PSYCHIATRIC NURSING

1. PSYCHIATRIC NURSING ANXIETY DISORDERS Chapter 18

2. Objectives • Define anxiety and differentiate it from other terms (stress, fear, etc.). • Describe various types of anxiety disorders. • Identify etiological factors in the development of anxiety disorders.

3. Theories: Anxiety Disorders • Biological changes in the brain • Noradrenergic system is sensitive to norepinephrine; locus ceruleus is involved in precipitating panic attacks. • Dopamine system involved in pathophysiology of OCD. • GABA dysfunction affects development of panic disorder.

4. Theories: Anxiety Disorders (cont'd) • Abnormal control of glutamate plays role in anxiety disorders. • Hormonal changes in pregnant women affect certain anxiety disorders. • Lactic acid may precipitate anxiety. • Caffeine and nicotine may trigger panic attacks.

5. Theories: Anxiety Disorders (cont'd) • Genetic theories: strong evidence for familial or genetic predisposition for anxiety disorders

6. Theories: Anxiety Disorders (cont'd) • Psychosocial theories: in psychoanalytic theory, anxiety is viewed as sign of psychologic conflict; anxiety is the outcome of repressing forbidden impulses

7. Theories: Anxiety Disorders (cont'd) • Behavioral theory • Anxiety is a learned response that can be unlearned. • Compulsive behavior is a maladaptive attempt to alleviate anxiety. • Behavior modification teaches new ways to behave.

8. Theories: Anxiety Disorders (cont'd) • Humanistic theories: • Environmental stressors, biological factors, and intrapsychic fears cannot be dealt with separately but rather as they interact with one another. • Treatment approaches are integrative.

9. Anxiety • A universal experience • A normal response that usually helps cope with threatening situations • Anxiety disorders are characterized by anxiety so disabling as to adversely affect day-to-day functioning • Affects all age groups

10. Anxiety (cont'd) • Anxiety disorders are most common of mental illnesses • All anxiety disorders have in common excessive, irrational fear and dread • Anxiety is either a dominant disturbance or an avoidance behavior • Free-floating anxiety is unrelated to a specific stimulus

11. Anxiety Disorders • Individuals face anxiety on a daily basis. • It is a necessary force for survival & provides motivation for achievement. • Anxiety is used interchangeably with stress, however, they are not the same. • stressor is an external pressure that is brought to bear on the individual. • Anxiety is the subjective emotional response to that stressor.

12. Anxiety Disorders • Anxiety: a vague diffuse apprehension that is associated with feelings of uncertainty and helplessness. • Stress: a state of disequilibrium that occurs when there is a disharmony between demands occurring within an individual’s internal or external environment and his/her ability to cope with those demands. • Fear: the intellectual appraisal of a threatening stimuli. It’s a cognitive process. • Anxiety is the emotional response to that appraisal.

13. Anxiety Disorders • Anxiety disorders are the most common of all psychiatric illnesses and may result in a considerable functional impairment. • More common in women (girls) than in men (boys) by 2:1. • More common in low socioeconomic and minority. • Familial predisposition to anxiety disorders. • Anxiety is usually considered a normal reaction to a realistic danger or threat to biological integrity or self-concept.

14. Anxiety Disorders • Anxiety considered abnormal if persists even when danger or threat is no longer present. • Anxiety is considered abnormal if: • It is out of proportion to the situation that is creating it. • It interferes with social, occupational, or other important areas of functioning.

15. Anxiety (cont'd) • Dissociation • Emotional numbing • Impaired social relationships • Separates emotions from behaviors • Consciousness, memory, identity, and/or perceptions of the environment are impaired.

16. Common Themes • Anxiety disorders and dissociative identity disorder originate in childhood. • Major common theme = disabling anxiety • Other common features: personality and mood changes, distorted perceptions, inability to concentrate, memory impairment, defense mechanisms

17. Common Themes (cont'd) • Both anxiety and dissociative disorders may have underlying comorbid illnesses like depression or substance abuse. • Both disorders profoundly affect quality of life.

18. Common Themes (cont'd) • Psychotropic medications and teaching adaptive coping are mainstays of treatment. • A holistic approach is best for caring for these clients.

19. 1. Panic disorder • This disorder is characterized by recurrent panic attacks, with unpredictable onset, and manifested by intense fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort. (ongoing worry about having another attack). • At least four of the following 13 symptoms must be present to identify the presence of panic disorder. If fewer than four symptoms are present, the individual is diagnosed as having a limited-symptom attack.

20. Panic disorder • Symptoms: • Palpitation, pounding heart, or accelerated heart rate. • Sweating • Trembling or shaking • Sensation of shortness of breath or smothering (suffocating) • Feeling of choking • Chest pain or discomfort • Nausea or abdominal distress • Feeling dizzy, unsteady, lightheaded, or faint

21. Panic disorder • Symptoms continue • Derealization (feelings of unreality) or depersonalization (being detached from self) • Fear of losing control or going crazy • Fear of dying • Paresthesis (numbness or tingling sensations) • Chills or hot flashes • The attacks usually last minutes or, more rarely, hours. Symptoms of depression are common.

22. Panic disorders • The average age of onset of panic disorder is the late 20s. • Frequency and severity varied (some people may have a moderate attacks weekly; others may have less sever attacks several times a weeks. • Panic disorder may/may not be accompanied by agoraphobia.

23. 2. Generalized anxiety disorder (GAD) • Characterized by chronic, unrealistic, and excessive anxiety and worry. Symptoms should exist for 6 months or longer, with no organic cause (caffeine intoxication, hyperthyroidism). • GAD symptoms (7 symptoms) must occurred more days than not for at least 6 months and cause clinically significant distress or impairment in functions. • These symptoms are: • Excessive anxiety & worry, • Restlessness or feeling on edge, • Being easily fatigued, • Difficulty concentrating (mind going blank),

24. Generalized anxiety disorder (GAD) • Irritability, • muscle tension, & • sleep disturbance (difficulty falling asleep, unsatisfied sleep) • Depression symptoms and somatic complaints may combine this disorder. • Onset is more common after 20 although the disorder may start in childhood or adolescent. • GAD tends to be chronic.

25. Generalized anxiety disorder (GAD) • There are many etiological implications for panic disorder and GAD: • Psychodynamic theory: inability of the ego to intervene with conflicts between id and superego, producing anxiety. • Cognitive theory: faulty thinking patterns precede maladaptive behaviors and emotional disorders leading to disturbance in feeling and behavior. Distorted thinking produce irrational appraisal. • Biological aspects: genetics

26. Generalized anxiety disorder (GAD) • Neuroanatomical: pathological changes in the temporal lobes, particularly hippocampus.

27. Generalized anxiety disorder (GAD) • Biochemical: abnormal elevation of blood lactate. • Neurochemical: involvement of the neurotransmitter norepinephrine. • Medical conditions: abnormality in hypothalamic-pituitary-adrenal & hypothalamic-pituitary-thyroid axes; acute MI, substance intoxication, hypoglycemia, caffeine intoxication, mitral valve prolapse..

28. 3. Phobias • Agoraphobia with panic disorder * Characterized by symptoms of panic disorder and the individual experiences a fear of being in places or situations from which escape might be difficult or in which help might not be available in the event that a panic attack should occur. Example: being outside the home alone. 2. Agoraphobia without history of panic disorder Less common than no 1

29. Phobias 3. Social phobia: excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others. • The individual may has extreme concern and fears any situation where social embarrassment may happen. • Examples (eating or speaking in public place, fear of use public toilets, fear of writing in the presence of others, saying thing infront of people, answering a question, etc.) • Exposure to the phobia situation usually produce feeling of anxiety, sweating, tachycardia and dyspnea).

30. Phobias • Onset often begins in the late childhood or early adolescence and runs chronic, sometimes lifelong. 4. Specific phobia (simple phobia):marked, persistent, excessive or unreasonable fear in the presence of, or in anticipating an encounter with, a specific object or situation. • Specific phobias frequently come with other anxiety disorders, but they are rarely the focus of clinical attention in these situations. • The phobic person may be no more anxious until exposed to the phobic object or situation. • Upon exposure, or even when the individual thinks about the phobic object, symptoms appear (palpitation, sweating, dizziness, difficult breathing, etc.).

31. Phobias • Individuals invariably recognize that the fear is excessive or unreasonable but powerless to change. • It may occur at any age. Those begin in childhood often disappear without treatment. • Women more than men. • The disorder is common among general population, however, people seldom seek treatment until the phobia interferes with their ability to function.

32. Phobias • There are 5 subtypes of the most common specific phobias: • Animal type (fear of animal or insect), • Natural-environment type (object/situation that occur in the natural environment such as height, storms, water), • Blood-injection-injury type (seeing blood, having injection, having any invasive medical procedure), • Situational type(fear of specific situation such as elevators, flight, driving, transportation) • Other type (all others irrational fears such as fear of contracting a serious illness)

33. Etiological implications for phobias • Psychoanalytical theory: Oedipal complex (opposite-sex parent) and castration anxiety (fears aggression from same-sex parent). To protect themselves these children repress this fear from the father and displace it onto something safer which becomes the phobic stimulus. (the phobic stimulus becomes the symbol of the father but the child does not realize this). • Learning theory: a stressful stimulus produces the ‘‘unconditioned’’ response to fear. When the stressful stimulus repeated with a harmless object, the harmless object alone produce the fear. This become phobia when the individual avoids harmless objects to escape fear.

34. Etiological implications for phobias • Phobia may also acquired by direct learning or modeling (a mother who exhibits fear toward an object will provide a model for the child who may also develop a phobia of same object). • Cognitive theory: faulty cognition/thinking such as negative self-statements and irrational beliefs. Some individual engage in a negative and irrational thinking that produce anxiety reaction. The individual begins to seek out avoidance to prevent the anxiety, and phobias result.

35. Etiological implications for phobias • Biological aspects: • Temperament: a 4 years old boy afraid of dogs and by age of 5 he overcomes his fear and used to play with dogs. Then, when he is 20, he is bitten by a dog and developed a dog phobia. • Life experiences: some researchers believe that phobias are symbolic of original anxiety-producing situations/subjects that have been repressed. (a child who is punished by locked in a room will develop phobia of closed places, a child who falls down stairs develops phobia of high places.

36. 4. Obsessive-compulsive disorder (OCD) OCD is characterized by recurrent obsessions (unwanted ideas) or compulsions (repetitive behavior to reduce anxiety) that are severe enough to be time-consuming or to cause marked distress or significant impairment. Etiological implications: • Psychoanalytical theory: weak, underdeveloped egos; regression to earlier developmental stage • Learning theory: conditioned response to traumatic event • Biological aspects: brain abnormalities, high serotonin secretion

37. 5. Posttraumatic stress disorder • PTSD is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving a personal threat to physical integrity or physical integrity of others. • The symptoms may be occur after learning about unexpected or violent death, serious harm, or threat of injury or death of a family member or close person. • PTSD is not related to common experiences. Examples (being kidnapped, being tortured, surviving sever automobile accident, etc.)

38. Posttraumatic stress disorder • Symptoms: high level of anxiety, nightmares, symptoms of depression, symptoms should be present for more than one month ( otherwise called acute stress disorder). • Etiological implications: Psychosocial theories, learning and cognitive theories

39. 6. Anxiety disorder due to a general medical condition • Symptoms as direct physiological consequence of a general medical condition. Examples: • Endocrine conditions (hypo and hyperthyroidism, hypoglycemia) • Cardiovascular conditions (congestive heart failure, pulmonary embolism) • Respiratory condition (COPD, pneumonia) • Metabolic conditions (B12 deficiency • Neurological conditions (encephalitis)

40. 7. Substance-induced anxiety disorder • Symptoms are due to direct physiological effects of a substance (drug, toxin exposure). • They symptoms may occur during substance withdrawal.

41. Treatment modalities for anxiety disorders • Individual psychotherapy • Cognitive therapy • Behavioral therapy • Group and family therapy • Psychopharmacology

42. Your Assessment Approach:The Client with an Anxiety Disorder • Physiological Assessment • How often do you experience palpitations? • Psychological Assessment • Do you feel sad and/or hopeless?

43. Your Assessment Approach:The Client with an Anxiety Disorder • Cognitive Assessment • Do you think about the same things over and over? • [More at Your Assessment Approach: Anxiety Disorder]

44. Your Assessment Approach:The Client with Panic Attack • To determine the psychological effects of panic on your client, ask: • How do you feel right now? • When did you start feeling this way?

45. Your Assessment Approach:The Client with Panic Attack • To determine the somatic effects of panic on your client, ask: • Are you having chest pains or shortness of breath? • Have you felt dizzy or faint? • [More at Your Assessment Approach: Panic Attack]

46. Your Assessment Approach: The Client with PTSD • Questions to help assess PTSD • When was the last time you struck out in anger? • How would you describe your mood right now? Happy? Sad? Depressed? • How much time do you spend thinking the same thing over and over?

47. Your Assessment Approach: The Client with PTSD • Questions to help assess PTSD • How do you sleep at night? Any nightmares or repetitive dreams? • [More at Your Assessment Approach: PTSD]

48. Comprehensive Assessment (cont'd) • Conduct a history and physical exam. • Gather subjective and objective information. • Interview family member(s) if possible.

49. Comprehensive Assessment (cont'd) • Complete psychosocial assessment to discover source of anxiety. • Differentiate between anxiety and depression. • Evaluate sleep and sleep quality.

50. Comprehensive Assessment (cont'd) • Complete suicide and homicide assessment. • Major focuses for a client with dissociative disorder are identity, memory, and consciousness.