Anxiety Anxiety Disorders

Chapter 8

Concept of Anxiety and Psychiatric Nursing

Anxiety
Universal human experience Dysfunctional behavior often defends against anxiety

Legacy of Hildegard Peplau (1909-1999)

Operationally defined concept and levels of anxiety Suggested specific nursing interventions appropriate to each of four levels of anxiety

Psychological Adaptation to Stress

Anxiety and grief have been described as two major, primary psychological response patterns to stress. A variety of thoughts, feelings, and behaviors are associated with each of these response patterns. Adaptation is determined by the extent to which the thoughts, feelings, and behaviors interfere with an individuals functioning.

Anxiety and Fear

Anxiety: feeling of apprehension, uneasiness, uncertainty, or dread resulting from real or perceived threat whose actual source is unknown or unrecognized Fear: reaction to specific danger Similarity between anxiety and fear
Physiological response to these experiences is the same (fight-or-flight response)

Anxiety
A diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. Extremely common in our society. Mild anxiety is adaptive and can provide motivation for survival.

Types of Anxiety
Normal Motivating force that provides energy to carry out tasks of living Acute or state Anxiety that is precipitated by imminent loss or change that threatens ones security (crisis) Chronic or trait Anxiety that persists over time Mild Occurs in normal everyday living Increases perception, improves problem solving Manifested by restlessness, irritability, mild tension-relieving behaviors

Types of Anxiety
Moderate Escalation from normal experience Decreases productivity (selective inattention) and learning Manifested by increased heart rate, perspiration, mild somatic symptoms Severe Greatly reduced perceptual field Learning and problem solving not possible Manifested by erratic, uncoordinated, and impulsive behavior Panic Results in loss of reality focus Markedly disturbed behavior occurs Manifested by confusion, shouting, screaming, withdrawal

Peplaus four levels of anxiety

Mild seldom a problem Moderate perceptual field diminishes Severe perceptual field is so diminished that concentration centers on one detail only or on many extraneous details Panic the most intense state

Behavioral adaptation responses to anxiety

At the mild level, individuals employ various coping mechanisms to deal with stress. A few of these include eating, drinking, sleeping, physical exercise, smoking, crying, laughing, and talking to persons with whom they feel comfortable.

Defense Mechanisms
Help protect people from painful awareness of feelings and memories that can cause overwhelming anxiety
Operate all the time Adaptive (healthy) or maladaptive (unhealthy)

First outlined and described by Sigmund Freud and his daughter Anna Freud

Properties of Defense Mechanisms

Major means of managing conflict and affect Relatively unconscious Discrete from one another Hallmarks of major psychiatric disorders Can be reversible Can be adaptive as well as pathological

Healthy, Intermediate, and Immature Defense Mechanisms

Healthy
Altruism, sublimation, humor, suppression

Intermediate
Repression, displacement, reaction formation, undoing, rationalization

Immature
Passive aggression, acting-out behaviors, dissociation, devaluation, idealization, splitting, projection, denial

Defense Mechanisms
Compensation Denial Displacement Identification Intellectualization Introjection Isolation Projection Rationalization Reaction formation Regression Repression Sublimation Suppression Undoing

 Anxiety at the moderate to severe level that remains unresolved over an extended period of time can contribute to a number of physiological disorders for example, migraine headaches, IBS, and cardiac arrhythmias. Extended periods of repressed severe anxiety can result in psychoneurotic patterns of behaving for example, anxiety disorders and somatoform disorders.

Introduction: Anxiety Disorder

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. Anxiety may be differentiated from fear in that the former is an emotional process, whereas fear is cognitive.

 Extended periods of functioning at the panic level of anxiety may result in psychotic behavior; for example, schizophrenic, schizoaffective, and delusional disorders.

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

How much is too much?

When anxiety is out of proportion to the situation that is creating it. When anxiety interferes with social, occupational, or other important areas of functioning.

Predisposing Factors
Psychodynamic theory Cognitive Theory Biological aspects Transactional Model of Stress Adaptation

Panic Disorders: Panic Attack, Panic Disorder with Agoraphobia

Panic attack
Sudden onset of extreme apprehension or fear of impending doom Fear of losing ones mind or having a heart attack

Panic disorder with agoraphobia

Panic attacks combined with agoraphobia
Agoraphobia is fear of being in places or situations from which escape is difficult or help unavailable

Feared places avoided, restricting ones life

Phobia
Phobia: persistent, irrational fear of specific objects, activities, or situations Types of phobias
Specific: response to specific objects Social: result of exposure to social situations or required performance Agoraphobia: fear of being in places/situations from which escape is difficult or help unavailable

Obsessive-Compulsive Disorder (OCD)

Obsession
Thoughts, impulses, or images that persist and recur
Ego-dystonic symptom: feels unacceptable to individual Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress

Compulsions
Ritualistic behaviors that individual feels driven to perform Primary gain from compulsive behavior: anxiety relief Unwanted repetitive behavior patterns or mental acts that are intended to reduce anxiety, not to provide pleasure or gratification

Generalized Anxiety Disorder (GAD)

Excessive anxiety or worry about numerous things lasting at least 6 months Common symptoms Restlessness Fatigue Poor concentration Irritability Tension Sleep disorders

Post-traumatic Stress Disorder (PTSD)

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 Characteristic symptoms include reexperiencing 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.

 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 Extent of control over recurrence Location where trauma was experienced

The individual
Degree of ego-strength Effectiveness of coping resources Presence of preexisting psychopathology Outcomes of previous experiences with stress/trauma Behavioral tendencies Current psychosocial developmental stage Demographic factors

 The recovery environment

Availability of social supports Cohesiveness and protectiveness of family and friends Attitudes of society regarding the experience Cultural and subcultural influences

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

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 prevails.

Treatment Modalities
Psychopharmacology
PTSD

Antidepressants

Anxiolytics Antihypertensives Others

 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. Disregulation of the opioid, glutamatergic, noradrenergic, serotonergic, and neuroendocrine pathways may be involved in the pathophysiology of PTSD.

Transactional Model of Stress Adaptation

The etiology of PTSD is most likely influenced by multiple factors

Acute Stress Disorder

Occurs within 1 month after exposure to highly traumatic event Characterized by at least three dissociative symptoms during/after event Subjective sense of numbing Reduction in awareness of surroundings Derealization Depersonalization Dissociative amnesia

Anxiety Caused by Medical Conditions

Direct physiological result of medical conditions such as:
Hyperthyroidism Pulmonary embolism Cardiac dysrhythmias

Evidence must be present in history, physical exam, or laboratory findings in order to diagnose

Nursing Process: Assessment Guidelines

Determine if anxiety is primary or secondary (due to medical condition)
Ensure sound physical/neurological exam

Use of Hamilton Rating Scale

Comprehensive data related to anxiety

Determine potential for self-harm/suicide Perform psychosocial assessment Determine cultural beliefs and background

Nursing Process: Diagnosis and Outcomes Identification

NANDA-International (NANDA-I)
Nursing diagnoses useful for patient with anxiety or anxiety disorder

Nursing Outcomes Classification (NOC)

Identifies desired outcomes for patients with anxiety or anxiety disorders

Considerations for Outcome Selection for Patients with Anxiety Disorders

Reflect patient values and ethical and environmental situations Be culturally relevant Be documented as measurable goals Include a time estimate of expected outcomes

Nursing Process: Planning and Implementation

Planning
Select interventions that can be implemented in a community setting Include patient in process of planning

Implementation
Follow PsychiatricMental Health Nursing: Scope and Standards of Practice (ANA, 2007)

Nursing Interventions for Patients with Anxiety Disorders

Identify community resources offering specialized treatments proven as effective Identify community support groups Use therapeutic communication, milieu therapy, promotion of self-care activities, and psychobiological and health teaching and health promotion

Nursing Interventions:
Milieu Therapy Cognitive-Behavioral Therapy (CBT)

Common Benzodiazepine Anxiolytics

Generic Brand

diazepam lorazepam alprazolam clonazepam chlordiazepoxide oxazepam

Valium Ativan Xanax Klonopin Librium Serax *Non- Anxiolytic: BusSpar

Non-sedating, non habit forming and not a prn. Good for the elderly

Non-benzodiazepine Hypnotic
Generic Zolpidem Zalepon Eszopiclone Ramelteon Brand Ambien, *Ambien CR Sonata Lunesta Rozerem
*contains a two layer coat One layer releases it simmediataely and other layer has a slow release of additional drug

The Nursing Process: Antianxiety Agents

Background Assessment Data
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

 Interactions Increased effects when taken with alcohol, barbiturates, narcotics, antipsychotics antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram Decreased effects with cigarette smoking and caffeine consumption DO NOT USE WITH ALCOHOL Nursing Diagnosis Risk for injury Risk for activity intolerance Risk for acute confusion

Planning/Implementation Monitor client for these 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

Common Medications
BZAs: short-term treatment only Causes dependence Buspirone: management of anxiety disorders Selective serotonin reuptake inhibitors (SSRIs): firstline treatment for all anxiety disordersSelective norepinephrine reuptake inhibitors (SNRIs): venlafaxine approved for panic disorder, GAD, and SAD Tricyclic antidepressants (TCAs): second- and thirdline treatment

Nursing Process: Evaluation

Does patient maintain satisfactory relationships? Can patient resume usual roles? Is patient compliant with medications? Does patient maintain satisfactory relationships? Can patient resume usual roles? Is patient compliant with medications?