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Anxiety Elisa A. Mancuso RNC, MS, FNS Professor.  Most common mental health problem –25 % adults Women>men Age men Age <45 – ↑ Divorced/separated –Lower.

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Presentation on theme: "Anxiety Elisa A. Mancuso RNC, MS, FNS Professor.  Most common mental health problem –25 % adults Women>men Age men Age <45 – ↑ Divorced/separated –Lower."— Presentation transcript:

1 Anxiety Elisa A. Mancuso RNC, MS, FNS Professor

2  Most common mental health problem –25 % adults Women>men Age men Age <45 – ↑ Divorced/separated –Lower socioeconomic status  Vague apprehension and feelings of uncertainty & helplessness  Subjective emotional response to a stressor –State of tension, or impending doom  Necessary force for survival  Mild → Moderate → Severe → Panic

3 Physiologic Responses  Hormones & Neurotransmitters “Fight or Flight Response” Depends on degree & duration of anxiety – ↑ Epinephrine (E) ↑ HR & ↑ SV = ↑ CO – ↑ Norepinphrine (NE) ↑ BP – ↑ Cortisone ↑ RR & depth = SOB – ↑ Serotonin (5-HT) – ↓ GABA

4 Physiologic Responses  Generalized Responses –RestlessnessHyperreflexia –Irritability Impatience –Fainting Chest Pressure –PalpitationsHeadache – ↑ Diaphoresis ↑ Muscle tension – ↑ UrinationGluconeogenesis – ↑ N & VDry Mouth – ↓ Libido Sexual Dysfunction

5 Cognitive Responses  Mild (+) – ↑ Sensory awareness ↑ Learning – ↑ Concentration = Optimal Functioning  Moderate (++) – ↓ Perceptual fieldImpaired attention – ↓ Concentration & Problem Solving  Severe (+++) –Limited Perceptual field Selective inattention –Disorganized processingTime distorted  Panic (++++) –Closed perceptual field – ↓ Contact with reality –Impaired thinking/function –Unable to process stimuli

6 Behavioral Responses  Mild (+) –Learn new skillsAlert & Confident – ↑ Startle reaction ↑ Speech & Coping Skills  Moderate (++) – ↑ Competitive activity ▲ Body position frequently –Frequent topic ▲ s ↑ Defense mechanisms –Focus on immediate events  Severe (+++) – ↑ Feeling of threat & tremors“Overload” – ↓ CoordinationNeurosis  Panic (++++) –Total loss of controlCling to source of safety –HelplessnessPsychosis –May strike physically or withdraw –Completely disorganized

7 Anxiety Disorders A group of symptoms & impaired reality testing.  Panic Disorder –Sudden onset –Multiple attacks –Intense & escalating apprehension –Poor judgment, confused & disoriented –Feelings of impending doom –Fears losing control or going insane –Lasts minutes or (rarely) hours

8 Panic Disorder  Intense Physical discomfort –Palpitations Chest pain ↑ HR –Dyspnea Choking/Smothering SOB  Hyperventilation ↑ RRDizziness –DiaphoresisChills/Hot flashes –Tremors & Shaking –GI distress NauseaDiarrhea –Fear of dying and/or going crazy –Depersonalization

9 Nursing Interventions  Stay with Pt and remain calm –Assess own level of anxiety  Ensure safety and reassure Pt  Pt take slow, deep breaths  Quiet environment –Focus on a single object in the room  Speak in short, simple sentences –Low, calm and soothing voice  Encourage verbalization of concerns, feelings and symptoms –Identify precipitating event  Sort term use of anxiolytics

10 Generalized Anxiety Disorder  Chronic unrealistic and excessive worry –Regarding several events the Pt can’t control  Symptoms last > 6 months  Impaired social & occupational functioning –Interferes with daily life  Symptoms –Autonomic Hyperactivity  Jumpiness, tremors, ↑ muscle tension  ↑ HR ↑ RR –Feeling on edgeHypervigilence –RestlessnessIrritability – ↓ Concentration “Mind going blank” –Easily fatigued

11 Obsessive-Compulsive Disorder  Recurrent obsessions & compulsions  ↑↑ Time consuming  Gradual conditioned response RT traumatic event  Obsessions –Unwanted intrusive, persistent images or impulses –Recurrent thoughts of violence, contamination, doubt or need for specific order.  Compulsions –Ritualized acts of behavior to neutralize/control obsessions  Touching Rearranging Opening & Closing  Washing handsCountingChecking –Pt aware behavior is excessive, yet continues to engage to seek relief and ↓ anxiety/tension –Interferes with usual routine  Defense Mechanism –Undoing –Displacement

12 OCD Nursing Interventions  Initiate conversation as ritual is performed  Allow behavior but set limits  Identify behavioral cues of ↑ anxiety  Present distracting ↑ frequency  Substitute socially acceptable behavior

13 Phobias Persistent or irrational fear of specific object, activity or situation that causes avoidance.  Exposure to stimulus = immediate anxiety response. –Blushing, Vomiting, Humiliation, Tremors, ↑HR ↑BP ↑RR  Agoraphobia –Fear of being alone in public place. No escape  Social Phobia –Fear of appearing embarrassed or evaluated negatively by others.  Simple Phobia (Specific object or situation) –Acrophobia = Fear of heights –Claustrophobia = Fear of closed in places –Mysophobia = Fear of dirt, germs  Nursing Interventions –1 st accept Pt’s fear as real –Relaxation techniques –Behavior Modification –Desensitization

14 Post Traumatic Stress Disorder  Extreme stressor and threat to physical integrity.  Characteristic symptoms after exposure to traumatic life experience –9-11, war, earthquakes, airplane crash  Symptoms –Re-experiencing event (Flashback) –Avoidance of thoughts, emotions or conversations –Sustained ↑ Anxiety –Angry Outbursts –Hypervigilence Nightmares Sleep Disturbances –Survivor Guilt Depression Substance Abuse –Psychic Numbing Feel detached from others

15 PTSD  Nursing Interventions – ↓ Environmental Stimuli –Reorient to reality –Reassure Pt is safe –Encourage verbalization of event and feelings –Facilitate grief process –Adaptive coping techniques –Anxiolytic meds during flashback

16 Somatoform Disorders Physical symptoms without any organic pathology  Women> men  Onset before age 30  Somatization –Anxiety transformed into physical illness –No labs, diagnostic tests support DX –Chronic course without structural ▲ s

17 Conversion Disorder-Hysteria  Loss or alteration in physical functioning –Voluntary motor/sensory  Abrupt onset after a psychological conflict  Symptom –Impaired sense (blind/deaf) or paralysis –“La belle indifference”  Pt demonstrates no concern for symptoms  Defense Mechanism –Repression –Conversion

18 Conversion Disorder-Hysteria  Primary Gain –Relief via repressing conflict –Anxiety converted to symptoms  Secondary Gain –Sympathy, support, ↑↑ attention –avoid activities & responsibilities  Nursing Interventions –Focus on ↑↑ anxiety, NOT symptoms –Encourage verbalization  Identify conflicts  ↓↓ stress & ↑↑ relaxation –Alternative coping skills

19 Hypochondriasis  Unrealistic preoccupation/fear of having or getting a serious illness –Specific organ, bodily function or minor alteration  Misinterpretation of symptoms –Cough = Lung CA –HA = Brain tumor  Symptoms –C/O Multiple symptoms & Persist > 6 months –Dr. Shopping –Demand diagnostic testing & invasive procedures  Nursing Interventions –Review objective data, symptoms & interpretation –Set limits on “whining” –↑ Self-worth and resolve internal anger

20 Dissociative Disorders  Severe precipitating stressor.  Splitting off an idea or emotion from one’s consciousness.  Psychological flight from anxiety  Psychogenic Amnesia –Sudden inability to recall important extensive personal information.  Psychogenic Fugue –Sudden unexpected travel away from home or usual workplace –Begin new job, relationships (Unaware of true life) –Assumes new identity –Escapes from overwhelming stress or rejection

21 Dissociative Disorders  Multiple Personality Disorder –Dissociative Identity Disorder (DID) –Existence of 2 or more distinct personalities within an individual. –Transition from 1 to another personality  Sudden & dramatic  Precipitated by stress –One personality is dominant –Usually RT sexual child abuse.

22 Dissociative Disorders  Depersonalization Disorder –Change in quality of self-awareness –Feelings of unreality, ▲ s in body image. –Detachment  Sense of observing oneself  (from outside of body)  Not in touch with body  No somatic sensations

23 Anxiety Nursing Interventions  # 1 is Patient safety!  Remain with Pt & provide support  Deep breathing –Controlled slow –Deep & regular abdominal breathing.  Progressive muscle relaxation  Guided imagery –Visualize favorite place –Embrace scenes, sounds, aromas, textures.  Distraction –Music, card games, reading

24 Anxiety Nursing Interventions  Journals – ↑↑ Self awareness –Make entries when calm & anxious qd  Identify anxiety cues & behavior responses  Self-Help Skills –+ Coping techniquesRole playingProblem solving –Assertiveness Set limits on inappropriate behavior  Social Skills Group – ↑ Socialization = ↓ Self absorption  Daily Schedule Planning – ↑ Autonomy  Support System –Family, friends, neighbors, pets  Nutrition –Balanced diets : NO CAFFEINE, CHOCOLATE, ETOH

25 Anxiety Nursing Interventions  Cognitive–Behavioral Therapy –Positive Reframing  Turn negative messages into positive ones. –Decatastrophizing  A more realistic appraisal of situation –Assertiveness Training  Learn to negotiate interpersonal situations

26 Anxiolytics Anti-Anxiety Meds  Used short term basis < 1 month  Symptomatic relief only  Potentiates GABA = ↓↓ CNS  Caution –Do not use ETOH or meds that ↑ CNS –Do not stop med abruptly = Severe Withdrawal  CNS agitation  ↓ BP ↑ Temp & Fatal Gran Mal seizures! –Takes 7-10 days for steady effect –Elderly have ↓ hepatic & ↓ renal function  ↑↑ risk for toxic effect

27 Anxiolytics Anti-Anxiety Meds Benzodiazepines Alprazolam (Xanax) Lorazepam (Ativan) Chlordiazepoxide (Librium) Diazepam (Valium) Clonazepam (Klonopin) Clorazepate (Tranxene) – ↑ Risk for physical dependence & tolerance –Lipophilic & cross blood-brain barrier  Side effects –Drowsiness Sedation – ↓ ConcentrationImpaired memory –Clouded Sensorium

28 Anxiolytics Anti-Anxiety Meds  Azaspirodecanediones Buspirone (Buspar) 5-HT receptor antagonist Takes 2-4 weeks to be effective ↓ potential for abuse  Propanediols Meprobamate (Equanil/Miltown) ↓ Thalamus & Limbic system response  Sedating Antihistamines Hydroxyzine (Vistaril/Atarax) CNS depressant effect

29 Anxiolytics Anti-Anxiety Meds  Selective Serotonin Reuptake Inhibitors (SSRIs) Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac/ Serafem Puvules-weekly) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Only prevents 5-HT reuptake ↑↑ 5-HT available = ↑ regulation of emotions, wakefulness No other neurotransmitters affected ↓↓ E & NE Side effects AnxietyAgitationNausea Insomnia Sexual Dysfunction Akathisia (Use Propanolol)

30 Anxiolytics Anti-Anxiety Meds Side Effects  Anticholinergic: –Daytime sedation, Drowsiness, Dry mouth, –HA, Lethargy, Ataxia, Blurred vision, N & V  Tolerance, physical & psychological dependence  Potentiates other CNS depressants  Orthostatic Hypotension  Blood Dyscrasias  Abrupt Withdrawal Syndrome –Flumazenil (Romazicon) –Benzodiazepam antagonist Reverse CNS effects  Must gradually taper down

31 Defense Mechanisms Protect the ego & cope with anxiety unconsciously  Denial –Refuse to acknowledge the problem –Substance abuse  Regression –Return to an earlier level of development –Holding teddy bear  Displacement (3 way) –Transfer feelings from 1 person, object or situation to less threatening person boss → kids or kick the dog  Reaction-Formation –Prevent unacceptable thoughts/behaviors from being expressed by developing opposite thoughts/behaviors –Unwanted pregnancy → New mom overprotective of baby

32 Defense Mechanisms  Projection (2 way) –Unacceptable feelings/impulses are attributed to another person –I’m needy but claim my husband is demanding  Repression –Involuntary blocking of unpleasant feelings and experiences –No memory of sexual abuse as a child  Suppression –Conscious voluntary denial of unpleasant feelings and experiences –Put away NCP & focus on studying for exam  Identification – ↑ Self worth by acquiring certain attributes & characteristics of an admitted individual –Gang members

33 Defense Mechanisms  Rationalization –Attempting to form logical reasons to justify unacceptable feelings –“Not getting accepted to Harvard I didn’t want to leave home”  Sublimation –Substituting constructive/socially acceptable activity for inappropriate impulses. –Aggressive person becomes hockey player  Compensation –Covering up a real or perceived weakness by emphasizing/excelling in another area –Poor in sports → Excell in chess  Conversion –Unconsciously transforming anxiety into a physical symptom –Paralysis/Blind  Undoing –Symbolically negate or cancel out a previous intolerable action –Man has an affair then buys his wife a new car.


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