Anxiety

Anxiety Disorders
Chapter 8
 Concept of Anxiety and
Psychiatric Nursing
• Anxiety
– Universal human experience
– Dysfunctional behavior often defends against
anxiety
• Legacy of Hildegard Peplau (1909-1999)
– Operationally defined concept and levels of anxiety
– Suggested specific nursing interventions
appropriate to each of four levels of anxiety
 Psychological Adaptation to
Stress
• Anxiety and grief have been described as two
major, primary psychological response patterns
to stress.
• A variety of thoughts, feelings, and behaviors
are associated with each of these response
patterns.
• Adaptation is determined by the extent to which
the thoughts, feelings, and behaviors interfere
with an individual’s functioning.
 Anxiety and Fear
• Anxiety: feeling of apprehension,
uneasiness, uncertainty, or dread resulting
from real or perceived threat whose actual
source is unknown or unrecognized
• Fear: reaction to specific danger
• Similarity between anxiety and fear
– Physiological response to these experiences is
the same (fight-or-flight response)
 Anxiety
• A diffuse apprehension that is vague in
nature and is associated with feelings of
uncertainty and helplessness.
• Extremely common in our society.
• Mild anxiety is adaptive and can provide
motivation for survival.
 Types of Anxiety
• Normal
– Motivating force that provides energy to carry out tasks of
living
• Acute or state
– Anxiety that is precipitated by imminent loss or change that
threatens one’s security (crisis)
• Chronic or trait
– Anxiety that persists over time
• Mild
– Occurs in normal everyday living
– Increases perception, improves problem solving
– Manifested by restlessness, irritability, mild tension-relieving
behaviors
 Types of Anxiety
• Moderate
– Escalation from normal experience
– Decreases productivity (selective inattention) and learning
– Manifested by increased heart rate, perspiration, mild somatic
symptoms
• Severe
– Greatly reduced perceptual field
– Learning and problem solving not possible
– Manifested by erratic, uncoordinated, and impulsive behavior
• Panic
– Results in loss of reality focus
– Markedly disturbed behavior occurs
– Manifested by confusion, shouting, screaming, withdrawal
 Peplau’s four levels of anxiety
• Mild – seldom a problem
• Moderate – perceptual field diminishes
• Severe – perceptual field is so diminished that
concentration centers on one detail only or on
many extraneous details
• Panic – the most intense state
Behavioral adaptation responses
to anxiety

• At the mild level, individuals employ

various coping mechanisms to deal with
stress. A few of these include eating,
drinking, sleeping, physical exercise,
smoking, crying, laughing, and talking to
persons with whom they feel comfortable.
 Defense Mechanisms
• Help protect people from painful awareness
of feelings and memories that can cause
overwhelming anxiety
– Operate all the time
– Adaptive (healthy) or maladaptive (unhealthy)
• First outlined and described by Sigmund
Freud and his daughter Anna Freud
 Properties of Defense
Mechanisms
• Major means of managing conflict and affect
• Relatively unconscious
• Discrete from one another
• Hallmarks of major psychiatric disorders
• Can be reversible
• Can be adaptive as well as pathological
 Healthy, Intermediate, and
Immature Defense Mechanisms
• Healthy
– Altruism, sublimation, humor, suppression
• Intermediate
– Repression, displacement, reaction formation,
undoing, rationalization
• Immature
– Passive aggression, acting-out behaviors,
dissociation, devaluation, idealization, splitting,
projection, denial
 Defense Mechanisms
– Compensation – 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.
 Predisposing Factors
• Psychodynamic theory
• Cognitive Theory
• Biological aspects
• Transactional Model of Stress
Adaptation
 Panic Disorders: Panic Attack,
Panic Disorder with Agoraphobia
• Panic attack
– Sudden onset of extreme apprehension or fear of
impending doom
– Fear of losing one’s mind or having a heart attack
• Panic disorder with agoraphobia
– Panic attacks combined with agoraphobia
• Agoraphobia is fear of being in places or situations
from which escape is difficult or help unavailable
– Feared places avoided, restricting one’s life
 Phobia
• Phobia: persistent, irrational fear of specific
objects, activities, or situations
• Types of phobias
– Specific: response to specific objects
– Social: result of exposure to social situations or
required performance
– Agoraphobia: fear of being in places/situations
from which escape is difficult or help
unavailable
 Obsessive-Compulsive Disorder
(OCD)
• Obsession
– Thoughts, impulses, or images that persist and recur
• Ego-dystonic symptom: feels unacceptable to individual
• Unwanted, intrusive, persistent ideas, thoughts, impulses,
or images that cause marked anxiety or distress
 Compulsions

• Ritualistic behaviors that individual feels driven to

perform
• Primary gain from compulsive behavior: anxiety
relief
• Unwanted repetitive behavior patterns or mental acts
that are intended to reduce anxiety, not to provide
pleasure or gratification
 Generalized Anxiety Disorder
(GAD)
• Excessive anxiety or worry about numerous things lasting at
least 6 months
• Common symptoms
– Restlessness
– Fatigue
– Poor concentration
– Irritability
– Tension
– Sleep disorders
 Post-traumatic Stress Disorder
(PTSD)
– Development of characteristic symptoms following
exposure to an extreme traumatic stressor involving a
personal threat to physical integrity or to the physical
integrity of others
– Characteristic symptoms include reexperiencing the
traumatic event, a sustained high level of anxiety or
arousal, or a general numbing of responsiveness.
Intrusive recollections or nightmares of the event are
common.
• Psychosocial theory
– The traumatic experience
• Severity and duration of the stressor
• Extent of anticipatory preparation before onset
• Exposure to death
• Numbers affected by life threat
• Extent of control over recurrence
• Location where trauma was experienced
– The individual
• Degree of ego-strength
• Effectiveness of coping resources
• Presence of preexisting psychopathology
– Outcomes of previous experiences with stress/trauma
– Behavioral tendencies
– Current psychosocial developmental stage
– Demographic factors
 – The recovery environment
• Availability of social supports
• Cohesiveness and protectiveness of family and friends
• Attitudes of society regarding the experience
• Cultural and subcultural influences
• Learning theory
– Negative reinforcement as behavior that leads to a reduction in an
aversive experience, thereby reinforcing and resulting in repetition
of the behavior
– Avoidance behaviors
– Psychic numbing
• Cognitive theory
– A person is vulnerable to post-traumatic stress disorder when
fundamental beliefs are invalidated by experiencing trauma
that cannot be comprehended and when a sense of helplessness
and hopelessness prevails.
 Treatment Modalities
• Psychopharmacology
– PTSD
• Antidepressants
• Anxiolytics
• Antihypertensives
• Others
• Biological aspects
– It has been suggested that a person who has experienced
previous trauma is more likely to develop symptoms after a
stressful life event.
– Disregulation of the opioid, glutamatergic, noradrenergic,
serotonergic, and neuroendocrine pathways may be involved
in the pathophysiology of PTSD.
• Transactional Model of Stress Adaptation
– The etiology of PTSD is most likely influenced by multiple
factors
 Acute Stress Disorder
• Occurs within 1 month after exposure to highly
traumatic event
• Characterized by at least three dissociative symptoms
during/after event
– Subjective sense of numbing
– Reduction in awareness of surroundings
– Derealization
– Depersonalization
– Dissociative amnesia
 Anxiety Caused by Medical
Conditions
• Direct physiological result of medical
conditions such as:
– Hyperthyroidism
– Pulmonary embolism
– Cardiac dysrhythmias
• Evidence must be present in history,
physical exam, or laboratory findings in
order to diagnose
 Nursing Process:
Assessment Guidelines
• Determine if anxiety is primary or
secondary (due to medical condition)
– Ensure sound physical/neurological exam
• Use of Hamilton Rating Scale
– Comprehensive data related to anxiety
• Determine potential for self-harm/suicide
• Perform psychosocial assessment
• Determine cultural beliefs and background
 Nursing Process: Diagnosis and
Outcomes Identification
• NANDA-International (NANDA-I)
– Nursing diagnoses useful for patient with
anxiety or anxiety disorder
• Nursing Outcomes Classification (NOC)
– Identifies desired outcomes for patients with
anxiety or anxiety disorders
 Considerations for Outcome Selection
for Patients with Anxiety Disorders
• Reflect patient values and ethical and
environmental situations
• Be culturally relevant
• Be documented as measurable goals
• Include a time estimate of expected
outcomes
 Nursing Process:
Planning and Implementation
• Planning
– Select interventions that can be implemented in
a community setting
– Include patient in process of planning
• Implementation
– Follow Psychiatric–Mental Health Nursing:
Scope and Standards of Practice (ANA, 2007)
 Nursing Interventions for
Patients with Anxiety Disorders
• Identify community resources offering
specialized treatments proven as effective
• Identify community support groups
• Use therapeutic communication, milieu
therapy, promotion of self-care activities,
and psychobiological and health teaching
and health promotion
 Nursing Interventions:
• Milieu Therapy
• Cognitive-Behavioral Therapy (CBT)
 Common Benzodiazepine
Anxiolytics
Generic 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

Outcome Criteria/Evaluation
 Common Medications
• BZAs: short-term treatment only
– Causes dependence
• Buspirone: management of anxiety disorders
• Selective serotonin reuptake inhibitors (SSRIs): first-
line treatment for all anxiety disordersSelective
norepinephrine reuptake inhibitors (SNRIs):
venlafaxine approved for panic disorder, GAD, and
SAD
• Tricyclic antidepressants (TCAs): second- and third-
line treatment
 Nursing Process: Evaluation
– Does patient maintain satisfactory
relationships?
– Can patient resume usual roles?
– Is patient compliant with medications?
– Does patient maintain satisfactory
relationships?
– Can patient resume usual roles?
– Is patient compliant with medications?