1. ANXIETY DISORDERS GAD, Specific Phobias, Social Phobias, OCD, Panic Disorder, Agoraphobia, PTSD

2. Is a subjective individual experience characterized by a feeling of apprehension, uneasiness, uncertainty or dread. It occurs as a result of threats that may be actual or imagined, misperceived or misinterpreted or from a threat to identity or self-esteem. It often precedes new experiences.

3. LEVELS OF ANXIETY 1.Mild/ Alertness Level (+1)  This is the type of anxiety associated with the normal tension of everyday life.  The individual is alert  Perceptual field is increased  Produce growth and creativity as it increases learning  The person uses adaptive coping mechanisms to solve problems and alleviate anxiety.

4. Nursing Interventions Recognize the anxiety by statements such as “I notice you being restless today”. Explore causes of anxiety and ways to solve problems that cause anxiety by statements such as “Let’s discuss ways to…”

5. 2. Moderate/ Apprehension Level (+2)  The response of the body to immediate danger and focus is directed to immediate concerns.  Narrows the perceptual field to pay attention to particular details.  Selective inattentiveness occurs  The increased tension makes this the optimal time for learning  The person uses palliative coping mechanisms.

6. Nursing Interventions Provide outlets for anxiety such as crying or talking. Tell client “It’s all right to cry”. Encourage in motor activity to reduce tension. Make client be aware of his behavior and feelings by statements such as “ I know you feel scare…” Encourage client to move from affecting (feeling) to cognitive mode (thinking). Refocus attention Encourage the client to talk about felings and concerns. Help the client identify thoughts and feelings that occurred prior to the onset of anxiety. Provide anti-anxiety oral medications.

7. 3. Severe/ Free-floating Level (+3)  Creates a feeling that something bad is about to happen, or feeling of an impending doom.  Fight and flight response sets in  Narrow perceptual field occurs and focus is on specific details or scattered details so that learning and problem solving is not possible.  All behaviors are directed at alternative the anxiety  The individual needs direction to focus  Dilated pupils, fixed vision  The person uses maladaptive coping mechanisms.

8. Nursing Interventions Do not focus on coping mechanisms Stay calm and stay with the client Give short and explicit direction Modify the environment by setting limits or seclusion, limit interaction with others, and reduce environmental stimuli to calm client. Provide IM antianxiety medications.

9. 4. Panic Level (+4)  Feelings of helplessness and terror  The personality and behavior is disorganized  The individual lessens perception of the environment to protect the ego from awareness and anxiety causing distorted perceptions and loss of rational thoughts.  Is unable to communicate or function effectively  Inability to concentrate  If prolonged, panic can lead to exhaustion and death  The person uses dysfunctional coping mechanisms.

10. Nursing Interventions Guide patient step by step to action. Restrain if necessary.

11. Three Components of Anxiety  Physical Symptoms  Cognitive Component  Behavioral Component

12. Physical System  Increase in heart rate and strength of heartbeat to speed up blood flow  Blood is redirected from places it is not needed (skin, fingers and toes) to places where it is more needed (large muscle groups like thighs and biceps)  Respiratory effects-increase in speed and depth of breathing  Sweat gland effects-increased sweating

13. Behavioral System  Fight/flight response prepares the body for action- to attack or run  When not possible behaviors such as foot tapping, pacing, or snapping at people

14. Cognitive System Shift in attention to search surroundings for potential threat Can’t concentrate on daily tasks Anxious people complain that they are easily distracted from daily chores, cannot concentrate, and have trouble with memory

15. Anxiety Disorder Generalized Anxiety Disorder (GAD)

16. Generalized Anxiety Disorder “Unfocused worry” “Excessive worry” “Severe stress”

17. Generalized Anxiety Disorder: Diagnostic Criteria Excessive anxiety or worry occurring more days than not for at least 6 months about a number of events or activities. Difficulty controlling worry. 3 of 6 symptoms are present for more days that not: Restlessness, Easily fatigued, Difficulty Concentrating, Irritability, Muscle Tension, Sleep Disturbance.

18. Generalized Anxiety Disorder: Neurotransmitters  Finding that benzodiazepines provide relief from anxiety (e.g. Valium)  Benzodiazepine receptors ordinarily receive GABA (Gamma-aminobutyric acid)  GABA causes neuron to stop firing (Calms things down)

19. Generalized Anxiety Disorder: Neurotransmitters Getting AnxiousCalming Down Hypothesized Mechanism:  Normal fear reactions  Key neurons fire more rapidly  Create a state of excitability throughout the brain and body perspiration, muscle tension etc.  Excited state is experienced as anxiety Feedback system is triggered Neurons release GABA Binds to GABA receptors on certain neurons and “orders” neurons to stop firing State of calm returns GAD: problem in this feedback system

20. GABA Problems?  Low supplies of GABA  Too few GABA receptors  GABA receptors are faulty and do not capture the neurotransmitter.

21. Generalized Anxiety Disorder: Cognitions  Intense EEG activity in GAD patients reflecting intense cognitive processing.  Worrying as a form of avoidance.  Restrict their thinking to thoughts but do not process the negative affect  Worry hinders complete processing of more disturbing thoughts or images  Content of worry often jumps from one topic to another without resolving any particular concern

22. Generalized Anxiety Disorder: Treatment  Short term - Benzodiazepine (Valium)  Cognitive Therapy (Focus on problem)

23. Anxiety Disorder Phobias: Specific & Social

24. Phobia  “Irritational fear”

25. Phobia: Diagnostic Criteria  Marked & persistent unreasonable fear of object or situation  Anxiety response  Unreasonable  Object or situation avoided or endured with distress

26. Differential Diagnosis of Specific Phobia  Vs. SAD: not related to fear of separation.  Vs. Social Phobia: not related to fear of a social situation or fear of humiliation.  Vs. Agoraphobia: fear not related to closed places.  Vs. PTSD: fear not related to a specific past traumatic event.

27. Phobias: Types Specific Phobias  Blood, Injection, Injury Phobias  Situational Phobia  Natural Environment Phobia  Animal Phobia

28. Developmentally Normal Fears AgeNormal Fear Birth- 6 MonthsLoud noises, loss of physical support, rapid position changes, rapidly approaching other objects 7-12 MonthsStrangers, looming objects, unexpected objects or unfamiliar people 1-5 YearStrangers, storms, animals, dark, separation from parents, objects, machines loud noises, the toilet 6-12 YearSupernatural, bodily injury, disease, burglars, failure, criticism, punishment 12-18Performance in school, peer scrutiny, appearance, performance

29. Biological Preparedness: Exercise  Write down an object or situation of which you are particularly afraid.  Write down the events that led to the fear.  As a group, tally the feared objects and the percentage of times the person could recall the beginning of the fear.  As a group, indicate which group of fears are associated with dangerous consequences, e.g. fear of snakes.

30. Hypothesis According to biological preparedness theory, objects of phobic fear are nonrandomly distributed to objects or situations that were threatening to the survival of the species. Hypothesis: More threatening objects or situations (that are threatening) will be listed than those that are not threatening

31. Specific Phobia: Cognitive Perspective

32. Specific Phobia: Social and Cultural Factors  Predominantly female.  Unacceptable in cultures around the world for men to express fears.

33. Specific Phobia: Treatment Systematic Desensitization

34. Social Phobia  Fearful apprehension  Social situations

35. Social Phobia: Diagnostic Criteria  Marked or persistent fear in one or more social or performance situations  Exposure to fear situation is associated with extreme anxiety  Person recognizes that fear is excessive or unreasonable  Feared social and performance situations are avoided or endured with intense anxiety

36. Etiology of Social Phobia Biological vulnerability to develop anxiety or be socially inhibited. May increase under stress or when the situation is uncontrollable Unexpected panic attack during a social situation or experience a social trauma resulting in conditioning (i.e. a learned alarm). Modeling of socially anxious parents Preparedness

37. Social Phobia: Treatment Cognitive-Behavioral Therapy  Assess which social situations are problematic  Assess their behavior in these situations  Assess their thoughts in these situations  Teaches more effective strategies  Rehearse or role play feared social situations in a group setting Medication  Tricyclic Antidepressants  Monoamine Oxidase Inhibitors  SSRI (Paxil) approved for treatment  Relapse is common with medications are discontinued

38. Anxiety Disorders Obsessive Compulsive Disorder (OCD)

39. Obsession and Compulsions Obsession: Unwanted repetitive intrusive thoughts, images or urges. Ex: Contamination, sexual impulses &/or hypochondriacal fears. Compulsion: Repeated thoughts or actions designed to provide relief. Ex: cleanliness, checking, avoiding certain objects perceived of as irrational or silly.

40. Relationship Between Compulsion and Obsession  The most common obsession - germs and dirt is related to the most common compulsion handwashing.  Obsessions create considerable anxiety.  Compulsions are an attempt to cope with the anxiety.  Repeating rituals (Second most common compulsion) is often a way-in their mind to avoid harm (Eg. “Step on the crack” game).  Children recognize that compulsions are unreasonable and will attempt to hide the behavior with nonfamily members.

41. OCD: Diagnostic Criteria A. Either obsession or compulsions B. Recognition that obsessions or compulsions are excessive or unreasonable (Does not apply to children) C. The obsession or compulsions cause marked distress, and are time consuming (Take over one hour a day) or significantly interfere with the person’s normal functioning D. If another Axis I disorder is present, the content of the obsession or compulsion is not restricted to it (Preoccupation in food in eating disorder concern with drugs in Substance Abuse disorder) E. The disturbance is not due to the direct effects of drugs, medication or a physical condition Specifier: With poor insight ; if, most of the time, the person does not recognize the obsessions and compulsions are unreasonable

42. OCD Etiology: Psychoanalytic  Obsessions and compulsions as a reaction to instinctual, Id, impulses  Due to harsh toilet training  Fixation in anal stage  Id vs. defense mechanisms (Ego)  Id: Obsessions  Ego: Compulsions  Toddler: Feel incompetent as a child, create control over environment through compulsions.

43. OCD Etiology: Cognitive & Behavioral Compulsions  Learned behaviors based on consequences  Reduced fear after completing compulsions  But not obsessions  Poor memories?  Compulsive checkers have poor recall for whether they had completed the compulsion (e.g. Turning off lights) previously Obsessions  Thought suppression: paradoxical effect  Increased preoccupation and negative mood

44. Etiology OCD: Biological Explanations Neurotransmitter (Low Serotonin) Brain Structures/Areas

48. OCD: Treatment Medication SSRI’s (Serotonin Reuptake Inhibitors) Average treatment gain with medication is moderate and relapse occurs when medication is discontinued Exposure and ritual prevention (ERP) Psychosurgery

49. Anxiety Disorders Panic Disorder With and Without Agoraphobia

50. Panic Disorder  Attack occurs suddenly, unexpectedly, peaking within a few minutes and lasting around ten minutes  Heart palpitations, nausea, chest pain, choking, dizziness, apprehension  Depersonalization: feeling outside your body  Derealization: feeling world is unreal  Fear losing control, dying, going insane  Interoceptive avoidance  Can develop agoraphobia

51. Panic Disorder: Diagnostic Criteria  Recurrent unexpected panic attacks( A discrete period of intense fear of discomfort in which four or more somatic/anxiety symptoms developed abruptly and reached a peak within 10 minutes)  At least one of the attacks has been followed by concern for additional attacks and significant change in behavior  Not due to physiological effects of medications, drugs, or medical conditions  Not accounted for by another disorder

52. Three Types of Panic Attacks  Unexpected: “Out of the blue”  Situationally Bound: Almost always occur in certain contexts.  Situationally Predisposed or “Cued”: Occur in certain contexts but not all the time  If only cued or situational could be phobia

53. Panic Disorder  Prevalence: 2% men, 5% women  Average age of onset is between 25 and 29  Commonly paired with a traumatic experience  With or without agoraphobia  Fears of public places and inability to escape from them (Shopping malls, crowds)  Fear having a panic attack in public  Often don’t leave the house  If avoidance widespread, agoraphobia results

55. Panic Disorder: Treatment Medication:  Antidepressant medications associated with some improvement in 80% of patients with 40% to 60% recovering markedly or fully  Improvements contingent on medications  Benzodiazepines such as (Xanax) have also been empirically effective Cognitive  Emphasis on correcting misinterpretations of body sensations  Educating about panic attacks  Teach more accurate interpretations  Exposure  70% of patients improve but few are cured

56. Panic: Combined Treatment Short Term Combined treatment no more effective than individuals treatments in the short term Long Term Those receiving CBT alone maintained most of their treatment gains Those taking medication (alone or in combination) deteriorated somewhat Recommendation: Psychological treatment offered first, followed by medication

57. Anxiety Disorders Post Traumatic Stress Disorder (PTSD)

58. PTSD  Extreme response to a stressor  Anxiety, avoidance of similar stimuli, emotional flattening  Significant impairment  Person must have experienced or witnessed: event involving actual/threatened death or serious injury to self or others  25% experiencing a trauma develop PTSD

59. PTSD Symptoms Symptoms in each category > 1 month: 1. Reexperiencing: Recalling the event, nightmares, emotional distress w/ similar stimuli or on anniversaries 2. Avoidance/Numbing: Attempt to avoid thinking about the event, amnesia, decreased ability to feel positive emotions, decreased contact/interest in others  Go back and forth between 1 & 2

60. PTSD Symptom 3. Increased Arousal: Sleep difficulties, low concentration, hypervigilance, exaggerated startle response  Comorbidities: MDD, anxiety disorders, marital problems, substance abuse, suicidality, somatic complaints

61. PTSD in KIDS Different manifestation of symptoms:  Nightmares (Monsters)  Behavioral Changes  Quiet to aggressive, outgoing to withdrawn  Regression  Loss of acquired skills (Toilet training, speech)  Difficulty discussing traumatic event

62. Risk Factors for PTSD Given exposure to a trauma: 1. Female gender 2. Early separation from parents 3. Family history 4. Preexisting mental illness 5. Increased severity of trauma 6. Initial reaction to trauma – Depressed, anxious, dissociative symptoms

63. PTSD Etiology: Behavioral  Classical conditioning to fear:  Ex: Woman fears parking lots because she was shot in one.  Avoidance builds due to negative reinforcement (i.e. Reduction in fear by avoiding parking lots)

64. Other PTSD Etiologies Psychodynamic: memories so painful they are repressed Person tries to reintegrate memories into consciousness Biology: twin studies support a genetic diathesis Heightened norepinephrine Increased startle Evidence still mixed No good evidence for why some develop PTSD & others do not

65. Etiology of Anxiety Disorders Stressful life events Many stressors activate biological and psychological vulnerabilities to anxiety Integrated model Interaction between biological, psychological, experiential, and social variables

66. PSYCHOPHARMACOLOGY ANTIANXIETY AGENTS (ANXIOLITICS/MINOR TRANQUILIZER)

67. COMMONLY USED ANTIANXIETY AGENTS:  Ativan (Lorazepam)  Valium (Diazepam)  Klonopin (Clonazepam)  Xanax (Alprazolam)  Serax (Oxazepam)  Buspar (Buspirone)  Librium (Chlordiazepoxide)  Atarax or Vistaril (Hydroxyzine)

68. ACTION: Depress activities of the cerebral cortex. USES: Decrease the effects of senses, anxiety and mild depression. They can be used preoperatively to help promote sedation.

69. SIDE EFFECTS: Can cause physical and psychological dependence. Drowsiness Lethargy Fainting Postural Hypertension Nausea and Vomiting

70. CONTAINDICATION: Patients with known hypersensitivity should not use these medications. People with a history of chemical dependency are not good candidates for this classification of drug because of the potential for addiction.

71. NURSING CONSIDERATION:  Monitor BP before and after giving medication.  Should be given at bedtime.  Administer IM dosage deeply and slowly into large muscle masses.  Teach the patient and family that is not safe for the patient to drive or use alcohol.  Patient should rise slowly from sitting or lying positions to prevent sudden drop in BP.