Anxiety Disorders

Biological Findings

GAD and Panic D/o

GABA Theory
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? problem binding to the BZD receptors ? Altered receptor sensitivity Abnormal NE and 5-HT neurotransmission Studies have shown CO2 inhalation precipitates panic attacks

OCD
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? if obsessions are r/t a defect in neural inhibition of dominant frontal systems 5-HT neurotransmission is dysregulated

Biological Findings (cont)

PTSD

Extreme stress is assoc with damaging effects to the brain Abuse causes reduction in the hippocampus (Bremner, et al 1997)

Psychological Factors

Psychodynamic

Anxiety results from breakthrough of repressed ideas and emotions Ego defense mechanisms are used to help manage anxiety Anxiety is linked to the emotional distress caused when early needs go unmet

Interpersonal

Psychological Factors (cont)

Learning Theories

Anxiety is a learned response that can be unlearned Learn to be anxious through modeling Anxiety is caused by distortions in thinking and perceiving

Cognitive Theories

Major Anxiety Disorders

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Panic disorder with or without agoraphobia Generalized anxiety disorder (GAD) Obsessive-compulsive disorder (OCD) Phobias Post traumatic stress disorder (PTSD)

Panic Disorder

Panic

Panic attacks—alone are not listed in the DSM IV classification as psychiatric illnesses

A discrete period of intense fear or discomfort in which 4 or more of the following sx develop abruptly and reach a peak within 10 minutes:
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Palpitations, pounding heart, accelerated heart rate Sweating Trembling or shaking Sensations of SOB or choking Chest pain or discomfort Nausea or abdominal distress Dizziness, lightheadedness, unsteadiness Derealization, depersonalization Fear of losing control or going crazy

DSM IV Criteria—Panic Disorder
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Recent and unexpected panic attacks At least one of the attacks has been followed for 1 or more months by 1 or more of the following:
1.

2.

Persistent concern about having additional attacks Worry about the implications of the attack or its consequences (losing control; having a heart attack; going

Panic D/O Without Agoraphobia

The previous 2 criteria are met as well as:
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The individual is free from agoraphobic sx The panic attacks are not r/t direct effects of a substance (illicit drugs or medications) The panic attacks are not due to a physiologic condition The panic attacks are not better accounted for by another mental d/o

Panic D/O With Agoraphobia

To meet this criteria, the individual must meet the criteria for panic d/o as well as experience debilitating agoraphobic sx

Agoraphobia—fear of being in any situation where escape might be difficult or help unavailable in the event of a panic attack

Treatment
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Interdisciplinary care is needed. Priority care issues include:
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Depression associated with panic disorder. Suicide needs to be assessed.

Nursing Management: Biologic Domain Assessment
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Ruling out of other disorders Assessment questions

Common features of panic attack (Table 21.5) Careful review of events prior to attack

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Substance use Sleep patterns Physical activity

Nursing Diagnosis: Biologic Domain
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Anxiety Risk for self-harm Risk of suicide

Biologic Interventions
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Breathing control – Reduce hyperventilation, and interrupt a panic attack. Practice. Nutritional planning

Reduce anxiety-provoking substances, such as caffeine, food coloring or MSG. Monitor symptoms after eating.

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Relaxation techniques Increase physical activity.

Psychopharmacologic Treatment
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Selective serotonin reuptake inhibitors (SSRIs) Fluoxetine and sertraline – can cause feelings of overstimulation, slow titration Side effects – anticholinergic, dizziness, anxiety, nervousness and sexual dysfunction Interact with MAOIs Fluoxetine interacts with flecainid, warfarin, phenytoin, carbamazepine and vinblastine. Paroxetine interacts with cimetidine, decrease digoxin levels, phobarbitol and phenytoin. Sertraline interacts with diazepan, tolbutamide and warfarin. Teaching points:
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Avoid over-the-counter medications. Sedative effects may impede judgment while operating machinery.

Psychopharmacologic Treatment
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Tricylcic antidepressants Imipramine and clomipramine reduce panic attacks. Therapeutic effects usually occur in three to four weeks. Single bedtime doses help deal with sedation. EKG before initiation (cardiac conduction) Taper discontinuation to avoid cholinergic rebound. Observe for anticholinergic effects. Start at low doses and gradually increase. Interacts with several medications (MAOIs and CNS depressants) Teaching points
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Take medication as prescribed. Avoid OTC medications without checking first. Warn about sedation; avoid operating machinery.

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Benzodiazepines Used during periods of extreme stress and for immediate symptom release Alprazolam, lorazepam and clonazepam Initiate benzodiazepines until antidepressants begin working. Short-acting, associated with rebound anxiety ( alprazolam, lorazepam). Give in divided doses. Avoid if patient has sleep apnea. Withdrawal symptoms can occur. Side effects include: headache, confusion, dizziness, disorientation, sedation and visual disturbances. Interactions with TCAs, digoxin, alcohol and other CNS depressants. Avoid histamine blockers. Cigarette smoking increases clearance. Teaching points: Avoid alcohol, sedative effects

Psychopharmacologic Treatment

Psychopharmacologic Treatment
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Monoamine Oxidase Inhibitors Phenelzine (Nardil) has been used effectively. Probably won’t be used because of safer medication Can take three to eight weeks to produce effects Side effects: sedation, weight gain, hypertension, hypotension, dizziness, edema, agranulocytosis Interacts with food and drugs Teaching points: Inform patient of side effects.

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Nursing Management: Psychological Domain Assessment
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Determining patterns of panic attack, symptoms and responses Mental status: restlessness, irritability, watchful or worried facial expression, decreased attention span, difficulty problem solving, apprehensive or helpless Suicidal assessment Cognitive thought patterns Avoidance behavior patterns Self-concept Risk assessment Rating scales

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Nursing Diagnoses: Psychological Domain
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Anxiety Risk for self-harm Powerlessness

Psychological Interventions

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Help patient attend to and react to input other than subjective experience. Provide patient with information. Distraction Positive self-talk “I will get through this” Panic control treatment: structured exposure to internal sensations Exposure therapy Systematic desensitization Implosive therapy Cognitive-behavioral therapy Psychoeducation

Nursing Management: Social Domain Assessment
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Family functioning Cultural factors

Social Interventions
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Stress time management Family support

Help with communication

Emergency Care Interventions for Panic Attack
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Stay with the patient. Reassure him/her that you will not leave. Give clear directions. Assist patient to an environment with minimal stimulation. Walk with the patient. Administer PRN anxiolytic medications.

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Phobias

Phobias

Specific phobia

Agoraphobia

marked and persistent fear; excessive and unreasonable; cued by presence or anticipation of object
marked and persistent fear of social or performance

Social phobia

Anxiety about being in places or situations where escape may be difficult or embarrassing, and a panic attack may occur Avoided or endured under stress There are those without a diagnosis of panic attack

Post Traumatic Stress Disorder (PTSD)

PTSD

1st described in soldiers to explain the pattern of responses following traumatic events Recently investigators have begun to adapt the PTSD model to other traumatic events in human experience
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Adult and child sexual abuse Physical abuse Disasters

To Be Diagnosed With PTSD….
A. The person has been exposed to a traumatic event in which both of the following were present:
1. The person witnessed, experienced, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2. The person’s response involved

To Be Diagnosed With PTSD….
B. The traumatic event is persistently reexperienced in 1 (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event 2. Recurrent distressing dreams of the event 3. Acting or feeling as if the traumatic event were recurring

To Be Diagnosed With PTSD….
4. The experience of psychologic distress when internal or external cues resemble the event 5. Physiologic reactivity on exposure to internal or external cues resembling the event

To Be Diagnosed With PTSD….
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness as indicated by 3 (or more) of the following:
1. Efforts to avoid thoughts, feelings, or conversations about the trauma 2. Efforts to avoid persons or places that evoke memories of the trauma 3. An inability to remember certain aspects of the trauma 4. Diminished interest or participation in

To Be Diagnosed With PTSD….
5. A feeling of estrangement or detatchment from others 6. Restricted range of affect 7. Sense of a foreshortened future

To Be Diagnosed With PTSD….
D. Persistent sx of increased arousal as indicated by 2 (or more) of the following:
1. 2. 3. 4. 5. Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilence Exaggerated startle response

To Be Diagnosed With PTSD….
D. Duration of disturbance is more than 1 month E. The disturbance causes significant impairment in social or occupational functioning

Generalized Anxiety Disorder (GAD)

GAD

Characterized by excessive anxiety and worry that occurs more days than not, for at least 6 months This anxiety involves concerns about a number of events and activities The individual finds it difficult to control the worry

GAD (cont)

3 of the following 6 sx must be present to some degree for a period of a least 6 months:
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Restlessness or feeling on edge Being easily fatigued Difficulties with concentration Irritability Muscle tension Sleep disturbance

Anxiety or worry interferes with normal social or occupational functioning Anxiety is not due to the effects of a

Obsessive Compulsive Disorder (OCD)

OCD

Characterized by the presence of either obsessions or compulsions

Obsessions—recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance as intrusive and inappropriate and cause marked distress or anxiety The individual attempts to suppress or ignore these thoughts or to neutralize them with some other thought or action Individual recognizes that the obsessional thoughts are a product of his or her own mind

OCD

Compulsions are repetitive behaviors that the person feels driven to perform in response to an obsession The behaviors are an attempt to prevent or reduce the distress invoked by the obsession

Treatment Modalities

Nursing Management: Biologic Domain
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Assessment for multiple physical symptoms Physical fears Physical consequences of compulsions Nutrition and sleep status Dermatologic lesions secondary to hand washing Head trauma

Biologic Interventions
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Electroconvulsive therapy Psychosurgery Maintaining skin integrity Psychopharmacologic treatment
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SSRI and TCA Antidepressants given in higher doses than for treatment of depression Side effect monitoring a problem for those preoccupied with somatic concerns Teaching points: Manage medication; do not stop prescribed medications abruptly; avoid OTC medications; and consider sedative effect.

Nursing Management Psychological Assessment

Type and severity of obsessions and compulsions Degree to which the OCD symptoms interfere with patient’s daily functioning Consider using rating scales Suicide assessment

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Psychological Interventions
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Response prevention Thought stopping Relaxation techniques Cognitive restructuring Cue cards Psychoeducation (See Psychoeducation Checklist.)

Nursing Management: Social Domain

Consider sociocultural factors and patient’s ability to relate to others. In the hospital, unit routines are carefully and clearly explained to decrease patient’s fear of unknown. Recognize significance of rituals. Assist patient in arranging schedule. Marital and family support are important.

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Nursing Management

Social interventions
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Milieu interventions Personal and environmental protective measures Family interventions

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Evaluation Continuum of care

Biologic interventions

Pharmacologic interventions alone or in combination with cognitive interventions are among the most successful treatments for anxiety and related disorders

Examples of Benzos

Aprazolam (Xanax)

Dose/day 0.75-4 mg Dose/day 25-200 mg Dose/day 1-6 mg Dose/day 2-40 mg Dose/day 0.5-10 mg

Chlordiazepoxide (Librium)

Clonazepam (Klonopin)

Diazepam (Valium)

Lorazepam (Ativan)

Examples of Benzos (cont)

Oxazepam (Serax)

Dose/day 30-120 mg Dose/day 20-60 mg Dose/day 15-30 mg

Prazepam (Centrax)

Temazepam (Restoril)

Mechanism of Action of Bezos

Exert their effect through GABA

Benzos facilitate the transmission of GABA by binding to GABA-A receptors and opening chloride channels

Side Effects of Benzos
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Sedation Fatigue Reduced motor coordination Impaired memory Cognitive dysfunction

Serious Side Effects of Benzos
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Can lead to tolerance, abuse, and dependence Rapid d/c produces withdrawal sx:
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Insomnia Diaphoresis Autonomic stimulation Irritability Seizures

Nonbenzodiazepine Anxiolytic

Buspirone (BuSpar)
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Antianxiety effects occur gradually over the first 2 weeks of therapy Mechanism of action is unknown—it is a partial agonist at the 5-HT receptor Indicated for the Rx of anxiety d/os (specifically GAD) Side effects include:
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Dizziness H/A Drowsiness

CNS sedation and cognitive impairment occur much less frequently with Buspar

Complementary Medicine

Kava (50-75 mg tid)
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An herb with antianxiety effects SE—GI c/o, H/As, dizziness, and allergic skin reactions Does not impair motor or mental fx when taken in normal doses

Biologic interventions

GAD
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SSRIs have found to be effective Venlafaxine (Effexor) Buspirone (Buspar) TCAs—imipramine (Tofranil) SSRIs have also found to be effective TCAs—clomipramine (Anafranil) SSRIs—fluvoxamine (Luvox)

Panic Disorder
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OCD
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Therapy

Systematic desensitization

Among the most effective treatments for panic d/o with agoraphobia Widely used in the Rx of anxiety disorders The client and the therapist identify target sx and then examine the circumstances associated with the sx Together they devise strategies to change either the cognitions or the

Cognitive Behavioral Therapy
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