Anxiety Disorders

1. Anxiety Disorders

2. ANXIETY DISORDERS • Anxiety—Vague, subjective non specific feeling. *uneasiness, apprehension *tension,feeling of dread or impending doom • Causes- result of threat to one’s Biologic, Physiologic and Social Integrity- external influences

3. Types of Anxiety • Signal Anxiety- (Phobic Disorders) • Precipitant is identified • A learned anxiety response-results from situations successfully repressed or coped with using another defense mechanism

4. Trait anxiety • A function of Personality structure • Link with developmental process/events • May be linked to unresolved conflict/confusion (Anxiety Diathesis)a pre-disposition to anxiety when exposed to stressor. • E.g.. One had a chronically ill mother and is overprotective w/own children.

5. State Anxiety • Develops in conflict or stressful situations • Experiences limited control • Anxiety occurs before the situation arises • E.g.. Woman who avoids making appt w/PMD after finding breast mass and has a strong family hx. Of cancer.

6. Free Floating Anxiety • Pervasive sense of dread or doom • Cannot be attached to any idea or event • May result in panic state if stressors exceed the individuals ability to cope.

7. Levels of Anxiety • Hildegard Peplau “Interpersonal Relations in Nursing 1952” identified Four stages of anxiety on a continuum • Mild • Moderate • Severe Panic • Panic

8. Perceptual field widens Î awareness & motivation Î problem solving & learning Irritable Related client Needs: Restlessness “butterflies in stomach” Î sleep disturbance More sensitive to noise Behavioral & Physiologic changes in Mild Anxiety

9. Immediate task oriented Attentive to immediate task Difficulty w/concentration,but can be redirected V/S normal –increased Frequent urination Dry mouth/muscle tension Î rate of speech diaphoretic Behavioral & Physiologic changes Moderate Anxiety

10. Narrowed perceptual field-one detail Difficulty completing task or solving problems Cannot learn effectively Feelings of dread/doom Crying Ritualistic behaviors ie. Rocking Headache/nausea&vomiting Vertigo Pale Tachycardia C/o chest pain Rigid stance Behavioral & Physiologic changes in Severe Anxiety

11. Unable to process environmental stimuli Distorted perceptions Can only focus on self Risk for self harm Unable to communicate Irrational thoughts/behaviors Possible delusions/hallucinations Can run away from scene or Can be immobilized & mute Dilated pupils Î B/P, P, R Flight,fight or freeze reaction Behavioral & Physiologic changes in Panic level anxiety

12. Etiological Theories/Anxiety • Biologic Model • Hans Selye- expanded the idea that endocrine system and CNS (hypothalamus and Pituitary gland ) have reciprocal relationships • Studies of the neuropharmacology of the Autonomic Nervous System (ANS) re: regulation of Cardiovascular/GI/Motor systems –was shown responsive to stimuli • RX’s target seratonin, noradrenergic,& y-amino-butyric acid(GABA)

13. Psychodynamic Model • Concept views Anxiety as a warning to the ego • Three types Anxiety identified • REALITY Anxiety(painful emotional experience resulting from perception of danger in external world) • MORAL Anxiety (THE Ego’s experience of Guilt and Shame) • NEUROTIC Anxiety (perception of threat according to one’s instincts) • Neurotic sx’s develop to defend against anxiety

14. Interpersonal /Social Psychology Models/Anxiety • Anxiety is the response to external environment • Sullivan:”Anxiety is the first great educative experience in living” • Symptoms were response to expectations/insecurities/frustrations/conflicts between person and Primary Groups i.e..family, colleagues, social associates. • Emphasis on early development

15. Behavioral Model/Anxiety • Based on Learning theory- etiology of sx’s based on generalization of an earlier traumatic experience to a benign setting or object. • Links past experiences with present responses – anxiety occurs when a “signal” predicts a painful or feared event • May be linked to PTSD

16. Epidemiology of Anxiety Disorders • Anxiety D/O’s ---6 – 8% of population • More prevalent in women 22-44 y/o & in separated/divorced group • Except for OCD’s and Social Phobias –anxiety greater in women • Clients w/major Depression –18.8% inc.risk for panic d/o and 15/3% risk for agoraphobia • 10-12% of general population have simple phobias

17. Epidemiology of Anxiety Disorders in the Older Adult • 3.5 –10 % of elders suffer from Anxiety disorders • 10-15% of Women >65 y/o seek help from MD (Hegel, et.al 2002) • RISK factors: female; urban living; hx. Of worry or rumination;poor physical health; low socioeconomic status; stressful life events;depression & alcoholism GAD – most common anxiety D/O in the elderly C/b worry- co-exist w/depression.

18. Behavioral manifestations of Panic attacks • PANIC ATTACK-sudden onset –intense apprehension-fearfulness-terror assoc w/impending doom-lasts 15-30 minutes • 4 or more sx’s i.e..palpitations, sweating, trembling; SOB,choking,smothering sensation

19. Behavioral manifestations of Phobias • PHOBIAS – avoidance of object or situation • Significant distress or impairment of daily routines,occupation or social functioning. • Fear recognized as excessive or unreasonable

20. Post Traumatic Stress Disorder (PTSD) • C/b re-experiencing an extremely traumatic event(begins within 3 months to years after event –lasting months or years • Person avoids the stimuli associated with the event, • numbing of responsiveness,increased arousal

21. PTSD---characteristics • Intense fear /helplessness/horror upon exposure • Dreams,flashbacks, • Physical/psychological distress over reminders of the event • Avoids memory provoking stimuli • Feeling detached or estranged from others • Increased arousal (irritability,angry outburst,sleep problems,hypervigilance,exaggerated startle response)

22. PTSD interventions • Promote desensitization through gradual exposure to event or situation similar to the event • Teach relaxation techniques • Provide individual therapy to address loss of control issues • Encourage use of support groups • Encourage use of hypnotherapy

23. Generalized Anxiety Disorder • C/b at least 6 months of persistent, excessive worry and anxiety. • Uncontrollable worrying • Significant distress w/impaired social or occupational functioning • 3 of the following:restlessness, fatigues easily,difficulty w/concentration, thought blocking,irritability, muscle tension sleep disturbance.

24. Interventions • Attend to physical symptoms • Assist client to identify thoughts that arouse the anxiety & their bases • Assist client to change unrealistic thoughts to more realistic thoughts • Use cognitive re-structuring • Administer anti-anxiety medications as prescribed

25. Obsessive Compulsive Disorder • Obsessions –( thoughts, impulses or images) which cause marked anxiety or Compulsions(repetitive behaviors or mental acts) • Recurrent, persistent, unwanted thoughts impulses or images • Attempts to ignore,suppress,or neutralizes obsessions with compulsions –are mostly ineffective.

26. OCD interventions • Identify the situation that precipitates the behavior • Do not interrupt compulsive behaviors • Allow time for compulsive rituals • Provide safety related to behaviors • Provide schedule to distract behaviors • Set limits on rituals that may interfere with client well-being • Establish written contract-decrease frequency of compulsive behaviors

27. Developmental considerations • Child • Adolescent • Adult • Elder

28. Cultural Considerations for Anxiety disorders in: • Hispanic • African –American • Asian • European- American • Middle Eastern

29. The nurse is working with the family of a client with Obsessive Compulsive D/O.Which of the following should the nurse incorporate in the teaching plan? A.) the thoughts images and impulses are voluntary B.) the family should pay immediate attention to symptoms C.) the thoughts, images and impulses worsen the stress D.) OCD is a chronic disorder not responsive to treatment

30. A client displays isolation, bizarre behaviors, unsafe actions and poor hygiene. Which will be the first priority in the nursing care plan? A.) Safety B.)Hygiene C.)Isolation D.) Bizarre behaviors

31. The nurse would analyze the symptoms of muscle rigidity, GI upset, rapid speech,and need to urinate as which level of anxiety? A.) Mild B.) Moderate C.) Severe D.) Panic

32. A client has recently been involved in assisting with the clean-up from a flood that washed away many homes in his area and caused loss of life.Which of these interventions would assist the client in dealing with the traumatic experience. A. Provide the opportunity to talk about the experience. B. Encourage the client to leave the area in order to forget the experience. C. Suggest admission to a mental health facility. D. Arrange for a minister to speak with the client.

33. Appropriate discharge criteria for a client with chronic anxiety disorder is the client will--- A.) experience no more anxiety B.) suppress the anxiety symptoms and focus on the future C.) Identify situations and events that trigger anxiety D.) recognize the need to take medications for the rest of his/her life to control anxiety

34. The nurse is working with a client with chronic anxiety. The goal is that the client will identify early warning symptoms of anxiety.The nurse would analyze the client as moving towards this goal when the client: A.) begins to connect panic symptoms with thoughts about a recent break-up in a relationship. B.) is free of anxiety for one week C.)practices relaxation techniques daily and when anxiety increases D.)recognizes that others also experience anxiety in varying situations

35. A client is to receive medication therapy for an anxiety disorder. To reduce the risk of dependence and problems related with withdrawal, which of the following agents would the nurse most likely anticipate as being prescribed? (select all that apply) • Paroxetine (Paxil) • Sertaline (Zoloft) • Lorazepam (Ativan) • Venlafaxine (Effexor) • Clonazepam (Klonopin)

36. The nurse assesses a client with a diagnosis of Generalized Anxiety disorder for which of the following symptoms? • Fear and avoidance of specific situations or places. • Persistent obsessive thoughts • Re-experience of feelings associated with traumatic events • Unrealistic worry about a number of events in one’s life.

37. A 4 year-old girl who is a victim of a bomb blast that demolished the building which housed her daycare constantly builds block houses and blows them up. She also has nightmares frequently. Which one of the following diagnoses is appropriate for the nurse to make regarding this child? • Post-trauma response related to terrorist attack as evidenced by destructive behaviors and sleep disturbance. • Explosive disorder related to dysfunctional personality as evidenced by destructive behaviors. • Sleep disturbance related to emotional trauma as evidenced by nightmares. • Ineffective individual coping related to internal stressors as evidenced by destructive behaviors and nightmares.

38. Nursing Care Plan: Anxiety • Assessment data: • Appearance,Behavior,Conversation i.e.: • Wringing hands,decreased communication,restlessness, irritability,pacing,decreased attn, poor impulse control • Identify stressors- intra,inter, extrapersonal • Identify lines of defense

39. Goals/expected outcomes: • Short term: The client will: be –free of injury • Discuss feelings of dread or anxiety • Respond to relaxation techniques • Demonstrate ability to perform relaxation

40. Implementation: anxiety • Remain with client at all times if level is severe or panic(safety important) • Remove client to Quiet area( client is not able to deal with excessive stimuli) • Remain calm upon approaching client(client will feel more secure if you are in control of situation) • Use short simple clear statements(impaired ability to deal with abstractions/complexities) • Use PRN meds as indicated

41. Nursing interventions: • Educate client re use of caffeine, nicotine etc.(prevents/minimizes cardiovascular responses i.e. Inc heart rate and jitteriness) • Provide instruction regarding anxiety reduction stretagies • Progression relaxation techniques • Listening to smoothing music or relaxation tapes

42. When planning discharge for a client with chronic anxiety the nurse directs the goal of promoting a safe environment at home.The most appropriate maintenance goal should focus on which of the following: A.Continues contract with a crisis counselor B.Identifying anxiety producing situations C.Ignoring feelings of anxiety D.Eliminating all anxiety from daily situations

43. A client with OCD is admitted to the psychiatric unit for hand washing rituals. The day after admission she is scheduled for lab tests. To assure that he client is there on time, the nurse should: • Remind the client several times of her appointment. • Limit the number of hand washings • Tell her it is her responsibility to be there on time • Provide ample time for her to complete her rituals.

44. A client admitted for ritualistic behaviors is constipated and dehydrated. Which nursing intervention would this client most likely comply with? • Drinking Ensure between meals • Drinking extra fluids with meals • Drinking 8 oz. Of water every hour between meals • Drinking adequate amounts of fluid during the day

45. A woman comes into the emergency room in a severe state of anxiety following a car accident. The most appropriate nursing intervention is to: • Remain with the client • Put the client in a quiet room • Teach the client deep breathing • Encourage the client to talk about her feelings and concerns

46. A client is unwilling to go out of the house for “fear of doing something crazy in public”. As a result the client remains homebound except when accompanied outside by the spouse. Based on this data the nurse determines that the client is experiencing: A.Social phobia B. Agoraphobia C. Claustrophobia D. Hypochondriasis

47. A client is admitted to a psych unit after having many test for acute blindness for which there is no organic cause.The nurse learns the client became blind after witnessing a hit and run accident, when a family of three was killed. The nurse suspects the client may be experiencing: • Psychosis • Conversion Disorder • Dissociative Disorder • Repression