ANXIETY DISORDERS

CONCEPT OF ANXIETY AND

PSYCHIATRIC NURSING
• Anxiety
• Universal human experience
• Dysfunctional behavior often defends against anxiety
• Legacy of Hildegard Peplau (1909-1999)
• Operationally defined concept and levels of anxiety
• Suggested specific nursing interventions appropriate to each of four levels of anxiety
 PSYCHOLOGICAL ADAPTATION TO
STRESS

• Anxiety and grief have been described as two major, primary psychological response
patterns to stress.
• A variety of thoughts, feelings, and behaviors are associated with each of these
response patterns.
• Adaptation is determined by the extent to which the thoughts, feelings, and behaviors
interfere with an individual’s functioning.
 ANXIETY AND FEAR

• Anxiety: feeling of apprehension, uneasiness, uncertainty,

or dread resulting from real or perceived threat whose
actual source is unknown or unrecognized
• Fear: reaction to specific danger
• Similarity between anxiety and fear
• Physiological response to these experiences is the same (fight-
or-flight response)
 ANXIETY

• A diffuse apprehension that is vague in nature and is

associated with feelings of uncertainty and helplessness.
• Extremely common in our society.
• Mild anxiety is adaptive and can provide motivation for
survival.
 TYPES OF ANXIETY
• Normal
• Motivating force that provides energy to carry out tasks of living
• Acute or state
• Anxiety that is precipitated by imminent loss or change that
threatens one’s security (crisis)
• Chronic or trait
• Anxiety that persists over time
• Mild
• Occurs in normal everyday living
• Increases perception, improves problem solving
• Manifested by restlessness, irritability, mild tension-relieving
behaviors
 TYPES OF ANXIETY

• Moderate
• Escalation from normal experience
• Decreases productivity (selective inattention) and learning
• Manifested by increased heart rate, perspiration, mild somatic
symptoms
• Severe
• Greatly reduced perceptual field
• Learning and problem solving not possible
• Manifested by erratic, uncoordinated, and impulsive behavior
• Panic
• Results in loss of reality focus
• Markedly disturbed behavior occurs
• Manifested by confusion, shouting, screaming, withdrawal
 P EPL A U ’ S FO U R LEV ELS O F A N X I ETY

• Mild – seldom a problem

• Moderate – perceptual field diminishes
• Severe – perceptual field is so diminished that concentration centers on one detail
only or on many extraneous details
• Panic – the most intense state
 BEHAVIORAL ADAPTATION RESPONSES
TO ANXIETY

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

• Help protect people from painful awareness of feelings and

memories that can cause overwhelming anxiety
• Operate all the time
• Adaptive (healthy) or maladaptive (unhealthy)
• First outlined and described by Sigmund Freud and his
daughter Anna Freud
 PROPERTIES OF DEFENSE
MECHANISMS

• Major means of managing conflict and affect

• Relatively unconscious
• Discrete from one another
• Hallmarks of major psychiatric disorders
• Can be reversible
• Can be adaptive as well as pathological
 HEALTHY, INTERMEDIATE, AND
IMMATURE DEFENSE MECHANISMS
• Healthy
• Altruism, sublimation, humor, suppression
• Intermediate
• Repression, displacement, reaction formation, undoing, rationalization
• Immature
• Passive aggression, acting-out behaviors, dissociation, devaluation, idealization, splitting,
projection, denial
 DEFENSE MECHANISMS

• Compensation • Rationalization
• Denial • Reaction formation
• Displacement • Regression
• Identification
• Repression
• Intellectualization
• Introjection • Sublimation
• Isolation • Suppression
• Projection • Undoing
•Anxiety at the moderate to severe level that
remains unresolved over an extended
period of time can contribute to a number of
physiological disorders – for example, migraine
headaches, IBS, and cardiac arrhythmias.

•Extended periods of repressed severe anxiety

can result in psychoneurotic patterns of
behaving – for example, anxiety disorders and
somatoform disorders.
 INTRODUCTION:
ANXIETY DISORDER

Anxiety provides the motivation for achievement, a

necessary force for survival.
Anxiety is often used interchangeably with the word
stress; however, they are not the same.
Anxiety may be differentiated from fear in that the former
is an emotional process, whereas fear is cognitive.
Extended periods of functioning at the panic level of
anxiety may result in psychotic behavior; for example,
schizophrenic, schizoaffective, and delusional disorders.
 EPIDEMIOLOGICAL STATISTICS

• Anxiety disorders are the most common of all psychiatric

illnesses
• More common in women than men
• Minority children and children from low socioeconomic
environments at risk
• A familial predisposition probably exists
• How much is too much?
• When anxiety is out of proportion to the situation that is
creating it.
• When anxiety interferes with social, occupational, or other
important
areas of functioning.
 PA NI C DI S O R D E R S : PA N I C AT TA C K ,
PA NI C DI S O RD E R W I T H
AGORAPHOBIA

• Panic attack
• Sudden onset of extreme apprehension or fear of
impending doom
• Fear of losing one’s mind or having a heart
attack
• Panic disorder with agoraphobia
• Panic attacks combined with agoraphobia
• Agoraphobia is fear of being in places or
situations from which escape is difficult or
help unavailable
• Feared places avoided, restricting one’s life
 PHOBIA

• Phobia: persistent, irrational fear of specific objects,

activities, or situations
• Types of phobias
• Specific: response to specific objects
• Social: result of exposure to social situations or
required performance
• Agoraphobia: fear of being in places/situations from
which escape is difficult or help unavailable
 OBSESSIVE-COMPULSIVE
DISORDER (OCD)

• Obsession

• Thoughts, impulses, or images that persist and recur

• Ego-dystonic symptom: feels unacceptable to individual
• Unwanted, intrusive, persistent ideas, thoughts, impulses, or
images that cause marked anxiety or distress
 COMPULSIONS

• Ritualistic behaviors that individual feels driven to

perform
• Primary gain from compulsive behavior: anxiety relief
• Unwanted repetitive behavior patterns or mental acts that are
intended to reduce anxiety, not to provide pleasure or
gratification
 GENERALIZED ANXIETY
DISORDER (GAD)

• Excessive anxiety or worry about numerous things lasting at

least 6 months
• Common symptoms
• Restlessness
• Fatigue
• Poor concentration
• Irritability
• Tension
• Sleep disorders
POST-TRAUMATIC STRESS
DISORDER (PTSD)

• Development of characteristic symptoms

following exposure to an extreme traumatic
stressor involving a personal threat to physical
integrity or to the physical integrity of others
• Characteristic symptoms include reexperiencing
the traumatic event, a sustained high level of
anxiety or arousal, or a general numbing of
responsiveness. Intrusive recollections or
nightmares of the event are common.
• Psychosocial theory
• The traumatic experience
• Severity and duration of the stressor
• Extent of anticipatory preparation before onset
• Exposure to death
• Numbers affected by life threat
• Extent of control over recurrence
• Location where trauma was experienced
• The individual
• Degree of ego-strength
• Effectiveness of coping resources
• Presence of preexisting psychopathology
• Outcomes of previous experiences with stress/trauma
• Behavioral tendencies
• Current psychosocial developmental stage
• Demographic factors
 • The recovery environment
• Availability of social supports
• Cohesiveness and protectiveness of family and friends
• Attitudes of society regarding the experience
• Cultural and subcultural influences
• Learning theory
• Negative reinforcement as behavior that leads to a reduction in an aversive
experience, thereby reinforcing and resulting in repetition of the behavior
• Avoidance behaviors
• Psychic numbing
• Cognitive theory
• A person is vulnerable to post-traumatic stress disorder when fundamental
beliefs are invalidated by experiencing trauma that cannot be
comprehended and when a sense of helplessness and hopelessness
prevails.
 TREATMENT MODALITIES

• Psychopharmacology
• PTSD

• Antidepressants
• Anxiolytics
• Antihypertensives
• Others
•Biological aspects
•It has been suggested that a person who has
experienced previous trauma is more likely to
develop symptoms after a stressful life event.
•Disregulation of the opioid, glutamatergic,
noradrenergic, serotonergic, and neuroendocrine
pathways may be involved in the pathophysiology
of PTSD.
•Transactional Model of Stress Adaptation
•The etiology of PTSD is most likely influenced by
 ACUTE STRESS DISORDER

• Occurs within 1 month after exposure to highly

traumatic event
• Characterized by at least three dissociative symptoms
during/after event
• Subjective sense of numbing
• Reduction in awareness of surroundings
• Derealization
• Depersonalization
• Dissociative amnesia
 ANXIETY CAUSED BY
MEDICAL CONDITIONS

• Direct physiological result of medical

conditions such as:
• Hyperthyroidism
• Pulmonary embolism
• Cardiac dysrhythmias
• Evidence must be present in history, physical
exam, or laboratory findings in order to
diagnose
 NURSING PROCESS:
ASSESSMENT GUIDELINES

• Determine if anxiety is primary or secondary (due to

medical condition)
• Ensure sound physical/neurological exam
• Use of Hamilton Rating Scale
• Comprehensive data related to anxiety
• Determine potential for self-harm/suicide
• Perform psychosocial assessment
• Determine cultural beliefs and background
 NURSING PROCESS: DIAGNOSIS
AND OUTCOMES IDENTIFICATION

• NANDA-International (NANDA-I)
• Nursing diagnoses useful for patient with
anxiety or anxiety disorder
• Nursing Outcomes Classification (NOC)
• Identifies desired outcomes for patients
with anxiety or anxiety disorders
 CONSIDERATIONS FOR OUTCOME
SELECTION FOR PATIENTS WITH
ANXIETY DISORDERS

• Reflect patient values and ethical and

environmental situations
• Be culturally relevant
• Be documented as measurable goals
• Include a time estimate of expected
outcomes
 NURSING PROCESS:
PLANNING AND IMPLEMENTATION

• Planning
• Select interventions that can be
implemented in a community setting
• Include patient in process of planning
• Implementation
• Follow Psychiatric–Mental Health
Nursing: Scope and Standards of
Practice (ANA, 2007)
 NU RS IN G INT E RVE NT IO NS FO R
PAT IE NT S WIT H A NX IE TY DIS OR DE R S

• Identify community resources offering

specialized treatments proven as effective
• Identify community support groups
• Use therapeutic communication, milieu
therapy, promotion of self-care activities,
and psychobiological and health teaching
and health promotion
 COMMON BENZODIAZEPINE ANXIOLYTICS

Generic Brand
diazepam Valium
lorazepam Ativan
alprazolam Xanax
clonazepam Klonopin
chlordiazepoxide Librium
oxazepam Serax
*Non- Anxiolytic: BusSpar
Non-sedating, non habit forming and
not a prn. Good for the elderly
 NON-BENZODIAZEPINE HYPNOTIC

Generic Brand
Zolpidem Ambien, *Ambien CR
Zalepon Sonata
Eszopiclone Lunesta
Ramelteon Rozerem

*contains a two layer coat

One layer releases it simmediataely
and other layer has a slow release
of additional drug
 THE NURSING PROCESS:
ANTIANXIETY AGENTS

Background Assessment Data

•Indications: anxiety disorders, anxiety symptoms, acute

alcohol withdrawal, skeletal muscle spasms, convulsive
disorders, status epilepticus, and preoperative sedation

•Action: depression of the CNS

•Contraindications/Precautions
–Contraindicated in known hypersensitivity; in combination
with other CNS depressants; in pregnancy and lactation,
narrow-angle glaucoma, shock, and coma
–Caution with elderly and debilitated clients, clients with
renal or hepatic dysfunction, those with a history of drug
abuse or addiction, and those who are depressed or
suicidal
• Interactions
• Increased effects when taken with alcohol, barbiturates,
narcotics, antipsychotics antidepressants, antihistamines,
neuromuscular blocking agents, cimetidine, or disulfiram
• Decreased effects with cigarette smoking and caffeine
consumption
• DO NOT USE WITH ALCOHOL

Nursing Diagnosis
• Risk for injury
• Risk for activity intolerance
• Risk for acute confusion
Planning/Implementation
• Monitor client for these side effects
• Drowsiness, confusion, lethargy; tolerance; physical and
psychological dependence; potentiation of other CNS
depressants; aggravation of depression; orthostatic
hypotension; paradoxical excitement; dry mouth; nausea
and vomiting; blood dyscrasias; delayed onset (with
buspirone only)
• Educate client/family about the drug
 COMMON MEDICATIONS

• BZAs: short-term treatment only

• Causes dependence

• Buspirone: management of anxiety disorders

• Selective serotonin reuptake inhibitors (SSRIs): first-
line treatment for all anxiety disordersSelective
norepinephrine reuptake inhibitors (SNRIs):
venlafaxine approved for panic disorder, GAD, and
SAD
• Tricyclic antidepressants (TCAs): second- and third-
line treatment
 NURSING PROCESS:
EVALUATION

•Does patient maintain satisfactory

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