NR36 Notes: February 27, 2004
These notes are brought to you by Cindy Beck a senior student in the program,
they are derived from Mr Manginos lecture on anxiety disorders.
Anxiety Disorders & Somatiform disorders
Mr. Mangino RN MSN NP-P
Most common of all psychiatric disorders.
Anxiety: A vague, uneasy feeling whose source is often non-specific or unknown
to the individual.
20% of the population will experience some anxiety disorder.
Agoraphobia, social phobia more common in women
OCD – same for men and women
Most anxiety disorders start in early adulthood, however
 OCD – obsessive – compulsive disorder
 BDD - Body dysmorphic disorder
 Social phobias
. … tend to start in early childhood
Anxiety disorders must be viewed in the context of the culture and developmental
level
Anxiety disorders tend to cluster with other disorders
 Depression
 Substance abuse
 Eating disorders
 Tourette’s disorder
Anxiety disorders appear to be related to a serotonin deficiency, so they tend to
respond to SSRI’s
Hildegard Peplau – the mother of psychiatric nursing; studied anxiety; identified
four stages on the anxiety continuum:
 Mild
 Moderate
 Severe
 Panic
Types
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Signal Anxiety: anticipating danger; the type seen with phobias
Trait Anxiety: Overall amount of anxiety in personality
State Anxiety: Anxiety over uncontrolled situation
Free-floating Anxiety: Can’t be attached to any event or reason
Causation
Biologic - possible alterations in hormones and/or neurotransmitters
 Genetic
 Too much adrenaline
 Too little serotonin
 Too little GABA
SSRI’s tend to work better for chronic anxiety than do benzodiazepines as
benzos develop tolerance and can be habit forming.
Psychosocial theories
Freud: unresolved conflicts, usually as a child. Ego uses defense mechanisms
to defend against anxiety and conflicts from within.
Interpersonal theory: conflicts from without, conflict arise from b/t people
Panic Disorder: very sudden onset, feeling of impending doom and/or death
GAD: generalized anxiety disorder, according to the DSM, involves excessive
anxiety and worry, must exist for >6 months
OCD: obsessions=recurrent intrusive thoughts; compulsions=action or ritual to
decrease anxiety usually created by obsession.
Acute stress disorder – severe anxiety, and other distressful symptoms r/t
exposure to a traumatic event last b/t 2 days to 1 month
PTSD: similar to acute stress, but occurs months to years later; characterized by
irritability, anger, dreams/nightmares of event, hypervigilance, risk-taking
behavior
Post-trauma response: a nursing Dx, A state in which the individual
experiences a sustained painful response to one or more overwhelming
traumatic events that have not been assimilated.
Phobias: experiences panic attack in response to particular situations or stimuli.
Pt learns to avoid stimulus.
Simple phobias: fears of specific object(s), situations
Social phobia: social anxiety disorder, severe shyness, fear of being humiliated
or embarrassed.
Agoraphobia: fear of open spaces, crowds of people or situations where escape
may be difficult.
Somatoform Disorders: Ch 19 Videbeck
Physical symptoms in the absence of a true physical
disorder.
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Somatization disorder: various physical complaints of various body
systems.
Hypochondriasis: PT thinks he has a specific, serious illness despite
evidence to the contrary.
Pain disorder: excessive pain which cannot be explained by actual
illness.
Body Dysmorphic Disorder: preoccupation with an imagined defect in
appearance (if there is a defect, overly concerned about it); probably
related to OCD
Conversion disorder: sensory motor symptoms that cannot be attributed
to an illness, usually connected to a very stressful or tragic event.
Dissociative Disorders
Disturbance of identity, memory, self
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Dissociation: lose connection between self, memory and perception
Derealization: Things don’t seem real. False perception that one’s
environment has changed.
Depersonalization: feel like in a dream state.
Dissociative Identity Disorder: 2 or more distinct personalities that can control
behavior, identity.
Dissociative fugue: sudden travel away from home or person’s routine. Can’t
remember identity (often during war, or in the aftermath of a disaster)
Dissociative amnesia: person forgets personal info about a specific event,
usually of a traumatic nature.
Treatments for anxiety:
 Goal: ↓sympathetic arousal, adrenaline
 short term anxiety – benzodiazepines (problems= tolerance, addiction)
 long term anxiety – SSRI’s, help treat and prevent chronic anxiety, panic
 PTSD, Dissociative identity disorder: treat symptoms, SSRI’s commonly
used.
 Biofeedback: monitor vitals, muscle tension, brain waves; helps pt to see
mind/body connection
 Stress inoculation: cognitive technique; four steps, prepare for stressor
 Preparing phase
 Confronting phase
 How to cope with emotional arousal if it does come (i.e. deep
breathing)
 Reinforce success
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Systematic desensitization
Behavioral: teaching relaxation techniques
Progressive muscle relaxation
Meditation – concentrate on breathing; word; object; attempt to clear mind;
decrease sympathetic response, increase
parasympathetic response
Guided imagery – therapist guides pt; envision relaxing situation
Meds to treat anxiety
Benzodiazepines: Xanax, Valium,
Buspar – non benzodiazipine antianxiety med
Tricyclic antidepressanst: Anafranil
SSRI: Paxil, Luvox
Etiology
Dissociative disorders: trauma in childhood; ego can’t cope with pain, begins to
disintegrate. Biological = ↑cortisol, damages hippocampus, impairs memory
formation
Somatic disorders: Hypersensitive to pain; probably low endorphin, serotonin
level; Freud = unresolved conflict; responds better to SSRI than opiate.
Nursing process for Anxiety Disorders:
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Not usually found on psychiatric unit, but in ER (often they believe it is a
physical problem)
Ask pt re: elimination patterns (Crohn’s disease, irritable bowel, urinary
frequency)
Observe for tics, twitching, stuttering, eye contact, blushing, shyness
Assess connection with people
Assess through culture
Assess substance abuse patterns
Look for derealization
Assess ability to make decisions
Assess for recent/past trauma
Assess orientation/memory
Amnesia?
Doctor shopping?
Past medical history
Nursing Outcomes:
 Pt needs to know early warning signs of disorder
 ↓ rituals
 For PTSD: ↓ anger, ↓ risk-taking, demonstrate knowledge of meds
 For dissociative disorders: pt responds to own name, refers to self in first
person
Tests for Anxiety
Hamilton Rating Scale for Anxiety:
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Experience sudden intense fear?
Worry a lot?
Have special routines?
Nervous around people?
Fear not being able to escape?