Types of Anxiety Disorders

Types of Anxiety Disorders  Situational anxiety: anxiety experienced by people faced with a stressful environment o Beneficial because it motivates people to accomplish tasks in a prompt manner; May be intense o Patients often learn coping mechanisms o Generalized anxiety disorder (GAD) difficult to control, excessive anxiety that lasts 6 months or more . Focuses on a variety of life events or activities, and interferes with normal day-to-day functions . Most common; most frequently encountered by the nurse . Symptoms = restlessness, fatigues, muscle tension, nervousness, inability to focus or concentrate, overwhelming sense of dread, sleep disturbances, elevated BP, heart palpitations, respiratory change, dry mouth, abdominal cramping, diarrhea, urinary urgency . Women are slightly more likely to experience GAD o Panic disorder: characterized by an intense feeling of immediate apprehension, fearfulness, terror, or impending doom, accompanied by increase autonomic nervous system activity o Phobias: fearful feelings attached to situations or objects . Common phobias include fear of snakes, spiders, crowds, and heights . Social anxiety = fear of crowds . Performance anxiety: performers may experience feelings of dread, nervousness, or apprehension before a performance . Phobias compel a patient to avoid the fearful stimulus entirely to the point that his or her behavior is unnatural o Obsessive-compulsive disorder (OCD): an unnatural behavior, that involves recurrent, intrusive thoughts or repetitive behaviors that interfere with normal activities or relationships . Fear of germs or repetitive hand washing o Post-traumatic stress disorder (PTSD): a type of situational anxiety that develops in response to re-experiencing a previous life event . Traumatic life events such as war, physical or sexual abuse, natural disasters, or murder may lead to a sense of helplessness and re- experiencing of the event

Specific Regions of the Brain Responsible for Anxiety and Wakefulness  Limbic system: an area in the middle of the brain responsible for emotional expression, learning and memory o Signals routed through the limbic system ultimately connect with the hypothalamus o Anxiety, fear, anger, aggression, remorse, depression, sexual drive, and euphoria  Hypothalamus – an important center responsible for unconscious response to extreme stress such as high BP, elevated respiratory rate, and dilated pupils  Responses associated with fight-or-flight response o Connects with the reticular formation o reticular formation: a network of neurons found along the entire length of the brainstem . stimulation causes heightened alertness and arousal . inhibition causes general drowsiness and the induction of sleep

Area responsible for Sleep and Wakefulness  reticular activating system (RAS) – larger area in which the reticular formation is found; connects the brainstem to the thalamus o responsible for sleeping and wakefulness o performs an alerting function for the entire cerebral cortex o helps a person focus attention on individual tasks by transmitting information to higher brain centers  if signals are prevented from passing through the RAS, no emotion-related signals are sent to the brain, resulting in a reduction in general brain activity

Anxiety Management through Pharmacologic  most productive way to manage stress = anxiolytics  stress is often a symptom of an underlying disorder  more productive to treat the cause of anxiety rather than just the symptoms with medication  Anxiolytics: drugs having the ability to relieve anxiety; provide treatment for phobias, PTSD, GAD, OCD, and panic attacks o Antidepressants o CNS depressants (drugs for seizures) o Emotional & mood disorder drugs o Antihypertensive drugs o Antidysrhythmic drugs

Indication for the need of pharmacotherapy in patient with anxiety  Assess intensity and duration of symptoms  Identify precipitating factors  Identify coping mechanisms  Assess for sleep disorders  Obtain a drug history o Hypersensitivity o Use of alcohol & other CNS depressants o Drug abuse & dependence  Use caution for certain clients o Those who are elderly o Those with suicidal potential o Those with impaired renal or liver function Table 14.1 Stages of Sleep Stage Description  At the onset of sleep, the patient is in a stage of drowsiness for about 1 to 7 minutes NREM Stage 1  patient can be easily awakened  lasts for about 4% to 5% of total sleep time.  The patient can still be easily awakened NREM Stage 2  This stage constitutes the greatest amount of total sleep time, 45% to 55%.  The patient may move into or out of a deeper sleep NREM Stage 3  HR & BP fall  GI activity rises  lasts for about 4% to 6% of total sleep time.  The deepest stage of sleep, 12% to 15% of total sleep time  nightmares occur in children NREM Stage 4  Sleepwalking is also a common behavior for this stage  HR & BP remain low  GI activity remains high.  This stage is characterized by eye movement and a loss of muscle tone REM Sleep  Eye movement occurs in burst of activity.  Dreaming takes place in this stage  The mind is very active and resembles a normal waking state.

Treating Anxiety & Insomnia with CNS Agents  Have an ability to reduce anxiety symptoms by altering levels of norepinephrine and serotonin  Restoration of neurotransmitter imbalances may reduce symptoms associated with depression, panic, OCD, and phobia  Typical antidepressants o Tricyclic antidepressants (TCAs) o Selective serotonin reuptake inhibitors (SSRIs) o Monoamine oxidase inhibitors (MAOIs)  Categorized into 2 classes = Benzodiazepines & Barbiturates  Other CNS depressants that have a calming effect in the body include the opioids and ethyl alcohol  Should be viewed as a continuum ranging from relaxation to sedation, to the induction of sleep and anesthesia  Coma and death are the end stages of CNS depression  Can cause physical or psychological dependence  Sedatives: medications that depress the CNS because of their ability to sedate or relax a patient  Hypnotics: at higher does, sedatives are called hypnotics because of their high ability to induce sleep  Sedative-Hypnotic: term used to describe a drug with the ability to produce a calming effect at lower doses and the ability to induce sleep at high doses  Tranquilizer: an older term, sometimes used to describe a drug that produces a calm or tranquil effect  Withdrawal Syndrome o for some CNS depressants can cause life threatening neurologic reactions o fever, psychosis, seizures o increased heart rate o lowered blood pressure o loss of appetite o muscle cramps o impairment of memory, concentration, and orientation o abnormal sounds in the ears and blurred vision o insomnia, agitation, anxiety, and panic

Table 14.3 SSRIs – Fluoxetine (Prozac) Adverse Effects  Stevens-Johnson Syndrome  Abnormal bleeding  Extreme mania/hypomania  Extreme psychomotor disturbances  Suicidality (especially in children)  Seizures  Autonomic instability with possible rapid fluctuations of vital signs  Severe hyperthermia  Serotonin syndrome

Antidepressants → treat major depression and anxiety conditions including GAD, OCD, panic, phobia, and PTSD  Mechanism of action – increase availability of serotonin at specific postsynaptic receptor sites located within the CNS o Adverse Effects – dizziness, nausea, insomnia, somnolence, confusion, seizures  MAOIs (monoamine oxidase inhibitors) o Avoid foods containing tyramine, a form of the amino acid tyrosine, to avoid a hypertensive crisis o Refrain from caffeine intake o MAOIs potentiate the effects of insulin and other diabetic drugs o Adverse Effects – orthostatic hypotension, headache, diarrhea o Rarely used because of the potential for serious adverse effects

Prototype Drug Escitalopram  Action and Uses – selective serotonin reuptake inhibitor (SSRI) o Increases the availability of serotonin at specific postsynaptic receptor sites located within the CNS o Selective inhibition of serotonin reuptake results in antidepressant activity without production of symptoms of sympathomimetics or anticholinergic activity o This medication is indicated for conditions of generalized anxiety and depression o Unlabeled uses include the treatment of panic disorder  Drug-Drug Interactions o Should be avoided dur to serotonin syndrome, marked by autonomic hyperactivity, hyperthermia, rigidity, diaphoresis, and neuroleptic malignant syndrome o Combination with MAOIs can result in hypertensive crisis, hyperthermia, and autonomic instability o Will increase plasma levels of metoprolol and cometidine o Concurrent use of alcohol and other CNS depressants may enhance CNS depressant effects

Treating Anxiety and insomnia with benzodiazepines  Withdrawal Effect?  Why are they the drug of choice? o Drug of choice for short-term treatment of insomnia caused by anxiety o They have replaced barbiturates because of their greater safety margin o Shorten the length of time it takes to fall asleep o Reduce the frequency of interrupted sleep

Table 14.4 Clonazepam (Klonopin) Adverse Effects  Acute hyperexcited states  increased Muscle spasticity  Hallucinations  Renal impairment  Congenital defects among women who are pregnant  Respiratory impairment due to hypersalivation  Respiratory depression  Laryngospasm  Cardiovascular collapse

Table 14.4 Lorazepam (Ativan) Adverse effect  Drowsiness and sedation  When given in higher doses or by the IV route, more severe effects may be observed o Amnesia o Blood pressure changes o Weakness o Blurred vision o Disorientation o Double vision o Ataxia o Nausea o Sleep disturbance o Vomiting  Should be monitored carefully due to rapid onset of CNS effects and potential respiratory depression with adjunctive therapies  Drug of choice for short-term treatment of insomnia cause by anxiety Barbiturates (Why are they not the drug of choice?)  Drugs derived from barbituric acid  Powerful CNS depressants prescribed for their sedative, hypnotic, and antiseizure effects  Rarely used because of significant adverse effects  High Risk of psychologic and physical dependence – Schedule II drugs  Withdrawal syndrome is extremely severe and can be fatal  Overdose results in profound respiratory depression, hypotension, and shock  Capable of depression CNS function at all levels  Intensify the effects of GABA throughout the brain by binding to GABA receptor- chloride channel molecules o low doses = reduce anxiety and cause drowsiness o moderate doses = inhibit seizure activity and promote sleep by inhibiting brain impulses traveling through the limbic system & the RAS o high doses = can induce anesthesia  tolerance can develop with repeated use

Table 14.5 Barbiturates for Sedation & Insomnia  Adverse Effects of Antiseizure Medication o Short acting = Respiratory depression, laryngospasm, & apnea o Intermediate acting = agranulocytosis, angioedema, Stevens-Johnson syndrome, respiratory depression, circulatory collapse, apnea, laryngospasm o Long Acting = agranulocytosis, respiratory depression, Stevens-Johnson syndrome, exfoliative dermatitis (rare), CNS depression, coma & death

Other CNS depressants for anxiety and sleep disorders  Chemically unrelated to either benzodiazepines or barbiturates  Antiseizure medication valporate  Beta blocker propanolol and Atenolol  Drugs used mainly for insomnia therapy include the newest of all nonbenzodiazepines CNS depressants o Zaleplon o Eszopiclone – used for hypnotic effects o Zolpidem – used for hypnotic effects  Older CNS depressants include o Paraldehyde o Chloral hydrate  Buspirone and zolpidem are commonly prescribed for anxiolytic effects  Buspirone mechanism of action is unclear o Appears to be related to D2 dopamine receptors in the brain o Has agonist effects on presynaptic dopamine receptors and a high affinity for serotonin receptors o Less likely to affects cognitive and motor performance o Rarely interacts with other CNS depressants o Adverse effects = dizziness, headache, drowsiness o Dependence and withdrawal problems are less of a concern  Zolpidem – Schedule IV controlled substance o Limited to short-term treatment of insomnia o Highly specific to GABA receptors o Produces muscle relaxation and anticonvulsant effects only at doses much higher than the hypnotic dose o Used cautiously in patients with respiratory impairment, older adults, and when used concurrently with other CNS depressants o Because it is metabolized in the liver and excreted by the kidneys, impaired liver or kidney function can increase serum drug levels o Adverse Effects = mild nausea, dizziness, diarrhea, daytime drowsiness, rebound insomnia may occur with discontinued use, amnesia, sleepwalking

Prototype drug Zolpidem (Ambien)  Adverse effects o Daytime sedation o Dizziness o Confusion o Depression o Amnesia o Nausea vomiting  Drug-Drug Interaction – drug interactions include an increase in sedation when used concurrently with other CNS depressants, including alcohol o Phenothiazines augment CNS depression  Herbal & Food Interaction – when taken with food, absorption is slowed significantly, and the onset of action may be delayed

Nursing implications  Assessment  Potential nursing diagnoses o Risk for injury o Knowledge deficit related to drug therapy o Ineffective individual coping  Reason for the drug, Monitoring vital signs, Cautions and contraindications  Possible drug interactions o Completing health history o Drug history o Evaluation of lab reports  Planning → client will o Experience therapeutic effects depending on drug o Be free of adverse effects o Demonstrate an understanding of the drugs activity o Accurately describe drug side effects and precautions o Demonstrate proper self-administration technique  Implementation o Interventions & rationales o Administration of drugs o Observe for adverse effects o Client education and discharge planning  Evaluation o Effectiveness of Drug therapy o Evaluate the achievement of the goals & expected outcomes