Psychiatric Nursing: ANXIETY DISORDER ANXIETY DISORDER

ANXIETY • A subjective and individual experience characterized by feeling of apprehension, uneasiness, uncertainty, or dread that warns a person of actual or imagined, misperceived or misinterpreted danger. It is often preceded by new and unknown situations or experiences that threaten the security, self-concept, self-esteem or identity of the person. • It is manifested by both psychological and physiological symptoms • It is a normal response to stressor but no identifiable, specific or certain cause

Fear – object can be identified

2 PRIMARY PURPOSES OF ANXIETY 1. Alerts the person to an actual or impending danger 2. Prepares the person to take defensive action (fight or flight)

TYPES of ANXIETY 1. Normal – a healthy type of anxiety that mobilizes a person to action 2. Acute – precipitated by imminent loss or change that threatens the sense of security 3. Chronic – anxiety that the individual has lived with for a long time

LEVELS OF ANXIETY

MILD ANXIETY MODERATE SEVERE PANIC ANXIETY ANXIETY ANXIETY PSYCHOLOGICAL RESPONSES

1 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER

• Wide • Perceptual field • Perceptual field • Perceptual field perceptual field narrowed to reduced to one reduced to • Sharpened immediate task detail or focus on self senses • Selectively scattered • Cannot process • Increased attentive details any motivation • Cannot connect • Cannot environmental • Effective thoughts or complete tasks stimuli problem- events • Cannot solve • Distorted solving independently problems or perceptions • Increased • Increased used learn effectively • Loss of rational learning ability of automatisms • Behavior thought • Irritability geared toward • Doesn’t anxiety relief recognize and usually potential danger ineffective • Can’t • Doesn’t communicate respond to verbally redirection • Possible • Feels awe, delusions and dread, or horror hallucination • Crying • May be suicidal • Ritualistic behavior PHYSIOLOGICAL RESPONSES • Restlessness • Muscle tension • Severe • May bolt and • Fidgeting • Diaphoresis headache run, or • GI “butterflies” • Pounding pulse • Nausea, • Totally • Difficulty • Headache vomiting, and immobile and 2 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER

sleeping • Dry mouth diarrhea mute • Hypersensitivity • High voice • Trembling • Dilated pupils to noise pitch • Rigid stance • Increased blood • Faster rate of • Vertigo pressure and speech • Pale pulse • • GI upset • Tachycardia Flight or fight or • Frequent • Chest pain freeze urination Note: • Patient’s safety is the primary concern! • This can lasts from 5-30 minutes!

NURSING INTERVENTIONS CALM • Calm the client • Administer anxiolytics • Listen to patient’s concern • Minimize environmental stimuli

ANTI-ANXIETY AGENTS • Also known as anxiolytics or minor tranquillizers • Benzodiazepines are the most commonly used and most effective medications for treatment of anxiety. • Facilitate sleep • Alcohol is the oldest drug to be used to reduce anxiety. 3 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER

Mechanism of Action • Depression of the central nervous system

Classification of Anti-Anxiety agents • Benzodiazepines • Buspirone- serotonin and dopamine agonist • Beta-blocker- (Propanolol)

BENZODIAZEPINES • Alprazolam (Xanax) • Chlordiazepoxide (Librium) • Clonazepam (Klonopin) • Diazepam (Valium) • Flurazepam (Dalmane) • Lorazepam (Ativan), usually administer for elderly • Oxazepam (Serax), usually administer for elderly

Indications of Benzodiazepines • Anxiety • Sedation/sleep • Muscle spasm • Seizure disorder • Alcohol withdrawal symptoms

BENZODIAZEPINES • Prolonged use may lead to dependency and abuse

4 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • They appear to increase the effectiveness of GABA and may also alter the brain’s metabolism of serotonin and norepinephrine • All benzodiazepines are readily absorbed in the GI tract after oral administration • The onset of action is very rapid and peak levels are often reached within an hour or less

MAJOR INTERACTIONS WITH BENZODIAZEPINES Alcohol and other CNS Depressants • Increased sedation, CNS depression Antacids • Impaired absorption rate of benzodiazepines

SIDE EFFECTS OF BENZODIAZEPINES • Drowsiness, confusion, lethargy • Addiction • Potentiates the effects of other CNS depressant • Aggravate symptoms in depressed persons • Orthostatic hypotension • Paradoxical excitement • Nausea

PATIENT TEACHING • Benzodiazepines are not for the minor stresses of everyday life. • Over-the-counter drug may potentiate the actions of benzodiazepines • Driving should be avoided until tolerance develops • Alcohol and other CNS depressants potentiate the effects of benzodiazepine

5 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Hypersensitivity to one benzodiazepine may mean hypersensitivity to another • These drugs should not be stopped abruptly

BUSPIRONE (BuSpar) • Is not a benzodiazepine but is from the azapirones chemical group • Does not bind to the benzodiazepine recognition sites but probably acts as serotonin agonist • It causes no sedation thus makes it less attractive for abuse; not habit forming • Not a controlled substance • Does not potentiate the depressant effects of alcohol, barbiturates and other CNS drugs • Because it does not induce an immediate calming effect it should not be used as a prn medication for anxiety • Because of its high cost and slow onset of action, buspirone is not widely prescribed • Haldol and MAOIs may cause some adverse effects when co-administered

PROPANOLOL (Inderal) • Beta-blockers have a calming effect on the CNS • Effectively interrupts the physiological responses of anxiety (tremors & tachycardia) • Less effective than benzodiazepines • Relatively safe • Little abuse potential • Bradycardia, light-headedness, and heart block

6 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER

ANXIETY DISORDERS • Know as neurotic disorders • A group of conditions that share a key feature of excessive anxiety with ensuing behavioral, emotional and physiologic responses • Most common of all psychiatric disorders • The defense mechanism used are repression, displacement and symbolization • Types: 1) General Anxiety Disorder (GAD) 2) Panic disorder 3) OCD 4) Phobic disorder 5) PTSD

INCIDENCE • Highest prevalence rate of all mental disorders in the US • More prevalent in women • People younger than 45 years old • People who are separated or divorced • Lower socioeconomic status • Exception in OCD, which is equally prevalent in men and women, but more prevalent among boys than girls

ETIOLOGY OF ANXIETY DISORDERS 1. BIOLOGIC THEORIES a. Genetic theories 7 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER b. Neurochemical theories • GABA

• Gamma- amino butyric acid is believed to be dysfunctional

• An inhibitory neurotransmitter

• GABA functions as the body’s natural anti- anxiety agent by reducing cell excitability, thus decreasing neuronal firing • NOREPINEPHRINE

• Increases anxiety

• Related to panic attacks

• SEROTONIN

• Related to OCD 2. PSYCHODYNAMIC THEORIES A. Psychoanalytic theories • Person’s innate anxiety is the stimulus for behavior • Defense mechanisms are used in an attempt to reduce anxiety B. Interpersonal Theories • Anxiety is generated from problems in interpersonal relationships • The higher the level of anxiety, the lower the ability to communicate and to solve problems C. Behavioral Theory • Anxiety is learned through experiences • Responses to stressors are often the result of learned or conditioned behavior • Individuals who experienced intense fear early in life are likely to be anxious later in life

8 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • When individuals experience too many life changes over a short period of time, they may be unable to adjust and may display maladaptive behavior

GENERALIZED ANXIETY DISORDER • Characterized by at least 6 months of persistent and excessive worry and anxiety • Has familial pattern • 60% diagnosed w/ GAD are female • Identified in children and adolescents • Formerly called OVERANXIOUS DISORDER OF CHILDHOOD • Symptoms interfere with normal activities • In an attempt to control the symptoms of GAD, individual sometimes become dependent on alcohol or other substances • Nurses should encourage clients with GAD to rethink their perceptions of the stressor, recognize that some anxiety is a normal part of life, and learn new coping mechanisms • The anxiety and worry are associated with 3 or more of the following 6 symptoms: (REDSIM)

• Restlessness

• Easily fatigued

• Difficulty concentrating

• Sleep disturbance

• Irritability

• Muscle tension 9 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER

NURSING DIAGNOSIS • Anxiety related to feeling of helplessness • Fatigue related to insomnia • Disturbed sleep pattern related to inability to relax • Ineffective health maintenance related to inattention to activities of daily living (ADLs) • Impaired social interaction related to withdrawal from social contracts

NURSING INTERVENTIONS • Assists the patient in identifying events that tend to increase anxiety and events during which the patient experiences relative internal calm • Engage the patient in anticipatory planning • Teach the patient about relaxation techniques, and practice them with the patient • Help the patient work on the problem one at a time • Accompany the patient to activities that the patient is too anxious to attend alone • Instruct the patient in the use of sensory interventions, such as music therapy or aroma therapy

TREATMENT • Relaxation training (breathing exercises, progressive muscle relaxation, guided imagery) • Benzodiazepine therapy (early phase of treatment, optional) • Selective serotonin reuptake inhibitors • Psychotherapy

10 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Education

PANIC DISORDER • Characterized by panic attacks that recur at unpredictable times • Readily distinguished from GAD by its intensity and rapid, powerful onset • Between panic attacks, the individual may have little or no debilitating anxiety or may suffer from chronic anxiety about future attacks • Usually lasts between 1 minute and 1 hour • The onset is sudden and the source of anxiety may not be identifiable • Individuals with panic attacks frequently associate their symptoms with physical illness and are concerned about death • Feelings of hopelessness, helplessness and despair may lead to suicidal ideations • Three serious effects often occurs when left untreated 1. Avoidance – in effort to avoid attack, the person avoids activities, places, people or situations that he thinks trigger the attacks 2. Agoraphobia – soon the person fears and avoid public places where he thinks he has no escape when panic attack occurs 3. Anticipatory Anxiety – the client develop intense anxiety between episodes, worrying when and where the next one will strike. • Characterized by the rapid onset of fear, terror and discomfort accompanied by at least 4 of the following manifestations:

CLINICAL SYMPTOMS 4. Palpitations, pounding heart, or accelerated heart rate 5. Diaphoresis 6. Shortness of breath 7. Feeling of choking 11 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER 8. Chest pain or discomforts 9. Nausea or abdominal distress 10. Vertigo 11. Feelings of unreality or of being detached from self 12. Fear of losing control or of going crazy 13. Fear of dying 14. Numbness or tingling sensation 15. Chills or hot flashes NURSING DIAGNOSIS • Anxiety • Risk for injury • Ineffective coping • Impaired social interaction

NURSING INTERVENTIONS • Remain calm • Remain with the client during attack • Do not touch the client during an attack • Offer reassurance • Use short clear sentences • Provide safety • Reduce environmental stimuli • Administer medication • Help the patient find a pattern to the attacks

TREATMENT • Benzodiazepine (such as Alprazolam [Xanax])

12 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Antidepressants (Sertraline [Zoloft] or paroxetine [Paxil]) • Relaxation techniques • Aerobic exercise (only after careful evaluation; some patients have experienced panic attacks from lactic acid buildup after exercise

OBSESSIVE-COMPULSIVE DISORDER • Characterized by recurrent obsessions or compulsions that interferes with normal life • Inability to control the thoughts and behaviors despite the recognition by the person of their absurdity and intensity

OBSESSION • Recurrent, persistent thoughts, ideas, images or impulses that are a significant source of distress

COMPULSION

13 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Emotional urges or need to acts • Anxiety will increase if obsessive thoughts and compulsive behaviors are interrupted • Depression and/or substance abuse may occur as complication • Selective serotonin reuptake inhibitor (SSRI) antidepressant agents are the most effective somatic treatment for OCD • Possible benefits (secondary gains) that the patient experiences thereby perpetuating the behavior

COMMON OBSESSIONS • Contamination • Questions • Order • Sex • Aggressive feelings • Religion • Exactness • Safety or harm

COMMON COMPULSIONS • Counting • Praying • Handwashing • Repeating words • Checking

NURSING INTERVENTIONS

14 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Alleviate anxiety • Provide time for client to carry out rituals • Don’t interrupt a ritual after it has started; to do so could result in panic-level anxiety • Initially, support the behavior until adaptive constructive behavior can be gradually modified. • Avoid punishment and criticisms • Allow episodes of compulsive acts but set limit to prevent harmful acts

TREATMENT • Behavioral techniques • Desensitization, or gradual exposure (having the patient gradually engage in anxiety-provoking activities or situations) • Modeling of desired behavior (showing the patient how to respond to a bothersome stimuli) • Response delay (having the patient wait for increasingly longer intervals before engaging in ritualistic behaviors) • Cognitive therapy such as thought stopping (having the patient willfully interrupt unwanted, anxiety-producing thoughts by engaging in competing, activity or by yelling “stop” • Antidepressants (such as Paroxetine [Paxil]) • Nonreinforcement of secondary gains

POST TRAUMATIC STRESS DISORDER (PTSD)

15 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Associated with exposure to an extremely traumatic, menacing event such as military combat, rape, assault, kidnapping, torture, disasters, life-threatening illness • PTSD may also result from witnessing such events or learning that a loved one has experienced such events • Lasts longer than 1 month and consists of persistent re- experiencing of the event, persistent avoidance of associated stimuli and persistent symptoms of increased arousal • Individuals with PTSD use denial, repression, and suppression to cope with anxious feelings

ACUTE PTSD • Less than 3 months after the event CHRONIC PTSD • 3 months or more after the event DELAYED PTSD • At least 6 months after the event

CLINICAL MANIFESTATIONS • Flashbacks • Nightmares • Acting or feeling as if the events were recurring 16 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Intense physiological distress to internal or external cues symbolizing an aspect of the event • Physiologic reactions on exposure to stimuli that resemble an aspect of the event • Avoidance of thoughts, feelings or conversations associated with the trauma • Avoidance of activities, places, or people associated with the trauma • Inability to recall an important aspect of the trauma • Inability to recall an important aspect of the trauma • Feeling of detachment or estrangement from others • Restricted affect • Insomnia • Labile emotion • Decreased concentration • Hypervigilance • Exaggerated startle response

NURSING DIAGNOSIS • Post-trauma syndrome related to the traumatic experience • Risk for self-directed violence related to anger and self-blame over the event • Disturbed sleep pattern related to persistent dreams about the event • Anxiety related to feelings of insecurity and being unsafe

NURSING INTERVENTIONS • Encourage the patient to recall the traumatic event; remain non-judgmental and accept what the patient is saying • Provide a secure environment for the patient to promote a sense of safety.

17 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Remain with the patient, especially one who’s extremely anxious; re- experiencing the traumatic event can trigger severe or panic anxiety • Institute suicide precautions if the patient manifests suicidal tendencies • Facilitate grieving by encouraging the patient to express emotions generated from the event • Teach the patient and family about posttraumatic behavior, and refer them to support groups for additional help

TREATMENT • Psychotherapy (directed toward helping the patient achieve cognitive mastery over the traumatic situation) • Benzodiazepine therapy (may be prescribed to manage uncontrollable anxiety) • Anti-depressant therapy

PHOBIC DISORDER • Individuals with phobic disorders recognize that their phobias (fears of specific objects, activities and situations) are irrational • Contact with the feared stimuli, or mere thought of the stimuli, causes immediate, severe anxiety • Individuals with phobic disorder attempt to manage their anxiety by avoiding the feared stimuli • Most common form of anxiety disorders • Individual experiences intermittent anxiety which arises in particular circumstances (in response to the phobic object or situation) • Avoidance of the feared stimuli may drastically interfere with routine activities

18 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Inability of the person to overcome the fear, despite the recognition that the fear is absurd. • Willingness of the person to do anything to avoid the phobic object, person, or event, regardless of the consequences

TYPES OF PHOBIA • SOCIAL PHOBIA • AGORAPHOBIA • SIMPLE PHOBIA OR SPECIFIC PHOBIA

SOCIAL PHOBIA • Also called Social Anxiety Disorder • Excessive fear of embarrassment and humiliation in public settings • Social phobias strain interpersonal relationships and the phobic individual may become more anxious when SO attempt to provide support and assistance • Treatment with Alprazolam and exposure therapy

Performance situations that are often feared: • Public speaking • Public performance • Eating in public • Writing in public (signing a check or a credit card receipt) • Interactive situations feared include: • Talking over the telephone • Speaking to a stranger (to ask for directions) • Social gatherings

19 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • Dating • Speaking to store clerks • Speaking to authority figure

Note: Alcohol is often used, at times in problematic proportions to reduce the anxiety in interactive situations.

AGORAPHOBIA • An irrational fear of being in places away from the familiar setting of home, in crowds, or in situations that patient cannot leave easily such as standing in line, being on a bridge, and traveling in a plane, bus ,train, or car. • Clients may fear leaving their home.

SIMPLE PHOBIA • Also called SPECIFIC PHOBIA • The most common specific phobia in the general population is fear of animals – particularly of dogs, snakes, insect and mice • Unrealistic fear of a particular object or situation • Panic level anxiety may be experienced • An irrational fear of an object, activity or situation that is out of proportion to the stimulus and results in avoidance of the identified object, activity, or situation.

COMMON FORMS OF PHOBIA • ABLUTOPHOBIA – fear of washing or bathing • ACHLUOPHOBIA – fear of darkness • ACROPHOBIA – fear of heights • AGYROPHOBIA – fear of street or crossing the street 20 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • ALGOPHOBIA – fear of pain • ANDROPHOBIA – fear of men • ARITHMOPHOBIA – fear of numbers • ASTROPHOBIA – fear of storms, lightning, thunder • AUTOPHOBIA – fear of being alone • AVIOPHOBIA – fear of flying • BIBLIOPHOBIA – fear of books • CALIGYNEPHOBIA – fear of beautiful women • CLAUTROPHOBIA – fear of enclosed places • DIDASKALEINOPHOBHIA – fear of going to school • ENTOMOPHOBIA – fear of insects • EPISTEMOPHOBIA – fear of knowledge • EUROTOPHOBIA – fear of female genitalia • GENOPHOBIA – fear of sex • HEMATOPHOBIA – fear of blood • IATROPHOBIA - fear of doctors • ITHYPHALLOPHOBIA - Fear of seeing, thinking about or having an erect penis • MALAXOPHOBIA – fear of love play • NECROPHOBIA – fear of dead bodies • NOSOCOMEPHOBIA – fear of going to hospital • NYCTOPHOBIA – fear of night • OCHLOPHOBIA – fear of crowd • OPHIDIOPHOBIA – fear of snakes • PATHOPHOBIA – fear of disease • PENTHERAPHOBIA – fear of mother-in-law • PHILEMAPHOBIA – fear of kissing

21 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER • PHILOPHOBIA – fear of being in-love • PROCTOPHOBIA – fear of rectum • SITOPHOBIA – fear of flood • TESTOPHOBIA – fear of taking test • THANATOPHOBIA – fear of death • TRYPANOPHOBIA – fear of injection • ZOOPHOBIA – fear of animal

NURSING DIAGNOSIS • Fear related to an irrational feeling toward something harmless • Powerlessness related to an inability to control the fear • Social isolation related to self-protected avoidance

NURSING INTERVENTION • Never force the patient to contact the phobic object; such contact may precipitate a panic attack • Reassure the patient that he won’t be forced to confront the phobic situation • Initially, adjust the environment to accommodate the patient’s phobia; as treatment progresses, adjustment won’t be necessary

TREATMENT • Social skills training • Behavioral therapy

22 Gerald T. Evangelista, RN, MAN Psychiatric Nursing: ANXIETY DISORDER

• Systematic desensitization - gradual systematic exposure of the client to the feared situations/ objects under controlled conditions

• Flooding – a rapid desensitization in which a patient is exposed to the feared object without as much as preparation as systemic desensitization. • Benzodiazepines to manage panic attacks

23 Gerald T. Evangelista, RN, MAN