MENTAL HEALTH: CHAPTER 14: ANXIETY & ANXIETY DISORDERS:

Treatment For Anxiety:

- Treatment for anxiety disorders usually involves medication and therapy. - This combination produces better results than either one alone - Cognitive-behavioral therapy (CBT) is used successfully to treat anxiety disorders.

Defense Mechanisms (OUTLINE):

- Unconscious mechanisms person uses to maintain being control of a situation - Person is unaware he's using them - Overuse can result in development of anxiety disorder

Stress (OUTLINE):

- Wear and tear that life causes on the body

Selective Mutism (OUTLINE):

- When children fail to speak in social situations even though they're able to speak

Specific Phobia:

- Which is an irrational fear of a particular object or a situation Specific phobias are subdivided into the following categories: •Natural environmental phobias: fear of storms, water, heights, or other natural phenomena •Blood-injection phobias: fear of seeing one's own or others' blood, traumatic injury, or an invasive medical procedure such as an injection •Situational phobias: fear of being in a specific situation such as on a bridge or in a tunnel, elevator, small room, hospital, or airplane •Animal phobia: fear of animals or insects (usually a specific type; often, this fear develops in childhood and can continue through adulthood in both men and women; cats and dogs are the most common phobic objects) •Other types of specific phobias: for example, fear of getting lost while driving if not able to make all right (and no left) turns to get to one's destination.

Mild Anxiety:

- Wide perceptual field - Focuses attention - Motivates people to make changes and engage in goal-oriented activity

More Prevalent In:

- Women - People under 45 years - People who are divorced or separated - People of lower socioeconomic status

Self-Awareness Issues:

- Working with people who have anxiety disorders is a different kind of challenge for the nurse. - These clients are usually average people in other respects who know that their symptoms are unusual but feel unable to stop them. - They experience much frustration and feelings of helplessness and failure. - Their lives are out of their control, and they live in fear of the next episode. - They go to extreme measures to try to prevent episodes by avoiding people and places where previous events occurred. - It may be difficult for nurses and others to understand why the person cannot simply stop being anxious and "calm down." - Nurses must understand what and how anxiety behaviors work, not just for client care but to help understand the role anxiety plays in performing nursing responsibilities. - Nurses are expected to function at a high level and to avoid allowing their own feelings and needs to hinder the care of their clients. - But as emotional beings, nurses are just as vulnerable to stress and anxiety as others, and they have needs of their own.

Specific Phobia Categories:

-Specific phobias are subdivided into the following categories: •Natural environmental phobias: fear of storms, water, heights, or other natural phenomena •Blood-injection phobias: fear of seeing one's own or others' blood, traumatic injury, or an invasive medical procedure such as an injection •Situational phobias: fear of being in a specific situation such as on a bridge or in a tunnel, elevator, small room, hospital, or airplane •Animal phobia: fear of animals or insects (usually a specific type; often, this fear develops in childhood and can continue through adulthood in both men and women; cats and dogs are the most common phobic objects)

Drugs Used To Treat Anxiety Disorders:

1. Alprazolam (Xanax): Class: Benzodiazepine; Used to treat: Anxiety, panic disorder, social phobia, agoraphobia 2. Buspirone (BuSpar): Class: Nonbenzodiazepine anxiolytic; Used to treat: Anxiety, social phobia, GAD 3. Clorazepate (Tranxene): Class: Benzodiazepine; Used to treat: Anxiety 3. Chlordiazepoxide (Librium): Class: Benzodiazepine; Used to treat: Anxiety 4. Clonazepam (Klonopin): Class: Benzodiazepine; Used to treat: Anxiety, panic disorder 5. Clonidine (Catapres): Class: Beta-blocker; Used to treat: Anxiety, panic disorder 6. Diazepam (Valium): Class: Benzodiazepine; Used to treat: Anxiety, panic disorder 7. Fluoxetine (Prozac): Class: SSRI antidepressant; Used to treat: Panic disorder, GAD 8. Hydroxyzine (Vistaril, Atarax): Class: Antihistamine; Used to treat: Anxiety 9. Imipramine (Tofranil): Class: Tricyclic antidepressant; Used to treat: Anxiety, panic disorder, agoraphobia 10. Meprobamate (Miltown, Equanil): ClassL Nonbenzodiazepine anxiolytic; Used to treat: Anxiety 11. Oxazepam (Serax): Class: Benzodiazepine; Used to treat: Anxiety 12. Paroxetine (Paxil): Class: SSRI antidepressant; Used to treat: Social phobia, GAD 13. Propranolol (Inderal): Class: Alpha-adrenergic agonist; Used to treat: Anxiety, panic disorder, GAD 14. Sertraline (Zoloft): Class: SSRI antidepressant; Used to treat: Panic disorder, social phobia, GAD

Anxiolytic Medications: Non-Benzodiazepines:

1. Buspirone (BuSpar): Onset: Very slow; Side effects: Dizziness, restlessness, agitation, drowsiness, headache, weakness, nausea, vomiting, paradoxical excitement or euphoria 2. Meprobamate (Miltown, Equanil): Onset: Rapid Nursing Implications: - Rise slowly from sitting position. - Take care with potentially hazardous activities, such as driving. - Take with food. - Report persistent restlessness, agitation, excitement, or euphoria to physician.

Anxiolytic Medications: Benzodiazepines:

1. Diazepam (Valium): Onset: Fast; Half-life: 20-100; Side Effects: Dizziness, clumsiness, sedation, headache, fatigue, sexual dysfunction, blurred vision, dry throat and mouth, constipation, high potential for abuse and dependence 2.Alprazolam (Xanax): Onset: Intermediate; Half-life: 6-12 3. Chlordiazepoxide (Librium): Onset: Intermediate; Half-life: 5-30 4. Lorazepam (Ativan): Onset: Intermediate; Half-life: 10-20 5. Clonazepam (Klonopin): Onset: Slow; Half-life: 18-50 6. Oxazepam (Serax): Onset: Slow; Half-life: 4-15 Nursing Implications: - Avoid other CNS depressants, such as antihistamines and alcohol. - Avoid caffeine. - Take care with potentially hazardous activities, such as driving. - Rise slowly from lying or sitting position. - Use sugar-free beverages or hard candy. - Drink adequate fluids. - Take only as prescribed. - Do not stop taking the drug abruptly.

Which of the following would a nurse expect to assess in a client with a panic disorder? A. Rational thinking B. Blaming of others C. Automatisms D. Organized thoughts

C. Automatism - Rationale: A client with panic disorder would demonstrate automatisms, irrational thinking, self-blame, and disorganized thoughts.

Is the following statement true or false? Phobias result from a past negative experience.

False - Rationale: Phobias usually do not result from past negative experiences. In fact, the person may never have had contact with the object of the phobia

Is the following statement true or false? The neurotransmitter dopamine is associated with anxiety disorders.

False - Rationale: The neurotransmitters GABA and serotonin are thought to play a role in anxiety disorders.

Outcome Identification:

Outcomes for clients with panic disorders include: •The client will be free from injury. •The client will verbalize feelings. •The client will demonstrate use of effective coping mechanisms. •The client will demonstrate effective use of methods to manage anxiety response. •The client will verbalize a sense of personal control. •The client will reestablish adequate nutritional intake. •The client will sleep at least 6 hours per night.

Data Analysis:

The following nursing diagnoses may apply to the client with panic disorder: •Risk for injury •Anxiety •Situational low self-esteem (panic attacks) •Ineffective coping •Powerlessness •Ineffective role performance •Disturbed sleep pattern

Is the following statement true or false? Anxiety and fear are considered to be two different things.

True - Rationale: Anxiety is different from fear. Anxiety is a vague feeling of dread or apprehension. Fear is a feeling of being afraid or threatened by an identifiable stimulus representing danger.

3. The best goal for a client learning a relaxation technique is that the client will a.confront the source of anxiety directly. b.experience anxiety without feeling overwhelmed. c.report no episodes of anxiety. d.suppress anxious feelings.

b.experience anxiety without feeling overwhelmed.

5. Which would be the best intervention for a client having a panic attack? a.Involve the client in a physical activity. b.Offer a distraction such as music. c.Remain with the client. d.Teach the client a relaxation technique.

c.Remain with the client.

6. A client with GAD states, "I have learned that the best thing I can do is to forget my worries." How would the nurse evaluate this statement? a.The client is developing insight. b.The client's coping skills have improved. c.The client needs encouragement to verbalize feelings. d.The client's treatment has been successful.

c.The client needs encouragement to verbalize feelings.

1. The nurse observes a client who is becoming increasingly upset. He is rapidly pacing, hyperventilating, clenching his jaw, wringing his hands, and trembling. His speech is high-pitched and random; he seems preoccupied with his thoughts. He is pounding his fist into his other hand. The nurse identifies his anxiety level as a.mild. b.moderate. c.severe. d.panic.

c.severe.

4. Which of the four classes of medications used for panic disorder is considered the safest because of low incidence of side effects and lack of physiological dependence? a.Benzodiazepines b.Tricyclics c.Monoamine oxidase inhibitors d.SSRIs

d.SSRIs

2. When assessing a client with anxiety, the nurse's questions should be a.avoided until the anxiety is gone. b.open-ended. c.postponed until the client volunteers information. d.specific and direct.

d.specific and direct.

7. A client with anxiety is beginning treatment with lorazepam (Ativan). It is most important for the nurse to assess the client's a.motivation for treatment. b.family and social support. c.use of coping mechanisms. d.use of alcohol.

d.use of alcohol.

Nursing Interventions:

•Provide a safe environment and ensure the client's privacy during a panic attack. •Remain with the client during a panic attack. •Help the client focus on deep breathing. •Talk to the client in a calm, reassuring voice. •Teach the client to use relaxation techniques. •Help the client use cognitive restructuring techniques. •Engage the client to explore how to decrease stressors and anxiety-provoking situations.

Points To Consider When Working With Someone With Anxiety & Anxiety Disorders:

•Remember that everyone occasionally suffers from stress and anxiety that can interfere with daily life and work. •Avoid falling into the pitfall of trying to "fix" the client's problems. •Discuss any uncomfortable feelings with a more experienced nurse for suggestions on how to deal with your feelings toward these clients. •Remember to practice techniques to manage stress and anxiety in your own life.

Client & Family Education: For Panic Disorders:

•Review breathing control and relaxation techniques. •Discuss positive coping strategies. •Encourage regular exercise. •Emphasize the importance of maintaining prescribed medication regimen and regular follow-up. •Describe time management techniques such as creating "to do" lists with realistic estimated deadlines for each activity, crossing off completed items for a sense of accomplishment, and saying "no." •Stress the importance of maintaining contact with community and participating in supportive organizations.

General Adaptation Syndrome: Resistance:

- "fight or flight" - Behavior vs. return of vitals to normal range if person is able to cope with situation

Generalized Anxiety Disorder:

- A person with GAD worries excessively and feels highly anxious at least 50% of the time for 6 months or more. - Unable to control this focus on worry, the person has three or more of the following symptoms: uneasiness, irritability, muscle tension, fatigue, difficulty thinking, and sleep alterations. - More people with this chronic disorder are seen by family physicians than by psychiatrists. - The quality of life is diminished greatly in older adults with GAD. Buspirone (BuSpar) and SSRI or serotonin-norepinephrine reuptake inhibitor antidepressants are the most effective treatments

Phobias:

- A phobia is an illogical, intense, and persistent fear of a specific object or a social situation that causes extreme distress and interferes with normal functioning. - Phobias usually do not result from past negative experiences. - In fact, the person may never have had contact with the object of the phobia. - People with phobias have a reaction that is out of proportion to the situation or circumstance. - Some individuals may even recognize that their fear is unusual and irrational but still feel powerless to stop it - People with phobias develop anticipatory anxiety even when thinking about possibly encountering the dreaded phobic object or situation. - They engage in avoidance behavior that often severely limits their lives. - Such avoidance behavior usually does not relieve the anticipatory anxiety for long. There are three categories of phobias: •Agoraphobia (discussed earlier in text) •Specific phobia, which is an irrational fear of a particular object or a situation •Social anxiety or phobia, which is anxiety provoked by certain social or performance situations - Many people express "phobias" about snakes, spiders, rats, or similar objects. - These fears are specific, easy to avoid, and cause no anxiety or worry. - The diagnosis of a phobic disorder is made only when the phobic behavior significantly interferes with the person's life by creating marked distress or difficulty in interpersonal or occupational functioning.

Anxiety (OUTLINE):

- A vague feeling of dread in response to internal or external stimuli that can have behavioral, emotional, cognitive, physical effects - Different from fear which is brought on by a clearly defined external stimulus

Anxiety Problems:

- Anxiety causes difficulty with logical thought, increasingly agitated motor activity, elevated vitals

Overview Of Anxiety Disorders:

- Anxiety disorders are diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change but becomes chronic and permeates major portions of the person's life, resulting in maladaptive behaviors and emotional disability. - Anxiety disorders have many manifestations, but anxiety is the key feature of each. Types of anxiety disorders include the following: •Agoraphobia •Panic disorder •Specific phobia •Social anxiety disorder (social phobia) •Generalized anxiety disorder (GAD)

Incidence:

- Anxiety disorders have the highest prevalence rates of all mental disorders in the United States for both children and adults. - Nearly one in four adults in the United States is affected, and the magnitude of anxiety disorders in young people is similar. - Anxiety disorders are more prevalent in women, people younger than 45 years of age, people who are divorced or separated, and people of lower socioeconomic status

Anxiety Disorder Etiology: Biologic Theories: Genetic Theories:

- Anxiety may have an inherited component because first-degree relatives of clients with increased anxiety have higher rates of developing anxiety. Heritability refers to the proportion of a disorder that can be attributed to genetic factors: •High heritabilities are greater than 0.6 and indicate that genetic influences dominate. •Moderate heritabilities are 0.3 to 0.5 and suggest an even greater influence of genetic and nongenetic factors. •Heritabilities less than 0.3 mean that genetics are negligible as a primary cause of the disorder. - Panic disorder, social anxiety disorder, and specific phobias, including agoraphobia, have moderate heritability. - GAD and OCD tend to be more common in families, indicating a strong genetic component, but still require further in-depth study. - Anxiety disorders aren't inherited in any simple Mendelian manner. - At this point, current research indicates a clear genetic susceptibility to or vulnerability for anxiety disorders; however, additional factors are necessary for these disorders to actually develop

Elderly Considerations:

- Anxiety that starts for the first time late in life is frequently associated with another condition such as depression, dementia, physical illness, or medication toxicity or withdrawal. - Phobias, particularly agoraphobia, and GAD are the most common late-life anxiety disorders. - Most people with late-onset agoraphobia attribute the start of the disorder to the abrupt onset of a physical illness or as a response to a traumatic event such as a fall or mugging. - Late-onset GAD is usually associated with depression. - Although less common, panic attacks can occur in later life and are often related to depression or a physical illness such as cardiovascular, GI, or chronic pulmonary diseases. - Ruminative thoughts are common in late-life depression and can take the form of obsessions, such as contamination fears, pathologic doubt, or fear of harming others. - The treatment of choice for anxiety disorders in the elderly is selective serotonin reuptake inhibitor (SSRI) antidepressants. - Initial treatment involves doses lower than the usual starting doses for adults to ensure that the elderly client can tolerate the medication; if started on too high a dose, SSRIs can exacerbate anxiety symptoms in elderly clients. - Despite evidence of many potential risks of prescribing benzodiazepines to older adults, the practice unfortunately continues

Heritability: Moderate:

- Are 0.3 to 0.5 and suggest an even greater influence of genetic and nongenetic factors.

Defense Mechanisms:

- Are cognitive distortions that a person uses unconsciously to maintain a sense of being in control of a situation, to lessen discomfort, and to deal with stress.

Heritability: High:

- Are greater than 0.6 and indicate that genetic influences dominate.

Levels Of Anxiety: Severe Anxiety:

- As the person progresses to severe anxiety and panic, more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantly. - A person with severe anxiety has trouble thinking and reasoning. - Muscles tighten, and vital signs increase. The person paces; is restless, irritable, and angry; or uses other similar emotional-psychomotor means to release tension. - In panic, the emotional-psychomotor realm predominates with accompanying fight, flight, or freeze responses. - Adrenaline surge greatly increases vital signs. - Pupils enlarge to let in more light, and the only cognitive process focuses on the person's defense. Psychological Response: - Perceptual field reduced to one detail or scattered details - Cannot complete tasks - Cannot solve problems or learn effectively - Behavior geared toward anxiety relief and is usually ineffective - Doesn't respond to redirection - Feels awe, dread, or horror - Cries - Ritualistic behavior Physiological Response: - Severe headache - Nausea, vomiting, and diarrhea - Trembling - Rigid stance - Vertigo - Pale - Tachycardia - Chest pain

Panic Disorder: Assessment: Mood & Affect:

- Assessment of mood and affect may reveal that the client is anxious, worried, tense, depressed, serious, or sad. - When discussing the panic attacks, the client may be tearful. - He or she may express anger at him or herself for being "unable to control myself." - Most clients are distressed about the intrusion of anxiety attacks in their lives. - During a panic attack, the client may describe feelings of being disconnected from him or herself (depersonalization) or sensing that things are not real (derealization).

Secondary Gain:

- Attention received from others as a result of this behavior

Panic Disorder: Assessment: Roles & Relationships:

- Because of the intense anticipation of having another panic attack, the person may report alterations in his or her social, occupational, or family life. - The person typically avoids people, places, and events associated with previous panic attacks. - For example, the person may no longer ride the bus if he or she has had a panic attack on a bus. - Although avoiding these objects does not stop the panic attacks, the person's sense of helplessness is so great that he or she may take even more restrictive measures to avoid them, such as quitting work and remaining at home.

Phobia (OUTLINE):

- Behavior that significantly interferes with the person's life by creating marked distress and difficulty in functioning

Psychodynamic Theories: Behavioral Theory:

- Behavioral theorists view anxiety as being learned through experiences. - Conversely, people can change or "unlearn" behaviors through new experiences. - Behaviorists believe that people can modify maladaptive behaviors without gaining insight into their causes. - They contend that disturbing behaviors that develop and interfere with a person's life can be extinguished or unlearned by repeated experiences guided by a trained therapist.

Phobia Treatment:

- Behavioral therapy works well. - Behavioral therapists initially focus on teaching what anxiety is, helping the client identify anxiety responses, teaching relaxation techniques, setting goals, discussing methods to achieve those goals, and helping the client visualize phobic situations. - Therapies that help the client develop self-esteem and self-control are common and include positive reframing and assertiveness training - One behavioral therapy often used to treat phobias is systematic (serial) desensitization, in which the therapist progressively exposes the client to the threatening object in a safe setting until the client's anxiety decreases. - During each exposure, the complexity and intensity of exposure gradually increase, but the client's anxiety decreases. - The reduced anxiety serves as a positive reinforcement until the anxiety is ultimately eliminated. - For example, for the client who fears flying, the therapist would encourage the client to hold a small model airplane while talking about his or her experiences; later, the client would hold a larger model airplane and talk about flying. - Even later, exposures might include walking past an airport, sitting in a parked airplane, and, finally, taking a short ride in a plane. - Each session's challenge is based on the success achieved in previous sessions

General Adaptation Syndrome: Exhaustion:

- Body stores are depleted because person has responded negatively to stress

Intervention: Providing Client & Family Education:

- Client and family education is of primary importance when working with clients who have anxiety disorders. - The client learns ways to manage stress and cope with reactions to stress and stress-provoking situations. - With education about the efficacy of combined psychotherapy and medication and the effects of the prescribed medication, the client can become the chief treatment manager of anxiety disorder. - It is important for the nurse to educate the client and family members about the physiology of anxiety and the merits of using combined psychotherapy and drug management. - Such a combined treatment approach along with stress reduction techniques can help the client manage these drastic reactions and allow him or her to gain a sense of self-control. - The nurse should help the client understand that these therapies and drugs do not "cure" the disorder but are methods to help him or her control and manage it. - Client and family education regarding medications should include the recommended dosage and dosage regimen, expected effects, side effects and how to handle them, and substances that have a synergistic or antagonistic effect with the drug. - The nurse encourages the client to exercise regularly. - Routine exercise helps metabolize adrenaline, reduces panic reactions, and increases production of endorphins; all these activities increase feelings of well-being.

Intervention: Using Therapeutic Communication:

- Clients with anxiety disorders can collaborate with the nurse in the assessment and planning of their care; thus, rapport between the nurse and the client is important. - Communication should be simple and calm because the client with severe anxiety cannot pay attention to lengthy messages and may pace to release energy. - The nurse can walk with the client who feels unable to sit and talk. - The nurse should carefully evaluate the use of touch because clients with high anxiety may interpret touch by a stranger as a threat and pull away abruptly. - As the client's anxiety diminishes, cognition begins to return. - When anxiety has subsided to a manageable level, the nurse uses open-ended communication techniques to discuss the experience:

Anxiety Disorders:

- Comprise a group of conditions that share a key feature of excessive anxiety with ensuing behavioral, emotional, cognitive, and physiological responses. - Clients suffering from anxiety disorders can demonstrate unusual behaviors such as panic without reason, unwarranted fear of objects or life conditions, or unexplainable or overwhelming worry. - They experience significant distress over time, and the disorder significantly impairs their daily routines, social lives, and occupational functioning.

Panic Disorder: Assessment: Thought Process & Content:

- During a panic attack, the client is overwhelmed, believing that he or she is dying, losing control, or "going insane." - The client may even consider suicide. - Thoughts are disorganized, and the client loses the ability to think rationally. - At other times, the client may be consumed with worry about when the next panic attack will occur or how to deal with it.

Panic Disorder: Assessment: Sensorium & Intellectual Processes:

- During a panic attack, the client may become confused and disoriented. He or she cannot take in environmental cues and respond appropriately. - These functions are restored to normal after the panic attack subsides.

Intervention: Promoting Safety & Comfort:

- During a panic attack, the nurse's first concern is to provide a safe environment and to ensure the client's privacy. - If the environment is overstimulating, the client should move to a less stimulating place. - A quiet place reduces anxiety and provides privacy for the client. - The nurse remains with the client to help calm him or her down and to assess client behaviors and concerns. - After getting the client's attention, the nurse uses a soothing, calm voice and gives brief directions to assure the client that he or she is safe.

Levels Of Anxiety: Panic:

- During panic anxiety, the person's safety is the primary concern. He or she cannot perceive potential harm and may have no capacity for rational thought. - The nurse must keep talking to the person in a comforting manner, even though the client cannot process what the nurse is saying. - Going to a small, quiet, and nonstimulating environment may help reduce anxiety. - The nurse can reassure the person that this is anxiety, it will pass, and he or she is in a safe place. - The nurse should remain with the client until the panic recedes. - Panic-level anxiety is not indefinite, but it can last from 5 to 30 minutes. Psychological Response: - Perceptual field reduced to focus on self - Cannot process any environmental stimuli - Distorted perceptions - Loss of rational thought - Doesn't recognize potential danger - Can't communicate verbally - Possible delusions and hallucination - May be suicidal Physiological Response: - May bolt and run or totally immobile and mute - Dilated pupils - Increased blood pressure and pulse - Flight, fight, or freeze

Cultural Considerations:

- Each culture has rules governing the appropriate ways to express and deal with anxiety. - Culturally competent nurses should be aware of them while being careful not to stereotype clients. - People from Asian cultures often express anxiety through somatic symptoms such as headaches, backaches, fatigue, dizziness, and stomach problems. - One intense anxiety reaction is koro, or a man's profound fear that his penis will retract into the abdomen and he will then die. - Accepted forms of treatment include having the person firmly hold his penis until the fear passes, often with assistance from family members or friends, and clamping the penis to a wooden box. - In women, koro is the fear that the vulva and nipples will disappear - Susto is diagnosed in some Hispanic clients (Peruvians, Bolivians, Colombians, and Central and South American Indians) during cases of high anxiety, sadness, agitation, weight loss, weakness, and heart rate changes. - The symptoms are believed to occur because supernatural spirits or bad air from dangerous places and cemeteries invades the body.

Psychodynamic Theories: Intrapsychic/Psychoanalytic Theories:

- Freud (1936) saw a person's innate anxiety as the stimulus for behavior. - He described defense mechanisms as the human's attempt to control awareness of and to reduce anxiety - Defense mechanisms are cognitive distortions that a person uses unconsciously to maintain a sense of being in control of a situation, to lessen discomfort, and to deal with stress. - Because defense mechanisms arise from the unconscious, the person is unaware of using them. - Some people overuse defense mechanisms, which stops them from learning a variety of appropriate methods to resolve anxiety-producing situations. - The dependence on one or two defense mechanisms also can inhibit emotional growth, lead to poor problem-solving skills, and create difficulty with relationships.

Anxiety Disorder Etiology: Biologic Theories: Neurochemical Theories:

- Gamma-aminobutyric acid (GABA) is the amino acid neurotransmitter believed to be dysfunctional in anxiety disorders. - GABA, an inhibitory neurotransmitter, functions as the body's natural antianxiety agent by reducing cell excitability, thus decreasing the rate of neuronal firing. - It is available in one-third of the nerve synapses, especially those in the limbic system and in the locus coeruleus, the area where the neurotransmitter norepinephrine, which excites cellular function, is produced. - Because GABA reduces anxiety and norepinephrine increases it, researchers believe that a problem with the regulation of these neurotransmitters occurs in anxiety disorders. - Serotonin, the indolamine neurotransmitter usually implicated in psychosis and mood disorders, has many subtypes. - 5-Hydroxytryptamine type 1a plays a role in anxiety, and it also affects aggression and mood. - Serotonin is believed to play a distinct role in OCD, panic disorder, and GAD. - An excess of norepinephrine is suspected in panic disorder, GAD, and PTSD

Treatment Techniques For Anxiety:

- Guided imagery - Deep breathing - Progressive muscle relaxation of the body

Panic Disorder: Assessment:

- Hamilton Rating Scale for Anxiety: The nurse can use this tool along with the following detailed discussion to guide his or her assessment of the client with panic disorder.

General Adaptation Syndrome:

- Hans Selye (1956, 1974), an endocrinologist, identified the physiological aspects of stress, which he labeled general adaptation syndrome. - He used laboratory animals to assess biologic system changes; the stages of the body's physical responses to pain, heat, toxins, and restraint, and later the mind's emotional responses to real or perceived stressors. - He identified three stages of reaction to stress: alarm reaction stage, resistance stage, exhaustion stage - Autonomic nervous system responses to fear and anxiety generate the involuntary activities of the body that are involved in self-preservation. - Sympathetic nerve fibers "charge up" the vital signs at any hint of danger to prepare the body's defenses. - The adrenal glands release adrenaline (epinephrine), which causes the body to take in more oxygen, dilate the pupils, and increase arterial pressure and heart rate while constricting the peripheral vessels and shunting blood from the gastrointestinal (GI) and reproductive systems and increasing glycogenolysis to free glucose for fuel for the heart, muscles, and central nervous system. - When the danger has passed, parasympathetic nerve fibers reverse this process and return the body to normal operating conditions until the next sign of threat reactivates the sympathetic responses. - Anxiety causes uncomfortable cognitive, psychomotor, and physiological responses, such as difficulty with logical thought, increasingly agitated motor activity, and elevated vital signs. - To reduce these uncomfortable feelings, the person tries to reduce the level of discomfort by implementing new adaptive behaviors or defense mechanisms. - Adaptive behaviors can be positive and help the person learn, for example, using imagery techniques to refocus attention on a pleasant scene, practicing sequential relaxation of the body from head to toe and breathing slowly and steadily to reduce muscle tension and vital signs. - Negative responses to anxiety can result in maladaptive behaviors such as tension headaches, pain syndromes, and stress-related responses that reduce the efficiency of the immune system. - People can communicate anxiety to others both verbally and nonverbally. - If someone yells "fire," others around him or her can become anxious as they picture a fire and the possible threat that represents. - Viewing a distraught parent searching for a lost child in a shopping mall can cause anxiety in others as they imagine the panic the parent is experiencing. - They can experience anxiety nonverbally through empathy, which is the sense of walking in another person's shoes for a moment in time - Examples of nonverbal empathetic communication are when the family of a client undergoing surgery can tell from the physician's body language that their loved one has died, when the nurse reads a plea for help in a client's eyes, or when a person feels the tension in a room where two people have been arguing and are now not speaking to each other.

Psychodynamic Theories: Interpersonal Theory:

- Harry Stack Sullivan (1952) viewed anxiety as being generated from problems in interpersonal relationships. - Caregivers can communicate anxiety to infants or children through inadequate nurturing, agitation when holding or handling the child, and distorted messages. - Such communicated anxiety can result in dysfunction, such as the failure to achieve age-appropriate developmental tasks. - In adults, anxiety arises from the person's need to conform to the norms and values of his or her cultural group. - The higher the level of anxiety, the lower the ability to communicate and to solve problems and the greater the chance for anxiety disorders to develop. - Hildegard Peplau (1952) understood that humans exist in interpersonal and physiological realms; thus, the nurse can better help the client achieve health by attending to both areas. - She identified the four levels of anxiety and developed nursing interventions and interpersonal communication techniques based on Sullivan's interpersonal view of anxiety. - Nurses today use Peplau's interpersonal therapeutic communication techniques to develop and to nurture the nurse-client relationship and to apply the nursing process.

Treatment For Anxiety: Assertiveness Training:

- Helps the person take more control over life situations. - These techniques help the person negotiate interpersonal situations and foster self-assurance. - They involve using "I" statements to identify feelings and to communicate concerns or needs to others. - Examples include "I feel angry when you turn your back while I'm talking," "I want to have 5 minutes of your time for an uninterrupted conversation about something important," and "I would like to have about 30 minutes in the evening to relax without interruption."

Social Anxiety Disorder (Social Phobia):

- In social phobia, also known as social anxiety disorder, the person becomes severely anxious to the point of panic or incapacitation when confronting situations involving people. - Examples include making a speech, attending a social engagement alone, interacting with the opposite sex or with strangers, and making complaints. - The fear is rooted in low self-esteem and concern about others' judgments. - The person fears looking socially inept, appearing anxious, or doing something embarrassing such as burping or spilling food. - Other social phobias include fear of eating in public, using public bathrooms, writing in public, or becoming the center of attention. - A person may have one or several social phobias; the latter is known as generalized social phobia.

Agoraphobia:

- In some cases, the person becomes homebound or stays in a limited area near home, such as on the block or within town limits. - This behavior is known as agoraphobia ("fear of the marketplace" or fear of being outside). - Some people with agoraphobia fear stepping outside the front door because a panic attack may occur as soon as they leave the house. - Others can leave the house but feel safe from the anticipatory fear of having a panic attack only within a limited area. - Agoraphobia can also occur alone without panic attacks.

General Adaptation Syndrome: Alarm Reaction:

- Increase in vitals

Treatment For Anxiety: Decatastrophizing:

- Involves the therapist's use of questions to more realistically appraise the situation. - The therapist may ask, "What is the worst thing that could happen? Is that likely? Could you survive that? Is that as bad as you imagine?" - The client uses thought-stopping and distraction techniques to jolt him or herself from focusing on negative thoughts. - Splashing the face with cold water, snapping a rubber band worn on the wrist, or shouting are all techniques that can break the cycle of negative thoughts.

Phobia Treatment: Flooding:

- Is a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety. - Because the client's worst fear has been realized and the client did not die, there is little reason to fear the situation anymore. - The goal is to rid the client of the phobia in one or two sessions. - This method is highly anxiety producing and should be conducted only by a trained psychotherapist under controlled circumstances and with the client's consent.

Levels Of Anxiety: Mild Anxiety:

- Is a sensation that something is different and warrants special attention. - Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect him or herself. - Mild anxiety often motivates people to make changes or engage in goal-directed activity. - For example, it helps students focus on studying for an examination. Psychological Response: - Wide perceptual field - Sharpened senses - Increased motivation - Effective problem-solving - Increased learning ability - Irritability Physiological Response: - Restlessness - Fidgeting - GI "butterflies" - Difficulty sleeping - Hypersensitivity to noise

Anxiety:

- Is a vague feeling of dread or apprehension; it is a response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms. - Anxiety is distinguished from fear, which is feeling afraid or threatened by a clearly identifiable external stimulus that represents danger to the person. - Anxiety is unavoidable in life and can serve many positive functions such as motivating the person to take action to solve a problem or to resolve a crisis. - It is considered normal when it is appropriate to the situation and dissipates when the situation has been resolved.

Related Disorders: Substance/Medication-Induced Anxiety Disorder:

- Is anxiety directly caused by drug abuse, a medication, or exposure to a toxin. - Symptoms include prominent anxiety, panic attacks, phobias, obsessions, or compulsions.

Panic Disorder:

- Is composed of discrete episodes of panic attacks, that is, 15 to 30 minutes of rapid, intense, escalating anxiety in which the person experiences great emotional fear as well as physiological discomfort. - During a panic attack, the person has overwhelmingly intense anxiety and displays four or more of the following symptoms: palpitations, sweating, tremors, shortness of breath, sense of suffocation, chest pain, nausea, abdominal distress, dizziness, paresthesias, chills, or hot flashes. - Panic disorder is diagnosed when the person has recurrent, unexpected panic attacks followed by at least 1 month of persistent concern or worry about future attacks or their meaning or a significant behavioral change related to them. - Slightly more than 75% of people with panic disorder have spontaneous initial attacks with no environmental trigger. - Half of those with panic disorder have accompanying agoraphobia. - Panic disorder is more common in people who have not graduated from college and are not married. - There is an increased risk of suicidality in persons with panic disorder. - Studies show suicidal ideation prevalent in 17% to 32% of those with panic disorder, while one-third had a history of suicide attempts

Related Disorders: Selective Mutism:

- Is diagnosed in children when they fail to speak in social situations even though they are able to speak. - They may speak freely at home with parents but fail to interact at school or with extended family. - Lack of speech interferes with social communication and school performance

Related Disorders: Anxiety Disorder Due To Another Medical Condition:

- Is diagnosed when the prominent symptoms of anxiety are judged to result directly from a physiological condition. - The person may have panic attacks, generalized anxiety, or obsessions or compulsions. - Medical conditions causing this disorder can include endocrine dysfunction, chronic obstructive pulmonary disease, congestive heart failure, and neurologic conditions.

Related Disorders: Separation Anxiety Disorder:

- Is excessive anxiety concerning separation from home or from persons, parents, or caregivers to whom the client is attached. - It occurs when it is no longer developmentally appropriate and before 18 years of age.

Levels Of Anxiety: Moderate Anxiety:

- Is the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated. - In moderate anxiety, the person can still process information, solve problems, and learn new things with assistance from others. - He or she has difficulty concentrating independently but can be redirected to the topic. - For example, the nurse might be giving preoperative instructions to a client who is anxious about the upcoming surgical procedure. - As the nurse is teaching, the client's attention wanders, but the nurse can regain the client's attention and direct him or her back to the task at hand. Psychological Response: - Perceptual field narrowed to immediate task - Selectively attentive -Cannot connect thoughts or events independently - Increased use of automatisms Physiological Response: - Muscle tension - Diaphoresis - Pounding pulse - Headache - Dry mouth - High voice pitch - Faster rate of speech - GI upset - Frequent urination

Stress:

- Is the wear and tear that life causes on the body - It occurs when a person has difficulty dealing with life situations, problems, and goals. - Each person handles stress differently; one person can thrive in a situation that creates great distress for another. - For example, many people view public speaking as scary, but for teachers and actors, it is an everyday enjoyable experience. - Marriage, children, airplanes, snakes, a new job, a new school, and leaving home are examples of stress-causing stimuli.

Panic Disorder: Assessment: Self-Concept:

- It is important for the nurse to assess self-concept in clients with panic disorder. - These clients often make self-blaming statements such as, "I can't believe I'm so weak and out of control" or "I used to be a happy, well-adjusted person." - They may evaluate themselves negatively in all aspects of their lives. - They may find themselves consumed with worry about impending attacks and may be unable to do many things they did before having panic attacks.

Panic Disorder: Assessment: Judgement & Insight:

- Judgment is suspended during panic attacks; in an effort to escape, the person can run out of a building and into the street in front of a speeding car before the ability to assess if safety has returned. Insight into panic disorder occurs only after the client has been educated about the disorder. - Even then, clients initially believe they are helpless and have no control over their anxiety attacks.

Heritability: Low:

- Less than 0.3 mean that genetics are negligible as a primary cause of the disorder.

Treatment For Anxiety: Positive Reframing:

- Means turning negative messages into positive messages. - The therapist teaches the client to create positive messages for use during panic episodes. - For example, instead of thinking, "My heart is pounding. I think I'm going to die," the client thinks, "I can stand this. This is just anxiety. It will go away." - The client can write down these messages and keep them readily accessible, such as in an address book, a calendar, or a wallet.

Moderate Anxiety:

- Narrowed perceptual field - Difficulty concentrating but CAN be brought back to the topic Intervention: Speak in short, simple sentences so client can follow along

Working With Anxious Clients:

- Nurses encounter anxious clients and families in a wide variety of situations, such as before surgery and in emergency departments, intensive care units (ICUs), offices, and clinics. - First and foremost, the nurse must assess the person's anxiety level because that determines what interventions are likely to be effective. - Mild anxiety is an asset to the client and requires no direct intervention. - People with mild anxiety can learn and solve problems and are even eager for information. - Teaching can be effective when the client is mildly anxious. - With moderate anxiety, the nurse must be certain that the client is following what the nurse is saying. - The client's attention can wander, and he or she may have some difficulty concentrating over time. - Speaking in short, simple, and easy-to-understand sentences is effective; the nurse must stop to ensure that the client is still taking in information correctly. - The nurse may need to redirect the client back to the topic if the client goes off on a tangent. - When anxiety becomes severe, the client can no longer pay attention or take in information. - The nurse's goal must be to lower the person's anxiety level to moderate or mild before proceeding with anything else. - It is also essential to remain with the person because anxiety is likely to worsen if he or she is left alone. - Talking to the client in a low, calm, and soothing voice can help. If the person cannot sit still, walking with him or her while talking can be effective. - What the nurse talks about matters less than how he or she says the words. - Helping the person take deep even breaths can help lower anxiety. - When working with an anxious person, the nurse must be aware of his or her own anxiety level. - It is easy for the nurse to become increasingly anxious. - Remaining calm and in control is essential if the nurse is going to work effectively with the client. - Short-term anxiety can be treated with anxiolytic medications - Most of these drugs are benzodiazepines, which are commonly prescribed for anxiety. - Benzodiazepines have a high potential for abuse and dependence, however; so their use should be short term, ideally no longer than 4 to 6 weeks. - These drugs are designed to relieve anxiety so that the person can deal more effectively with whatever crisis or situation is causing stress. - Unfortunately, many people see these drugs as a "cure" for anxiety and continue to use them instead of learning more effective coping skills or making needed changes

Nurse Assessment Anxiety:

- Nurses must assess clients level of anxiety to determine interventions

General Adaptation Syndrome: Exhaustion Stage:

- Occurs when the person has responded negatively to anxiety and stress; body stores are depleted or the emotional components are not resolved, resulting in continual arousal of the physiological responses and little reserve capacity.

Panic Disorder Treatment:

- Panic disorder is treated with CBTs, deep breathing and relaxation, and medications such as benzodiazepines, SSRI antidepressants, tricyclic antidepressants, and antihypertensives such as clonidine (Catapres) and propranolol (Inderal). FROM SLIDES: - Cognitive-behavioral techniques - Deep breathing, relaxation - Benzodiazepines, SSRIs, tricyclic antidepressants, antihypertensives (clonidine, propranolol)

Panic (OUTLINE):

- Perceptual field is oriented to self - Loss of rational thought - "impending doom" - Cannot communicate verbally - May be suicidal Intervention: Safety is key concern, stay with client, move to less stimulating/quiet area

Severe Anxiety:

- Perceptual field limited to one detail - Doesn't response to redirection - Crying Intervention: Stay with client, bring them back down to moderate/mild level, speak in calm/soothing tone, if client can't sit still then walk with them

Primary Gain:

- Relief of anxiety through performance of anxiety-ridden behavior

General Adaptation Syndrome: Alarm Reaction Stage:

- Stress stimulates the body to send messages from the hypothalamus to the glands (such as the adrenal gland, to send out adrenaline and norepinephrine for fuel) and organs (such as the liver, to reconvert glycogen stores to glucose for food) to prepare for potential defense needs.

Stress-Related Illness:

- Stress-related illness is a broad term that covers a spectrum of illnesses that result from or worsen because of chronic, long-term, or unresolved stress. - Chronic stress that is repressed can cause eating disorders, such as anorexia nervosa and bulimia - Traumatic stressors can cause a short, acute stress reaction or, if unresolved, may occur later as PTSD, both - Stress that is ignored or suppressed can cause physical symptoms with no actual organic disease called somatic symptom disorders - Stress can also exacerbate the symptoms of many medical illnesses, such as hypertension and ulcerative colitis. - Chronic or recurrent anxiety resulting from stress may also be diagnosed as anxiety disorder.

Primary Gain & Secondary Gain:

- The behavior patterns of people with agoraphobia clearly demonstrate the concepts of primary and secondary gain associated with many anxiety disorders. - Primary gain is the relief of anxiety achieved by performing the specific anxiety-driven behavior, such as staying in the house to avoid the anxiety of leaving a safe place. - Secondary gain is the attention received from others as a result of these behaviors. - For instance, the person with agoraphobia may receive attention and caring concern from family members who also assume all the responsibilities of family life outside the home (e.g., work and shopping). - Essentially, these compassionate significant others become enablers of the self-imprisonment of the person with agoraphobia.

Panic Disorder: Assessment: Physiological & Self-Care Concerns:

- The client often reports problems with sleeping and eating. - The anxiety of apprehension between panic attacks may interfere with adequate, restful sleep, even though the person may spend hours in bed. - Clients may experience loss of appetite or eat constantly in an attempt to ease the anxiety.

Panic Disorder: Assessment: History:

- The client usually seeks treatment for panic disorder after he or she has experienced several panic attacks. - The client may report, "I feel like I'm going crazy. I thought I was having a heart attack, but the doctor says it's anxiety." - Usually, the client cannot identify any trigger for these events.

General Adaptation Syndrome: Resistance Stage:

- The digestive system reduces function to shunt blood to areas needed for defense. - The lungs take in more air, and the heart beats faster and harder so that it can circulate this highly oxygenated and highly nourished blood to the muscles to defend the body by fight, flight, or freeze behaviors. - If the person adapts to the stress, the body responses relax, and the gland, organ, and systemic responses abate.

Panic Disorder: Assessment: General Appearance & Motor Behavior:

- The nurse assesses the client's general appearance and motor behavior. - The client may appear entirely "normal" or may have signs of anxiety if he or she is apprehensive about having a panic attack in the next few moments. - If the client is anxious, speech may increase in rate, pitch, and volume, and he or she may have difficulty sitting in a chair. - Automatisms, which are automatic, unconscious mannerisms, may be apparent. - Examples include tapping fingers, jingling keys, or twisting hair. - Automatisms are geared toward anxiety relief and increase in frequency and intensity with the client's anxiety level.

Intervention: Managing Anxiety:

- The nurse can teach the client relaxation techniques to use when he or she is experiencing stress or anxiety. - Deep breathing is simple; anyone can do it. - Guided imagery and progressive relaxation are methods to relax taut muscles. - Guided imagery involves imagining a safe, enjoyable place to relax. - In progressive relaxation, the person progressively tightens, holds, and then relaxes muscle groups while letting tension flow from the body through rhythmic breathing. - Cognitive restructuring techniques may also help the client manage his or her anxiety response. - For any of these techniques, it is important for the client to learn and practice them when he or she is relatively calm. - When adept at these techniques, the client is more likely to use them successfully during panic attacks or periods of increased anxiety. - Clients are likely to believe that self-control is returning when using these techniques helps them manage anxiety. - When clients believe they can manage the panic attack, they spend less time worrying about and anticipating the next one, which reduces their overall anxiety level.

Onset & Clinical Course:

- The onset and clinical course of anxiety disorders are extremely variable, depending on the specific disorder.

Avoidance Behavior:

- The onset of panic disorder peaks in late adolescence and the mid-30s. - Although panic anxiety might be normal in someone experiencing a life-threatening situation, a person with panic disorder experiences these emotional and physiological responses without this stimulus. - The memory of the panic attack, coupled with the fear of having more, can lead to avoidance behavior

Mental Health Promotion:

- Too often, anxiety is viewed negatively as something to avoid at all costs. - Actually, for many people, anxiety is a warning that they are not dealing with stress effectively. - Learning to heed this warning and to make needed changes is a healthy way to deal with the stress of daily events. - Stress and the resulting anxiety are not associated exclusively with life problems. - Events that are "positive" or desired, such as going away to college, getting a first job, getting married, and having children, are stressful and cause anxiety. - Managing the effects of stress and anxiety in one's life is important to being healthy. Tips for managing stress include the following: •Keep a positive attitude and believe in yourself. •Accept there are events you cannot control. •Communicate assertively with others: Talk about your feelings to others, and express your feelings through laughing, crying, and so forth. •Learn to relax. •Exercise regularly. •Eat well-balanced meals. •Limit intake of caffeine and alcohol. •Get enough rest and sleep. •Set realistic goals and expectations, and find an activity that is personally meaningful. •Learn stress management techniques, such as relaxation, guided imagery, and meditation; practice them as part of your daily routine. - For people with anxiety disorders, it is important to emphasize that the goal is effective management of stress and anxiety, not the total elimination of anxiety. - Although medication is important to relieve excessive anxiety, it does not solve or eliminate the problem entirely. - Learning anxiety management techniques and effective methods for coping with life and its stresses is essential for overall improvement in life quality.