Anxiety DisorderAnxiety Disorder

DefinitionsDefinitions

Anxiety is a diffuse, vague apprehension associated with Anxiety is a diffuse, vague apprehension associated with feelings on uncertainty and helplessness. This feelings on uncertainty and helplessness. This emotion has no specific object. It is subjectively emotion has no specific object. It is subjectively experienced and communicated interpersonally. It is experienced and communicated interpersonally. It is different from fear, which is the intellectual appraisal of different from fear, which is the intellectual appraisal of danger. Anxiety is the emotional response to that danger. Anxiety is the emotional response to that appraisal. The capacity to be anxious is necessary for appraisal. The capacity to be anxious is necessary for survival, but severe levels of anxiety are incompatible survival, but severe levels of anxiety are incompatible with life. Anxiety disorders are the most common with life. Anxiety disorders are the most common

psychiatric problems in the United Statespsychiatric problems in the United States . .

TypeType

11 - -Panic disorder without agoraphobiaPanic disorder without agoraphobia::

Recurrent unexpected panic attacks and at least Recurrent unexpected panic attacks and at least one of the attacks has been followed by a month one of the attacks has been followed by a month

(or more) of(or more) of : :A>A> Persistent concern about having additional Persistent concern about having additional

attacksattacks . .B>B> Worry about the implications of the attack or its Worry about the implications of the attack or its

consequences, orconsequences, or. .

C>C> A significant change in behavior related to the A significant change in behavior related to the attacks.attacks. Also the absence of agoraphobiaAlso the absence of agoraphobia..

22 - -Panic disorder with agoraphobiaPanic disorder with agoraphobia::Meets the above criteria. In addition, the presence of Meets the above criteria. In addition, the presence of agoraphobia, which is anxiety about being in places or agoraphobia, which is anxiety about being in places or situations from which escape might be difficult (or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed event of having an unexpected or situationally predisposed panic attack. Agoraphobic fears typically involve panic attack. Agoraphobic fears typically involve characteristics clusters of situations that include being characteristics clusters of situations that include being outside the home alone; being in a crowd or standing in a outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or car. line; being on a bridge; and traveling in a bus, train, or car. Agoraphobic situations are avoided, or are endured with Agoraphobic situations are avoided, or are endured with marked distress or with anxiety about having a panic marked distress or with anxiety about having a panic

attack, or require the presence of a companionattack, or require the presence of a companion . .

33 - -Agoraphobia without history of panic Agoraphobia without history of panic disorderdisorder::

Present of agoraphobia and has never met Present of agoraphobia and has never met criteria for panic disordercriteria for panic disorder . .

Marked and persistent fear that is excessive Marked and persistent fear that is excessive or unreasonable, cued by the presence or or unreasonable, cued by the presence or anticipation of a specific object or situation anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an (e.g., flying, heights, animals, receiving an injection, seeing blood). Exposure to the injection, seeing blood). Exposure to the response. The person recognizes the fear response. The person recognizes the fear is excessive, and the distress or is excessive, and the distress or avoidance interferes with the person's avoidance interferes with the person's

normal routinesnormal routines..

44-- SpecificSpecific phobiaphobia::

55 - -Social phobiaSocial phobia : :Marked and persistent fear of one or more social or Marked and persistent fear of one or more social or performance situations in which the person is performance situations in which the person is exposed to unfamiliar people or to possible exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. that will be humiliating or embarrassing. Exposure to the feared situation almost invariably Exposure to the feared situation almost invariably provokes anxiety. The person recognizes the fear provokes anxiety. The person recognizes the fear is excessive, and the distress or avoidance is excessive, and the distress or avoidance

interferes with the person's normal routineinterferes with the person's normal routine . .

66 - -Obsessive-compulsive disorderObsessive-compulsive disorder : :

Either obsessions or compulsions are Either obsessions or compulsions are recognized as excessive and interfere with recognized as excessive and interfere with

the person's normal routinethe person's normal routine . .

77 - -Posttraumatic stress disorderPosttraumatic stress disorder : :The person has been exposed to a traumatic event in The person has been exposed to a traumatic event in

which both the following occurredwhich both the following occurred : :

A>A> The person experienced, or was confronted with an The person experienced, or was confronted with an event or events that involved actual or threatened event or events that involved actual or threatened death or serious injury or a threat to the physical death or serious injury or a threat to the physical

integrity of self or othersintegrity of self or others . .B>B> The person's response involved intense fear, The person's response involved intense fear, helplessness, or horror. The person experiences the helplessness, or horror. The person experiences the traumatic event, avoids stimuli associated with the traumatic event, avoids stimuli associated with the trauma, and experiences a numbing of general trauma, and experiences a numbing of general

responsivenessresponsiveness . .

88 - -Acute stress disorderAcute stress disorder : :Meets the above criteria for exposure to a traumatic Meets the above criteria for exposure to a traumatic event, and the person experiences three of the event, and the person experiences three of the following symptoms: sense of detachment, reduced following symptoms: sense of detachment, reduced awareness of surroundings, derealization, awareness of surroundings, derealization,

depersonalization, and dissociated amnesiadepersonalization, and dissociated amnesia . .

99 - -Generalized anxiety disorderGeneralized anxiety disorder : :

Excessive anxiety and worry, occurring more Excessive anxiety and worry, occurring more days that not for at least 6 months, about a days that not for at least 6 months, about a number of events or activities. The person number of events or activities. The person finds it difficult control the worry and finds it difficult control the worry and experiences at least three of the following experiences at least three of the following six symptoms: restlessness or feeling six symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep irritability, muscle tension, and sleep

disturbancedisturbance . .

Classification of anxiety disorderClassification of anxiety disorder::

11..Mild anxiety:Mild anxiety: is associated with the tension of is associated with the tension of daily living and makes a person alert and daily living and makes a person alert and increases the person's perceptual field. This increases the person's perceptual field. This anxiety can motivate learning and produce anxiety can motivate learning and produce

growth and creativitygrowth and creativity . .

22..Moderate anxiety:Moderate anxiety: allows a person to focus allows a person to focus on immediate concerns and blocks out on immediate concerns and blocks out the periphery. It narrows the person's the periphery. It narrows the person's perceptual field. The person thus perceptual field. The person thus experiences selective inattention but can experiences selective inattention but can

focus on more areas if directed to so dofocus on more areas if directed to so do . .

33..Severe anxiety:Severe anxiety: greatly reduces a person's greatly reduces a person's perceptual field. The person tends to focus on perceptual field. The person tends to focus on a specific detail and not think about anything a specific detail and not think about anything else. All behavior is aimed at obtaining relief. else. All behavior is aimed at obtaining relief. The person needs much direction to focus on The person needs much direction to focus on

any other areaany other area . .

44..Panic level of anxiety:Panic level of anxiety: is associated with awe, is associated with awe, dread, and terrordread, and terror..

Risk Factors:Risk Factors:

Body systemBody systemResponsesResponses

Cardiovascular Cardiovascular Palpitations Palpitations Heart "racing" Heart "racing"

Increased blood pressure Increased blood pressure Faintness Faintness

Actual faintingActual faintingDecreased blood pressureDecreased blood pressure

Decreases pulse rate Decreases pulse rate

Respiratory Respiratory Rapid breathing Rapid breathing Shortness of breath Shortness of breath

Pressure on chestPressure on chestShallow breathing Shallow breathing

Lump in throat Lump in throat Chocking sensation Chocking sensation

Gasping Gasping

Neuromuscular Neuromuscular Increased reflexes Increased reflexes Startle reaction Startle reaction

Eyelid twitchingEyelid twitchingInsonia Insonia

Tremors Tremors Figidity Figidity

Ridgeting, pacing Ridgeting, pacing Strained face Strained face

Generalized weakness Generalized weakness Wobbly legs Wobbly legs

Clumsy movement Clumsy movement

Gastrointestinal Gastrointestinal Loss of appetite Loss of appetite Revulsion toward food Revulsion toward food

Abdominal pain Abdominal pain Nausea Nausea

Heartburn Heartburn Diarrhea Diarrhea

Physiological responses to anxietyPhysiological responses to anxiety::

Body systemResponses

Gastrointestinal Loss of appetite Revulsion toward food Abdominal discomfort

Abdominal pain Nausea

Heartburn Diarrhea

Urinary tract Pressure to urinate Frequent urination

Face flushed

Skin Localized sweating (palms0 Itching

Hot and cold spells Face pale

Generalized sweating

Con’tCon’t

Behavioral, cognitive and effective responsesBehavioral, cognitive and effective responses

SystemResponses

Behavioral Restlessness Physical tension

Tremors Startle reaction

Rapid speech Lack of coordination

Accident proneness Interpersonal withdrawal

InhibitionFlight

Avoidance Hyperventilation

Hypervigilance

Cognitive Impaired attention Poor concentration

Forgetfulness Errors in judgment

Behavioral, cognitive and effective responses to anxietyBehavioral, cognitive and effective responses to anxiety

SystemResponses

Cognitive (continued)Preoccupation Blocking of thoughts

Decreased perceptual field Reduced creativity

Diminished productivity Confusion

Hypervigilence Self-consciousness Loss of objectivity

Fear of losing control Freighting visual images

Fear of injury or death Flashbacks Nightmares

Affective Edginess Impatience Uneasiness

Tension Nervousness

Fearfulness Alarm Terror

Jitteriness Jumpiness Numbness

Guilt Shame

Nursing Care PlanNursing Care Plan::

Nursing DiagnosisNursing Diagnosis: : Sarah, a 47-year old woman, presented to the Sarah, a 47-year old woman, presented to the employee health department of a teaching employee health department of a teaching hospital after walking there from her office. She hospital after walking there from her office. She was complaining of chest pain and shortness of was complaining of chest pain and shortness of breath. Sarah's medical history included breath. Sarah's medical history included psoriasisl. Her vital signs were remarkable for a psoriasisl. Her vital signs were remarkable for a pulse of 116; her electrocardiogram and pulse of 116; her electrocardiogram and laboratory work were within normal limits. Sarah laboratory work were within normal limits. Sarah mentioned to the staff that her son had died 3 mentioned to the staff that her son had died 3

months agomonths ago . .

During her evaluation Sarah and the nurse During her evaluation Sarah and the nurse explored her symptoms of anxiety and explored her symptoms of anxiety and depression, the exacerbation of her psoriasis, depression, the exacerbation of her psoriasis, and her chronic headaches, which had become and her chronic headaches, which had become worse since her son's death. In addition to worse since her son's death. In addition to concern about financial matters and her son's concern about financial matters and her son's alcoholism, she now worried frequently about alcoholism, she now worried frequently about her performance at work. The nurse her performance at work. The nurse recommended a medication trial. Sarah refused recommended a medication trial. Sarah refused because of her fears of addition and loss of because of her fears of addition and loss of

controlcontrol . .

Anxiety related to change in role functioning, Anxiety related to change in role functioning, recent loss of son (dysfunctional grieving) recent loss of son (dysfunctional grieving) threat to socioeconomic status, and stressors threat to socioeconomic status, and stressors exceeding ability to cope, as evidenced by exceeding ability to cope, as evidenced by uncertainty, intermittent sympathetic nervous uncertainty, intermittent sympathetic nervous system stimulation, restlessness, and system stimulation, restlessness, and

exacerbation of medial condition (psoriasis)exacerbation of medial condition (psoriasis) . .

Client outcomesNursing interventionsEvaluation

Sarah will identify common situations that provoke anxiety.

Assign "homework" to client (e.g., keeping a panic attack and headache diary). Documenting anxiety responses helps client link symptoms with precipitating events.

Sarah identifies returning home after work as a critical time for symptoms to develop. She reports that she visits her mother or does errands daily.

Sarah will describe early warning symptoms of anxiety.

Assist Sarah in associating her panic attach symptoms with thoughts about separation from her husband. This will help illustrate to Sarah specific situations in her life that result in panic anxiety.

Sarah reports that she does not experience headaches when her husband is traveling.

Sarah will report willingness to tolerate mild to moderate levels of anxiety.

In weekly sessions, explore with Sarah the advantages and disadvantages of separation and divorce. These discussions will help Sarah problem solve viable options that may offer some control over her anxiety.

Sarah reveals unwillingness to live alone.

Sarah will demonstrate adaptive coping mechanisms.

During weekly sessions discuss options that will allow Sarah maximum control over her choices. Increased choices over life situations tend to minimize anxiety response to some degree.

Sarah informs her husband that she wants a trial separation. The husband moves into their son's former room.

Nursing InterventionsNursing Interventions : :

A>A> Assess own level of anxiety and make a conscious Assess own level of anxiety and make a conscious effort to remain calm. Anxiety is readily transferable from effort to remain calm. Anxiety is readily transferable from

one person to anotherone person to another . .B>B> Recognize the client's use of relief behaviors (pacing, Recognize the client's use of relief behaviors (pacing, wringing of hands) as indicators of anxiety. Early wringing of hands) as indicators of anxiety. Early interventions help to manage anxiety before symptoms interventions help to manage anxiety before symptoms

escalate to more serious levelsescalate to more serious levels . .C>C> Inform the client of the importance of limiting caffeine, Inform the client of the importance of limiting caffeine, nicotine, and other central nervous system stimulants. nicotine, and other central nervous system stimulants. Limiting these substances, prevents/ minimizes physical Limiting these substances, prevents/ minimizes physical symptoms of anxiety such as rapid heart rate and symptoms of anxiety such as rapid heart rate and

jitterinessjitteriness . .

D>D> Teach the client to distinguish between Teach the client to distinguish between anxiety that can be connected to anxiety that can be connected to identifiable objects of sources (illness, identifiable objects of sources (illness, prognosis, hospitalization, know stressors) prognosis, hospitalization, know stressors) and anxiety for which there is no and anxiety for which there is no immediate identifiable object of source. immediate identifiable object of source. Knowledge of anxiety and its related Knowledge of anxiety and its related components increase the client's control components increase the client's control

over the disorderover the disorder . .

E>E> Instruct the client in the following anxiety- Instruct the client in the following anxiety-reducing strategies, which help reduce anxiety in reducing strategies, which help reduce anxiety in a variety of ways and distract the client from a variety of ways and distract the client from

focusing on the anxietyfocusing on the anxiety . .

11-- Progressive relaxation techniqueProgressive relaxation technique . .

22-- Slow deep-berating exercisesSlow deep-berating exercises

33-- Focusing on a single object in the roomFocusing on a single object in the room . .

44-- Listening to soothing music or relaxation tapesListening to soothing music or relaxation tapes . .

55-- Visual imageryVisual imagery

MedicationMedication::

In recent years, there has been a growing In recent years, there has been a growing interest in Eastern techniques of interest in Eastern techniques of medication. Experimental evidence of the medication. Experimental evidence of the efficacy of medication is still in its infancy, efficacy of medication is still in its infancy, but it seems to have a striking effect on but it seems to have a striking effect on physiological functions as measured by physiological functions as measured by

oxygen compositionoxygen composition . .

Tricyclics:Tricyclics: Several studies have demonstrated that Several studies have demonstrated that imipramine is effective in the treatment of panic imipramine is effective in the treatment of panic disorder. The presumed mechanisms of action is disorder. The presumed mechanisms of action is impipramine's apparent ability to block panic attacks. impipramine's apparent ability to block panic attacks. Starting does not imipramine should be somewhat Starting does not imipramine should be somewhat lower than the typical starting doses prescribed in the lower than the typical starting doses prescribed in the treatment of depression. This conservative approach treatment of depression. This conservative approach is recommended because many anxiety patients, is recommended because many anxiety patients, particularly those with panic disorder. The particularly those with panic disorder. The relationship between plasma levels of imipramine relationship between plasma levels of imipramine and the antipanic efficacy of imipramine is poorly and the antipanic efficacy of imipramine is poorly understood. Although imipramine has been the most understood. Although imipramine has been the most systematically studied tricyclic in the treatment of systematically studied tricyclic in the treatment of panic disorder, an increasing number of case reports panic disorder, an increasing number of case reports and clinical studies suggest that other tricyclic and clinical studies suggest that other tricyclic

antidepressants may be equally effectiveantidepressants may be equally effective . .

MAO inhibitorsMAO inhibitors::

Like tricyclic antidepressants, MAO Like tricyclic antidepressants, MAO inhibitors appear to be quite effective in inhibitors appear to be quite effective in the treatment of panic disorder. Some the treatment of panic disorder. Some investigators have suggested that MAO investigators have suggested that MAO inhibitors may be slightly more effective inhibitors may be slightly more effective

than imipraminethan imipramine . .

Antihypertensive agentsAntihypertensive agents::

There is some evidence to suggest that β-There is some evidence to suggest that β-blockers possess anxiolytic properties. blockers possess anxiolytic properties. Clinical experience, however, suggests Clinical experience, however, suggests that β-blockers may be less effective in the that β-blockers may be less effective in the treatment of panic disorder than tricyclic treatment of panic disorder than tricyclic

antidepressantsantidepressants . .

BenzodiazepinesBenzodiazepines:: Many investigators have suggested that Many investigators have suggested that

benzodiazepines are effective in the treatment of benzodiazepines are effective in the treatment of generalized anxiety but fail to prevent panic generalized anxiety but fail to prevent panic attacks. Recent research ahs cast doubt on this attacks. Recent research ahs cast doubt on this popular but unsubstantiated notion. Despite the popular but unsubstantiated notion. Despite the ongoing controversy regarding this issue, many ongoing controversy regarding this issue, many patients with panic disorder achieve inadequate patients with panic disorder achieve inadequate relief with low to moderate doses of traditional relief with low to moderate doses of traditional benzodiazepines. Emerging data suggest that this benzodiazepines. Emerging data suggest that this relative lack of response to many benzodiazepines relative lack of response to many benzodiazepines may be related to issues of potency. Consistent may be related to issues of potency. Consistent with this concept, two high-potency with this concept, two high-potency benzodiazepines and clonazepam have been benzodiazepines and clonazepam have been found to be effective in the treatment of panic found to be effective in the treatment of panic

disorderdisorder . .