Anxiety Anxiety Disorders

Chapter 8

Concept of Anxiety and Psychiatric Nursing

• Anxiety– Universal human experience– Dysfunctional behavior often defends against

anxiety

• Legacy of Hildegard Peplau (1909-1999)– Operationally defined concept and levels of anxiety– Suggested specific nursing interventions

appropriate to each of four levels of anxiety

Psychological Adaptation to Stress

• Anxiety and grief have been described as two major, primary psychological response patterns to stress.

• A variety of thoughts, feelings, and behaviors are associated with each of these response patterns.

• Adaptation is determined by the extent to which the thoughts, feelings, and behaviors interfere with an individual’s functioning.

Anxiety and Fear

• Anxiety: feeling of apprehension, uneasiness, uncertainty, or dread resulting from real or perceived threat whose actual source is unknown or unrecognized

• Fear: reaction to specific danger

• Similarity between anxiety and fear– Physiological response to these experiences is

the same (fight-or-flight response)

Anxiety

• A diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness.

• Extremely common in our society. • Mild anxiety is adaptive and can provide

motivation for survival.

Types of Anxiety• Normal

– Motivating force that provides energy to carry out tasks of living

• Acute or state– Anxiety that is precipitated by imminent loss or change that

threatens one’s security (crisis)• Chronic or trait

– Anxiety that persists over time

• Mild

– Occurs in normal everyday living

– Increases perception, improves problem solving

– Manifested by restlessness, irritability, mild tension-relieving behaviors

Types of Anxiety• Moderate

– Escalation from normal experience

– Decreases productivity (selective inattention) and learning

– Manifested by increased heart rate, perspiration, mild somatic symptoms

• Severe– Greatly reduced perceptual field– Learning and problem solving not possible– Manifested by erratic, uncoordinated, and impulsive behavior

• Panic– Results in loss of reality focus– Markedly disturbed behavior occurs– Manifested by confusion, shouting, screaming, withdrawal

Peplau’s four levels of anxiety

• Mild – seldom a problem

• Moderate – perceptual field diminishes

• Severe – perceptual field is so diminished that concentration centers on one detail only or on many extraneous details

• Panic – the most intense state

Behavioral adaptation responses to anxiety

• At the mild level, individuals employ various coping mechanisms to deal with stress. A few of these include eating, drinking, sleeping, physical exercise, smoking, crying, laughing, and talking to persons with whom they feel comfortable.

Defense Mechanisms

• Help protect people from painful awareness of feelings and memories that can cause overwhelming anxiety– Operate all the time– Adaptive (healthy) or maladaptive (unhealthy)

• First outlined and described by Sigmund Freud and his daughter Anna Freud

Properties of Defense Mechanisms

• Major means of managing conflict and affect

• Relatively unconscious

• Discrete from one another

• Hallmarks of major psychiatric disorders

• Can be reversible

• Can be adaptive as well as pathological

Healthy, Intermediate, and Immature Defense Mechanisms

• Healthy– Altruism, sublimation, humor, suppression

• Intermediate– Repression, displacement, reaction formation,

undoing, rationalization

• Immature– Passive aggression, acting-out behaviors,

dissociation, devaluation, idealization, splitting, projection, denial

Defense Mechanisms

– Compensation– Denial– Displacement– Identification– Intellectualization– Introjection– Isolation– Projection

– Rationalization

– Reaction formation

– Regression

– Repression

– Sublimation

– Suppression

– Undoing

• Anxiety at the moderate to severe level that remains unresolved over an extended

period of time can contribute to a number of physiological disorders – for example, migraine headaches, IBS, and cardiac arrhythmias.

• Extended periods of repressed severe anxiety can result in psychoneurotic patterns of behaving – for example, anxiety disorders and somatoform disorders.

Introduction: Anxiety Disorder

Anxiety provides the motivation for achievement, a necessary force for survival.

Anxiety is often used interchangeably with the word stress; however, they are not the same.

Anxiety may be differentiated from fear in that the former is an emotional process, whereas fear is cognitive.

• Extended periods of functioning at the panic level of anxiety may result in psychotic behavior; for example, schizophrenic, schizoaffective, and delusional disorders.

Epidemiological statistics

– Anxiety disorders are the most common of all psychiatric illnesses

– More common in women than men

– Minority children and children from low socioeconomic environments at risk

– A familial predisposition probably exists

• How much is too much?– When anxiety is out of proportion to the situation that is

creating it.– When anxiety interferes with social, occupational, or other

important areas of functioning.

Predisposing Factors

• Psychodynamic theory

• Cognitive Theory

• Biological aspects

• Transactional Model of Stress Adaptation

Panic Disorders: Panic Attack, Panic Disorder with Agoraphobia• Panic attack

– Sudden onset of extreme apprehension or fear of impending doom

– Fear of losing one’s mind or having a heart attack

• Panic disorder with agoraphobia– Panic attacks combined with agoraphobia

• Agoraphobia is fear of being in places or situations from which escape is difficult or help unavailable

– Feared places avoided, restricting one’s life

Phobia

• Phobia: persistent, irrational fear of specific objects, activities, or situations

• Types of phobias– Specific: response to specific objects– Social: result of exposure to social situations or

required performance– Agoraphobia: fear of being in places/situations

from which escape is difficult or help unavailable

Obsessive-Compulsive Disorder (OCD)

• Obsession– Thoughts, impulses, or images that persist and recur

• Ego-dystonic symptom: feels unacceptable to individual

• Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress

Compulsions

• Ritualistic behaviors that individual feels driven to perform

• Primary gain from compulsive behavior: anxiety relief

• Unwanted repetitive behavior patterns or mental acts that are intended to reduce anxiety, not to provide pleasure or gratification

Generalized Anxiety Disorder (GAD)

• Excessive anxiety or worry about numerous things lasting at least 6 months

• Common symptoms

– Restlessness

– Fatigue

– Poor concentration

– Irritability

– Tension

– Sleep disorders

Post-traumatic Stress Disorder (PTSD)

– Development of characteristic symptoms following exposure to an extreme traumatic stressor involving a personal threat to physical integrity or to the physical

integrity of others – Characteristic symptoms include reexperiencing the

traumatic event, a sustained high level of anxiety or arousal, or a general numbing of responsiveness. Intrusive recollections or nightmares of the event are common.

• Psychosocial theory– The traumatic experience

• Severity and duration of the stressor• Extent of anticipatory preparation before onset• Exposure to death• Numbers affected by life threat• Extent of control over recurrence• Location where trauma was experienced

– The individual• Degree of ego-strength• Effectiveness of coping resources• Presence of preexisting psychopathology

– Outcomes of previous experiences with stress/trauma– Behavioral tendencies– Current psychosocial developmental stage– Demographic factors

– The recovery environment• Availability of social supports

• Cohesiveness and protectiveness of family and friends

• Attitudes of society regarding the experience

• Cultural and subcultural influences

• Learning theory– Negative reinforcement as behavior that leads to a reduction in an

aversive experience, thereby reinforcing and resulting in repetition of the behavior

– Avoidance behaviors– Psychic numbing

• Cognitive theory– A person is vulnerable to post-traumatic stress disorder when

fundamental beliefs are invalidated by experiencing trauma that cannot be comprehended and when a sense of helplessness and hopelessness prevails.

Treatment Modalities

• Psychopharmacology – PTSD

• Antidepressants

• Anxiolytics

• Antihypertensives

• Others

• Biological aspects– It has been suggested that a person who has experienced

previous trauma is more likely to develop symptoms after a stressful life event.

– Disregulation of the opioid, glutamatergic, noradrenergic, serotonergic, and neuroendocrine pathways may be involved in the pathophysiology of PTSD.

• Transactional Model of Stress Adaptation– The etiology of PTSD is most likely influenced by multiple

factors

Acute Stress Disorder• Occurs within 1 month after exposure to highly

traumatic event • Characterized by at least three dissociative symptoms

during/after event– Subjective sense of numbing– Reduction in awareness of surroundings– Derealization– Depersonalization– Dissociative amnesia

Anxiety Caused by Medical Conditions

• Direct physiological result of medical conditions such as:– Hyperthyroidism– Pulmonary embolism– Cardiac dysrhythmias

• Evidence must be present in history, physical exam, or laboratory findings in order to diagnose

Nursing Process: Assessment Guidelines

• Determine if anxiety is primary or secondary (due to medical condition)– Ensure sound physical/neurological exam

• Use of Hamilton Rating Scale– Comprehensive data related to anxiety

• Determine potential for self-harm/suicide

• Perform psychosocial assessment

• Determine cultural beliefs and background

Nursing Process: Diagnosis and Outcomes Identification

• NANDA-International (NANDA-I) – Nursing diagnoses useful for patient with

anxiety or anxiety disorder

• Nursing Outcomes Classification (NOC)– Identifies desired outcomes for patients with

anxiety or anxiety disorders

Considerations for Outcome Selection for Patients with Anxiety Disorders

• Reflect patient values and ethical and environmental situations

• Be culturally relevant

• Be documented as measurable goals

• Include a time estimate of expected outcomes

Nursing Process: Planning and Implementation

• Planning– Select interventions that can be implemented in

a community setting– Include patient in process of planning

• Implementation– Follow Psychiatric–Mental Health Nursing:

Scope and Standards of Practice (ANA, 2007)

Nursing Interventions for Patients with Anxiety Disorders

• Identify community resources offering specialized treatments proven as effective

• Identify community support groups

• Use therapeutic communication, milieu therapy, promotion of self-care activities, and psychobiological and health teaching and health promotion

Nursing Interventions:

• Milieu Therapy

• Cognitive-Behavioral Therapy (CBT)

Common Benzodiazepine Anxiolytics

Generic

diazepam

lorazepam

alprazolam

clonazepam

chlordiazepoxide

oxazepam

Brand

Valium

Ativan

Xanax

Klonopin

Librium

Serax

*Non- Anxiolytic: BusSpar

Non-sedating, non habit forming and not a prn. Good for the elderly

Non-benzodiazepine Hypnotic

Generic

Zolpidem

Zalepon

Eszopiclone

Ramelteon

Brand

Ambien, *Ambien CR

Sonata

Lunesta

Rozerem

*contains a two layer coat

One layer releases it simmediataely and other layer has a slow release of additional drug

The Nursing Process: Antianxiety Agents

Background Assessment Data• Indications: anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation

• Action: depression of the CNS

• Contraindications/Precautions – Contraindicated in known hypersensitivity; in combination with other CNS depressants; in pregnancy and lactation, narrow-angle glaucoma, shock, and coma– Caution with elderly and debilitated clients, clients with renal or hepatic dysfunction, those with a history of drug abuse or addiction, and those who are depressed or suicidal

• Interactions– Increased effects when taken with alcohol,

barbiturates, narcotics, antipsychotics antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram

– Decreased effects with cigarette smoking and caffeine consumption

– DO NOT USE WITH ALCOHOL

Nursing Diagnosis

• Risk for injury• Risk for activity intolerance• Risk for acute confusion

Planning/Implementation• Monitor client for these side effects

– Drowsiness, confusion, lethargy; tolerance; physical and psychological dependence; potentiation of other CNS depressants; aggravation of depression; orthostatic hypotension; paradoxical excitement; dry mouth; nausea and vomiting; blood dyscrasias; delayed onset (with buspirone only)

• Educate client/family about the drug

Outcome Criteria/Evaluation

Common Medications• BZAs: short-term treatment only

– Causes dependence• Buspirone: management of anxiety disorders• Selective serotonin reuptake inhibitors (SSRIs): first-

line treatment for all anxiety disordersSelective norepinephrine reuptake inhibitors (SNRIs): venlafaxine approved for panic disorder, GAD, and SAD

• Tricyclic antidepressants (TCAs): second- and third-line treatment

Nursing Process: Evaluation

– Does patient maintain satisfactory relationships?

– Can patient resume usual roles?– Is patient compliant with medications?– Does patient maintain satisfactory

relationships?– Can patient resume usual roles?– Is patient compliant with medications?