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