Anxiety Disorders

Chapter 19

Concept of Anxiety

Uncomfortable feeling of apprehension or dread

Response to internal or external stimuli

Physical, emotional, cognitive, and behavioral symptoms

Normal vs. Abnormal Intensity Cause Symptom Cluster See Table 19.1 Symptoms of Anxiety See Table 19.2 for Degrees of Anxiety (Peplau’s

model) Mild Moderate Severe Panic

Anxiety Disorders Up to 19 million of people in US Higher in women Individuals < 45 Separated, divorced Experienced childhood sexual abuse Low socioeconomic groups

Panic Extreme overwhelming form of anxiety when

individual placed in a life-threatening (or perceived) situation

Normal becomes abnormal when panic is experienced routinely or in situations that do not pose threats

Panic Disorder Experience panic in non-threatening

situations

Panic attack Discrete periods of fear or discomfort (10-30

minutes)

Physical (palpitations, rapid pulse, trembling, SOB)

Cognitive(disorganized thinking, irrational fears, fear going crazy, going to die)

Phobias: persistent, unrealistic fears (see box19.2)

Clinical Course of Panic Disorder Lifelong disorder, peaks in teenage years

and again in 30s

Chronic conditions that has several exacerbations and remissions during the course of the disease

Characterized by disabling attacks of panic that lead to other symptoms, such as phobia

Panic Attacks

Similar symptoms as heart attack, palpitation, heart racing, rapid breathing, shortness of breath (25% of ER visits for chest pain)

Types Unexpected cued

Situational cued (exposure to trigger)

Situational predisposed Diagnostic Criteria - table 19.3

With agoraphobia Without agoraphobia

Special Populations

Children

Most frequent psychiatric disorder

Often have separation anxiety and OCD

Elderly people

Very common

Epidemiology of Panic Disorder 2.9 million people

Panic disorder with agoraphobia --most severe comorbid anxiety disorders

Number of attacks

Anticipatory anxiety

Women more likely than men to experience panic disorder with agoraphobia

No difference between white and African American, Hispanic has lower

EtiologyBiological Evidence and Theories

Genetic predisposition: substantial Neuroanatomic changes

Focal areas of abnormal activity in the fear network Biochemical changes

Panicogenic substances that produce panic attacks yohimbine, fenfluamine, norepinephrin, epinephrine, sodium

lactate, and carbon dioxide Norepinephrine and locus ceruleus

Stimulate locus ceruleus, increased fear Inhibit locus ceruleus are anxiolytic Yohimbine - antagonist 2 - panicogenic

Serotonin- implicated, SSRI’s provide relief after 2-6 wks, initially, may increase anxiety

GABA- stimulation cause anxiolytic, sedating effects

Etiology (Cont.)

CRF

Neuropeptide that produces neuroendocrine, autonomic, and behavioral responses to stress

Severe stress results in an increased CRF concentrations in hippocampus, amygdala, locus ceruleus

CRF stimulations tests are conflicting

Long term use of SSRI antidepressants may inhibit release of CRF

Cholesyctokinin (CCK) -- neuropeptide

High concentrations found in cerebral cortex, amygdala, and hippocampus

Important interactions with other neurotransmitters

Carbon dioxide -- needs more study

Psychological Theories

Psychanalytic and psychodynamic theories Explain the importance of development of anxiety Commonalities of background and personality traits

Fearful or shy as a child Remembering parents as angry, critical Feelings of discomfort with aggression Long-term feelings of low self-esteem Experiencing stressful events prior to initial onset

Cognitive-behavioral theories Fear response can be learned--classical conditioning Interoceptive conditioning--pairing a somatic discomfort with

impending panic attack Catastrophic interpretation--misinterpretation of mild physical

sensations

Risk Factors Family history Substance and stimulant use or abuse Undertaking severe stressors Genetic predisposition Female gender For children

physical or sexual abuse behavioral inhibition by adults

Comorbidity More somatic complaints than general

populations

Vertigo, cardiac disease, GI disorders, asthma

Mitral valve prolapse, migraine headaches, and hypertension

Treatment

Interdisciplinary care is needed.

Priority care issues include Depression associated with panic disorder

Suicide needs to be assessed

Nursing Management: Biologic Domain

Rule out other disorders

Assessment questions Common features of panic attack. Careful review of

events prior to attack

Substance use

Sleep patterns

Physical activity

Nursing DiagnosisBiologic Domain

Anxiety

Risk for self-harm

Risk of suicide

Biologic Interventions

Breathing control -- reduce hyperventilation and interrupt a panic attack. Need to practice

Nutritional planning reduce anxiety provoking substances:

caffeine, food coloring or MSG monitor symptoms after eating

Relaxation techniques (Increase physical activity) Box 19.3

Psychopharmacologic Treatment

Selective serotonin reuptake inhibitors (SSRI) Fluoxetine and sertraline -- can cause feelings of

overstimulation, slow titration Side effects -- anticholinergic, dizziness, anxiety,

nervousness, and sexual dysfunction Interact with MAOIs Fluoxetine interacts with flecainid, warfarin, phenytoin,

carbamazepine, and vinblastine Paroxetine interacts with cimetidine, decrease digoxin levels,

phobarbitol, and phenytoin Sertraline interacts with diazepan and tolbutamide, warfarin Teaching points:

Avoid over-the-counter medications Sedative effects may impede judgment while operating machinery

Psychopharmacologic Treatment

Tricylcic antidepressants Imipramine,nortriptyline and clomipramine reduce panic attacks Therapeutic effects usually occur in 3-4 weeks Single bedtime doses help deals with sedation EKG before initiation (cardiac conduction) Taper discontinuation to avoid cholinergic rebound Observe for anticholinergic effects Start at low doses and gradually increase Interacts with several medications (MAOIs, and CNS depressants) Teaching points

Take medication as prescribed Avoid OTC medications without checking first Warn about sedation, avoid operating machinery

Psychopharmacologic Treatment

Benzodiazepines Used during periods of extreme stress and for immediate

symptom release Alprazolam, lorazepam, and clonazepam Initiate benzodiazepines until antidepressants begin

working Short acting associated with rebound anxiety ( alprazolam,

lorazepam). Give in divided doses Avoid if sleep apnea Withdrawal symptoms can occur Side effects: headache, confusion, dizziness, disorientation,

sedation, and visual disturbances Interactions with TCAs, digoxin, alcohol, and other CNS

depressants. Avoid histamine blockers. Cigarette smoking increases clearance

Teaching points: avoid alcohol, sedative effects

Nursing Management:Psychlogical Assessment

Determining patterns of panic attack, symptoms, and responses

Mental status : restlessness, irritability, watchful or worried facial expression, decreased attention span, difficulty problem solving, apprehensive, or helpless,self-report scales

Suicidal assessment

Cognitive thought patterns

Self-concept

Rating scales (text box 19.6,table 19.5)

Nursing DiagnosesPsychological Domain

Anxiety

Risk for self-harm

Powerlessness

Psychological Interventions Help patient attend to and react to input other than

subjective experience (table19.7) Provide patient with information Distraction Positive self-talk “I will get through this” Panic control treatment: structured exposure to

internal sensations Exposure therapy Systematic desensitization Implosive therapy Cognitive-behavioral therapy Psychoeducation

Nursing Management Social DomainAssessment

Family functioning

Cultural factors

Social Interventions

Stress time management

Family support Help with communication

Emergency CareInterventions for Panic Attack

Stay with the patient

Reassure that you will not leave

Give clear directions

Assist patient to an environment with minimal stimulation

Walk with the patient

Administer PRN anxiolytic medications

Obsessive-Compulsive Disorder

Severe obsessions or compulsions that interfere with life

Obsessions - unwanted thoughts, intrusive persistent thoughts, impulses or images that

cause anxiety and distress fear of contamination

Compulsions - repetitive behaviors performed in a ritualistic way that relieve anxiety

Obsessive-Compulsive Disorder

Special PopulationsOCD

Children 1%-2.3% of child and adolescent population ritualistic behaviors are typical of childhood parents begin to notice grades fall because of

decrease concentration

Elderly can occur in adulthood

OCD

2.5% lifetime prevalence of individuals

Similar rates in men and women

First-degree relatives most common

Less common in African Americans

Highly somatic

Comorbid anxiety disorders, personality disorders

EtiologyBiologic Domain

Genetic first degree relatives monozygotic twins

Neuropathologic Abnormalities in frontal cortex, limbic system, and basal

ganglia PET scans (see Ch. 18, Fig. 18-3) Increased glucose metabolism in caudate nuclei, orbitofrontal

gyri, and the cingulate gyri

Biochemical Serotonin implicated (because of SSRIs) Others probably involved

EtiologyPsychological Theories

Psychodynamic symptoms and character traits arise from

unconscious defense mechanisms: isolation, undoing, and reaction formation

not scientifically tested Behavioral

based on learning theory obsessions seen as conditioned stimuli compulsions develop to reduce obsessional

anxiety

Risk Factors Infection with -hemolytic streptococci

Young

Divorced

Separated

Unemployed

Treatment

Interdisciplinary Staff needs to be consistent in

expectations

Priority Care Issues Suicide

Common Reponses Obsessions create anxiety and compulsions are

performed to reduce anxiety Common compulsions

washing, cleaning, checking, counting, repeating actions ordering, making confessions, and requesting assurances if sequence disturbed, person experiences anxiety

Most common obsessions fear of contamination, resulting compulsion toward handwashing

Dissociation: a breakdown in integrated functions of memory, consciousness, perception of self, environment, or sensory and motor behavior

Depersonalization: loss of sense of personality Coexists with Tourette’s Syndrome

Nursing ManagementBiologic Domain

Assess for multiple physical symptoms

Physical fears

Physical consequences of compulsions

Nutrition and sleep status

Dermatologic lesions secondary to hand washing

Head trauma

Biologic Interventions

Electroconvulsive therapy Psychosurgery Maintaining skin integrity Psychopharmacologic treatment

SSRI and TCA Antidepressants given in higher doses than for

treatment of depression Side effect monitoring a problem for those

preoccupied with somatic concerns Teaching points: medication management, do not stop

prescribed medications abruptly, avoid OTC medications, consider sedative effect

Nursing ManagementPsychological Assessment

Type and severity of obsessions and compulsions

Degree to which the OCD symptoms interfere with patient’s daily functioning

Consider using rating scales (Text Box 21.5)

Suicide assessment

Psychological Interventions

Response prevention

Thought stopping

Relaxation techniques

Cognitive restructuring

Cue Cards (Text Box 21.6)

Psychoeducation (See Psychoeducation Checklist)

Nursing Management Social Domain

Consider sociocultural factors and ability to relate to others

In hospital, unit routines carefully and clearly explained to decrease patient’s fear of unknown

Recognize significance of rituals

Assist patient in arranging schedule

Marital and family support important

Nursing Management Social interventions

Milieu interventions Personal and environmental protective

measures Family interventions

Evaluation Continuum of care

General Anxiety Disorder

Worry obsessively and interferes with life Very common -- 5% will experience it in

their life Onset gradual Comorbid psychiatric disorders, mild

depressive symptoms common Associated with alcoholism

GAD Etiology Neurochemical theories (little research)

Genetic theories (moderately inherited)

Psychological theories inaccurate assessment of environment

selective focus on negative details, distorted information, processing, and overly pessimistic view

Social theories (no specific theories) High-stress lifestyle

Multiple stressful events

Risk Factors

Unresolved conflicts

Cognitive misinterpretations

Life stressors

Genetic predisposition

Behavioral inhibition

Nursing ManagementBiologic DomainAssessment

Diet and nutrition may be hypersensitive to caffeine

Sleep patterns disturbances are common

Substance use

Nursing InterventionsBiologic Domain

Medications Buspirone (Buspar) Antidepressants

Nutrition counselingSleep hygiene

Psychosocial DomainAssessment and interventions

similar to panic disorderCognitive psychotherapy is

effective treatment of GADOutcomes include reducing

frequency and intensity of anxiety and controlling factors that contribute to anxiety

Other Anxiety Disorders

Specific Phobia

Social Phobia

PTSD (discussed later)

Acute Stress Disorder

Dissociative Disorders

Dissociative amnesia

Dissociative fugue

Depersonalization disorder

Dissociative Identity Disorder

General Anxiety Disorder

Evaluation

Continuum of care

Dissociative Disorders

Failure to integrate identity, memory, and consciousness

Types Dissociative amnesia -- inability to recall Dissociative fugue -- unexpected travel away from

home Depersonalization disorder -- being detached for

one’s body Dissociative identity disorder (multiple

personality disorder) Dissociative disorder not otherwise specified

Anxiety Disorders