1. Chapter 17
Anxiety Disorders

2. Anxiety Disorders Introduction
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
Stress is an external pressure that is brought to bear on an individual; anxiety is the subjective emotional response to that stressor

3. Anxiety Disorders (cont.)
Introduction (cont.)
Anxiety may be differentiated from fear in that the former is an emotional process, whereas fear is cognitive

4. Anxiety Disorders (cont.)
Epidemiological statistics
Anxiety disorders are the most common type of all psychiatric illnesses
More common in women than men
Minority children and children from low socioeconomic environments are at risk
A familial predisposition probably exists

5. Anxiety Disorders (cont.)
How much is too much?
May be considered abnormal if
Anxiety is out of proportion to the situation that is creating it
Anxiety interferes with social, occupational, or other important areas of functioning

6. Application of the Nursing Process
Panic disorder: Assessment
Characterized by recurrent panic attacks, onset of which are unpredictable, and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort

7. Application of the Nursing Process (cont.)
Panic disorder with agoraphobia
Assessment
Characterized by same symptoms characteristic of panic disorder
In addition, affected person
experiences a fear of being
in places or situations from
which escape might be difficult
(or embarrassing) or in which
help might not be available
in the event that a panic attack
should occur

8. Application of the Nursing Process (cont.)
Generalized anxiety disorder
Assessment
Characterized by chronic, unrealistic,
and excessive anxiety and worry

9. Etiological Implications
Panic and generalized anxiety disorders
Psychodynamic theory
Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety
S. Freud

10. Etiological Implications (cont.)
Panic and generalized anxiety disorders (cont.)
Cognitive theory
Faulty, distorted, or counterproductive thinking patterns accompany or precede maladaptive behaviors and emotional disorders

11. Etiological Implications (cont.)
Panic and generalized anxiety disorders (cont.)
Biological aspects
Genetics
Neuroanatomical
Biochemical
Neurochemical
Medical conditions

12. Diagnosis/Outcome Identification
Panic Anxiety related to real or perceived threat to biological integrity or self-concept
Powerlessness related to impaired cognition

13. Outcomes The client Is able to recognize signs of escalating anxiety
Is able to intervene so that anxiety does not reach level of panic

14. Outcomes (cont.) The client (cont.)
Is able to discuss long-term plan to prevent panic anxiety when stressful situations occur
Practices techniques of relaxation daily
Engages in physical exercise three times a week

15. Outcomes (cont.) The client (cont.)
Performs activities of daily living independently
Expresses satisfaction with independent functioning
Is able to maintain anxiety at a manageable level without use of medication

16. Outcomes (cont.) The client (cont.)
Is able to participate in decision-making, thereby maintaining control over life situation
Verbalizes acceptance of life situations over which he or she has no control

17. Planning/Implementation
Interventions are aimed at
Maintaining anxiety at manageable level
Problem-solving to increase client’s level of personal control

18. Evaluation
Reassessment will determine whether the nursing actions have been successful in achieving the objectives of care

19. Phobias Agoraphobia without history of panic disorder: Assessment
Fear of being in places or situations from which escape might be difficult or in which help might not be available if a limited-symptom attack or panic-like symptoms should occur

20. Phobias (cont.) Social phobia: Assessment
Excessive fear of situations in which the person might do something embarrassing or be evaluated negatively by others

21. Phobias (cont.) Specific phobia: Assessment
Marked, persistent, and excessive or unreasonable fear when in the presence of, or when anticipating, an encounter with a specific object or situation

22. Phobias (cont.) Specific phobia: Assessment (cont.) DSM-IV-TR subtypes
Animal type
Natural environment type
Blood-injection-injury type
Situational type
Other type

23. Phobias (cont.) Etiological implications for phobias
Psychoanalytical theory
Unconscious fears may be expressed in a symbolic manner as phobia
S. Freud

24. Phobias (cont.) Learning theory
Learning theorists believe that fears are learned and become conditioned responses when the individual escapes panic anxiety (a negative reinforcement) by avoiding phobic stimulus

25. Phobias (cont.) Cognitive theory
Anxiety is the product of faulty cognitions or anxiety-inducing self-instructions
Negative self-statements
Irrational beliefs

26. Phobias (cont.) Biological aspects Temperament
Characteristics with which one is born that influence how he/she responds throughout life to specific situations (e.g., innate fears)

27. Phobias (cont.) Life experiences
Early experiences may set the stage for phobic reactions later in life

28. Nursing Diagnosis
Fear related to causing embarrassment to self in front of others, to being in a place from which one is unable to escape, or to a specific stimulus

29. Nursing Diagnosis (cont.)
Social Isolation related to fears of being in a place from which one is unable to escape

30. Outcomes
The client
Functions adaptively in the presence of the phobic object or situation without experiencing panic anxiety

31. Outcomes (cont.) The client (cont.)
Demonstrates techniques that can be used to maintain anxiety at a manageable level
Voluntarily attends group activities and interacts with peers

32. Outcomes (cont.) The client (cont.)
Discusses feelings that may have contributed to irrational fears
Verbalizes a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety

33. Planning/Implementation
Nursing care of the client with a phobia is aimed at
Helping the client learn to function in the presence of the phobic object without experiencing panic anxiety
Assisting the client to overcome fear of leaving home alone

34. Evaluation
Reassessment is conducted to determine whether the nursing actions have been successful in achieving the objectives of care

35. Obsessive–Compulsive Disorder (OCD)
Assessment data
Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment

36. Obsessive–Compulsive Disorder (OCD) (cont.)
Obsessions: unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress

37. Obsessive–Compulsive Disorder (OCD) (cont.)
Compulsions: unwanted repetitive behavior patterns or mental acts that are intended to reduce anxiety, not to provide pleasure or gratification

38. Obsessive–Compulsive Disorder (OCD) (cont.)
Etiological implications of OCD
Psychoanalytical theory
Clients with OCD have weak, underdeveloped egos
Aggressive impulses are channeled into thoughts and behaviors that prevent the feelings of aggression from surfacing and producing intense anxiety fraught with guilt
S. Freud

39. Obsessive–Compulsive Disorder (OCD) (cont.)
Etiological implications of OCD (cont.)
Learning theory
Conditioned response to a traumatic event
Passive avoidance
Active avoidance

40. Obsessive–Compulsive Disorder (OCD) (cont.)
Biological aspects
Neurobiological disturbances may play a role
Neuroanatomy
Abnormalities in various regions of the brain have been implicated in the neurobiology of OCD

41. Obsessive–Compulsive Disorder (OCD) (cont.)
Biological aspects (cont.)
Physiology
Electrophysiological, sleep electroencephalogram, and neuroendocrine studies have suggested that there are commonalities between depressive disorders and OCD

42. Obsessive–Compulsive Disorder (OCD) (cont.)
Biological aspects (cont.)
Biochemical
Neurotransmitter serotonin may be influential in the etiology of OCD

43. Obsessive–Compulsive Disorder (OCD) (cont.)
Diagnosis
Ineffective Coping related to underdeveloped ego, punitive superego; avoidance learning, possible biochemical changes

44. Obsessive–Compulsive Disorder (OCD) (cont.)
Diagnosis (cont.)
Ineffective Role Performance related to need to perform rituals evidenced by inability to fulfill usual patterns of responsibility

45. Obsessive–Compulsive Disorder (OCD) (cont.)
Outcomes
The client
Is able to maintain anxiety at a manageable level without resorting to the use of ritualistic behavior
Is able to perform activities of daily living independently

46. Obsessive–Compulsive Disorder (OCD) (cont.)
Outcomes (cont.)
The client (cont.)
Verbalizes understanding of relationship between anxiety and ritualistic behavior
Verbalizes specific situations that in the past have provoked anxiety and resulted in seeking relief through rituals

47. Obsessive–Compulsive Disorder (OCD) (cont.)
Outcomes (cont.)
The client (cont.)
Demonstrates more adaptive coping strategies to deal with stress, such as thought stopping, relaxation techniques, and physical exercise

48. Obsessive–Compulsive Disorder (OCD) (cont.)
Outcomes (cont.)
The client (cont.)
Is able to resume role-related responsibilities because of decreased need for ritualistic behaviors

49. Planning/Implementation
Nursing care of the client with OCD is aimed at
Helping the client learn new, more adaptive coping strategies without resorting to obsessive–compulsive behaviors
Helping the client gain independence and greater control over life situations

50. Evaluation
Reassessment is conducted to determine whether nursing actions have been successful in achieving the objectives of care

51. Post-Traumatic Stress Disorder
Assessment
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

52. Post-Traumatic Stress Disorder (cont.)
Characteristic symptoms include re-experiencing 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

53. Post-Traumatic Stress Disorder (cont.)
Etiological implications
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
Amount of control over recurrence
Location where trauma was experienced

54. Post-Traumatic Stress Disorder (cont.)
Etiological implications (cont.)
Psychosocial theory (cont.)
The individual
Degree of ego-strength
Effectiveness of coping resources
Presence of pre-existing psychopathology
Outcomes of previous stressor/traumas
Behavioral tendencies (temperament)
Current developmental stage
Demographic factors

55. Post-Traumatic Stress Disorder (cont.)
Etiological implications (cont.)
Psychosocial theory (cont.)
The recovery environment
Availability of social supports
Cohesiveness and protective ness of family and friends
Attitudes of society regarding the experience
Cultural and subcultural influences

56. Post-Traumatic Stress Disorder (cont.)
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

57. Post-Traumatic Stress Disorder (cont.)
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 prevail

58. Post-Traumatic Stress Disorder (cont.)
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

59. Post-Traumatic Stress Disorder (cont.)
Biological aspects (cont.)
People who have suffered traumatic experiences may be more likely to become exposed to future traumas because they may be inclined to reactivate those behaviors associated with the original trauma

60. Post-Traumatic Stress Disorder (cont.)
Biological aspects (cont.)
Dysregulation of the opioid, glutamatergic, noradrenergic, serotonergic, and neuroendocrine pathways may be involved in the pathophysiology of PTSD

61. Post-Traumatic Stress Disorder (cont.)
Diagnosis/outcome identification
Post-Trauma Syndrome related to distressing event considered to be outside the range of usual human experience

62. Post-Traumatic Stress Disorder (cont.)
Diagnosis/outcome identification (cont.)
Complicated Grieving related to loss of self as perceived before the trauma or other actual or perceived losses incurred during or after the event

63. Post-Traumatic Stress Disorder (cont.)
Outcomes
The client
Can acknowledge the traumatic event and the impact it has had on his or her life
Is experiencing fewer flashbacks, intrusive recollections, and nightmares than he or she was on admission

64. Post-Traumatic Stress Disorder (cont.)
Outcomes (cont.)
The client (cont.)
Can demonstrate adaptive coping strategies
Can concentrate and has made realistic goals for the future
Includes significant others in the recovery process and willingly accepts their support

65. Post-Traumatic Stress Disorder (cont.)
Outcomes (cont.)
The client (cont.)
Verbalizes no ideas or intent of self-harm
Has worked through feelings of survivor’s guilt
Gets enough sleep to avoid risk of injury

66. Post-Traumatic Stress Disorder (cont.)
Outcomes (cont.)
The client (cont.)
Verbalizes community resources from whom he or she may seek assistance in times of stress
Attends support group
Verbalizes desire to put the trauma in
the past

67. Post-Traumatic Stress Disorder (cont.)
Planning/implementation
Nursing care of the client with PTSD is aimed at providing assistance with
Integration of the trauma into his or her persona
Renewing significant relationships
Establishing meaningful goals for the future
Progressing through the grief process
Developing a sense of optimism and hope for the future

68. Post-Traumatic Stress Disorder (cont.)
Evaluation
Reassessment is conducted to determine whether nursing actions have been successful in achieving the objectives of care

69. Anxiety Disorder Due to General Medical Condition
Assessment
Symptoms of this disorder are judged to be the direct physiological consequence of a general medical condition

70. Substance-Induced Anxiety Disorder
Assessment
Prominent anxiety symptoms that are judged to be due to the direct physiological effects of a substance

71. Client/Family Education
Nature of the illness
What is anxiety?
What might it be related to?
What is OCD?
What is PTSD?
Symptoms of anxiety disorders

72. Client/Family Education (cont.)
Management of the illness
Medication management
Possible adverse effect
Length of time to take effect
What to expect from the medication

73. Client/Family Education (cont.)
Management of the illness (cont.)
Stress management
Teach ways to interrupt escalating anxiety
Teach relaxation techniques

74. Client/Family Education (cont.)
Support services
Crisis hotline
Support groups
Individual psychotherapy

75. Treatment Modalities
Individual psychotherapy
Cognitive therapy

76. Treatment Modalities (cont.)
Behavior therapy
Systematic desensitization
Implosion therapy
Group/family therapy

77. Treatment Modalities Psychopharmacology

78. Anti-Anxiety Agents
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

79. Anti-Anxiety Agents (cont.)
Interactions
Increased effects when taken with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram, and with herbal depressants (e.g., kava and valerian)
Decreased effects with cigarette smoking and caffeine consumption

80. Anti-Anxiety Agents (cont.)
Monitor client for 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

81. Panic and Generalized Anxiety Disorder
Anxiolytics
Antidepressants
Antihypertensive agents

82. Phobic Disorders
Anxiolytics
Antidepressants
Antihypertensive agents

83. Obsessive Compulsive Disorder (OCD)
Antidepressants
Post-Traumatic Stress Disorder (PTSD)
Anxiolytics
Antihypertensives
Others