1. Anxiety Disorders

2. Prevalence  Anxiety Disorders more prevalent than mood disorders- 18 %  Primary gain: the individuals desire to relieve the anxiety to feel better  Secondary gain: refers to attention and support the person gets from the illness

3. Primary Gain  The individual’s desire to relieve the anxiety –Physical symptoms  Stomach Ache  Inability to walk –Obsessions –Compulsions  Cleans  Exercise –Fears  Cannot drive –Worry –Isolation

4. Secondary Gain  Attention or benefit –Health Care Providers –Spouse does more –Children take care of younger siblings  Can become more important than relieving the anxiety than relieving the anxiety –Decreases motivation to get well –Others take care of individual  Complicates treatment

5. Axis 1 Anxiety Disorders 1. Generalized Anxiety Disorder (GAD) 2. Panic Disorder with Agoraphobia with Agoraphobia without Agoraphobia without Agoraphobia 3. Phobias 4. Somatoform Disorders

6. Etiology of Anxiety Disorders  Biological and Genetic –Defects in Brain Chemistry; Person over responds to Stimuli –Inherited trait for shyness has been discovered –Brazelton; believes in the biological basis of temperament

8. Psychoanalytic  Result of conflict in values  Client is often perfectionist and driven  Defense mechanisms –Repression –Displacement –Conversion

9. Generalized Anxiety Disorder (GAD)  Cognitive and Physical Symptoms –Worry; unable to focus –Dry mouth, stomach ache  Anxiety or worry is chronic and excessive  Significant Distress  Worry is debilitating and habitual –Focus changes  Causes impairment –Interpersonal or social –Occupational –Sense of helplessness –Depression –Chemical dependency

10. Generalized Anxiety Disorder  Excessive worry occurring more often than not for 6 months  Person cannot control the worry  Anxiety and worry are evident and three or more of the following: –Restlessness –Fatigue –Irritability –Decreased ability to concentrate –Muscle tension –Disturbed sleep

12. Interventions for GAD  Goal is to assist the client to develop adaptive coping responses  Assess for level of anxiety: moderate to severe  Reduce level of Anxiety –Must occur prior to problem solving –Promotes trust  Acceptance of feelings  Acknowledgment of discomfort  Identify and describe feelings (repression; displacement) (repression; displacement)  Assist to identify causes of feelings

14. Milieu Management for GAD  Calm environment  Cognitive Behavioral Therapy –Corrects faulty assumptions –If you change others will change  Recreational activities –Relaxation exercises or tapes  Groups –Stress Management –Problem solving –Self esteem –Assertiveness –Goal setting

15. Medication  Serotonin Reuptake Inhibitors –Long-Term treatment  Serotonin and Norepinephrine Reuptake Inhibitors (SNRI) –Long-Term treatment  Buspirone (Buspar) –Nonaddicting non-benzodiazepine  Benzodiazepine –Immediate effect

17. Four Symptoms for Diagnosis of Panic Disorder  Chest pain  Choking  Dizziness  Dyspnea  Fear of going crazy  Fear of dying  Sweating  Palpitations  Trembling and shaking  Nausea  Hot flashes and chills

18. Etiology  Psychological –Life stresses  Separation and disruption of attachment in childhood  Biological –Heredity –3 systems  Cognitive (catastrophic thinking “what if”) –Triggers physiology  Nervous System –Sympathetic (flight fight response) –Respiratory, cardiovascular, gastrointestinal, neuromuscular  Endocrine System –Andrenal cortex (cortisol)  Libido, insomnia, anxiety –Adrenal Medulla (epinephrine)  Anxiety

19. The Nurse Patient Relationship: Acute Phase  Communication: Similar to panic level anxiety, reassure that they are safe –Have client breath with you (set the pace)  Keep stimulation down  Assess for suicidal ideation: 1 in 5 are suicidal  Use touch carefully  PRN Medications: Xanax, Ativan

20. The Nurse Patient Relationship and Panic Disorder  Teaching: give client a handout on Panic Disorder –Client need to know there is a diagnosis –They are not “crazy” –Symptoms –Medications that can help  When clients learn about the diagnosis they usually improve

21. Interventions and Milieu  Cognitive restructuring  Reinterpret their beliefs regarding the danger of the event  Identify feelings  Identify triggers  Avoidance makes it worse  Meeting Fears –What is the worst that can happen? –What will I do –Options  Recognize bodily sensations and symptoms of anxiety  Relaxation Exercises –Stretching –Yoga –Soft music  Gross motor activities –Walking –Jogging –Basketball

22. Panic Disorder Recurring, sudden intense feelings of  Apprehension  Terror  Impending doom  Loosing control  Going crazy  Somatic Symptoms –Heart Attack –Dying  Can happen in the middle of the night –fearful and exhausted.  Situational –Often recur in the same place –Can occur with anticipation –Avoid places or situations  Peaks within 10 minutes

23. Medication  Serotonin Reuptake Inhibitors –Long-Term treatment  Benzodiazepine –Immediate effect

24. Obsessive Compulsive Disorder  Obsessions –Recurrent and Persistent  Thoughts  Ideas  Impulses  Images  Experienced as intrusive and senseless  Compulsions –Repetitive behaviors  Performed in a particular manner  Response to obsession  Prevent discomfort  Neutralize anxiety

25. OCD  Depression –Low self-esteem –Rigid thinking –Unable to Relax  Increase anxiety when they resist the compulsion  Need to control –Themselves –Others –environment  Interferes with normal routine –Time-consuming  Interferes with relationships –Not enough time to relate to others –Magical thinking  Believes thinking equals doing

26. OCD Nurse-Patient Relationship  Assist to meet Basic Needs  Allow time to perform rituals –Work to limit  Explain expectation routines and changes  Identify feelings  Connect feeling to behaviors  Reinforce and recognize positive non-ritualistic behaviors non-ritualistic behaviors

27. OCD and Milieu  Relaxation Exercises  Stress management  Recreational and Social Skills  Cognitive Behavior Therapy –Outpatient –Contact feared stimuli –Limit the rituals –7-week exposure and response prevention therapy

28. OCD Medication  Antidepressants –Tricyclic Antidepresants  Clomipramine (Anafranil) –SSRIs  Fluoxetine (Prozac)  Paroxetine (Paxil)

29. Phobias/DSM IV  Marked and specific fear that is excessive and unreasonable cued by the presence or anticipation of object.  Person recognizes fear as unreasonable  Situation or object avoided –Animal –Natural environment; heights –Blood/injection –Situational/elevators

30. Phobias-Continued  Agoraphobia without Panic disorder: a fear of being in public places  Social phobia: fear of being humiliated in public, fear of stumbling while dancing, choking while eating  Specific phobia: fear of a specific object or situation; animals, heigth, flying

31. Treatment for Phobias  Outpatient is most common  Behavior therapy: systematic desensitization; like Fear of Flying groups  Nurse patient relationship –Interventions are very similar to GAD

32. Interventions  Medications –No effect on avoidant behaviors –SSRIs  Reduce anxiety and depression  Block Panic  Milieu –Cognitive Behavioral Therapy

33. Somatoform Disorders  Anxiety is relieved by developing physical symptoms for which no known organic cause or physiologic mechanism can be identified  Somatization Disorder  Conversion Disorder  Pain Disorder  Hypochondriasis

34. Somatoform Disorders  Client expresses psychological conflict through symptoms  Client is not in control of symptoms and complaints  See general practitioners not mental health professionals  Repression of feelings, conflicts, and unacceptable impulses  Denial of psychological problems  Individuals are dependent and needy

35. Somatization Disorder  Recurrent frequent somatic complaints for years  Complaints change over time  No physiological cause  Onset prior to 30years old  See many physicians  May have unnecessary surgical procedures  Impairment –Social functioning –Occupational functioning  Etiology –Chronic emotional abuse –Unable to verbalize anger  Helped by having them talk about experiences and feelings

36. Pain Disorder  Severe Pain in one or more areas –Significant distress and impairment –Location or complaint does not change  Unlike somatization disorder –No organic basis –Doctor Shoppers –Pain may allows secondary gain  Avoidance –Does not have to go to work  Pain medication –Sometime there is a physiologic disorder  The amount of pain is out of proportion

37. Hypochondriasis  Worry they have a serious illness despite no medical evidence  Misinterpretation of bodily symptoms  Check for reassurance from doctors and friends

38. Conversion Disorder  Suggests a Neurological Condition –Deficit or alteration in voluntary motor or sensory function  Psychological factors that proceed symptoms –Conflicts –Stressors  Symptoms –Paralysis –Blindness –seizures

39. Conversion Disorder:  Primary Gain –Alleviation of anxiety –Conflict kept out of consciousness  Secondary Gain –Response of others to the illness –Can prolong symptoms

40. Somatoform Disorders  The Clients can develop a health problem just like anyone else  Be careful  Always rule out the physical  READ: “Conversion Disorder and the Nursing Student”

41. MEDICATIONS FOR ANXIETY

42. BENZODIAZEPINES  CNS Depressants  Compete for GABA receptors; decrease response of excitatory neurons  Tolerance, dependence are problems  Cause dizziness, somnolence, confusion  Best for short-term use  Shorter acting benzodiazepines –PRN for episodes of anxiety or panic: clonazepam (Klonipin) alprazolam (Ativan) alprazolam (Ativan)

43. NON-BENZODIAZEPINES  First line agent: buspirone (BuSpar)  Binds to serotonin and dopamine receptors  No CNS depression  No abuse potential documented  May have paradoxical effects (increased anxiety, depression, insomnia, etc.)  May not be fully effective for 3-6 weeks  May cause EPS

44. NON-BENZODIAZEPINES: ANTIHISTAMINES  Very sedating  No addiction potential  May be used long-term  Examples: –diphenhydramine (Benadryl) –hydroxyzine (Vistaril)

45. ANTIDEPRESSANTS  Useful in treatment of panic (with or without agoraphobia), obsessional thinking  Low abuse potential  SSRI’s: first line drugs due to low sedation

46. ANTIDEPRESSANTS, CONT’D  Selective Serotonin Re-uptake Inhibitors  fluoxetine (Prozac)  sertraline (Zoloft)  paroxetine (Paxil)  citalopram (Celexa)  escitalopram (Lexapro)  fluvoxamine (Luvox): best for OCD  Tricyclics:  clomipramine (Anafranil): for OCD

47. MISCELLANEOUS  Clonidine (Catapres) and Propranolol (Inderal) –Decreases autonomic symptoms in panic : tachycardia, muscle tremors  Gabapentin (Neurontin)  For OCD and social phobias

48. GENERAL GUIDELINES FOR USE OF ANTIANXIETY AGENTS  Sedation increases falls, accidents  Cautious use in elderly, renal, liver problems  Do not combine with other CNS depressants or alcohol  Paradoxical effects common: esp. with benzodiazapines, buspirone, some antidepressants