– Situational: airplanes, elevators
• B. The phobic object or situation almost
always provokes immediate fear or anxiety
Specific Phobias: diagnostic criteria
• C. The phobic object or situation is actively
avoided or endured with intense fear or
anxiety
• D. The fear or anxiety is out of proportion to
the actual danger posed by the specific object
or situation and to the sociocultural context
• E. The fear anxiety or avoidance is persistent,
typically lasting for 6 months
Specific Phobias: diagnostic criteria
• F. The fear, anxiety or avoidance causes
clinically significant distress or impairment in
social, occupational, or other important areas
of functioning
• G. Exclude any other mental disorders
– Such as fear, anxiety and avoidance of situations
associated with panic-like symptoms
– Agoraphobia
– Object or situation related to obsessions (OCD)
– Reminder of traumatic event (PTSD)
– Social situation (social phobia)
Specific Phobias: diagnostic criteria
• Associated features:
– Individuals with situational, environmental or
animal phobias show sympathetic nervous system
arousal
– Individuals with blood-injection-injury phobia
demonstrate a vasovagal fainting and elevation of
blood pressure followed by a deceleration of heart
rate and a drop in blood pressure
• Prevalence:
– Women more than men 2:1
• Suicide risk is 60% more than normal people
Specific Phobias: diagnostic criteria
• Developmental course:
– Sometimes develops after a traumatic event (e.g..;
being attacked by an animal) or through observing
others going in a traumatic event (watching some
burning)
– Develops early childhood between ages 7-11 years
Social anxiety disorder (social phobia)
diagnostic criteria
• A. Marked fear or anxiety about one or more
social situations in which the person exposed
to possible scrutiny by others.
– Social interaction: meeting new people
– Being observed: eating or drinking
– Performing in front of others: giving speech
• B. The person feels that he/she will act in a
way or show anxiety symptoms that will be
negatively evaluated (that will be humiliating
or embarrassing; will lead to rejection or
offend others)
Social anxiety disorder (social phobia): diagnostic criteria
• C. The social situations almost always provoke
anxiety or fear
• D. the social situations are avoided or endured
with intense anxiety or fear
• E. The fear or anxiety is out of proportion to
the actual threat posed by the social situation
and to the socio-cultural context
• F. The fear anxiety or avoidance is persistent,
typically lasting for 6 months
Social anxiety disorder (social phobia): diagnostic criteria
• G. The fear or anxiety or avoidance causes
clinically significant distress or impairment in
social, occupational or other important areas
of functioning
• H. The fear or anxiety or avoidance is not
attributed to the physiological affects of
substance or another medical condition
Social anxiety disorder (social phobia): diagnostic criteria
• I. The fear or anxiety or avoidance is not
explained by other mental disorders
• J. If another medical condition (parkinson’s
disease, disfigurement from burn, or injury) is
present, The fear or anxiety or avoidance is
clearly unrelated or is excessive
Social anxiety disorder (social phobia): diagnostic criteria
• Associated features:
– Person may be inadequately assertive or
excessively submissive
– Show rigid body posture or inadequate eye
contact or speak with low voice
– May be shy and withdrawn and less open in
conversations
– Employed in jobs that does not need high contact
with people
– Drinking for becoming sociable is common
Social anxiety disorder (social phobia): diagnostic criteria
• Prevalence:
– Women more than men
– Gender differences occur more in adolescent
• Developmental course:
– Occurs early childhood
– History of social inhibition
– In adult rare but occurs after a painful or humiliating
situation
• Functional consequences
– Drop out from school
– Unemployment
– Affects productivity in work
Panic attacks
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Panic Disorder
diagnostic criteria
• A. recurrent unexpected panic attacks. A panic
is an abrupt surge of intense fear or
discomfort that reaches a peak within minutes
(the whole attack 5-10 minutes)
Panic Anxiety Disorder
A discrete period of intense fear or discomfort in which at least
4 of the following symptoms develop abruptly and reached a
peak within few minutes
• Palpitation, pounding
heart, accelerated heart
beats
• Sweating
• Trembling or shaking
• Sensations of shortness
of breath
• Chills or heat sensations
• Fear of dying
• Feeling dizzy, unsteady,
lightheaded, or faint
• Feeling of choking
• Chest pain
• Nausea or abdominal
distress
• Numbness
• Derealization
• Fear of losing control
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Panic Anxiety Disorder
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B. At least one of the attacks has been
followed by one month (or more) of one or
both of the following:
– Persistent concern about having
additional panic attack or their
consequences (losing control or having a
heart attack)
– A significant maladaptive change in
behavior related to the attacks (avoiding
unfamiliar situations, or exercise…)
Panic Anxiety Disorder
• C. The disturbance is not caused by
physiological effects of substances,
medications, or medical condition
• D. the disturbance is not explained by another
mental disorder
Agoraphobia
diagnostic criteria
• A. Marked fear or anxiety about 2 or more of
the following
– 1. Using public transportation: buses, trains
– 2. Being in open spaces: parking lots,
bridges
– 3. Being in enclosed places: shops, cinemas
– 4. Standing in line or being in a crowed
– 5. Being outside of the home alone
Agoraphobia
• B. The person fears or avoids these situations
because of thoughts that escape might be
difficult or help might not be available in the
event of developing panic-like symptoms or
other incapacitating or embarrassing
symptoms (fear of incontinence)
• C. The agoraphobia situation almost always
provoke fear or anxiety
Agoraphobia
• D. the agoraphobia situations are actively
avoided, require the presence of a companion,
or endured with intense fear or anxiety
• E. The fear or anxiety is out of proportion to
the actual threat posed by the social situation
and to the socio-cultural context
• F. The fear or anxiety or avoidance is
persistent typically for 6 months or more
Agoraphobia
• G. The fear or anxiety or avoidance causes
clinically significant distress or impairment in
social, occupational or other important areas
of functioning
• H. if another medical condition (eg.;
inflammatory bowel disease, parkinson’s
disease) is present the fear, anxiety or
avoidance is clearly excessive
• The fear, anxiety or avoidance is not explained
by the symptoms of another mental disorder
Generalized Anxiety Disorder
Generalized Anxiety Disorder
diagnostic criteria
• A. Excessive anxiety and worry (apprehensive
expectation), occurring more days than not,
for at least 6 months, related to several events
or activities (such as work or school
performance)
• B. The person finds it difficult to control the
worry
Generalized Anxiety Disorder
• C. The anxiety and worry are associated with 3
or more of the following 6 symptoms (with at
least some symptoms having been present for
more days than not for the last 6 months)
– 1. Restlessness or feeling keyed up or on edge
– 2. Being easily fatigued
– 3. Difficulty concentrating or mind going blank
– 4. Irritability
– 5. Muscle tension
– 6. Sleep disturbance (difficulty falling or staying
asleep or restless unsatisfying sleep)
Generalized Anxiety Disorder
• D. The anxiety, worry or physical symptoms
cause significant distress or impairement in
social, occupational or other important areas
of functioning
• E. The disturbance is not attributed to the
physiological effects of substances,
medications or medical condition
• F. The disturbance is not explained by other
mental disorders
Nursing Care of Clients with
Anxiety Disorders
Social Phobia
• Alia a 19 year old college student, complains of
extreme anxiety about her classes. She said “I am
doing very well with my written assignments
and exams but I am worried that I am going to
fail two of my courses because each requires
participation in the discussion of topics in the
class and an oral presentation in front of all the
students”. She states that she will not be able to
do this because “every one will think I am
stupid”, although she recognizes that “It does not
make any sense, I just started the college last
semester, I was not like this in the high school”.
A case of simple phobia: Fear from riding elevators
• MS. A 32 year old woman seeks help because she fears
losing her job
• She work for a large company and was recently
promoted to a new job on the 20th floor of the
building. She reports a long inability to ride on
elevators due to overwhelming fear accompanied
with palpitations, diaphoresis and dyspnea.
• She has always taken the stairs to her office, but now
this has made her late for meetings. She realizes her
fears are irrational but has been unable to change her
behavior. She reports normal sleep, appetite, and
energy level. There is no past history of traumatic
events or OCD.
• Physical and neurological exams normal.
• Normal Lab tests & MRI
Nursing diagnosis: Fear
• On assessment MS A. she says “I am afraid to
get in the elevator. I fear if it stops no one
will come to rescue or it will fall down.
(related to) When ever I think of riding it, I
become anxious, my heart pounds highly and
I become sweaty all over my body and I feels
as if I am going to suffocate. So I decide it is
safer to climb the stairs even if I am late. I
know this is not rational but I can not stop it
(evidence)”
Goals of Nursing Interventions
 Long Term Goal:
◦ MS. A. will be able to ride the elevator to her office
without experiencing a panic attack
 Short term Goal: MS A. will
◦ Verbalize feelings of fear and discomfort
◦ Respond to relaxation techniques with decreased
anxiety
◦ Effectively decrease own anxiety level
◦ Decrease avoidance behaviors
◦ Manage the anxiety response effectively
• Develop trust relationship and interact with the
client on one-to-one session, in-order to help MS.
A talk about her feelings of fear and discomfort
– Reassure MS. A. that she will not be forced to
confront the phobic situation (riding the
elevator) until she is prepared and ready to do
so
– Assist the client to distinguish between the
phobic trigger and thoughts (elevator will fall)
and her physiological responses and the
avoidance behaviors that are interfering with
daily life
I fear if it stops no one will come
So I decide it is safer to to rescue or it will fall down.
climb the stairs even if I Thoughts
am late.
I know this is not
rational but I can not
Physical
Behavior
stop it
my heart
Feelings
I am afraid to get in the
elevator.
I decide it is safer to climb the
stairs even if I am late
pounds highly
and I become
sweaty all over
my body and I
feels as if I am
going to
suffocate.
Respond to relaxation techniques with decreased
anxiety
• Instruct MS. A. in progressive relaxation
techniques. These include deep breathing,
focusing on specific muscles to decrease
tenseness, and imagining.
• Encourage the client to practice relaxation until
he or she is comfortable and successful.
• Explain systematic desensitization thoroughly to
the client (see next slide).
• Reassure the client that you will allow him or her
as much time as needed at each step.
•
Effectively decrease own anxiety level
desensitization
 Have the client develop a hierarchy of
situations that relate to the phobia.
 Begin with the least anxiety-producing
situation. Have the client use progressive
relaxation in that situation until he or she is
able to decrease the anxiety.
 If the client becomes excessively anxious or
begins to feel out of control, return to the
former step with which the client was
comfortable and successful.
Decrease avoidance behavior
• Give positive feedback for the client's efforts
at each step. Avoid equating success only with
mastery of the entire process.
• Discuss the previously identified avoidance
behaviors with client to determine if there is a
corresponding decrease as client progress in
systematic desensitization
Panic Anxiety Disorder
• Yara a 35 year old woman admitted to the hospital for
check up test. Yara complained of recurrent episodes of
chest pain, palpitation, heat in the back of the neck
and dizziness. She states “the symptoms comes
suddenly without any stress, I had three episodes one
when I was working alone in the office, one while I was
in the bus and the last was today as I was leaving home
to work, it makes me feel scared, and as if something
very bad is going to happen as if I am going to die”.
Yara states that these attaches started since 5 weeks
and she is afraid of having another attack to the extent
that she can not leave home alone.
• Physical exam, lab tests, ECG, x-rays and ECHO are
normal
• No past psychiatric illness
GAD
• Norma a 29 year old woman was complaining to the
clinic nurse that she has been unable to conceive for 3
months
• Norma is restless and fidgety, states “I am worried that
I might not have a child”. After being reassured she
states that “ I always feel like I am on the edge for the
last 6 months, I am almost always irritable, I have
difficulty falling asleep, my mind is always in worry, for
the simplest things almost all the day, I think that my
husband might leave me, even something bad might
happen to my mother and I keep calling her to make
sure she is ok, I also worry that my boss is going to fire
me. This continuous worry is exhausting me and casing
muscle tension and lack of concentration in my work”
• Normal physical, neurological & lab exams (all exams
normal) no other psychiatric disorders
Nursing Diagnosis: Panic Anxiety
• Evidenced by: Any or all of the physical
symptoms identified by the DSM-5
• Long Term Goals:
– By discharge the client will be able to recognize
symptoms of anxiety onset and intervene before
reaching panic level
• Short Term Goals:
– The client will verbalize ways to intervene in
escalating anxiety within 1 week
Nursing Intervention for Panic Anxiety
• Develop trust relationship through
communicating core communication values
(caring, acceptance, empathy, …)
• Stay with the client and offer reassurance of
safety & security during the periods of anxiety
attacks or worry
• Maintain a calm (staff & client),
nonthreatening, matter-of-fact approach
• Use simple wards & messages, spoken calmly
& clearly, to explain any procedure
Panic Anxiety
 Decrease environmental stimuli (dim light,
decrease number of people, simple décor,…)
 Administer PRN Tranquilizers
 When level of anxiety decrease,
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Explore possible reasons for occurrence
Help client recognize precipitating factors
Help client recognize early signs
Teach client ways to interrupt escalation of signs by
diverting attention to something relaxing or deep
breathing (progressive relaxation, breathing
exercises, or physical exercises…)