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Anxiety Anxiety Disorders

Dec 30, 2015



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 - PowerPoint PPT Presentation

  • Anxiety Anxiety Disorders

    Chapter 8

  • Concept of Anxiety and Psychiatric NursingAnxietyUniversal human experienceDysfunctional behavior often defends against anxietyLegacy of Hildegard Peplau (1909-1999)Operationally defined concept and levels of anxietySuggested specific nursing interventions appropriate to each of four levels of anxiety

  • Psychological Adaptation to StressAnxiety 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 FearAnxiety: feeling of apprehension, uneasiness, uncertainty, or dread resulting from real or perceived threat whose actual source is unknown or unrecognizedFear: reaction to specific dangerSimilarity between anxiety and fearPhysiological response to these experiences is the same (fight-or-flight response)

  • AnxietyA 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 AnxietyNormalMotivating force that provides energy to carry out tasks of livingAcute or stateAnxiety that is precipitated by imminent loss or change that threatens ones security (crisis)Chronic or traitAnxiety that persists over timeMildOccurs in normal everyday livingIncreases perception, improves problem solvingManifested by restlessness, irritability, mild tension-relieving behaviors

  • Types of AnxietyModerateEscalation from normal experienceDecreases productivity (selective inattention) and learningManifested by increased heart rate, perspiration, mild somatic symptomsSevereGreatly reduced perceptual fieldLearning and problem solving not possibleManifested by erratic, uncoordinated, and impulsive behaviorPanicResults in loss of reality focusMarkedly disturbed behavior occursManifested by confusion, shouting, screaming, withdrawal

  • Peplaus four levels of anxiety

    Mild seldom a problemModerate perceptual field diminishesSevere perceptual field is so diminished that concentration centers on one detail only or on many extraneous detailsPanic 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 MechanismsHelp protect people from painful awareness of feelings and memories that can cause overwhelming anxietyOperate all the timeAdaptive (healthy) or maladaptive (unhealthy)First outlined and described by Sigmund Freud and his daughter Anna Freud

  • Properties of Defense MechanismsMajor means of managing conflict and affectRelatively unconsciousDiscrete from one anotherHallmarks of major psychiatric disordersCan be reversibleCan be adaptive as well as pathological

  • Healthy, Intermediate, and Immature Defense MechanismsHealthyAltruism, sublimation, humor, suppressionIntermediateRepression, displacement, reaction formation, undoing, rationalizationImmaturePassive aggression, acting-out behaviors, dissociation, devaluation, idealization, splitting, projection, denial

  • Defense Mechanisms


    RationalizationReaction formationRegressionRepressionSublimationSuppressionUndoing

  • 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 DisorderAnxiety 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 illnessesMore common in women than menMinority children and children from low socioeconomic environments at riskA familial predisposition probably existsHow 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 FactorsPsychodynamic theoryCognitive TheoryBiological aspectsTransactional Model of Stress Adaptation

  • Panic Disorders: Panic Attack, Panic Disorder with AgoraphobiaPanic attackSudden onset of extreme apprehension or fear of impending doomFear of losing ones mind or having a heart attackPanic disorder with agoraphobiaPanic attacks combined with agoraphobiaAgoraphobia is fear of being in places or situations from which escape is difficult or help unavailableFeared places avoided, restricting ones life

  • Phobia

    Phobia: persistent, irrational fear of specific objects, activities, or situationsTypes of phobiasSpecific: response to specific objectsSocial: result of exposure to social situations or required performanceAgoraphobia: fear of being in places/situations from which escape is difficult or help unavailable

  • Obsessive-Compulsive Disorder (OCD)ObsessionThoughts, impulses, or images that persist and recurEgo-dystonic symptom: feels unacceptable to individualUnwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress

  • Compulsions

    Ritualistic behaviors that individual feels driven to performPrimary gain from compulsive behavior: anxiety reliefUnwanted 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 monthsCommon symptomsRestlessnessFatiguePoor concentrationIrritabilityTensionSleep 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 theoryThe traumatic experienceSeverity and duration of the stressorExtent of anticipatory preparation before onsetExposure to deathNumbers affected by life threatExtent of control over recurrenceLocation where trauma was experiencedThe individualDegree of ego-strengthEffectiveness of coping resourcesPresence of preexisting psychopathologyOutcomes of previous experiences with stress/traumaBehavioral tendenciesCurrent psychosocial developmental stageDemographic factors

  • The recovery environmentAvailability of social supportsCohesiveness and protectiveness of family and friendsAttitudes of society regarding the experienceCultural and subcultural influencesLearning theoryNegative reinforcement as behavior that leads to a reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behaviorAvoidance behaviorsPsychic numbingCognitive theoryA 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 ModalitiesPsychopharmacology PTSD Antidepressants Anxiolytics Antihypertensives Others

  • Biological aspectsIt 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 AdaptationThe etiology of PTSD is most likely influenced by multiple factors

  • Acute Stress DisorderOccurs within 1 month after exposure to highly traumatic event Characterized by at least three dissociative symptoms during/after eventSubjective sense of numbingReduction in awareness of surroundingsDerealizationDepersonalizationDissociative amnesia

  • Anxiety Caused by Medical ConditionsDirect physiological result of medical conditions such as:HyperthyroidismPulmonary embolismCardiac dysrhythmiasEvidence must be present in history, physical exam, or laboratory findings in order to diagnose

  • Nursing Process: Assessment GuidelinesDetermine if anxiety is primary or secondary (due to medical condition)Ensure sound physical/neurological exam Use of Hamilton Rating ScaleComprehensive data related to anxietyDetermine potential for self-harm/suicidePerform psychosocial assessmentDetermine cultural beliefs and background

  • Nursing Process: Diagnosis and Outcomes IdentificationNANDA-International (NANDA-I) Nursing diagnoses useful for patient with anxiety or anxiety disorderNursing Outcomes Classification (NOC)Identifies desired outcomes for patients with anxiety or anxiety disorders

  • Considerations for Outcome Selection for Patients with Anxiety DisordersReflect patient values and ethical and environmental situationsBe culturally relevantBe documented as measurable goalsInclude a time estimate of expected outcomes

  • Nursing Process: Planning and ImplementationPlanningSelect interventions that can be implemented in a community settingInclude patient in process of planningImplementationFollow PsychiatricMental Health Nursing: Scope and Standards of Practice (ANA, 2007)

  • Nursing Interventions for Patients with Anxiety DisordersIdentify community resources offering specialized treatments proven as effectiveIdentify community support groupsUse therapeutic communication, milieu therapy, promotion of self-care activities, and psychobiological and health teaching and health promotion

  • Nursing Interventions:Milieu TherapyCognitive-Behavioral Therapy (CBT)

  • Common Benzodiazepine Anxiolytics Genericdiazepam lorazepam alprazolam clonazepam chlordiazepoxide oxazepam

    BrandValiumAtivanXanaxKlonopinLibriumSerax*Non- Anxiolytic: BusSparNon-sedating, non habit forming and not a prn. Good for the elderly

  • Non-benzodiazepine Hypnotic GenericZolpidemZaleponEszopicloneRamelteon BrandAmbien, *Ambien CRSonataLunestaRozerem

    *contains a two layer coatOne layer releases it simmediataely and other layer has a slow release of additional drug

  • The Nursing Process: Antianxiety AgentsBackground 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 consumptionDO NOT USE WITH ALCOHOL Nursing DiagnosisRisk for injuryRisk for activity intoleranceRisk for acute confusion

  • Planning/ImplementationMonitor 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

    Outcome Criteria/Evaluation

  • Common MedicationsBZAs: short-term treatment onlyCauses dependenceBuspirone: management of anxiety disordersSelective serotonin reuptake inhibitors (SSRIs): first-line treatment for all anxiety disordersSelective norepinephrine reuptake inhibitors (SNRIs): venlafaxine approved for panic disorder, GAD, and SADTricyclic antidepressants (TCAs): second- and third-line treatment

  • Nursing Process: EvaluationDoes 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?

    Also used for Alcohol withdrawal, depression as an adjunct, muscle spasm, preoperative sedation, seizure disorders.

    *Antihistamines are also used as anxiolytics because of their ability to depress the CNS by sedating the patient.*Nursing Dx are? Why?*What would you want to teach the patient about anxiolytics? Early adverse effects such as nausea, diaphoresis, tremor , fatigue, derowsiness first few days/weks, should soon subside, report all symptoms to primary care provider, take medication as prescribed. Avoid the use of SSRIs with MAOI antidepressants related to Serotonin Syndrome. Do no stop medication abruptly to prevent withdrawal syndrome. Medication should be tapered slowly,


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