UNIT-10

ANXIETY DISORDERS

Submitted to: submitted by:

Mr. D Elakkuvana Bhaskara Raj Mr.ASBHIN REJO. V
HOD, MHN IInd year M.Sc Nursing.
PION. PION.
The term neurosis and psychosis are currently not widely used. The term neurosis is
defined as the presence of a symptom or group of symptoms which cause subjective
distress to patient.

In ICD-10, Neurotic, stress related and somatoform disorders are classified into:

 Phobic anxiety disorder

 Other anxiety disorder(anxiety disorder)

 OCD(obsessive compulsive disorder)

 Post traumatic stress disorder

 Dissociative disorder

 Somatoform disorder

INTRODUCTION

Individuals face anxiety on a daily basis. Anxiety which provides the motivation for
achievement is a necessary force for survival. The term anxiety is often used interchangeably
with the word stress; however, they are not the same. Stress, or more properly, a stressor, is
an external pressure that is brought to bear on the individual. Anxiety is subjective individual
emotional response to that stressor.

Anxiety may be distinguished from fear in that the former is an emotional process,
whereas fear is a cognitive one. Fear involves the intellectual appraisal of a threatening
stimulus; anxiety involves the emotional response to that appraisal.

We have all experienced anxiety symptoms, perhaps suffer from a particular phobia,
or are a little bit obsessive about certain things but to be clinically significant, these problems
must be severe enough to cause marked distress and/or substantially interfere with our day-
to-day lives.

Anxiety disorders are blanket terms covering several different forms of abnormal
and pathological fear and anxiety which only came under the aegis of psychiatry at the very
end of the 19th century. Current psychiatric diagnostic criteria recognize a wide variety of
anxiety disorders. Recent surveys have found that as many as 18% of Americans may be
affected by one or more of them.

OBJCTIVES
At the end of the unit student should be able to:
 Define anxiety disorders
 To know history and incidence of anxiety disorders
To classify the anxiety disorder
To know etiology ,clinical features and diagnosis of anxiety disorders
To understand the different pharmacological and nursing management of anxiety
Disorders
.
TERMINOLOGIES

 Neurosis: once used to refer to excessive anxiety, somatoform, dissociative disorders,

and some kinds of depression as a group

 Anxiety: An emotional response (apprehension, tension, uneasiness) to anticipation

of danger the source of which largely unknown or unrecognized.

 Obsessions: Persistent ideas, thoughts impulses or images that are experienced as

intrusive and inappropriate, and which cause significant distress to the individual

 Compulsions: Repetitive behaviors or mental acts the goal of which is to prevent or

reduce anxiety or distress (and not to provide pleasure and gratification).

HISTORICAL PERSPECTIVE

Individuals have experienced anxiety throughout the ages. Yet anxiety, like fear, was
not clearly defined or isolated as a separate entity by psychiatrists or psychologists until the
19th and 20th centuries. In fact, what we now know as anxiety was once solely identified by its
physiological symptoms, focusing largely on the cardiovascular system. For example it was
called as cardiac neurosis, Dacosta’s syndrome, irritable heart, nervous tachycardia, soldier’s
heart etc.

Freud first introduced the term anxiety neurosis in 1895. Freud wrote, “I call this
syndrome anxiety neurosis” because all its components can be grouped round the chief
symptom of anxiety”.

For many years, anxiety disorders were viewed as purely psychological or purely
biological in nature. It is likely that various factors, including genetic, developmental,
environmental and psychological, play a role in the etiology of anxiety disorders.

The term neurosis was coined by William Cullen in 1777, replacing illness of the
nerves (coined by Robert Whytt in 1764 to replace the old vapours), and meaning any disease
of the nervous system without a known organic basis (which at the time also included
epilepsy). Clinical descriptions of neurotic symptoms can be found in the works of
Hippocrates.

Anxiety Disorders were only recognized in 1980 by the American Psychiatric

Association. Before this recognition people experiencing one of these Disorders usually
received a generic diagnosis of 'stress' or 'nerves'. As there was no understanding of the
Disorders by the health professionals, very few people received effective treatment. Since
1980, international research has shown the severe disabilities associated with these Disorders.
Most of these disabilities can be prevented with early diagnosis and effective treatment.
These disabilities include agoraphobia, drug and/or alcohol abuse and major depression.
Recently, there has been more media on the prevalence of Anxiety, panic attacks and Anxiety
Disorders. As more people become aware of the presence of anxiety disorders, there is more
bnow as more-and-more people from all walks of life report to their health professionals for
treatment.

Although Anxiety Disorders have been on recently officially recognized, they have
existed throughout the history of mankind. Many great and influential people in history have
reported experiencing panic attacks and Anxiety Disorders.
Anxiety is an unpleasurable emotional state, associated with psycho-physiological changes in
response to an intrapsychic activity.
Anxiety is a commonest psychiatric symptom in clinical practice and anxiety disorder
is one of the commonest psychiatric disorders in general population.
Anxiety is often differentiated from fear, as tear is an apprehension in response to an
external danger while in anxiety the danger is largely unknown.
Normal anxiety becomes pathological when it causes significant subject distress and/or
impairment in functioning of an individual.
Some authors anxiety into two types:
1. Trait anxiety: this is habitual tendency to be anxious in general and is exemplified by
“I often feel anxious”
2. State anxiety: this is anxiety felt at the present, cross-sectional moment and is
exemplified by “I feel anxious now”

EPIDEMIOLOGICAL STATISTICS

Anxiety disorders are the most common of all psychiatric illnesses and result in
considerable functional impairment and distress. Statistics vary widely, but most agree that
anxiety disorders are more common in women than in men by at least 2 to1.

The National Comorbidity Study reported that one in four persons met the diagnostic
criteria for at least one anxiety disorder. Anxiety disorders have a 12-month prevalence rate
of 17.7 percent.

 Prevalence rate has been given at 1.5 to 5 percent for panic disorder;
 2 to 3 percent for OCD; 8 percent for PTSD, and
 0.6 to 6 percent for agoraphobia.

A review of literature revealed a wide range of reports regarding the prevalence of

anxiety disorders in children (2 to 45%).
 Epidemiological studies suggest that the symptoms are more prevalent among girls
than boys and that minority children and children from low socioeconomic environments may
be at greater risk for all emotional illness.

Studies of familial patterns suggest that a familial predisposition to anxiety disorders

probably exists.

Women have a lifetime prevalence of 30.5 percent versus 19.2 percent prevalence in
men. Prevalence of anxiety disorders decreases with higher socioeconomic status.

HOW MUCH IS TO MUCH

Anxiety is usually considered a normal reaction to a realistic danger or threat to

biological integrity or self concept. Normal anxiety dissipates when the danger or threat is no
longer present.

It is difficult to draw a precise line between normal and abnormal anxiety. Normality
is determined by societal standards; what is considered normal in Chicago, Illinois may not
be considered so in Cairo, Egypt. There may even be regional differences within a country or
cultural difference within region. So what criteria can be used to determine if an individual’s
anxious response is normal?

Anxiety can be considered abnormal or pathological if:

1. It is out of proportion to the situation that is creating it.
2. The anxiety interferes with social, occupational or other important area of
functioning.

RISK FACTORS

1. Gender:
 With the exception of obsessive-compulsive disorder (OCD) and possibly social
anxiety, women have twice the risk for most anxiety disorders as men.
 A number of factors may increase the reported risk in women, including hormonal
factors, cultural pressures to meet everyone else's needs except their own, and fewer
self-restrictions on reporting anxiety to doctors.
 Pregnant women and women experiencing menopause may be more susceptible to
symptoms of anxiety. Also, women have about twice the risk for panic disorder as
men.
2. Age:
 In general, phobias, OCD and separation anxiety show up early in childhood, while
social phobia and panic disorder are often diagnosed during the teen years.
 Reports have estimated that approximately 3-5% of children and adolescents have
some type of anxiety disorder.
 Reports indicate that if such children could be identified as early as two years of age
they possibly could be treated to avoid later anxiety disorders.
3. Environmental factors:
 A person's environment can play a huge role in the development of anxiety disorders.
Difficulties such as poverty, early separation from the mother, family conflict, critical
and strict parents, parents who are fearful and anxious themselves, and the lack of a
strong support system can all lead to chronic anxiety.
 Studies report that anxiety in the new mother can affect their infants. One study
reported a higher rate of crying and an impaired ability to adapt to new situations in
infants of mothers who had been stressed and anxious during pregnancy.
 In another, infants of mothers with panic disorder had higher levels of stress hormones
and more sleep disturbances than other children.
4. Personality traits:
 Personality differences can affect whether or not an anxiety disorder develops. People
with anxiety disorders often are very self-conscious, have poor coping skills, and have
low self-esteem.
 Children's personalities may indicate higher or lower risk for future anxiety disorders,
such as extremely shy children and those likely to be the target of bullies, who are at a
higher risk for developing anxiety disorders later in life.
5. Heredity:
 Anxiety disorders tend to run in families. People with anxiety disorders often have a
family history of anxiety disorders, mood disorders, or substance abuse.

CAUSES

1. Brain chemistry:
Studies suggest that an imbalance of the brain's neurotransmitters (chemical
messengers) such as serotonin, gamma-amino butyric acid (GABA), epinephrine, and nor
epinephrine may contribute to anxiety disorders. Abnormalities in the stress hormone
cortisol, produced by the adrenal glands, have also been found. Most medications
prescribed for anxiety disorders aim to readjust the brain's chemical balance.

2. Trauma:
An anxiety disorder may develop in response to a traumatic event, such as a car
accident or a marital separation. Anxiety may also have its roots in early life abuse or
developmental trauma. Trauma in infancy and early childhood can be particularly
damaging, leaving a pervasive and lasting sense of helplessness that can develop into
anxiety or depression in later life.
3. Medications:
Some prescription and non-prescription medications may cause symptoms of anxiety,
including caffeine and other stimulants, drugs such as heroin, cocaine, and amphetamines,
over-the-counter medications such as decongestants, steroids such as cortisone and
prednisone, inhalers and other respiratory medications, some herbal supplements, high
blood pressure medications, withdrawal from alcohol, ADHD medications (Ritalin,
Adderall, Dexedrine), withdrawal from benzodiazepines (Xanax, Valium), and hormones
such as birth control pills and thyroid medications.
4. Medical conditions:
Many medical conditions can cause or mimic symptoms of anxiety disorders. They
include thyroid disorders, diabetes, hypoglycemia (low blood sugar), asthma, sleep
disorders, adrenal disorders, epilepsy (seizures), heart conditions including arrhythmias
(irregular heart beat), migraine headaches, certain psychiatric illnesses, such as bipolar
disorder (characterized by mania and depression) and depression.
5. Nutritional deficiencies:
Nutritional deficiencies stemming from poor diet and/or digestion can also contribute
to anxiety. Depleted levels of minerals, especially magnesium and zinc, have been linked
to the presence of anxiety. A deficiency of B vitamins, especially vitamin B-12, can be a
significant contributing factor to the development of anxiety disorders.
6. Stress:
Anxiety disorder can arise in response to life stresses such as financial worries or
chronic physical illness. Somewhere between 4% and 10% of older adults are diagnosed
with anxiety disorder, a figure which is probably an underestimate due to the tendency of
adults to minimize psychiatric problems or to focus on their physical manifestations.
Anxiety is also common among older people who have dementia. On the other hand,
anxiety disorder is sometimes misdiagnosed among older adults when doctors
misinterpret symptoms of a physical ailment (for instance, racing heartbeat due to cardiac
arrhythmia) as signs of anxiety.

CLASSIFICATION

o 1.1 Generalized anxiety disorder

o 1.2 Panic disorder
o 1.3 Phobias
 1.3.1 Agoraphobia
 1.3.2 Social anxiety disorder
o 1.4 Obsessive–compulsive disorder
o 1.5 Post-traumatic stress disorder
o 1.6 Separation anxiety
o 1.7 Childhood anxiety disorders

1. GENERALIZED ANXIETY DISORDER

Background assessment data

Generalized anxiety disorder (GAD) is an anxiety disorder that is characterized by chronic,
unrealistic, excessive, uncontrollable and often irrational worry about everyday things that is
disproportionate to the actual source of worry. This excessive worry often interferes with
daily functioning, as individuals suffering GAD typically anticipate disaster, and are overly
concerned about everyday matters such as health issues, money, death, family problems,
friend problems, relationship problems or work difficulties. They often exhibit a variety of
physical symptoms, including fatigue, fidgeting, headaches, nausea, numbness in hands and
feet, muscle tension, muscle aches, difficulty swallowing, bouts of difficulty in breathing,
difficulty concentrating, trembling, twitching, irritability, sweating, restlessness, insomnia, hot
flashes, and rashes. These symptoms must be consistent and on-going, persisting at least 6
months, for a formal diagnosis of GAD to be introduced and cannot be attributed to specific
organic factors, such as caffeine intoxication or hyperthyroidism. Approximately 6.8 million
American adults experience GAD.

Prevalence
The World Health Organization's Global Burden of Disease project did not include
generalized anxiety disorders. In lieu of global statistics, here are some prevalence rates from
around the world:

 Australia: 3% of adults
 Canada: Between 3-5% of adults
 Italy: 2.9 %
 Taiwan: 0.4%
 United States: approximately 3.1% of people, age 18 and over in a given year (9.5
million) 55 to 60% of people diagnosed in clinical settings are women.

Epidemiology
The usual age of onset is variable - from childhood to late adulthood, with the median
age of onset being approximately 31. Most studies find that GAD is associated with an earlier
and more gradual onset than the other anxiety disorders.

Women are two to three times more likely to suffer from generalized anxiety disorder
than men, although this finding appears to be restricted to only developed countries, the
spread of GAD is somewhat equal in developing nations. GAD is also common in the elderly
population.

Potential Causes of GAD

 Psychodynamics theory

The Freudian view involves conflict between demands of the id and superego, with the
ego serving as mediator. Anxiety occurs when the ego is not strong enough to resolve the
conflict. Sullivanian theory states that fear of disapproval from the mothering figure are the
basis for anxiety. Conditional love results in a fragile ego and lack of self-confidence. The
individual with anxiety disorder has low self-esteem, fears failure, and is easily threatened.

Dollard and Miller believe anxiety is a learned response based on an innate drive to avoid
pain. Anxiety results from being faced with two competing drives or goals.

 Cognitive theory

The main thesis of cognitive view is that faulty, distorted or counterproductive thinking
patterns accompany or precede maladaptive behaviours and emotional disorders. It suggests
that there is a disturbance in the central mechanism of cognition or information processing
with the consequent disturbance in feeling and behavior. Anxiety is maintained by this
distorted thinking with mistaken or dysfunctional appraisal of a situation. There is a loss of
ability to reason regarding the problem, whether it is physical or interpersonal. The individual
feels vulnerable, and the distorted thinking results in a negative outcome.
  Biological aspects

Genetics: panic disorder has a strong genetic element. The concordance rate for identical
twins is 30%, and the risk for the disorder in a close relative is 10 to 20%.

Substance induced: Long-term use of benzodiazepines can worsen underlying anxiety.

Evidences show that reduction of benzodiazepines can lead to a lessening of anxiety
symptoms. Similarly, long-term alcohol use is associated with anxiety disorders, with
evidence that prolonged abstinence can result in a disappearance of anxiety symptoms.

Neuroanatomical: Modern theory on the physiology of emotional states places the key in
the lower brain centres, including the limbic system, the diecephalon (thalamus and
hypothalamus) and the reticular formation. Structural brain imaging studies in patient with
panic disorder have implicated pathological involvement in the temporal lobes, particularly
the hippocampus.

Biochemical: Abnormal elevation of blood lactate have been noted in clients with panic
disorder. Likewise, infusion of sodium lactate into clients with anxiety neuroses produced
symptoms of panic disorder. No specific mechanism that triggers the panic symptoms can be
explained.

Neurochemical: Stronger evidence exists for the involvement of the neurotransmitter nor
epinephrine in the etiology of panic disorder. Norepinephrine is known to mediate arousal,
and it causes hyperarousal and anxiety.

Medical conditions:

 Abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-

thyroid axes.
 Acute myocardial infection
 Substance intoxication and withdrawal (cocaine, alcohol, opioids)
 Hypoglycaemia
 Caffeine intoxication
 Mitral valve prolapse

Family Dynamics

The individual exhibiting dysfunctional behavior is seen as the representation of

family system problems. The “identified patient” is carrying the problems of the other
members of the family, which are seen as the result of the interrelationships (disequilibrium)
between family members rather than as isolated individual problems. It is recognized that
multiple factors contribute to anxiety disorder

DSM-IV diagnostic criteria for Generalized Anxiety Disorder

1. Excessive anxiety and worry (apprehensive expectation), occurring more days than
not for at least 6 months, about a number of events or activities (such as work or
school performance).
2. The person finds it difficult to control the worry.
 3. The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms present for more days than not for the past 6
months). Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying
sleep)
4. The focus of the anxiety and worry is not confined to features of an Axis I disorder,
e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder),
being embarrassed in public (as in Social Phobia), being contaminated (as in
Obsessive-Compulsive Disorder) being away from home or close relatives (as in
Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), or having a
serious illness (as in Hypochondriasis), and the anxiety and worry do not occur
exclusively during Posttraumatic Stress Disorder.
5. The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
6. The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism)
and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a
Pervasive Developmental Disorder.

Symptoms of GAD

According to DSM-IV at least 3 (or 1 in children) out of:

 restlessness or feeling keyed up or on edge;
 easy fatigability;
 concentration difficulties or mind going blank irritability;
 muscle tension;
 Sleep disturbance.

ICD-10 At least 4 (with at least 1 from autonomic arousal out of:

 Symptoms of autonomic arousal: palpitations/tachycardia; sweating;

trembling/shaking; dry mouth.
 Physical symptoms: breathing difficulties; choking sensation; chest pain/discomfort;
nausea/abdominal distress.
 Mental state symptoms: feeling dizzy, unsteady, faint or lightheaded;
derealisation/depersonalisation; fear of losing control, going crazy, passing out, dying.
 General symptoms: hot flushes/cold chills; numbness or tingling sensations.
 Symptoms of tension: muscle tension/aches and pains; restlessness/ inability to relax;
feeling keyed up, on edge, or mentally tense; a sensation of a lump in the throat or
difficulty swallowing.
 Other symptoms: exaggerated responses to minor surprises/being startled;
concentration difficulties; mind going blank due to worry or anxiety; persistent
irritability; difficulty getting to sleep due to worrying.

Treatment
 Studies shows cognitive Behavioral therapy to be more effective in the long term than
pharmacologic treatment (drugs such as SSRIs), and while both treatments reduce anxiety,
CBT is more effective in reducing depression.

 Cognitive Behavioral therapy

Cognitive Behavioral therapy (CBT) is a psychological method of treatment for GAD,

which involves a therapist working with the patient to understand how thoughts and feelings
influence behavior. The goal of the therapy is to change negative thought patterns that lead to
the patient's anxiety, replacing them with positive, more realistic ones. Elements of the
therapy include exposure strategies to allow the patient to gradually confront their anxieties
and feel more comfortable in anxiety-provoking situations, as well as to practice the skills
they have learned. CBT can be used alone or in conjunction with medication.

CBT usually helps one third of the patients substantially, while another third does not
respond at all to treatment.

 SSRIs ( Selective serotonin reuptake inhibitor)

Pharmacological treatments for GAD include selective serotonin reuptake inhibitors

(SSRIs), which are antidepressants that influence brain chemistry to block the reabsorption of
serotonin in the brain. SSRIs are mainly indicated for clinical depression, but are also very
effective in treating anxiety disorders. Common side effects include nausea, sexual
dysfunction, headache, diarrhoea, constipation etc. Common SSRIs prescribed for GAD
include

 fluoxetine (Prozac, Sarafem)

 paroxetine (Paxil, Aropax)
 escitalopram (Lexapro, Cipralex)
 sertraline (Zoloft)

 Other Drugs

 Buspirone (BuSpar): is a serotonin receptor agonist belonging to the

azaspirodecanedione class of compounds.
 Duloxetine (Cymbalta)
 Imipramine (Tofranil): is a tricyclic antidepressant (TCA). TCAs are thought to act on
serotonin, norepinephrine, and dopamine in the brain.
 Venlafaxine (Effexor, Effexor XR): is a serotonin-norepinephrine reuptake inhibitor
(SNRI). SNRIs, a class of drugs related to the SSRIs, alter the chemistries of both
norepinephrine and serotonin in the brain.
 Propranolol (Inderal)

 Benzodiazepines

Benzodiazepines are fast-acting sedatives that are also used to treat GAD and other
anxiety disorders. Benzodiazepines are often prescribed for generalised anxiety disorder and
show beneficial effects in the short-term. The World Council of Anxiety does not recommend
the long-term use of benzodiazepines because they are associated with the development of
tolerance, psychomotor impairment, cognitive and memory impairments, physical
dependence and a withdrawal syndrome. Side effects include drowsiness, reduced motor
coordination etc. Common benzodiazepines used to treat GAD include:

 alprazolam (Xanax, Xanax XR, Niravam)

 chlordiazepoxide (Librium)
 clonazepam (Klonopin)
 clorazepate (Tranxene)
 diazepam (Valium)
 lorazepam (Ativan)

DIAGNOSTIC STUDIES

 Drug Screen: Rules out drugs as contribution to cause of symptoms.

 Other diagnostic studies may be conducted to rule out physical disease as basis for
individual symptoms (e.g., ECG for severe chest pain, echocardiogram for mitral
valve prolapse; EEG to identify seizure activity; thyroid studies).

NURSING MANGMENT OF GAD

Client assessment data base

 Activity/Rest
 Restlessness, pacing anxiously, or, if seated, restlessly moving extremities
 Feeling “keyed up”/“on edge,” unable to relax
 Easily fatigued
 Difficulty falling or staying asleep; restlessness, unsatisfying sleep

 Circulation
 Heart pounding or racing/palpitations; cold and clammy hands; hot or cold spells,
sweating; flushing, pallor
 High resting pulse, increased blood pressure

 Ego Integrity
 Excessive worry about a number of events/activities, occurring more days than not for
at least 6 months
 Complains vociferously about inner turmoil, has difficulty controlling worry
 May demand help
 Facial expression in keeping with level of anxiety felt (e.g., furrowed brow, strained
face, eyelid twitch)
 May report history of threat to either physical integrity (illness, inadequate food and
housing, etc.) or self-concept (loss of significant other; assumption of new role)

 Elimination
 Frequent urination; diarrhea

 Food/Fluid
 Lack of interest in food, dysfunctional eating pattern (e.g., responding to internal cues
other than hunger)
 Dry mouth, upset stomach, discomfort in the pit of the stomach, lump in the throat
 Neurosensory
 Absence of other mental disorder, such as depressive disorder or schizophrenia
 Motor tension: shakiness, jitteriness, jumpiness, trembling, muscle tension, easily
startled
 Dizziness, lightheadedness, tingling hands or feet
 Apprehensive expectation: anxiety, worry, fear, rumination, anticipation of misfortune
to self or others, inability to act differently (feeling stuck)
 Excessive vigilance/hyperattentiveness resulting in distractibility, difficulty in
concentrating or mind going blank, irritability, impatience
 Free-floating anxiety usually chronic or persisting over weeks/months

 Pain/Discomfort;Muscle aches, headaches

 Respiratory
 Increased respiratory rate, shortness of breath, smothering sensation

 Sexuality
 Women twice as likely to be affected as men

 Social Interactions
 Significant impairment in social/occupational functioning

 Teaching/Learning
 Age of onset usually 20s and 30s

NURSING PRIORITIES

1. Assist client to recognize own anxiety.

2. Promote insight into anxiety and related factors.
3. Provide opportunity for learning new, adaptive coping responses.
4. Involve client and family in educational/support activities.

DISCHARGE GOALS

1. Feelings of anxiety recognized and handled appropriately.

2. Coping skills developed to manage anxiety-provoking situations.
3. Resources identified and used effectively.
4. Client/family participating in ongoing therapy program.
5. Plan in place to meet needs after discharge

2. PANIC DISORDER

Introduction
Panic disorder is a potentially disabling disorder, but can be controlled and successfully
treated. Because of the intense symptoms that accompany panic disorder, it may be mistaken
for a life-threatening physical illness such as a heart attack. This misconception often
aggravates or triggers future attacks. People frequently go to hospital emergency rooms when
they are having panic attacks, and extensive medical tests may be performed to rule out these
other conditions, thus creating further anxiety.

Background
Panic disorder is an anxiety disorder characterized by recurrent panic attacks, the
onset of which are unpredictable, and manifested by intense apprehension, fear, or terror,
often associated with feelings of impending doom and accompanied by intense physical
discomfort. The symptoms come on unexpectedly; that is, they do not occur immediately
before or on exposure to a situation that usually causes anxiety. They are not triggered by the
situation in which the person is the focus of others attention. It may also include significant
Behavioral change lasting at least a month and of ongoing worry about the implications or
concern about having other attacks. Panic disorder is not the same as agoraphobia, although
many with panic disorder also suffer from agoraphobia.

Prevalence
 The average age of onset of panic disorder is the late 20s. Frequency and severity of
the panic attacks vary widely.
 Some individuals may have attacks of moderately severity weekly; others may have
less severe or limited- symptom attacks several times a week. The disorder may last
for a weeks or months or for a number of years.

Aetiology:

The cause of the anxiety disorder is not clearly known. There are however several theories, of
which more than one may be applicable in particular patients:

1. Psychodynamic theory:

According to this theory, anxiety is a signal that something is disturbing the internal
psychological equilibrium. This is called signal anxiety. This signal anxiety arouses the ego
to take defence action which is usually 9n the form of repression, a primary defence
mechanism. When repression fails second defence mechanism (such as conversion, isolation)
are called into action.

In anxiety repression fails to function adequately but the secondary defence mechanism is not
activated. Hence anxiety comes to the fore-front unopposed.

2. Behavioural theory:

According to this theory anxiety is vied as an unconditioned inherent response of the

organism to painful or dangerous stimuli. In anxiety and phobias, this becomes attached to
relatively neutral stimuli by conditioning.

Other causes are:

 There is no single cause for panic disorder, however, panic disorder has been found to
run in families, and suggests that inheritance plays a strong role in determining who
will get it.
  It has also been found to exist as a co-morbid condition with many hereditary
disorders, such as bipolar disorder, and a genetic predisposition to alcoholism.
 Psychological factors, stressful life events, life transitions, environment, and thinking
in a way that exaggerates relatively normal bodily reactions are also believed to play a
role in the onset of panic disorder.
 Often the first attacks are triggered by physical illnesses, major stress, or certain
medications.
 People who tend to take on excessive responsibilities may develop a tendency to
suffer panic attacks.
 Post-traumatic stress disorder (PTSD) patients also show a much higher rate of panic
disorder than the general population.
 There is some evidence to suggest hypoglycemia, hyperthyroidism, mitral valve
prolapse, labyrinthitis and pheochromocytoma can cause or aggravate panic disorder.
 Stimulants are a rather common cause for panic attacks. An excess of common
stimulants such as caffeine.
 There are other researchers looking at some individuals with panic disorder as having
a chemical imbalance within the limbic system and one of its regulatory chemicals
GABA-A. The reduced production of GABA-A sends false information to the
amygdala which regulates the body's "fight or flight response" mechanism and in
return, produces the physiological symptoms that lead to the disorder.

Mediators and Moderators of Panic Disorder

Recently, researchers have begun to identify mediators and moderators aspects of

panic disorder. One such mediator is the partial pressure of carbon dioxide, which mediates
the relationship between panic disorder patients receiving breathing training and anxiety
sensitivity; thus, breathing training affects the partial pressure of carbon dioxide in a patient’s
arterial blood, which in turn lowers anxiety sensitivity.

 Substance abuse and panic disorder: A growing body of evidence exists that shows
a link between substance abuse and panic disorder.
 Smoking: Several studies have found that cigarette smoking increases the risk of panic
attacks and panic disorder in young people.
 Alcohol and sedatives: About 30% of people with panic disorder use alcohol and 17%
use other psychoactive drugs.

Signs and symptoms

Physical symptoms/signs are related to autonomic arousal (e.g. tremor, tachycardia,

tachypnea, hypertension, and sweating, GI upset).

 Concerns of death from cardiac or respiratory problems may be a major focus, leading
to patients presenting (often repeatedly) to emergency medical services.
 Panic disorder may be undiagnosed in patients with unexplained medical symptoms
(chest pain, back pain, GI symptoms, fatigue, headache, dizziness, or multiple
symptoms).
 Thoughts of suicide (or homicide) should be elicited as acute anxiety (particularly
when recurrent) can lead to impulsive acts (usually directed towards self). Risk of
 attempted suicide is substantially raised where there is co-morbid depression, alcohol
misuse, or substance misuse.

Symptoms associated with panic attacks (in order of frequency of occurrence)

 Palpitations, pounding heart, or accelerated heart rate.

 Sweating.
 Trembling or shaking.
 Sense of shortness of breath or smothering.
 Feeling of choking or difficulties swallowing.
 Chest pain or discomfort.
 Nausea or abdominal distress.
 Feeling dizzy, unsteady, light-headed, or faint.
 Derealisation or depersonalisation (feeling detached from oneself or one's
surroundings).
 Fear of losing control or going crazy.
 Fear of dying.
 Numbness or tingling sensations (paresthesias).
 Chills or hot flashes.

Panic disorder sufferers usually have a series of intense episodes of extreme anxiety during
panic attacks.

DSM-IV diagnostic criteria for Panic disorder:

A discrete period of intense fear or discomfort, in which 4 (or more) of the following
symptoms developed abruptly and reached a peak within ten minutes.

1. Palpitations, pounding heart or accelerated heart rate.

2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering.
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light headed or faint.
9. Derealisation(feelings of unreality) or depersonalisation (being detached from
oneself)
10. Fear of losing control or going crazy.
11. Fear of dying
12. Paresthesias (numbness or tingling sensations)
13. Chills or hot flushes.

DIAGNOSTIC STUDIES

Drug Screen: Identifies drugs that may be used by client to reduce anxiety, rules out
drugs that may produce symptoms.

Other diagnostic studies may be conducted to rule out physical disease as a basis for
individual symptoms. (EEG, thyroid studies)
MANGEMENT

Cognitive behavioural therapy is the treatment of choice for panic disorder. When
cognitive behavioural therapy is not an option pharmacotherapy can be used. SSRIs are
considered a first line pharmacotherapeutic option.

In addition, people with panic disorder may need treatment for other emotional
problems. Co-morbid clinical depression, personality disorders and alcohol abuse are known
risk factors for treatment failure.

As with many disorders, having a support structure of family and friends who
understand the condition can help increase the rate of recovery. During an attack, it is not
uncommon for the sufferer to develop irrational, immediate fear, which can often be dispelled
by a supporter who is familiar with the condition. For more serious or active treatment, there
are support groups for anxiety sufferers which can help people understand and deal with the
disorder.

Psychotherapy

Phobic symptoms are often resistant to pharmacological interventions. CBT and one
tested form of psychodynamic psychotherapy have been shown efficacious in treating panic
disorder with and without agoraphobia

Psychotherapy can improve the effectiveness of medication, reduce the likelihood of

relapse for someone who has discontinued medication, and offer help for people with panic
disorder who do not respond at all to medication.

The goal of cognitive behavior therapy is to help a patient reorganize thinking

processes and anxious thoughts regarding an experience that provokes panic. Symptom
inductions generally occur for one minute and may include:

 Intentional hyperventilation – creates light-headedness, derealisation, blurred

vision, dizziness
 Spinning in a chair – creates dizziness, disorientation
 Straw breathing – creates dyspnea, airway constriction
 Breath holding – creates sensation of being out of breath
 Running in place – creates increased heart rate, respiration, perspiration
 Body tensing – creates feelings of being tense and vigilant .

Pharmacological management

 SSRIs (e.g. paroxetine, fluoxetine, fluvoxamine, citalopram, sertraline) are

recommended as the drug of choice. In view of the possibility of initially increasing
panic symptoms, start with low dose and gradually increase.
 Alternative antidepressant TCAs (e.g. imipramine or clomipramine) although not
specifically licensed have been shown to be 70 to 80% effective.
 BDZs (e.g. alprazolam or clonazepam) should be used with caution (due to potential
for abuse/dependence/cognitive impairment) but may be effective for severe,
frequent, incapacitating symptoms.
  If initial management is ineffective Consider change to a different class agent (i.e.
TCA, SSRI, MAOI) or combination (e.g. TCA+Lithium, SSRI+TCA). If treatment-
resistant consider alternative agent (e.g. carbamazepine, valproate, gabapentin, low-
potency BDZ (diazepam), venlafaxine, inositol, verapamil).
 If successful Continue treatment for -1yr before trial discontinuation (gradual tapering
of dose). If symptoms reoccur, continue for-1yr before considering second trial
discontinuation.

Psychological

 Behavioural methods: to treat phobic avoidance by exposure, use of relaxation,

biofeedback and control of hyperventilation.
 Cognitive methods: teaching about bodily responses associated with
anxiety/education about panic attacks, modification of thinking errors.
 Psychodynamic methods: there is some evidence for brief dynamic psychotherapy,
particularly emotion-focused treatment (e.g. panic-focused psychodynamic
psychotherapy was typical fears of being abandoned or trapped are explored).

Despite increasing focus on the use of antidepressants and other agents for the treatment
of anxiety as recommended best practice, benzodiazepines have remained a commonly used
medication for panic disorder.

Emergency treatment of an acute panic disorder:

 Maintain a reassuring and calm attitude (most panic attacks spontaneously resolve
within 30 mins).
 If symptoms are severe and distressing consider prompt use of BDZs (immediate
relief of anxiety may help reassure the patient, provide confidence that treatment is
possible, and reduce subsequent emergency presentations).
 If first presentation exclude medical causes (may require admission to hospital for
specific tests).
 If panic attacks are recurrent, consider differential diagnosis for panic disorder and
address underlying disorder (may require psychiatric referral).

NURSING PRIORITIES

1. Provide physical safety.

2. Assist client to recognize onset of anxiety.
3. Help client learn alternative responses.
4. Assist with desensitization to phobic object/situation, if present.
5. Promote involvement of client/family in group or community support activities.

DISCHARGE GOALS

1. Stays in feared situation even when discomfort is experienced.

2. Identifies techniques to lower/keep fear at manageable level.
3. Confronts the phobia and is desensitized to the stimulus.
4. Demonstrates greater independence and an increasingly freer lifestyle.
5. Plan in place to meet needs after discharge.
Nursing diagnosis for GAD and panic disorder

1. Panic anxiety related to real or perceived threat to biological integrity or self-concept

evidenced by any or all of the physical symptoms identified by the DSM-IV-TR.
Interventions:
 Stay with the client and offer reassurance of safety and security.
 Maintain a calm, nonthreatening, matter of fact approach.
 Use simple words and brief messages; speak calmly and clearly, to explain hospital
experiences.
 Keep immediate surroundings low in stimuli.
 Administer tranquilizing medication, as ordered by physician. Assess for effectiveness
and for side effects.
 When level of anxiety has been reduced, explore possible reasons for occurrence.
 Teach signs and symptoms of escalating anxiety, and ways to interrupt its progression.

2. Powerlessness related to impaired cognition evidenced by verbal expression of no control

over life situation and nonparticipation in decision making related to own care or life
situation.
Interventions:
 Allow client to take as much responsibilities as possible for self care practices.
 Allow client to establish own schedule for self care activities.
 Include client in setting goals of care.
 Provide client with privacy as need is determined.
 Provide positive feedback for decisions made.
 Assist client in setting realistic goals.
 Help identify areas of life situation that client can control.
 Help client identify areas of life situation that are not within his or her ability to
control. Encourage verbalization of feelings related to this inability.

3. PHOBIC DISORDER:

Introduction

"Phobias are irrational fears of a specific object, situation or activity, often leading to
persistence avoidance of the feared object, situation or activity."

In an effort to reduce the intense anxiety attached to phobic objects and situations,
patients do their best to avoid the feared stimuli. Thus, phobias consist both of the fears and
the avoidance components.

The common types of phobias are of three categories:

(1) Agoraphobia
(2) Specific phobia, and
(3) Social phobia- two subtypes, nongeneralized type (a fear of public situations such as
public speaking or performing on stage) and a generalized type (almost all social interactions
are feared)
Definition & Description

Agoraphobia
"Agoraphobia is defined as a irrational fear and avoidance of being in places or
situations from which escape might be difficult or in which help might not be available in the
event of sudden incapacitation."

As a result of such fears, the agoraphobic person avoids travel outside the home or requires
accompaniment when away from home.

 It is characterised by an irrational fear of being in places away from the familiar

setting at home.
 It includes fear of open spaces, public places, crowded places, and any other places
where there is no escape to a safe place.
 A full blown panic attack may occur (agoraphobia with panic disorder) or a few
symptoms like dizziness or tachycardia may occur (agoraphobia without panic
disorder).
 As symptoms worsen, there is a gradual restriction of normal day-to-day activities,
and even person confines to home, often depend on a person to go outside (phobic
companion).

Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years. It
is diagnosed more commonly in women than in men.

DSM-IV criteria for Agoraphobia:

Agoraphobia is not a codable disorder. Code the specific disorder in which the Agoraphobia
occurs (e.g. 300.21 Panic Disorder with Agoraphobia or 300.22 Agoraphobia without history
of panic disorder).

1. Anxiety about being in places or situations from which escape might be difficult (or
embarrassing) or in which help may not be available in the event of having an
unexpected or situationally predisposed panic attack or panic like symptoms.
Agoraphobia fears typically involve characteristic clusters of situations that include
being outside the home alone: being in a crowd or standing in a line; being on a
bridge: and traveling in a bus, train, or automobile. Note: consider the diagnosis of
Specific Phobia if the avoidance is limited to one or only a few specific situations or
Social Phobia if the avoidance is limited to social situations.
2. The situations are avoided (e.g. travel is restricted) or else are endured with marked
distress or with anxiety about having a panic attack or panic like symptoms, or require
the presence of a companion.
3. The anxiety or phobic avoidance is not better accounted for by another mental
disorder, such as social phobia (e.g. avoidance limited to social situations because of
fear of embarrassment), Specific phobia (avoidance limited to a single situation like
elevators), Obsessive Compulsive Disorder (e.g. avoidance of dirt in someone with an
obsession about contamination), Posttraumatic Stress Disorder (e.g. Avoidance of
stimuli associated with a severe stressor) or Separation Anxiety Disorder (e.g.
avoidance of leaving home or relatives).
Social phobia

"The central feature of social phobia is a persistent, irrational fear of activities or social
interactions, characterised by fear of performing activities in the presence of other people or
interacting with others."

“Social phobia is an excessive fear of situations in a person might do something

embarrassing or be evaluated negatively by others.

 Common social phobias involve fears of speaking or eating in public, urinating in

public lavatories, writing in front of others, or saying foolish things in social
situations.
 Many individuals with social phobia are self-critical and perfectionist-attempting to
conduct themselves according to extreme and exacting standards to avoid the negative
evaluation of others that they may perceive as epidemic.
 By leaving anxiety-provoking situations (escape) them entirely (avoidance),
individuals with social phobia may reduce or prevent the immediate experience of
anxiety, but this relief may also reinforce their belief in their inadequacies.
 Individuals with social phobia experience significant impairment in social,
educational, and vocational functioning.
 They may find it difficult to initiate or maintain social or romantic relationships, avoid
classes that require public presentations, discontinue their education prematurely, or
take jobs below their ability to avoid social or performance demands.
 Often individuals rarely seek treatment.

Onset of symptoms of this disorder often begins in late childhood or early adolescence and
runs a chronic, sometimes lifelong, course. It appears to be equally common among men and
women.

DSM-IV diagnostic criteria for Social Phobia:

1. A marked and persistent fear of one or more social or performance situations in which
the person is exposed to unfamiliar people or to possible scrutiny by others. The
individual fears that he or she will act in a way (or show anxiety symptoms) that will
be humiliating or embarrassing. Note: In children, there must be evidence of the
capacity for age-appropriate social relationships with familiar people and the anxiety
must occur in peer settings, not just in interactions with adults.
2. Exposure to the feared social situation almost invariably provokes anxiety, which may
take the form of a situationally bound or situationally predisposed Panic
Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing,
or shrinking from social situations with unfamiliar people.
3. The person recognizes that the fear is excessive or unreasonable. Note: In children,
this feature may be absent.
4. The feared social or performance situations are avoided or else are endured with
intense anxiety or distress.
5. The avoidance, anxious anticipation, or distress in the feared social or performance
situations(s) interferes significantly with the person’s normal routine,
occupational functioning, or social activities or relationships, or there is marked
distress about having the phobia.
6. In individuals under age 18 years, the duration is at least 6 months.
 7. The fear or avoidance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition and is not better
accounted for by another mental disorder (e.g., Panic Disorder With or Without
Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive
Developmental Disorder, or Schizoid Personality Disorder).
8. If a general medical condition or another mental disorder is present, the fear in
Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in
Parkinson’s disease, or exhibiting abnormal eating behaviour in Anorexia Nervosa or
Bulimia Nervosa.

Specify if:

Generalized: if the fears include most social situations, also consider the additional diagnosis
of Avoidant Personality Disorder.

Specific Phobia or simple phobia

"A condition characterized by marked and persistent fear that is excessive or

unreasonable and is brought on "by the presence or anticipation of a specific object or
situation (e.g., flying, heights, animals, receiving an injection, seeing blood)."

 The response may take the form of a situationally bound or predisposed panic attack,
and the phobia causes marked distress or interferes with role functioning.

Classifications of specific phobias

Acrophobia Height
Ailurophobia Cats
Algophobia Pain
Anthophobia Flowers
Anthropophobia People
Aquaphobia Water
Arachnophobia Spiders
Astraphobia Lightning
Belonephobia Needles
Brontophobia Thunder
Claustrophobia Closed spaces
Cynophobia Dogs
Equinophobia Horses
Gamaphobia Marriage
Herpetophobia Lizards and reptile
Homophobia Homosexuality
Murophobia Mice
Mysophobia Dirt, germs,
contamination
Numerophobia Numbers
Nyctophobia Darkness
Ochophobia Riding in a car
Ophidiophobia Snakes
 Pyrophobia Fire
Thanatophobia Death
Trichophobia Hair
Xenophobia Strangers
Zoophobia animals

The DSM-IV-TR identifies subtypes of the most common specific phobias. They include the
following:

1. Animal type: fear is of animals or insects

2. Natural environment type: heights, storms or water
3. Situational type: fear involves a specific situation, such as public transportation,
tunnels, bridges, elevators, flying, driving etc
4. Blood-injection-injury type: fear of seeing blood or an injury or of receiving an
injection or other invasive medical or dental procedure.
5. Other type: this category covers all other excessive or irrational fears, including
serious illness fear of situation which might lead to vomiting or choking, fear of loud
noises or fear of driving.

Epidemiology

 Phobias are the most common of all anxiety disorders.

 Social phobia is the most common of all phobias
 Lifetime prevalence rates of agoraphobia have been reported from a number of
studies.
 Social phobia in males -11.1 and females -15.5 and a total of 13.3.
 Specific phobia occurs in 2.4 to 9.2 percent of children and adolescents, with usual
onset between 5 and 13 years of age.
 Women receive diagnoses of specific phobia more often than men.
 Onset is often sudden and course usually chronic.

Etiology

Classical conditioning theory

 This theory holds that phobias are learned through the association of negative
experience with an object or situation. Responses of avoidance or escape are learned
and serve to decrease the discomfort arising from conditioned stimuli. Repeated
negative reinforcement of avoidance behaviour maintains the fear and makes it
resistant to extinction.

Psychoanalytical Theory:

 Deployment of three specific ego defense mechanisms in phobias.

o The first of these is displacement, which involves the redirection of anxiety
associated with an unconscious source to a conscious substitute that is often
intrinsically harmless.
o Projection is the second specific defense mechanism used by phobics to get
the source outside of themselves and into the external world.
 o The third defense is avoidance, which is simply a systematic process of not
coming into contact with the displaced and projected item that the anxiety is
associated with.
o If the item is dogs, the individual avoids dogs. The end result is that the three
combined defenses may eliminate the anxiety because the unacceptable or
forbidden thought is re-repressed.
 Freud believed that phobias developed when a child experiences normal incestual
feelings towards the opposite sex parent and fears aggression from the same- sex
parent. To protect themselves, these children repress this fear of hostility from the
same-sex parent, and displace it onto something safer and more neutral, which
becomes the symbol for the parent, but the child does not realize it. Modern day
psychoanalysts also believe that other unconscious fears may also be expressed in a
symbol manner as phobia.

Cognitive theory

 Cognitive theorists espouse that anxiety is the product of faulty cognitions or anxiety
inducing self instructions. Two types of faulty thinking have been investigated:
negative self statements and irrational beliefs. Cognitive theorists believe that some
individuals engage in negative and irrational thinking that produces anxiety reactions.

Biological aspects

 Temperament: children experience fears as a part of normal development. Most

infants are afraid of loud noises. Common fears of toddlers and preschoolers include
strangers, animals, darkness and fears of being separated from parents or attachment
figures. During the school age years, there is a fear of death and anxiety about school
achievement. Fears of social rejection and sexual anxieties are common among
adolescents.

Life experiences

 Certain early experiences may set the stage for phobic reactions later in the life. Some
researchers believe that phobias, particularly specific phobias, are symbolic of
original anxiety producing objects or situations that have been repressed.

Diagnosis and Clinical features (ICD-10)

Agoraphobia

A. There is marked and consistently manifests fear in, or avoidance of, at least two of the
following situations:

(1) Crowds; (2) public places; (3) travelling alone; (4) travelling away from home.

B. At least two symptoms of anxiety in the feared situation must have been present together,
on at least one occasion since the onset of the disorder, and one of the symptoms must have
been from items (1) to (4) listed below:

Autonomic arousal symptoms

(1) Palpitations or pounding heart, or accelerated heart rate;

(2) Sweating;

(3) Trembling or shaking;

(4) Dry mouth

(5) Difficulty in breathing;

(6) Feeling of choking;

(7) Chest pain or discomfort;

(8) Nausea or abdominal distress (e.g., churning in stomach);

Symptoms involving mental state

(9) Feeling dizzy, unsteady, faint, or light-headed;

(10) Feelings that objects are unreal (Derealization), or that the self is distant or "not really
here" (depersonalization);

(11) Fear of losing control, "going crazy," or passing out;

(12) Fear of dying;

General symptoms

(13) Hot flushes or cold chills;

(14) Numbness or tingling sensations.

C. Significant emotional distress is caused by the avoidance or by the anxiety symptoms, and
the individual recognizes that these are excessive or unreasonable.

D. Symptoms are restricted to, or predominate in, the feared situations or contemplation of
the feared situations. Most commonly used exclusion clause. Fear or avoidance of situations
(criterion A) is not the result of delusions, hallucinations, or other disorders, and is not
secondary to cultural beliefs.

Social phobias

A. Either of the following must be present:

(1) marked fear of being the focus of attention, or fear of behaving in a way that will be
embarrassing or humiliating;

(2) marked avoidance of being the focus of attention, or of situations in which there is fear of
behaving in an embarrassing or humiliating way.
These fears are manifested in social situations, such as eating or speaking in public,
encountering known individuals in public, or entering or enduring small group situations
(e.g., parties, meetings, classrooms).

B. At least two symptoms of anxiety in the feared situation as defined in agoraphobia,

criterion B, must have been manifest at some time since the onset of the disorder, together
with at least one of the following symptoms:

(1) blushing or shaking; (2) fear of vomiting; (3) urgency or fear of micturition or defecation.

C. Significant emotional distress is caused by the symptoms or by the avoidance, and the
individual recognizes that these are excessive or unreasonable.

D. Symptoms are restricted to, or predominate in, the feared situations or contemplation of
the feared situations.

E. The symptoms listed in criteria A and B are not the result of delusions, hallucinations, or
other disorders and are not secondary to cultural beliefs.

Specific phobias

A. Either of the following must be present:

(1) marked fear of a specific object or situation not included in agoraphobia or social phobia;

(2) marked avoidance of a specific object or situation not included in agoraphobia or social
phobia.

 Among the most common objects and situations are animals, birds, insects, heights,
thunder, flying, small enclosed spaces, the sight of blood or injury, injections,
dentists, and hospitals.

B. Symptoms of anxiety in the feared situation as defined in agoraphobia, criterion B, must

have been manifest at some time since the onset of the disorder.

C. Significant emotional distress is caused by the symptoms or by the avoidance, and the
individual recognizes that these are excessive or unreasonable.

D. Symptoms are restricted to the feared situation or contemplation of the feared situation.

E. The symptoms listed in criteria A and B are not the result of delusions, hallucinations, or
other disorders and are not secondary to cultural beliefs.

DSM-IV criteria for Specific phobias

1. Marked and persistent fear that is excessive or unreasonable, cued by the presence or
anticipation of a specific object or situation (e.g. flying, heights, animals, receiving an
injection, seeing blood)
2. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety
response, which may take the form of a situationally bound or situationally pre
 disposed panic attack. Note: in children, the anxiety may be expressed by crying,
tantrums, freezing or clinging.
3. The person recognizes that the fear is excessive and unreasonable. Note: in children
this feature may be absent.
4. The phobic situation is avoided or is endured with intense anxiety or distress.
5. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes
significantly with a person’s routine, occupational (or academic) functioning, or social
activities or relationships or there is a marked distress about having the phobia.
6. In individuals under the age of 18 years the duration is at least 6 months.
7. The anxiety panic attacks or phobic avoidance associated with the specific object or
situation are not better accounted for by another mental disorder such as OCD (e.g.
fear of dirt in someone with an obsession about contamination), post traumatic stress
disorder (e.g. avoidance of school), social phobia, panic disorder with agoraphobia or
agoraphobia without history of panic disorder)

Differential Diagnosis

 Anxiety disorder, panic disorder, major depression, schizophrenia, schizotypal

personality, and schizoid personality, avoidant personality disorder, adjustment
disorder obsessive compulsive disorder, delusional disorder, and hypochondriaisis.

Management

Pharmacotherapy

 SSRIs are the drug of choice- Paroxetine is the most widely used. Fluoxetine and
Sertraline are also effective.
 Benzodiazepines- Alprazolam (anti-phobic, anti-panic, and anti-anxiety) to reduce
anticipatory anxiety.
 Drug treatments for specific phobia have consistently been shown to be less effective
than behavioural treatments.
 B-Blockers reduce some symptoms of sympathetic arousal during exposure to feared
stimuli. However, they fail to decrease subjective fear.
 While benzodiazepines may facilitate approach to the feared stimuli, they may also
reduce the efficacy of behaviour therapies by inhibiting the experience of anxiety
during exposure.
 Beta blockers-Propranolol has been found to effective in reducing autonomic
symptoms associated with

Behavioural therapy

 Combining progressive relaxation and graduated imaginal exposure to the feared

stimulus, systematic desensitization has been used.
 Systematic desensitization works by the principle of reciprocal inhibition, which
asserts that the sympathetic response associated with anxiety is incompatible with,
and thus inhibited by, the parasympathetic response that occurs during deep muscle
relaxation.
 Exposure and response prevention:
 Prolonged and repeated in vivo exposure to fear stimuli is by far the most
studied and effective form of treatment for specific phobia.
  Cognitive restructuring- Phobia-specific irrational thoughts may contribute to
the development of the phobia, maintain avoidance behaviour, and contribute
to physiological symptoms. Cognitive restructuring treatments help patients to
monitor irrational thoughts and change underlying beliefs, so that they are
better able to enter feared situations.
 flooding

Nursing Process:

Assessment

Anticipatory anxiety (when thinking about the phobic object)

 Panic anxiety (when confronted with the phobic object)

 Avoidance behaviours that interfere with relationships or functioning
 Recognition of the phobia as irrational
 Embarrassment over the phobic fear
 Sufficient discomfort to seek treatment

Outcomes Identification

 Verbalize feelings of fear and discomfort

 Respond to relaxation techniques with decreased anxiety
 Effectively decrease own anxiety level
 Decrease avoidance behaviours
 Demonstrate effective socio-occupational functioning
 Manage the anxiety response effectively

Nursing Diagnosis:

1. Fear causing embarrassment to self in front of others, being in place from which one
is unable to escape, or a specific stimulus evidenced by behavior directed towards
avoidance of fear object or situation.
2. Social isolation related to fears of being in a place from one is unable to escape
evidenced by staying alone, refusing to leave room or home.

Nursing Interventions

 Encourage the client to express feelings, initially, without discussing the phobic
situation specifically.
 Teach the client and family or significant others about phobic reactions.
 Reassure the client that he or she can learn to decrease the anxiety and gain control
over the anxiety attacks.
 Reassure the client that he or she will not be forced to confront the phobic situation
until prepared to do so.
 Assist the client to distinguish between the actual phobic trigger and problems related
to avoidance behaviors.
 Instruct the client in progressive relaxation techniques, including deep breathing,
progressive muscle relaxation, and imagining himself or herself in a quiet, peaceful
place.
  Encourage the client to practice relaxation until he or she is successful.
 Explain systematic desensitization thoroughly to the client.
 Reassure the client that you will allow him or her as much time as needed at each
step.
 Have the client develop a hierarchy of situations that relate to the phobia by ranking
from the least anxiety- producing to the most anxiety- producing situation. (For
example, a client with a phobia of dogs might rank situations beginning with looking
at a picture of a dog, up to actually petting a dog.)
 Beginning with the least anxiety-producing situation, have the client use progressive
relaxation until he or she is able to decrease the anxiety. When the client is
comfortable with that situation, go to the next item on the list, and repeat the
procedure.
 If the client becomes excessively anxious or begins to feel out of control, return to the
former step with which the client was successful; then proceed slowly to subsequent
steps.
 Give positive feedback for the client's efforts at each step. Convey the idea that he or
she is succeeding at each step. Avoid equating success only with mastery of the entire
process.
 As the client progresses in systematic desensitization, ask the client if his or her
avoidance behaviors are decreasing.
 It may be necessary to address specific avoidance behavior(s) if any persist after the
client has completed the desensitizing process

 Poor prognosis: Giving in to compulsions, longer duration, early onset, bizarre

compulsions, symmetry, comorbid depression, delusional beliefs or overvalued ideas,
personality disorder (esp. schizotypal PD).
 Better prognosis: Good premorbid social and occupational adjustment, a precipitating
event, episodic symptoms.

4. OBSESSIVE–COMPULSIVE DISORDER

An obsession is defined as:

 An idea, impulse or image which intrudes into the conscious awareness repeatedly.
 Is is recognised as one’s own idea, impulse or image but is perceived as ego-alien
(foreign to ones personality)
 It is recognised as irrational and absurd (insight is present)
 Patient tries to resist against it but is unable to.
 Failure to resist, leads to marked distress.

Differentiation has been made clinically from delusion (recognised as one’s own ideas not
foreign) and thought insertion (not thought of as one’s own ideas, but instead somebody else).

An obsession is usually associated with compulsion(s) a compulsion is defined as

1. A form of behaviour which usually follows obsession.

2. It is aimed as either prevention or neutralizing the distress of fear arising out if
obsession.
3. The behaviour is not realistic and is either irrational or excessive.
4. Insight is present, so the patient realise the irrationality of compulsion.
 5. The behaviour is performed with a sense of subjectivity compulsion (urge or impulse
to act). Compulsion may diminish the anxiety associated with obsession.

Epidemiology:

In India, OCD is more common in unmarried males, while in other countries, no gender
difference is reported. Recent studies show the life time prevalence of OCD to be as high as
2-3%, though the Indian data shows the lower prevalence rate.

Etiological theories

 Psychodynamics

Freud placed origin for obsessive-compulsive characteristics in the anal stage of

development. The child is mastering bowel and bladder control at this developmental stage
and derives pleasure from controlling his or her own body and indirectly the actions of others.

Erikson’s comparable stage for this disorder is autonomy versus shame and doubt. The
child learns that to be neat and tidy and to handle bodily wastes properly gains parental
approval and to be messy brings criticism and rejection.

The obsessional character develops the art of the need to obtain approval by being
excessively tidy and controlled. Frequently the parents’ standards are too high for the child to
meet, and the child continually is frustrated in attempts to please parents.

The defensive mechanisms used in obsessive-compulsive behaviors are unconscious

attempts by the client to protect the self from internal anxiety. The greater the anxiety, the
more time and energy will be tied up in the completion of the client’s rituals. First, the client
uses regression, a return to earlier methods of handling anxiety. Second, the obsessive
thoughts are either devoid of feeling or are attached to anxiety. Thus, isolation is used. Third,
the client’s overt attitude toward others is usually the opposite of the unconscious feelings.
Thus, reaction formation is being used. Last, compulsive rituals are a symbolic way of
undoing or resolving the underlying conflict.

 Biological

Although biological and neurophysiological influences in the etiology of anxiety disorders

have been investigated, no relationship has yet been established. The mind-body connection
is well accepted, but it is difficult to establish whether the biological changes cause anxiety or
the emotional state causes physiological manifestations. However, recent findings suggest
that neurobiological disturbances may play a role in obsessive-compulsive disorder, with
physiological and biochemical factors also playing significant roles.

 Family Dynamics

The individual exhibiting dysfunctional behavior is seen as the representation of family

system problems. The “identified patient” (IP) is carrying the problems of the other members
of the family, which are seen as the result of the interrelationships (disequilibrium) between
family members rather than as isolated individual problems.
 Neurotransmitters role

Researchers have yet to pinpoint the exact cause of obsessive-compulsive disorder

(OCD), but brain differences, genetic influences, and environmental factors are being studied.
Brain scans of people with OCD have shown that they have different patterns of brain
activity than people without OCD and that different functioning of circuitry within a certain
part of the brain, the striatum, may cause the disorder. Differences in other parts of the brain
and an imbalance of brain chemicals, especially serotonin and dopamine, may also contribute
to OCD. Independent studies have consistently found unusual dopamine and serotonin
activity in various regions of the brain in individuals with OCD. These can be defined as
dopaminergic hyperfunction in the prefrontal cortex and serotonergic hypofunction in the
basal ganglia.

 Symptoms may include:

 repetitive hand-washing;
 extensive hoarding;
 preoccupation with sexual or aggressive impulses, or with particular religious
beliefs;
 aversion to odd numbers; and
 Nervous habits, such as opening a door and closing it a certain number of times
before one enters or leaves a room.

These symptoms can be alienating and time-consuming, and often cause severe
emotional and economic loss. The acts of those who have OCD may appear paranoid and
come across to others as psychotic. However, OCD sufferers generally recognize their
thoughts and subsequent actions as irrational, and they may become further distressed by this
realization.

Diagnostic Guidelines

For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be

present on most days for at least 2 successive weeks and be a source of distress or
interference with activities. The obsessional symptoms should have the following
characteristics:

(a) they must be recognized as the individual's own thoughts or impulses:

(b) there must be at least one thought or act that is still resisted unsuccessfully, even though
others may be present which the sufferer no longer resists;
(c) the thought of carrying out the act must not in itself be pleasurable (simple relief of
tension or anxiety is not regarded as pleasure in this sense);
(d) the thoughts, images, or impulses must be unpleasantly repetitive.

Includes:
1. anankastic neurosis
2. obsessional neurosis
3. obsessive-compulsive neurosis

Differential Diagnosis
 Differentiating between obsessive-compulsive disorder and a depressive disorder may be
difficult because these two types of symptoms so frequently occur together. In an acute
episode of disorder, precedence should be given to the symptoms that developed first;
when both types are present but neither predominates, it is usually best to regard the
depression as primary.
 In chronic disorders the symptoms that most frequently persist in the absence of the other
should be given priority.
 Occasional panic attacks or mild phobic symptoms are no bar to the diagnosis. However,
obsessional symptoms developing in the presence of schizophrenia, Tourette's syndrome,
or organic mental disorder should be regarded as part of these conditions.
 Although obsessional thoughts and compulsive acts commonly coexist, it is useful to be
able to specify one set of symptoms as predominant in some individuals, since they may
respond to different treatments

Management

According to psychiatrists, Behavioral therapy (BT), cognitive behavioral therapy

(CBT), and medications should be regarded as first-line treatments for OCD. Psychodynamic
psychotherapy may help in managing some aspects of the disorder.

 Behavioral therapy

The specific technique used in BT/CBT is called exposure and ritual prevention (also
known as "exposure and response prevention") or ERP; this involves gradually learning to
tolerate the anxiety associated with not performing the ritual behavior.

Example: might be leaving the house and checking the lock only once (exposure) without
going back and checking again (ritual prevention). The person fairly quickly habituates to the
anxiety-producing situation and discovers that their anxiety level has dropped considerably;
they can then progress to not checking the lock at all—again, without performing the ritual
behavior of washing or checking.

Exposure ritual/response prevention (ERP) has a strong evidence base. It is generally

considered the most effective treatment for OCD. Using ERP alone, one can become
completely symptom free. However, the individual must be highly motivated and consistent.

It has generally been accepted that psychotherapy, in combination with psychotropic

medication, is more effective than either option alone. However, more recent studies have
shown no difference in outcomes for those treated with the combination of medicine and
CBT versus CBT alone.

More recent behavioral work has focused on associative splitting. It is a new technique
aimed at reducing obsessive thoughts. The method draws upon the “fan effect” of associative
priming. The sprouting of new associations diminishes the strength of existing ones. As OCD
patients show marked biases or restrictions in OCD-related semantic networks (e.g., cancer is
only associated with “illness” or “death”, fire is only associated with “danger” or
“destruction”), they are encouraged to imagine neutral or positive associations to OCD-
related cognitions (cancer = zodiac sign, animal, crab; fire = fireflies, fireworks, candlelight-
dinner).
  Medication

Medications as treatment include selective serotonin reuptake inhibitors (SSRIs) such

as paroxetine, sertraline, fluoxetine, escitalopram, and fluvoxamine and the tricyclic
antidepressants, in particular clomipramine. SSRIs prevent excess serotonin from being
pumped back into the original neuron that released it. Instead, serotonin can then bind to the
receptor sites of nearby neurons and send chemical messages or signals that can help regulate
the excessive anxiety and obsessive thoughts. In some treatment-resistant cases, a
combination of clomipramine and an SSRI has shown to be effective even when neither drug
on its own has been efficacious.

Serotonergic antidepressants typically take longer to show benefit in OCD than with
most other disorders they are used to treat. It is common for 2–3 months to elapse before any
tangible improvement is noticed. In addition to this, treatment usually requires high dosages.
Fluoxetine, for example, is usually prescribed in dosages of 20 mg per day for clinical
depression, whereas with OCD the dosage often ranges from 20 mg to 80 mg or higher, if
necessary.

Low dosages of the newer atypical antipsychotics olanzapine, ziprasidone, and

risperidone have also been found to be useful as adjuncts in the treatment of OCD. The use of
antipsychotics in OCD must be undertaken carefully, however, because although there is very
strong evidence that at low dosages they are beneficial.

 Experimental drug treatments

The naturally occurring sugar inositol has been suggested as a treatment for OCD, as it
appears to modulate the actions of serotonin and reverse desensitisation of neurotransmitter
receptors.

Nutrition deficiencies may also contribute to OCD and other mental disorders. Vitamin
and mineral supplements may aid in such disorders and provide nutrients necessary for
proper mental functioning.

 Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) has been found effective in severe and refractory cases.

 Psychosurgery

For some, neither medication, support groups nor psychological treatments are helpful in
alleviating obsessive–compulsive symptoms. These patients may choose to undergo
psychosurgery as a last resort. In this procedure, a surgical lesion is made in an area of the
brain (the cingulate cortex). Deep-brain stimulation and vagus nerve stimulation are possible
surgical options that do not require destruction of brain tissue.

Nursing management

Assessment
 During the assessment interview, determine the patient's personality type.
  The obsessional personality usually is rigid and conscientious and has great
aspirations. He exhibits a formal, reserved manner, with precise and careful
movements and posture; he takes responsibility seriously and finds decision-making
difficult.
 He lacks creativity and the ability to find alternate solutions to his problems.
 Also evaluate the impact of obsessive-compulsive phenomena on the patient's normal
routine.
 He'll typically report moderate to severe impairment of social and occupational
functioning.

Diagnoses Nursing Care Plans For Obsessive Compulsive Disorder

 Ineffective coping related to underdeveloped ego; punitive superego; avoidance

learning; possible biochemical changes evidenced by ritualistic behaviour or
obsessive thoughts.
 Ineffective role performance related to need to perform rituals evidenced by inability
to fulfill usual patterns of responsibility
 Anxiety
 Chronic low self-esteem
 Fear
 Impaired social interaction
 Risk for injury
 Social isolation

Key outcomes Nursing Care Plans For Obsessive–Compulsive Disorder

 The patient will express feelings of anxiety as they occur.

 The patient will develop self-esteem.
 The patient will express fears and concerns.
 The patient will demonstrate effective social interaction skills.
 The patient will cope with stress without excessive obsessive-compulsive behavior.
 The patient will reduce the amount of time spent each day on obsessing and
ritualizing.
 Ritualistic behavior won't produce harmful effects.
 The patient will maintain family and peer relationships
 Client is able to maintain anxiety at level in which problemsolving can be
accomplished.
 Client is able to verbalize signs and symptoms of escalating anxiety.
 Client is able to demonstrate techniques for interrupting the progression of anxiety to
the panic level.

Interventions Nursing Care Plans For Obsessive–Compulsive Disorder

 Approach the patient unhurriedly.

 Provide an accepting atmosphere; don't show shock, amusement, or criticism of the
ritualistic behavior.
  Allow the patient time to carry out the ritualistic behavior (unless it's dangerous) until
he can be distracted into some other activity. Blocking this behavior raises anxiety to
an intolerable level.
 Keep the patient's physical health in mind. For example, compulsive hand washing
may cause skin breakdown, and rituals or preoccupations may cause inadequate food
and fluid intake and exhaustion. Provide for basic needs, such as rest, nutrition, and
grooming, if the patient becomes involved in ritualistic thoughts and behaviors to the
point of self-neglect.
 Let the patient know you're aware of his behavior. For example, you might say, I
noticed you've made your bed three times today; that must be very tiring for you.
Help the patient explore feelings associated with the behavior. For example, ask him,
what do you think about while you are performing your chores?
 Make reasonable demands, and set reasonable limits; make their purpose clear. Avoid
creating situations that increase frustration and provoke anger, which may interfere
with treatment.
 Explore patterns leading to the behavior or recurring problems.
 Listen attentively, offering feedback.
 Encourage the use of appropriate defense mechanisms to relieve loneliness and
isolation.
 Engage the patient in activities to create positive accomplishments and raise his self-
esteem and confidence.
 Encourage active diversional resources, such as whistling or humming a tune, to
divert attention from the unwanted thoughts and to promote a pleasurable experience.
 Assist the patient with new ways to solve problems and to develop more effective
coping skills by setting limits on unacceptable behavior (for example, by limiting the
number of times per day he may indulge in obsessive behavior). Gradually shorten the
time allowed. Help him focus on other feelings or problems for the remainder of the
time.
 Identify insight and improved behavior (reduced compulsive behavior and fewer
obsessive thoughts). Evaluate behavioral changes by your own and the patient's
reports.
 Identify disturbing topics of conversation that reflect underlying anxiety or terror.
 Observe when interventions don't work; reevaluate and recommend alternative
strategies.
 Monitor effects of pharmacologic therapy.

Nursing priorities

1. Assist client to recognize onset of anxiety.

2. Explore the meaning and purpose of the behavior with the client.
3. Assist client to limit ritualistic behaviors.
4. Help client learn alternative responses to stress.
5. Encourage family participation in therapy program.

Discharge goals

1. Anxiety decreased to a manageable level.

2. Ritualistic behaviors managed/minimized.
3. Environmental and interpersonal stress decreased.
 4. Client/family involved in support group/community programs.
5. Plan in place to meet needs after discharge.

5. POST-TRAUMATIC STRESS DISORDER

Introduction
An anxiety disorder resulting from exposure to a traumatic event in which the
individual has experienced, witnessed, or been confronted with an event or events that
involve actual or threatened death/serious injury or a threat to the physical integrity of the self
or others. The individual’s response involved intense fear, helplessness, or horror.

Definition
Severe psychological disturbance following a traumatic event characterised by
involuntary re-experiencing of elements of the event, with symptoms of hyperarousal,
avoidance, and emotional numbing.

Etiological theories

 Psychodynamics

The client’s ego has experienced a severe trauma, often perceived as a threat to physical
integrity or self-concept. This results in severe anxiety, which is not controlled adequately by
the ego and is manifested in symptomatic behavior. Because the ego is vulnerable, the
superego may become punitive and cause the individual to assume guilt for traumatic
occurrence; the id may assume dominance, resulting in impulsive, uncontrollable behavior.

 Biological

Research is exploring the possibility of a genetic vulnerability including the belief that
neurological disturbances in the womb or during childhood may influence the development of
PTSD.

 Family Dynamics

Types of formal education, family life, and lifestyle are significant forecasters of PTSD.
Below average or lack of success in education, negative parenting behaviors, and parental
poverty have been identified as predictors for development of PTSD, as well as for
peritraumatic dissociation.

Current research also suggests that the effects of severe trauma may last for generations,
meaning someone else’s traumatic experience can be internalized by another, intruding into
the second individual’s own mental life.

Risk factors

 Vulnerability factors Low education, lower social class, Afro-Carribbean/Hispanic,

female gender, low self-esteem/neurotic traits, previous (or family) history of
psychiatric problems (esp. mood/ anxiety disorders), previous traumatic events
(including childhood experiences).
  Protective factors High IQ, higher social class, Caucasian, male gender, psychopathic
traits, chance to view body of dead relative/friend.

Symptoms/signs

Symptoms arise within 6mths (ICD-10) of the traumatic event (delayed onset in -10%
of cases) or are present for at least 1mth, with clinically significant distress or impairment in
social, occupational, or other important areas of functioning (DSM-IV).
Both ICD-10 and DSM-IV include:

 2 or more persistent symptoms of increased psychological sensitivity and arousal (not

present before exposure to the stressor):
 Difficulty falling or staying asleep
 Irritability or outbursts of anger
 Difficulty in concentrating
 Hypervigilance
 Exaggerated startle response

Other ICD-10 Criteria:

 Persistent remembering or reliving of the stressor in intrusive flashbacks, vivid

memories, or recurring dreams; and in experiencing distress when exposed to
circumstances resembling or associated with the stressor.
 Actual or preferred avoidance of circumstances resembling or associated with the
stressor which was not present before exposure to the stressor.
 Inability to recall, either partially or completely, some important aspects or the period
of exposure to the stressor.

Additional Symptoms of PTSD

 Alienating yourself to prevent stressful situations

 Avoiding people and places that remind you of the trauma
 Panicking in social situations you cannot escape
 Hiding your feelings of anxiety and fear
 Smiling or laughing so others think you’re happy
 Withdrawing from relationships with loved ones
 Struggling to fall asleep … and stay asleep
 Reliving the trauma in dreams and flashbacks
 Suffering in your performance at work
 Drinking or abusing drugs to mask your problems
 Avoiding plans for a future you doubt you’ll see
 Thinking about suicide
 Feeling like you’re facing all of this alone

Diagnostic studies

Drug Screen: Rules out drugs as contribution to cause of symptoms.

Other diagnostic studies may be conducted to rule out physical disease as basis for individual
symptoms (e.g., ECG for severe chest pain, echocardiogram for mitral valve prolapse; EEG
to identify seizure activity; thyroid studies)

Management

 Psychological

 CBT Treatment of choice should include elements of: education about the nature of
PTSD, self-monitoring of symptoms, anxiety management (stress inoculation),
exposure to anxiety-producing stimuli in a supportive environment, cognitive
restructuring (esp. for complicated trauma), anger management.
 Eye movement desensitisation and reprocessing (EMDR) a novel (controversial)
treatment using voluntary multi-saccadic eye movements to reduce anxiety
associated with disturbing thoughts.
 Psychodynamic therapy Aims to understand the meaning of the traumatic event for
the individual and to work through and resolve the provoked unconscious conflict.

 Pharmacological

 There is limited evidence for the efficacy of any particular medication in PTSD
 Treatments should be directed towards predominant symptoms
 Depressive symptoms SSRIs (reasonable evidence for fluoxetine, fluvoxamine,
sertraline); TCAs (some evidence for amitriptyline, desipramine, imipramine);
MAOIs (e.g. phenelzine) may also reduce anxiety (overarousal) and intrusiveness.
 Anxiety symptoms consider use of BDZs (clonazepam, alprazolam), buspirone,
antidepressants.
 Sleep disturbance may be improved by use of sedative antidepressants (e.g.
trazodone), cyproheptadine, or specific hypnotics.
 Intrusive thoughts possibilities include carbamazepine, lithium, fluvoxamine.
 Hyperarousal some evidence for SSRIs, propranolol/clonidine, lithium, valproate.
 Hostility/impulsivity carbamazepine, valproate.
 Psychotic symptoms/severe aggression or agitation may warrant use of an
antipsychotic.

Outcome

 50% will recover within 1st year, 30% will run a chronic course.
 Outcome depends on initial symptom severity.
 Recovery will be helped by:
o Good social support
o Lack of negative responses from others
o Absence of maladaptive coping mechanisms (e.g. avoidance, denial of
problems, safety behaviours™, not talking about the experience, thought
suppression or rumination)

 No further traumatic life events (including secondary problems such as physical

health, acquired disability, disfigurement, disrupted relationships, financial worries,
ongoing litigation.)
Nursing priorities

1. Provide safety for client/others.

2. Assist client to enhance self-esteem and regain sense of control over feelings/actions.
3. Encourage development of assertive, not aggressive, behaviors.
4. Promote understanding that the outcome of the present situation can be significantly
affected by own actions.
5. Assist client/family to learn healthy ways to deal with/realistically adapt to changes and
events that have occurred.

Discharge goals

1. Self-image improved/enhanced.
2. Individual’s feelings/reactions are acknowledged, expressed, and dealt with appropriately.
3. Physical complications treated/minimized.
4. Appropriate changes in lifestyle planned/made.
5. Plan in place to meet needs after discharge.

Nursing diagnosis

1. Posttrauma syndrome related to distressing event considered to be outside the range of

usual human experience evidenced by flashbacks, intrusive recollections, nightmares,
psychological numbness related to the event, dissociation or amnesia.
2. Dysfunctional grieving related to loss of self as perceived prior to the trauma or other
actual/perceived losses incurred during/following the event evidenced by irritability
and explosiveness, self-distructiveness, substance abuse.

6. ANXIETY DISORDER DUE TO A GENERAL MEDICAL CONDITION

The symptoms of this disorder are judged to be the direct physiological consequences
of a general medical condition.

Symptoms may include prominent generalized anxiety symptoms, panic attacks, or

obsessions or compulsions. History, physical examination or laboratory findings must be
evident to substantiate the diagnosis.

The DSM-IV-TR lists the following types and examples of medical conditions that
may cause anxiety symptoms:

Endocrine conditions Hyperthyroidism and hypothyroidism, hypoglycaemia

Cardiovascular CCF, pulmonary embolism, arrhythmia
Respiratory COPD, pneumonia, hyperventilation
Metabolic Vitamin B12 deficiency
Neurological Neoplasms, vestibular dysfunction, encephalitis

Management
  Care of this client with disorder must take into consideration the underlying cause of
the anxiety.
 Holistic nursing care is essential to ensure that the client’s physiological and
psychological needs are met.
 Nursing actions appropriate for the specific medical condition must be considered.

7. SUBSTANCE-INDUCED ANXIETY DISORDER

The DSM-IV-TR describes the essential features of this disorder as prominent anxiety
symptoms that are judged to be due to the direct physiological effects of a substance.

The symptoms may occur during substance intoxication or withdrawal, and may involve
prominent anxiety, panic attacks, phobias or obsessions or compulsions.

Diagnosis of this disorder is made only if the anxiety symptoms are in excess of those
usually associated with the intoxication or withdrawal syndrome and warrant independent
clinical attention.

Nursing care of the client with substance induced anxiety disorder must take into
consideration the nature of the substance and the context in which the symptoms occur; that
is, intoxication or withdrawal.

Conclusion

Anxiety is a necessary force for survival and has been experienced by humanity
throughout the ages. It was first described as a physiological disorder and identified by its
physical symptoms, particularly the cardiac symptoms.

Anxiety is considered a normal reaction to a realistic danger or threat to biological

integrity or self-concept. Treatment of anxiety includes individual psychotherapy, cognitive
therapy, behavioral therapy, group therapy and psychopharmacology.

Nurses should be able to recognize the symptoms of anxiety and help client
understand that these symptoms are normal and acceptable.

JOURNAL ABSTRACT

1. Daniel S. Pine; Patricia Cohen; Diana Gurley; Judith Brook; Yuju Ma. “The Risk for
Early-Adulthood Anxiety and Depressive Disorders in Adolescents With Anxiety and
Depressive Disorders”. Arch Gen Psychiatry. January 1998; Vol 55(1). 56-64.

Abstract:

An epidemiologically selected sample of 776 young people living in upstate New

York received DSM-based psychiatric assessments in 1983, 1985, and 1992 using structured
interviews. The magnitude of the association between adolescent and adult anxiety or
depressive disorders was quantified using odds ratios generated from logistic regression
analyses and from a set of latent Markov analyses. In simple logistic models, adolescent
anxiety or depressive disorders predicted an approximate 2- to 3-fold increased risk for
adulthood anxiety or depressive disorders. There was evidence of specificity in the course of
simple and social phobia but less specificity in the course of other disorders. Results from the
analyses using latent variables suggested that while most adolescent disorders were no longer
present in young adulthood, most adult disorders were preceded by adolescent disorders.

2. Kemuel L Philbrick, James R Rundell et al. “Effectiveness of a meditation-based stress

reduction program in the treatment of anxiety disorders”. The American journal of
psychiatry. Vol 149. No. 7. 1992; 936-943.

Abstract:

This study was designed to determine the effectiveness of a group stress reduction
program based on mindfulness meditation for patients with anxiety disorders. The 22 study
participants were screened with a structured clinical interview and found to meet the DSM-
III-R criteria for generalized anxiety disorder or panic disorder with or without agoraphobia.
Assessments, including self-ratings and therapists' ratings, were obtained weekly before and
during the meditation-based stress reduction and relaxation program and monthly during the
3-month follow-up period. Repeated measures analyses of variance documented significant
reductions in anxiety and depression scores after treatment for 20 of the subjects--changes
that were maintained at follow-up. The number of subjects experiencing panic symptoms was
also substantially reduced. A comparison of the study subjects with a group of nonstudy
participants in the program who met the initial screening criteria for entry into the study
showed that both groups achieved similar reductions in anxiety scores on the SCL-90- R and
on the Medical Symptom Checklist, suggesting generalizability of the study findings. A
group mindfulness meditation training program can effectively reduce symptoms of anxiety
and panic and can help maintain these reductions in patients with generalized anxiety
disorder, panic disorder, or panic disorder with agoraphobia.

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