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RNSG 2213 Mental Health Nursing
• Anxiety is a normal response to threatening situations. It becomes pathological when it interferes with adaptive behavior, causes physical symptoms, or exceeds a tolerable level. Individuals with anxiety disorders use rigid, repetitive, and ineffective behaviors to try to control anxiety.
• Anxiety disorders are the most common of all psychiatric disorders in the United States, affecting up to 13.3% of the population. People may have more that one anxiety disorder. Anxiety disorders and depression occur together frequently. Other disorders include substance abuse, somatization, and other anxiety disorders. Women are affected more than men.
• Genetic—anxiety disorders tend to run in families even though no specific gene has been identified • Biological– research suggests that aberrant production of a substance that interferes with benzodiazepine binding to receptors or altered receptor sensitivity interfering with proper benzodiazepine receptor function is involved.
– Phobias- social phobias may well be related to noradrenergic dysfunction – Obsessive-compulsive disordersneuroimaging techniques point to orbitofrontal-limbic-basal ganglia circuit dysfunction, whereas neurochemistry points to serotonin dysregulation
– Posttraumatic stress disorder (PTSD)- a number of theories exist, including one suggesting that extreme stress is associated with damaging effects to the brain
• Culture-bound illnesses must be differentiated from anxiety disorders. In some cultures, anxiety is expressed through somatic symptoms; in other words, cognitive symptoms predominate.
• Recurrent, unexpected panic attacks of sudden onset are a clinical symptom of this disorder. Physical symptoms of sympathetic arousal are accompanied by terror, limited perceptual field, and severe personality disorganization
DSM-IV-TR Criteria for Anxiety Disorders
• See Varcarolis text page 232 figure 14-2 • Anxiety Disorders
– Panic Disorder – Phobias – Obsessive-Compulsive Disorder (OCD) – Generalized Anxiety Disorder (GAD)
DSM-IV-TR Criteria for Anxiety Disorders: Stress Related
• See Varcarolis page 238 figure 14-3 • Anxiety Disorders: Stress Related
– Posttraumatic Stress Disorder – Acute Stress Disorder
Panic Disorder with Agoraphobia
• Recurrent panic attacks accompanied by fear of being in an environment or situation from which escape might be difficult or embarrassing or in which help may not be available (such as being alone outside; being home alone; traveling in a car; bus, or plane; being on a bridge or in an elevator)
• Fear of being in an environment or situation from which escape might be difficult (as listed previous slide) • The client generally acknowledges that the behavior is not constructive and doesn’t really like it and will state an inability to change the behavior.
• Persistent, irrational fears of a specific object, activity, or situation that lead to a desire for avoidance or actual avoidance of the specific object or situation.
– Specific phobias are provoked by a specific object (dog, or spider, etc) or situation (a storm, etc); they are common and usually do not cause much difficulty because people can avoid the situation/object. – Social phobias, or social anxiety disorder, is provoked by exposure to a social situation or a performance situation and can cause great difficulty
• Obsessions are thoughts, impulses, or images that persist and recur and that cannot be dismissed from the mind (such as where are the door keys, etc.). • Compulsions are ritualistic behaviors that an individual feels driven to perform to reduce anxiety (such as checking to make sure doors are locked repeatedly, etc.). They can be seen separately but usually co-exist
Generalized Anxiety Disorder
• Characterized by the presence of excessive anxiety or worry lasting for 6 months or longer; symptoms can include poor concentration, tension, sleep disturbance, and restlessness
Posttraumatic Stress Disorder
• Posttraumatic Stress Disorder (PTSD) involves re-experiencing of a highly traumatic event involving actual or threatened death or serious injury to self or others to which the person responded with intense fear or helplessness. Symptoms usually begin within 3 months after the traumatic incident and include flashbacks, persistent avoidance of stimuli associated with the trauma, numbness, or detachment, and increased arousal.
Acute Stress Disorder
• Occurs within 1 month after exposure to a highly traumatic event, such as described for PTSD. Individuals must display three dissociative symptoms during or after the event (numbness, detachment, derealization, depersonalization, or dissociative amnesia
Substanced-Induced Anxiety Disorder
• Symptoms of anxiety, panic attacks, obsessions, and compulsions that develop with the use of a substance or within a month of stopping use
Anxiety due to Medical Condition
• Symptoms of anxiety are sometimes the physiological result of a medical condition such as, cardiac dysrhythmias, hyperthyroidism, pheochromocytoma, etc
• Assessment will usually involve determining if the anxiety is from a secondary source (medical condition) or a primary source (anxiety disorder). Symptoms specific to various anxiety disorders include panic attacks, phobias, obsessions, and compulsions
Defenses used in Anxiety Disorders
• Defense mechanisms associated with anxiety disorders p 240 table 14-7. Preliminary screening test for anxiety disorders p 240 box 14-1 • Hamilton Rating Scale for Anxiety p 241 table 14-8; for example: feeling like one is going to die or having a sense of impending doom; having narrowed perceptions and difficulty concentrating or problem-solving; increased vital signs, muscle tension, dilated pupils; complaints of palpitations, urinary frequency or urgency, nausea, tight throat; complaints of fatigue, insomnia, irritability, disorganization
• Nurse’s feelings may include tension or anxiety, frustration, anger, being overwhelmed, fatigue, desire to withdraw, and guilt related to having negative feelings
• 1) Physical and neurological examinations will help determine if anxiety is primary or secondary • 2) Assess for potential for self-harm and suicide • 3) Do a psychosocial assessment to identify problems that should be addressed by counseling • 4) Note that cultural differences can affect the way in which anxiety is manifested
• Anxiety, ineffective coping, disturbed thought processes, chronic low selfesteem, situational low self-esteem, powerlessness, deficient diversional activity, social isolation, ineffective role performance, ineffective health maintenance, disturbed sleep pattern, selfcare deficit, imbalanced nutrition, and impaired skin integrity
• Describe the client’s state or situation that is expected to be influenced by nursing interventions. Examples of outcomes for anxiety control include the following: client will monitor intensity of anxiety, eliminate precursors of anxiety, seek information to reduce anxiety, plan successful coping strategies, use relaxation techniques, report adequate sleep, report decrease in frequency of episodes, etc
• Selecting interventions that can be implemented in a community setting, since clients with anxiety disorders are not usually hospitalized in an inpatient psychiatric unit • Clients with mild to moderate anxiety should be encouraged to be involved in planning, whereas for clients with severe anxiety, the nurse will need to be more directive
• 1) identify community resources that can off the client effective therapy • 2) identify community support groups that can offer the client effective therapy • 3) assess need for intervention for families and significant others • 4) provide thorough teaching when medications are used
Interventions for Anxiety Disorders
• See Varcarolis page 243 box 14-2
– Anxiety reduction – Coping enhancement – Hope instillation – Self-esteem enhancement – Simple relaxation therapy
Interventions for Anxiety Disorders
• Anxiety reduction
• Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger
• Coping enhancement
• Assisting a client to adapt to perceived stressors, changes, or threat that interfere with meeting life demands and roles
• Hope instillation
• Facilitation of the development of a positive outlook in a given situation
• Self-esteem enhancement
• Assisting a client to increase his/her personal judgment of self-worth
• Simple relaxation
• Use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety
• To assist clients to improve or regain coping abilities, counseling is often combined with other cognitive and behavioral therapies
• Cognitive therapy • Cognitive restructuring • Cognitive-behavioral therapy • Relaxation training • Modeling • Systematic desensitization • Flooding • Response prevention • Thought stopping
• Assumes that cognitive errors made by the client produce negative beliefs that persist. Counseling calls for the nurse to assist the client to identify these thoughts and negative beliefs and to appraise the situation realistically
• This therapy calls for the nurse to assist a client to identify automatic negative anxiety-arousing thoughts and negative self-talk, discover the basis for the thoughts and to assist the client to appraise the situation realistically and replace automatic thoughts and negative self-talk with realistic thinking (such as with agoraphobiaincreasing self-esteem by replacing negative thoughts with more realistic evaluation of client’s own abilities.
• Uses a variety of approaches such as psychoeducational methods, continuous panic self-monitoring, breathing retraining, development of anxiety management skills, and in vivo exposure to feared stimuli
• Teaching muscle relaxation will result in reduction of tension and anxiety
• Shows client how an individual copes effectively and expects the client to imitate the adaptive behavior
• Gradual exposure gradually introduces the client to a phobic object or situation in a predetermined sequence of least to most frightening. Teaches the client to use a relaxation technique for anxiety management
Flooding (Implosion Therapy)
• Extinguishes anxiety as a conditioned response by exposing a client to a large amount of the stimulus he/she finds undesirable
• The individual who would reduce anxiety by performing a ritual is not permitted to perform the ritual
• A technique calling for the client to shout “STOP” or snap a rubber band on the wrist whenever an obsessive thought begins. This helps the client dismiss the thought.
• The environment should be structured to offer safety and predictability, should have activities to shift the client’s focus from his or her anxiety and symptoms, and should provide therapeutic interactions (for hospitalized patient)
• Clients with anxiety disorders can usually meet their own basic physical needs. Self-care activities most likely to be affected are discussed below. • Nutrition & fluid intake-those with OCD who are involved with their rituals to the exclusion of all else, nutrition & fluid intake could be affected. Assess weight and encourage intake.
• Personal hygiene & grooming—excessive neatness, rituals associated with bathing and grooming, indecision are common among clients with phobias and OCD. Skin integrity may be a problem when rituals involve washing. • Elimination—clients with OCD may suppress urges to void and defecate • Sleep—anxious clients often have difficulty sleeping. Clients with generalized anxiety disorder (GAD), Posttraumatic stress disorder (PTSD), and stress disorder may have nightmares.
• See Varcarolis page 246 table 14-12 • Antidepressants
– – – – SSRIs TCA MAOI SNRI
• Venlafaxine (Effexor)
– Benzodiazepines for short-term (2-4 weeks for full effects)
• Beta blockers
– Social anxieties and panic disorder – Antihistamines relieve symptoms of anxiety but produces no dependence
• Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for anxiety disorders (esp. treatment of panic disorder/attacks). They are more prevalent than the tricyclic antidepressants (TCAs) because of their more rapid onset of action and fewer problematic side effects. Monoamine oxidase inhibitors (MAOIs) are reserved for treatment-resistant conditions because of the life-threatening risks from hypertensive crisis. With MAOIs, there are many dietary restriction as well which can lead to difficulties for clients. Also effective for treatment of anxiety is Venlafaxine (Effexor) which is a serotonin-norepinephrine reuptake inhibitor (SNRI).
Medications and Psychotherapy for Anxiety Disorders
• See Varcarolis page 245 table 14-11
– Generalized anxiety disorder – Obsessive-compulsive disorder – Panic disorder – Posttraumatic stress disorder – Social phobia or social anxiety disorder
Client and Family Medication Teaching: Anxiety Disorders
• See Varcarolis page 247 box 14-4
• Consumers are using a wide number of herbs and dietary supplements to relieve stress. Caution is urged because herbs and dietary supplements are not subjected to rigorous testing. Kava kava is one herb that studies show may have considerable promise as a treatment for anxiety
• Identified outcomes serve as a basis for evaluation. In general, evaluation will focus on whether or not there is reduced anxiety, recognition of symptoms as anxiety-related, reduced incidence of symptoms, performance of self-care activities, maintenance of satisfying interpersonal relationships, assumption of usual roles, and use of adaptive coping strategies
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