Anxiety Disorders

ANXIETY DISORDERSAnxiety—Vague,

subjective non specific feeling. *uneasiness, apprehension*tension,feeling of dread or impending doom

Causes- result of threat to one’s Biologic, Physiologic and Social Integrity- external influences

Types of AnxietySignal Anxiety- (Phobic Disorders)Precipitant is identifiedA learned anxiety response-results from

situations successfully repressed or coped with using another defense mechanism

Trait anxietyA function of Personality structureLink with developmental process/eventsMay be linked to unresolved

conflict/confusion (Anxiety Diathesis)a pre-disposition to anxiety when exposed to stressor.

E.g.. One had a chronically ill mother and is overprotective w/own children.

State AnxietyDevelops in conflict or stressful

situationsExperiences limited controlAnxiety occurs before the situation

arisesE.g.. Woman who avoids making appt

w/PMD after finding breast mass and has a strong family hx. Of cancer.

Free Floating AnxietyPervasive sense of dread or doomCannot be attached to any idea or eventMay result in panic state if stressors

exceed the individuals ability to cope.

Levels of AnxietyHildegard Peplau “Interpersonal

Relations in Nursing 1952” identified Four stages of anxiety on a continuum

MildModerateSevere PanicPanic

Behavioral & Physiologic changes in Mild Anxiety

Perceptual field widens

Î awareness & motivation

Î problem solving & learning

Irritable

Related client Needs:

Restlessness “butterflies in

stomach” Î sleep disturbance More sensitive to

noise

Behavioral & Physiologic changes Moderate Anxiety

Immediate task oriented

Attentive to immediate task

Difficulty w/concentration,but can be redirected

V/S normal –increased

Frequent urination Dry mouth/muscle

tension Î rate of speech diaphoretic

Behavioral & Physiologic changes in Severe Anxiety

Narrowed perceptual field-one detail

Difficulty completing task or solving problems

Cannot learn effectively Feelings of dread/doom Crying Ritualistic behaviors ie.

Rocking

Headache/nausea&vomiting

Vertigo Pale Tachycardia C/o chest pain Rigid stance

Behavioral & Physiologic changes in Panic level anxiety Unable to process

environmental stimuli Distorted perceptions Can only focus on self Risk for self harm Unable to communicate Irrational

thoughts/behaviors Possible

delusions/hallucinations

Can run away from scene or

Can be immobilized & mute

Dilated pupils Î B/P, P, R Flight,fight or freeze

reaction

Etiological Theories/Anxiety Biologic Model

Hans Selye- expanded the idea that endocrine system and CNS (hypothalamus and Pituitary gland ) have reciprocal relationships

Studies of the neuropharmacology of the Autonomic Nervous System (ANS) re: regulation of Cardiovascular/GI/Motor systems –was shown responsive to stimuli

RX’s target seratonin, noradrenergic,& y-amino-butyric acid(GABA)

Psychodynamic Model Concept views Anxiety as a warning to the

ego Three types Anxiety identified

REALITY Anxiety(painful emotional experience resulting from perception of danger in external world)

MORAL Anxiety (THE Ego’s experience of Guilt and Shame)

NEUROTIC Anxiety (perception of threat according to one’s instincts)

Neurotic sx’s develop to defend against anxiety

Interpersonal /Social Psychology Models/Anxiety Anxiety is the response to external

environment Sullivan:”Anxiety is the first great educative

experience in living” Symptoms were response to

expectations/insecurities/frustrations/conflicts between person and Primary Groups i.e..family, colleagues, social associates.

Emphasis on early development

Behavioral Model/AnxietyBased on Learning theory- etiology of

sx’s based on generalization of an earlier traumatic experience to a benign setting or object. Links past experiences with present

responses – anxiety occurs when a “signal” predicts a painful or feared event

May be linked to PTSD

Epidemiology of Anxiety Disorders Anxiety D/O’s ---6 – 8% of population More prevalent in women 22-44 y/o & in

separated/divorced group Except for OCD’s and Social Phobias –

anxiety greater in women Clients w/major Depression –18.8% inc.risk

for panic d/o and 15/3% risk for agoraphobia 10-12% of general population have simple

phobias

Epidemiology of Anxiety Disorders in the Older Adult 3.5 –10 % of elders suffer from Anxiety

disorders 10-15% of Women >65 y/o seek help from MD

(Hegel, et.al 2002) RISK factors: female; urban living;hx. Of worry or rumination;poor physical health;

low socioeconomic status; stressful life events;depression & alcoholism

GAD – most common anxiety D/O in the elderlyC/b worry- co-exist w/depression.

Behavioral manifestations of Panic attacksPANIC ATTACK-sudden onset –intense

apprehension-fearfulness-terror assoc w/impending doom-lasts 15-30 minutes 4 or more sx’s i.e..palpitations, sweating,

trembling; SOB,choking,smothering sensation

Behavioral manifestations of PhobiasPHOBIAS – avoidance of object or

situation Significant distress or impairment of daily

routines,occupation or social functioning. Fear recognized as excessive or

unreasonable

Post Traumatic Stress Disorder (PTSD)C/b re-experiencing an extremely

traumatic event(begins within 3 months to years after event –lasting months or years Person avoids the stimuli associated with

the event, numbing of responsiveness,increased

arousal

PTSD---characteristics Intense fear /helplessness/horror upon exposure Dreams,flashbacks, Physical/psychological distress over reminders

of the event Avoids memory provoking stimuli Feeling detached or estranged from others Increased arousal (irritability,angry

outburst,sleep problems,hypervigilance,exaggerated startle response)

PTSD interventionsPromote desensitization through

gradual exposure to event or situation similar to the event

Teach relaxation techniquesProvide individual therapy to address

loss of control issuesEncourage use of support groupsEncourage use of hypnotherapy

Generalized Anxiety DisorderC/b at least 6 months of persistent,

excessive worry and anxiety. Uncontrollable worrying Significant distress w/impaired social or

occupational functioning 3 of the following:restlessness, fatigues

easily,difficulty w/concentration, thought blocking,irritability, muscle tension sleep disturbance.

InterventionsAttend to physical symptomsAssist client to identify thoughts that

arouse the anxiety & their basesAssist client to change unrealistic

thoughts to more realistic thoughtsUse cognitive re-structuringAdminister anti-anxiety medications as

prescribed

Obsessive Compulsive DisorderObsessions –( thoughts, impulses or

images) which cause marked anxiety or Compulsions(repetitive behaviors or mental acts) Recurrent, persistent, unwanted thoughts

impulses or images Attempts to ignore,suppress,or neutralizes

obsessions with compulsions –are mostly ineffective.

OCD interventions Identify the situation that precipitates the

behavior Do not interrupt compulsive behaviors Allow time for compulsive rituals Provide safety related to behaviors Provide schedule to distract behaviors Set limits on rituals that may interfere with client

well-being Establish written contract-decrease frequency of

compulsive behaviors

Developmental considerationsChild

Adolescent

Adult

Elder

Cultural Considerations for Anxiety disorders in:

HispanicAfrican –AmericanAsianEuropean- AmericanMiddle Eastern

The nurse is working with the family of a client with Obsessive Compulsive D/O.Which of the following should the nurse incorporate in the teaching plan?

A.) the thoughts images and impulses are voluntaryB.) the family should pay immediate attention to

symptomsC.) the thoughts, images and impulses worsen the

stressD.) OCD is a chronic disorder not responsive to

treatment

A client displays isolation, bizarre behaviors, unsafe actions and poor hygiene. Which will be the first priority in the nursing care plan?

A.) SafetyB.)HygieneC.)IsolationD.) Bizarre behaviors

The nurse would analyze the symptoms of muscle rigidity, GI upset, rapid speech,and need to urinate as which level of anxiety?

A.) Mild

B.) Moderate

C.) Severe

D.) Panic

A client has recently been involved in assisting with the clean-up from a flood that washed away many homes in his area and caused loss of life.Which of these interventions would assist the client in dealing with the traumatic experience.

A. Provide the opportunity to talk about the experience.

B. Encourage the client to leave the area in order to forget the experience.

C. Suggest admission to a mental health facility.D. Arrange for a minister to speak with the client.

Appropriate discharge criteria for a client with chronic anxiety disorder is the client will---

A.) experience no more anxiety

B.) suppress the anxiety symptoms and focus on the future

C.) Identify situations and events that trigger anxiety

D.) recognize the need to take medications for the rest of his/her life to control anxiety

The nurse is working with a client with chronic anxiety. The goal is that the client will identify early warning symptoms of anxiety.The nurse would analyze the client as moving towards this goal when the client:

A.) begins to connect panic symptoms with thoughts about a recent break-up in a relationship.

B.) is free of anxiety for one weekC.)practices relaxation techniques daily and when

anxiety increasesD.)recognizes that others also experience anxiety in

varying situations

A client is to receive medication therapy for an anxiety disorder. To reduce the risk of dependence and problems related with withdrawal, which of the following agents would the nurse most likely anticipate as being prescribed? (select all that apply)

A. Paroxetine (Paxil)B. Sertaline (Zoloft)C. Lorazepam (Ativan)D. Venlafaxine (Effexor)E. Clonazepam (Klonopin)

The nurse assesses a client with a diagnosis of Generalized Anxiety disorder for which of the following symptoms?

A. Fear and avoidance of specific situations or places.

B. Persistent obsessive thoughtsC. Re-experience of feelings associated with

traumatic eventsD. Unrealistic worry about a number of events

in one’s life.

A 4 year-old girl who is a victim of a bomb blast that demolished the building which housed her daycare constantly builds block houses and blows them up. She also has nightmares frequently. Which one of the following diagnoses is appropriate for the nurse to make regarding this child?

A. Post-trauma response related to terrorist attack as evidenced by destructive behaviors and sleep disturbance.

B. Explosive disorder related to dysfunctional personality as evidenced by destructive behaviors.

C. Sleep disturbance related to emotional trauma as evidenced by nightmares.

D. Ineffective individual coping related to internal stressors as evidenced by destructive behaviors and nightmares.

Nursing Care Plan: Anxiety Assessment data:

Appearance,Behavior,Conversation i.e.: Wringing hands,decreased

communication,restlessness, irritability,pacing,decreased attn, poor impulse control

Identify stressors- intra,inter, extrapersonal Identify lines of defense

Goals/expected outcomes:Short term:

The client will: be –free of injury Discuss feelings of dread or anxiety Respond to relaxation techniques Demonstrate ability to perform relaxation

Implementation: anxiety Remain with client at all times if level is

severe or panic(safety important) Remove client to Quiet area( client is not able

to deal with excessive stimuli) Remain calm upon approaching client(client

will feel more secure if you are in control of situation)

Use short simple clear statements(impaired ability to deal with abstractions/complexities)

Use PRN meds as indicated

Nursing interventions: Educate client re use of caffeine, nicotine etc.

(prevents/minimizes cardiovascular responses i.e. Inc heart rate and jitteriness)

Provide instruction regarding anxiety reduction stretagies Progression relaxation techniques Listening to smoothing music or relaxation tapes

When planning discharge for a client with chronic anxiety the nurse directs the goal of promoting a safe environment at home.The most appropriate maintenance goal should focus on which of the following:

A.Continues contract with a crisis counselorB.Identifying anxiety producing situationsC.Ignoring feelings of anxietyD.Eliminating all anxiety from daily situations

A client with OCD is admitted to the psychiatric unit for hand washing rituals. The day after admission she is scheduled for lab tests. To assure that he client is there on time, the nurse should:

A. Remind the client several times of her appointment.

B. Limit the number of hand washingsC. Tell her it is her responsibility to be there on timeD. Provide ample time for her to complete her

rituals.

A client admitted for ritualistic behaviors is constipated and dehydrated. Which nursing intervention would this client most likely comply with?

A. Drinking Ensure between mealsB. Drinking extra fluids with mealsC. Drinking 8 oz. Of water every hour between

mealsD. Drinking adequate amounts of fluid during

the day

A woman comes into the emergency room in a severe state of anxietyfollowing a car accident. The most appropriate nursing intervention is to:A. Remain with the clientB. Put the client in a quiet roomC. Teach the client deep breathingD. Encourage the client to talk about her

feelings and concerns

A client is unwilling to go out of the house for “fear of doing something crazy in public”. As a result the client remains homebound except when accompanied outside by the spouse.

Based on this data the nurse determines that the client is experiencing:

A.Social phobiaB. AgoraphobiaC. ClaustrophobiaD. Hypochondriasis

A client is admitted to a psych unit after having many test for acute blindness for which there is no organic cause.The nurse learns the client became blind after witnessing a hit and run accident, when a family of three was killed. The nurse suspects the client may be experiencing:

A. PsychosisB. Conversion DisorderC. Dissociative DisorderD. Repression