1. Anxiety Disorder

2. Definitions Anxiety : associated with feelings on uncertainty and helplessness. This emotion has no specific object. It is subjectively experienced and communicated interpersonally. It is different from fear, which is the intellectual appraisal of danger. Anxiety is the emotional response. The capacity to be anxious is necessary for survival, but severe levels of anxiety are incompatible with life. Anxiety disorders are the most common psychiatric problems in the world.

3. Type 1- Panic disorder without agoraphobia: Recurrent unexpected panic attacks and at least one of the attacks has been followed by a month (or more) of: A> Persistent concern about having additional attacks. B> Worry about the implications of the attack or its consequences, or. C> A significant change in behavior related to the attacks. Also the absence of agoraphobia.

4. 2- Panic disorder with agoraphobia: Meets the above criteria. In addition, the presence of agoraphobia, which is anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack. Agoraphobic fears typically involve characteristics clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or car. Agoraphobic situations are avoided, or are endured with marked distress or with anxiety about having a panic attack, or require the presence of a companion.

5. 3- Agoraphobia without history of panic disorder: Present of agoraphobia and has never met criteria for panic disorder.

6. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). The person recognizes the fear is excessive, and the distress or avoidance interferes with the person's normal routines. 4- Specific phobia :

7. 5- Social phobia: Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The person recognizes the fear is excessive, and the distress or avoidance interferes with the person's normal routine.

8. 6- Obsessive-compulsive disorder: Either obsessions or compulsions are recognized as excessive and interfere with the person's normal routine.

9. 7- Posttraumatic stress disorder: The person has been exposed to a traumatic event in which both the following occurred: A> The person experienced, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others. B> The person's response involved intense fear, helplessness. The person experiences the traumatic event, avoids stimuli associated with the trauma.

10. 9- Generalized anxiety disorder: Excessive anxiety and worry, occurring more days for at least 6 months, about a number of events or activities. The person finds it difficult control the worry and experiences at least three of the following six symptoms: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance.

11. Classification of anxiety disorder: 1.Mild anxiety: is associated with the tension of daily living and makes a person alert and increases the person's perceptual field. This anxiety can motivate learning and produce growth and creativity.

12. 2.Moderate anxiety: allows a person to focus on immediate concerns. It narrows the person's perceptual field. The person thus experiences selective inattention but can focus on more areas if directed to so do.

13. 3.Severe anxiety: greatly reduces a person's perceptual field. The person tends to focus on a specific detail and not think about anything else. All behavior is aimed at obtaining relief. The person needs much direction to focus on any other area. 4.Panic level of anxiety: is associated with awe, dread, and terror.

14. Responses Body system Palpitations Heart "racing" Increased blood pressure Faintness Actual fainting Decreased blood pressure Decreases pulse rate Cardiovascular Rapid breathing Shortness of breath Pressure on chest Shallow breathing Lump in throat Chocking sensation GaspingRespiratory Increased reflexes Startle reaction Eyelid twitching InsoniaTremorsFigidity Ridgeting, pacing Strained face Generalized weakness Wobbly legs Clumsy movement Neuromuscular Loss of appetite Revulsion toward food Abdominal pain NauseaHeartburnDiarrheaGastrointestinal Physiological responses to anxiety:

15. ResponsesBody system Loss of appetite Abdominal discomfort Abdominal pain Nausea Heartburn Diarrhea Gastrointestinal Pressure to urinate Frequent urination Face flushed Urinary tract Localized sweating (palms0 Itching Hot and cold spells Face pale Generalized sweating Skin Con’t

16. Behavioral, cognitive and effective responses ResponsesSystem Restlessness Physical tension Tremors Startle reaction Rapid speech Lack of coordination Accident proneness Interpersonal withdrawal Inhibition Flight Avoidance Hyperventilation Hypervigilance Behavioral Impaired attention Poor concentration Forgetfulness Errors in judgment Cognitive

17. Behavioral, cognitive and effective responses to anxiety ResponsesSystem Preoccupation Blocking of thoughts Decreased perceptual field Reduced creativity Diminished productivity Confusion Self-consciousness Loss of objectivity Fear of losing control Fear of injury or death Flashbacks Nightmares Cognitive (continued) Impatience Uneasiness Tension Nervousness Fearfulness Alarm Terror Numbness Guilt Shame Affective

18. Nursing Care Plan: Nursing Diagnosis : Sarah, a 47-year old woman, presented to the employee health department of a teaching hospital after walking there from her office. She was complaining of chest pain and shortness of breath. Sarah's medical history included psoriasisl. Her vital signs were remarkable for a pulse of 116; her electrocardiogram and laboratory work were within normal limits. Sarah mentioned to the staff that her son had died 3 months ago.

19. During her evaluation Sarah and the nurse explored her symptoms of anxiety and depression, the exacerbation of her psoriasis, and her chronic headaches, which had become worse since her son's death. In addition to concern about financial matters and her son's alcoholism, she now worried frequently about her performance at work. The nurse recommended a medication trial. Sarah refused because of her fears of addition and loss of control.

20. Anxiety related to change in role functioning, recent loss of son (dysfunctional grieving) threat to socioeconomic status, and stressors exceeding ability to cope, as evidenced by uncertainty, intermittent sympathetic nervous system stimulation, restlessness, and exacerbation of medial condition (psoriasis).

21. EvaluationNursing interventionsClient outcomes Sarah identifies returning home after work as a critical time for symptoms to develop. She reports that she visits her mother or does errands daily. Assign "homework" to client (e.g., keeping a panic attack and headache diary). Documenting anxiety responses helps client link symptoms with precipitating events. Sarah will identify common situations that provoke anxiety. Sarah reports that she does not experience headaches when her husband is traveling. Assist Sarah in associating her panic attach symptoms with thoughts about separation from her husband. This will help illustrate to Sarah specific situations in her life that result in panic anxiety. Sarah will describe early warning symptoms of anxiety. Sarah reveals unwillingness to live alone.In weekly sessions, explore with Sarah the advantages and disadvantages of separation and divorce. These discussions will help Sarah problem solve viable options that may offer some control over her anxiety. Sarah will report willingness to tolerate mild to moderate levels of anxiety. Sarah informs her husband that she wants a trial separation. The husband moves into their son's former room. During weekly sessions discuss options that will allow Sarah maximum control over her choices. Increased choices over life situations tend to minimize anxiety response to some degree. Sarah will demonstrate adaptive coping mechanisms.

22. Nursing Interventions: A> Assess own level of anxiety and make a conscious effort to remain calm. Anxiety is readily transferable from one person to another. B> Recognize the client's use of relief behaviors (pacing, wringing of hands) as indicators of anxiety. Early interventions help to manage anxiety before symptoms escalate to more serious levels. C> Inform the client of the importance of limiting caffeine, nicotine, and other central nervous system stimulants. Limiting these substances, prevents/ minimizes physical symptoms of anxiety such as rapid heart rate and jitteriness.

23. D> Teach the client to distinguish between anxiety that can be connected to identifiable objects of sources (illness, prognosis, hospitalization, know stressors) and anxiety for which there is no immediate identifiable object of source. Knowledge of anxiety and its related components increase the client's control over the disorder.

24. E> Instruct the client in the following anxiety- reducing strategies, which help reduce anxiety in a variety of ways and distract the client from focusing on the anxiety. 1- Progressive relaxation technique. 2- Slow deep-berating exercises 3- Focusing on a single object in the room. 4- Listening to soothing music or relaxation tapes. 5- Visual imagery

25. Medication: In recent years, there has been a growing interest in Eastern techniques of medication. Experimental evidence of the efficacy of medication is still in its infancy, but it seems to have a striking effect on physiological functions as measured by oxygen composition.

26. Tricyclics: imipramine is effective in the treatment of panic disorder. Tricyclics: imipramine is effective in the treatment of panic disorder. Starting does not imipramine should be somewhat lower than the typical starting doses prescribed in the treatment of depression.

27. MAO inhibitors: Like tricyclic antidepressants, MAO inhibitors appear to be quite effective in the treatment of panic disorder. Some investigators have suggested that MAO inhibitors may be slightly more effective than imipramine. Like tricyclic antidepressants, MAO inhibitors appear to be quite effective in the treatment of panic disorder. Some investigators have suggested that MAO inhibitors may be slightly more effective than imipramine.

28. Antihypertensive agents: There is some evidence to suggest that β- blockers possess anxiolytic properties. Clinical experience, however, suggests that β-blockers may be less effective in the treatment of panic disorder than tricyclic antidepressants.

29. Benzodiazepines: benzodiazepines are effective in the treatment of generalized anxiety but fail to prevent panic attacks.