Anxiety Disorders Note Taking Outline
WHAT IS ANXIETY?
Levels of Anxiety
Mild Anxiety
Moderate Anxiety
Severe Anxiety
Panic
“Fight, Flight or Freeze”
Dealing with Anxiety
Comparison: Coping and Defense Mechanisms
 Coping – Client is usually aware
 Defense Mechanisms- Client most likely is not consciously aware
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Avoidance
Denial
Secondary gain
Key Nursing Interventions for Anxiety
 Assess level of anxiety/degree of discomfort
 Assess client’s coping and defense methods
 Choose appropriate interventions for anxiety level
 Calm environment with reduced stimuli
 Mild-to-Moderate: assist to verbalize feelings and possible causes
 Severe-to-Panic level: assess for self-harm
 Provide activities to reduce tension, aid relaxation, promote security
 Client teaching for anxiety reduction:
 severe or panic level anxiety-teaching not appropriate
 if moderate anxiety-simple, step-by step
 mild-good time to teach
 CBT is a primary method for addressing anxiety-producing thoughts
ANXIETY DISORDERS
 Anxiety symptoms interfere with functioning and self-care
 Most are chronic
 Challenging to treat/manage
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Prevalence ( NIMH )
More prevalent than mood disorders
18.1% of US population over 17
Avg. first episode by age 21.5
Co-morbid with depression and substance abuse
Common to have more than one anxiety disorder
Selected Anxiety-Related Disorders
(There are many in the DSM)
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Generalized Anxiety Disorder (GAD)
Panic Disorder
Obsessive-Compulsive Disorders (OCD)
Phobias
Somatoform Disorders (DSM V- Somatic Symptom Disorders)
Etiology/Theories of Anxiety Disorders
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Biological Theories
 Over-responsiveness to stimuli : HPA axis dysfunction
 Neurotransmitter dysregulation
 Lower number of benzodiazepine receptors
 Genetic Theory
Psychological Theories
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Internal conflicts
Interpersonal Theory
 threat to self-esteem, security or self-control
Generalized Anxiety Disorder
(GAD)
Most common type
Cognitive and Physical Symptoms
Chronic and excessive worry (> 6 months)
Worry is habitual, cannot be controlled
 Interventions for GAD
 Initial goal: reduce anxiety to manageable level
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Improve self-esteem and assertiveness
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Manage stress and develop adaptive coping responses
Medications: SSRI for chronic anxiety
Panic Disorder
 Recurring, unexpected, sudden intense feelings of terror, fear of losing
control, fear of dying
 Somatic Symptoms, e.g.
 Chest pain, respiratory distress, diaphoresis, dizziness
 May be triggered by environmental changes e.g. cold or light
 Episodes may or may not be situational
 If situational, will avoid places or situations
 Panic Disorder with Agoraphobia (fear of open, crowded or
public places) is complication of situational panic
 Peaks within 10 minutes; self-limiting
Etiology of Panic Disorder
 Biological
 Severe
overactivity of HPA axis
 Psychological
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Life stresses
 Separation and disruption of attachment in childhood
Catastrophic thinking ( “what if”) often triggers physiologic response in
panic
Nursing Interventions: Acute Phase of Panic Disorder
 Communication: as in panic level anxiety: stay with them, reassure that
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they are safe
Calm environment, stimulation down, use touch carefully
Assess for suicidal ideation: 1 in 5 are suicidal; protect from injury
Slow, deep breaths
 Medications: PRN benzodiazepines, atypical antipsychotic meds.
Panic D/O Nursing Interventions: After Acute Distress is Managed
 Client Teaching: improvement often follows
 You are not crazy
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Recognize and address triggers
Recognize symptoms
 Outpatient Tx.
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Reinterpret beliefs via CBT
 Maintenance medications: SSRI; with option of PRN benzodiazepine
Calcium channel blockers/ beta adrenergic blockers:
for control of ANS symptoms
Obsessive-Compulsive Disorder (OCD): Several Types in DSM
 Obsessions
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Recurrent and persistent thoughts, ideas, impulses
 Compulsions
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Repetitive behaviors performed in particular manner (rituals)
Response to obsession
Prevent discomfort and “neutralize” anxiety feelings
Anxiety increases when they resist their compulsions
OCD symptoms are time-consuming; interfere with normal routines
Sx. interfere with relationships
Engage in Magical Thinking: Belief that “ thinking equals doing”
Recognition that behavior is abnormal
 Etiology:
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Psychological:
“OCD Personality:”
 Have high need for control
 Strong sense of right and wrong
 Often have difficulty expressing emotions
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Biological: serotonin dysregulation
OCD: Nursing Interventions
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Assist to meet basic needs
Allow structured time to perform rituals
Explain expectations of program
Identify feelings--Connect feeling to behaviors
Introduce new activities slowly
Reinforce and recognize positives
 Therapeutic Groups
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Outpatient Tx
CBT and Thought Stopping
Relaxation Exercises
Stress management
Recreation
Social Skills
 Medications:
SSRIs:
 fluoxetine (Prozac)
 paroxetine (Paxil)
 sertraline (Zoloft)
 fluvoxamine (Luvox)
TCA
 clomipramine (Anafranil)
Phobias/DSM IV
 Specific Phobia: Fear that is excessive and unreasonable, cued by the
presence or anticipation of object or situation, e.g. animals, needles,
flying, etc.
 Situation or object is actively avoided
 Fear or avoidance causes significant distress or impairment
 Social Phobia ( Same as Social Anxiety Disorder)
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Social situations cause fear and are avoided: very fearful of
embarrassing self or offending others
 Agoraphobia: fear or anxiety of being in open (or enclosed) spaces , or
being in a crowd, being outside the home, using public transportation
Treatment for Phobias
 Outpatient is most common
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Behavioral therapies: exposure therapy and systematic
desensitization
 Nursing Interventions
 Very similar to GAD: assertiveness, social skills, etc.
 Medications: SSRIs
Somatoform Disorders
 Excessive thoughts, anxiety and/ or time spent on somatic
symptoms
 Impairment results
 Some types have no known organic cause, believed to be
psychological only
 Person may seek repeated medical attention or unnecessary medical
treatment or procedures
Types:
1. Somatization Disorder (DSM V –Somatic Symptom Disorder)
2. Pain Disorder-DSM V lists this as one feature of Somatic Symptom
Disorder
3. Hypochondriasis (is now Illness Anxiety Disorder)
4). Conversion Disorder (is now Functional Neurological Symptom
Disorder)
1. Somatization Disorder
 Persistent or frequent somatic complaints (> 6 months)
 Symptoms may change to different area, type or severity
 Onset prior to 30years old
 May have unnecessary surgical procedures
 Impairment in interpersonal relationships
 Etiology
 Chronic emotional abuse
 Unable to verbalize anger
2. Pain Disorder (now listed as feature of Somatic Symptom Disorder)
 Severe Pain in one or more areas;
 Preoccupation with pain
3. Hypochondriasis (DSM V-Illness Anxiety Disorder)
 Worry they have or will acquire a serious illness despite no medical
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evidence
Excessive health-related behaviors
May either “doctor shop” or avoid health practitioners
Misinterpretation of bodily symptoms
Need for reassurance
4. Conversion Disorder (Functional Neurological Symptom Disorder)
 Symptoms of altered voluntary motor or sensory function:
paralysis/weakness, sensory loss, seizures, abnormal movement, etc.
 No evidence of actual medical condition
 Conflicts or stressors often proceed emergence of symptoms
 May show little concern or anxiety about symptoms
Nurse-Client Relationship and Management of Somatoform Disorders
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Always rule out the physical
Show acceptance (of person) and empathy
Do not challenge or dismiss symptoms
Refocus away from symptoms; encourage diversional activities
Encourage identification and appropriate expression of emotions
Teach adaptive coping, e.g. decision making, assertiveness skills, stress
management
 Family education, involvement/therapy