Irene Dunn, MA,MSN,RNC

Physiological Responses to
Anxiety
Cardiovascular System

Palpitations

Racing heart

Increased blood pressure

Faintness*

Actual fainting*

Decreased blood pressure*

Decreased pulse rate*

Physiological Responses to
Anxiety
Respiratory System

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

Abdominal pain*

Nausea*

Heartburn

Diarrhea*

Physiological Responses to
Anxiety
Neuromuscular System

Increased reflexes

Startle reaction
Eyelid twitching

Insomnia

Tremors

Rigidity

Fidgeting

Pacing

Strained face

Generalized weakness

Wobbly legs

Clumsy movement




Physiological Responses to
Anxiety
Skin
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

Restlessness

Physical tension

Tremors

Startle reaction

Hypervigilance

Rapid speech

Lack of coordination

Accident proneness

Interpersonal withdrawal

Inhibition

Flight

Avoidance

Hyperventilation

Cognitive Responses to Anxiety
 Impaired attention

Poor concentration
 Forgetfulness

Errors in judgment
 Preoccupation

Blocking of thoughts

Decreased perceptual filed

Reduced creativity
 Diminished productivity

Confusion
 Self-consciousness

Loss of objectivity

Fear of losing control

Frightening visual images

Fear of injury or death

Flashbacks

Nightmares

Affective Responses to Anxiety

Edginess

Impatience

Uneasiness

Tension

Nervousness

Fear

Fright

Shame

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

Carcinoid
 Cushing’s syndrome

Hyperthyroidism

Hypoglycemia

Hypoparathyroidism

Hypothyroidism

Menopause

Pheochromocytoma

Premenstrual syndrome

Medical Disorders Associated with Anxiety
Neurological

Collagen vascular disease

Epilepsy
 Huntington’s disease

Multiple sclerosis

Organic brain syndrome

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
 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

Anxiety
 Breathing disturbances

Tremors and palpitations

Sweating and hot or cold spells

Faintness, lightheadedness, dizziness

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

Anxiety

Sees some prospects for the future

Does not regard defects or mistakes as irrevocable

Uncertain in negative evaluation

Predicts that only certain events may go badly right

Depression

Regards mistakes as beyond redemption

Absolute in negative evaluations

Global view that nothing will turn out

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)

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

Modeling

Shaping

Token economy

Role playing

Social skills training

Aversion therapy

Contingency contracting