NUR210CH12

• The person experiencing mild anxiety sees, hears, and grasps more information.
• Problem solving becomes more effective.
• Physical symptoms may include slight discomfort, restlessness, irritability and mild tension-relieving behaviors, e.g. nail biting, finger/toe tapping or fidgeting.

• Perceptual field narrows and some details are excluded from observation.
• The person sees, hears, and grasps less information and may demonstrate selective inattention, in which only certain things in the environment are seen or heard unless they are pointed out.
• The ability to think clearly is hampered, but learning and problem solving can still take place, although not at an optimal level. Physical symptoms include tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (gastric discomfort, headache, urinary urgency).
• Voice tremors and shaking may be noticed. Mild or moderate anxiety levels can be constructive, because anxiety may be a signal that something in the person's life needs attention or is dangerous.

• The perceptual field of a person experiencing severe anxiety is greatly reduced.
• A person with severe anxiety may focus on one particular detail or many scattered details and have difficulty noticing what is going on in the environment, even when it is pointed out by another.
• Learning and problem solving are not
• possible at this level, and the person may be dazed and confused. Behavior is automatic and aimed at reducing or relieving anxiety. Somatic symptoms (headache, nausea, dizziness, insomnia) often increase; trembling and a pounding heart are common, and the person may experience hyperventilation and a sense of impending doom or dread.

Mild

Moderate

Severe

Panic

Mild

Moderate

Severe

Panic

Mild

Severe

Panic

Severe

Severe to Panic

Mild

Moderate

Severe

Panic

Mild

Moderate

Severe

Panic

Compensation

A - A shorter-than-average man becomes assertively verbal and excels in business.

M - An individual drinks alcohol when self-esteem is low to temporarily diffuse discomfort.

Conversion

A - A student is unable to take a final examination because of a terrible headache.

M - A man becomes blind after seeing his wife flirt with other men.

Denial

A - A man reacts to news of the death of a loved one by saying, "No, I don't believe you. The doctor said he was fine."

M - A woman whose husband died 3 years earlier still keeps his clothes in the closet and talks about him in the present tense.

Displacement

A - A patient criticizes a nurse after his family fails to visit.

M - A child who is unable to acknowledge fear of his father becomes fearful of animals.

Dissociation

A - An art student is able to mentally separate herself from the noisy environment as she becomes absorbed in her work.

M - As the result of an abusive childhood and the need to separate from its realities, a woman finds herself perpetually in a world where she feels disconnected from reality.

Identification

A - An 8-year-old girl dresses up like her teacher and puts together a pretend classroom for her friends.

M - A young boy thinks a neighborhood pimp with money and drugs is someone to look up to.

Intellectualization

A - Despite the fact that a man has lost his farm to a tornado, he analyzes his options and leads his child to safety.

M - A man responds to the death of his wife by focusing on the details of day care and operating the house-hold, rather than processing the grief with his children.

Introjection

A - After his wife's death, a man has transient complaints of chest pains and difficulty breathing — the symptoms his wife had before she died.

M - A young child whose parents were overcritical and belittling grows up thinking that she is no good. She has taken on her parents' evaluation of her as part of her self-image.

Projection

A - A man who is unconsciously attracted to other women teases his wife about flirting.

M - A woman who has repressed an attraction toward other women refuses to socialize. She fears another woman will make homosexual advances toward her.

Rationalization

A - An employee says, "I didn't get the raise because the boss doesn't like me."

M - A man who thinks his son was fathered by another man excuses his malicious treatment of the boy by saying, "He is lazy and disobedient," when that is not the case.

Reaction formation

A - A recovering alcoholic constantly preaches about the evils of drink.

M - A woman who has an unconscious hostility toward her daughter is overprotective and hovers over her to protect her from harm, interfering with her normal growth and development.

Regression

A - A 4-year-old boy with a new baby brother starts sucking his thumb and wanting a bottle.

M - A man who loses a promotion starts complaining to others, hands in sloppy work, misses appointments, and comes in late for meetings.

Repression

A -  A man forgets his wife's birthday after a marital fight.

M - A woman is unable to enjoy sex after having pushed out of awareness a traumatic sexual incident from childhood.

Splitting

A - A toddler views her parents as super-human and wants to be like them.

M - A 26-year-old woman has difficulty maintaining close relationships. Despite the fact that she can initially find many positive qualities about new acquaintances, eventually she becomes disillusioned when they turn out to be flawed.

Sublimation

A - A woman who is angry with her boss writes a short story about a heroic woman.

M - The use of sublimation is always constructive, i.e. "healthy"

Suppression

A - A businessman who is preparing to make an important speech later in the day is told by his wife that morning that she wants a divorce. Although visibly upset, he puts the incident aside until after his speech, when he can give the matter his total concentration.

M - A woman who feels a lump in her breast shortly before leaving for a 3-week vacation puts the information in the back of her mind until after returning from her vacation.

Undoing

A - After flirting with her male secretary, a woman brings her husband tickets to a concert he wants to see.

M - A man with rigid, moralistic beliefs and repressed sexuality is driven to wash his hands to gain composure when around attractive women.

3. “Bill, slow down. Listen to me. You are safe. Take a nice, deep breath.”

Rationale: In this situation, the patient is demonstrating a severe level of anxiety as evidenced by his hyperventilation, increased purposeless motor activity, inability to focus to respond to his environment, and intensified somatic complaints. Patients at a severe level of anxiety are usually unable to focus sufficiently to engage in a conversation or process complex information. They respond better to short, direct statements or commands. Although the patient might benefit from sedating medication, as presented here, this intervention is more likely to be perceived as an ultimatum or a threat than a form of assistance and is likely to worsen his anxiety rather than calm him. Delaying the trial pass to the group home might also calm the patient but is not an appropriate first response; given that doing so would delay the patient’s discharge, it would be better to withhold this response until less disruptive calming measures had been tried.

1, 3, 5

Rationale:

Rationalization involves justifying one’s illogical or maladaptive responses by developing acceptable explanations for them; this is evident in the patient’s supporting his claim that he is not upset by stating that the visit was unimportant to him.

Projection involves taking the unacceptable feelings that are within oneself and projecting them onto others, so that others (in the patient’s view) possess them instead of the patient; this is in evidence here in the patient saying that he is not the angry one but that his family is angry with him instead.

Denial is escaping anxiety by ignoring or denying its existence; an example of this is the patient’s reporting that he is not angry.

Introjection involves incorporating within oneself some distressing element from one’s environment (e.g., a person who was raised by excessively critical parents assumes a very critical view of herself in adulthood).

Regression involves coping by returning to an earlier developmental or functional stage (e.g., a patient who has been criticized by a peer assumes a fetal position and begins to rock back and forth).

Dissociation involves responding to stress by separating oneself from one’s reality (e.g., during an episode of abuse, a child psychologically detaches herself from the present and enters a fantasy state wherein she feels safe and is able to defend herself from abusers).

B. John is experiencing anxiety and grief and should be monitored for PTSD symptoms.

Rationale: John is grieving for his lost coworkers and experiencing survivor’s guilt, a common reaction when events cost some their lives while sparing others. He is also evidencing some symptoms associated with anxiety, such as tremor and being sometimes preoccupied with the stressful event. However, he is not experiencing key features of PTSD such as re-experiencing the tragedy, avoidance of focusing on or talking about the event, or emotional numbing. Acute stress disorder is characterized by the presence of at least three dissociative elements in response to a stressor, such as feeling unreal, being less aware of one’s surroundings, or feeling a sense of unreality relative to oneself or one’s environment. In this case, John is experiencing only two such symptoms and has others that are not part of acute stress disorder. As noted, John is experiencing grief and mild-to-moderate anxiety in response to the tragedy he witnessed; however, given the intensity of this tragedy, it is important to monitor John for signs of PTSD, because he is at risk for developing this disorder (which usually manifests within 3 months of the traumatic event). Failure to monitor for PTSD would place John at risk of developing this potentially disabling anxiety disorder, which in some patients can even lead to suicidal behavior. Therefore, although his levels of anxiety and grief are not pathological at this time, because he is at risk for PTSD, he does requirement further intervention in the form of periodic reassessment and support.

1. Benzodiazepines

Rationale: All of the medications listed can be used to treat anxiety disorders, but benzodiazepines are the only type that are potentially addictive.

all

Rationale: Many medical conditions can cause or mimic anxiety. In an older adult, who would be more likely to have medical illnesses than a younger person (both diagnosed and undiscovered), it is especially important to rule out contributing medical conditions before assuming that symptoms resembling anxiety are of a mental health origin. Since disorders of the respiratory, circulatory, endocrine, metabolic, and neurological systems can all mimic anxiety or cause anxiety symptoms, further assessment of all these body systems is indicated. A professional in the role of patient advocate would use assertive communication techniques to alert the APRN to consider other possible causes for the patient’s presentation before concluding that primary anxiety is behind the patient’s symptoms.

A. often involve some degree of self-deception.

Most ego defense mechanisms, with the exception of the mature defenses, alter the individual's perception of reality to produce varying degrees of self-deception. Text page: 214

D. moderate.

When moderate anxiety is present the individual's perceptual field is reduced and the client is not able to see the entire picture of events. Text page: 213

A. often involve some degree of self-deception.

Most ego defense mechanisms, with the exception of the mature defenses, alter the individual's perception of reality to produce varying degrees of self-deception. Text page: 214

C. altruism and sublimation.

These defenses are termed mature defenses. They cannot be used in unhealthy ways.

Altruism results in resolving emotional conflicts by meeting the needs of others.

Sublimation substitutes socially acceptable activity for unacceptable impulses. Text page: 215

B. Procrastinating

A passive-aggressive person deals with emotional conflict by indirectly and unassertively expressing aggression toward others. Procrastination is an expression of resistance. Text page: 215

A. reaction formation.

Reaction formation keeps unacceptable feelings or behaviors out of awareness by developing the opposite behavior or emotion. Text page: 216

D. before age 40 years.

A. A second anxiety disorder may coexist with the first.

In many instances where one anxiety disorder is present, a second one coexists. Clinicians and researchers have clearly shown that anxiety disorders frequently co-occur with other psychiatric problems. Major depression often co-occurs and produces a greater impairment with poorer response to treatment. Text page: 224

C. Hypothalamus-pituitary-adrenal system

B. "Have you ever considered suicide?"

The presence of anxiety may cause an individual to consider suicide as a means of finding comfort and peace. Suicide assessment is appropriate to perform with any client with higher levels of anxiety. Text page: 229

C. severe.

Severe anxiety is characterized by feelings of falling apart and impending doom, impaired cognition, and severe somatic symptoms such as headache and pounding heart. Text page: 213

B. "Can you tell me what you were feeling just before your attack?"

A response that helps the client identify the precipitant stressor is most therapeutic. Text page: 219

C. suddenly tremble severely

Ataque de nervios (attack of the nerves) is a culture-bound syndrome that is seem in undereducated, disadvantaged females of Hispanic ethnicity. Text page: 227

B. a sibling with the disorder

Research shows that first-degree biological relatives of those with OCD have a higher frequency of the disorder than exists in the general population. Text page: 225

B. being so worried he hasn't been able to work for the last 12 months

GAD is characterized by symptomology that lasts 6 months or longer. Text page: 220

A. fear of dying.

Panic attacks in Latin Americans and Northern Europeans often involve sensations of choking, smothering, numbness or tingling, as well as fear of dying. Text page: 226

A. Not allowing the client to wash hands after touching a "dirty" object

Response prevention is a technique by which the client is prevented from engaging in the compulsive ritual. A form of behavior therapy, response prevention is never undertaken without physician approval.Text page: 238

C. telling the client to take slow, deep breaths.

Slow diaphragmatic breathing can induce relaxation and reduce symptoms of anxiety. Often the nurse has to tell the client to "breathe with me" and keep the client focused on the task. The slower breathing also reduces the threat of hypercapnia with its attendant symptoms. Text page: 238

C. a short-acting benzodiazepine

A short-acting benzodiazepine is the only type of medication listed that would lessen the client's symptoms of anxiety within a few minutes. Anticholinergics do not lower anxiety; tricyclic antidepressants have very little antianxiety effect and have a slow onset of action; and standard antipsychotic medication will lower anxiety but has a slower onset of action and the potential for more side effects. Text page: 236

A. determine use of chemical substances for anxiety relief.

Substance abuse often coexists with posttraumatic stress disorder. It is often the client's way of self-medicating to gain relief of symptoms. Text page: 223

C. teach the client to limit caffeine intake.

Caffeine is an antagonist of antianxiety medication. Text page: 237

C. sleep disturbance.

Clients who must engage in compulsive rituals for anxiety relief are rarely afforded relief for any prolonged period. The high anxiety level and need to perform the ritual may interfere with sleep. Text page: 220

C: Escort the manic client to her room, with assistance

The client is at risk for injury to self and others and should be escorted out of the dayroom. Option D may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is inappropriate already has been attempted by the nurse.

C: Conversion disorder

conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind.

A dissociated disorder is a disturbance or alteration in the normally integrative function of identity, memory or consciousness.

Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired interfering with the person's ability to deal with life's demands.

Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

B. At the same time each evening

Sertraline (***Zoloft***) is classified as an anti-depressant. Sertraline generally is administered once every 24 hours. It may be administered in the morning or evening, but evening administration may be preferable because drowsiness is a side effect. The medication may be administered without food or with food if gastrointestinal distress occurs. Sertraline is not prescribed for use as needed.

A. Diphenhydramine (Benadryl)

Over-the-counter medications used for allergies and cold symptoms are contraindicated because they will increase the sympathomimetic effects of MAOIs, possibly causing a hypertensive crisis. None of the remaining medications will increase the sympathomimetic response and, therefore, are not contraindicated.

Agoraphobia

It is a SSRI, generic Sertraline

OCD

It is SSRI, generic Fluvoxamine

an anxiety disorder

• Requires:
• A. Recurrent panic attacks
• B. At least one attack followed by 1 or more months of:
• 1 - Concern about additional attacks
• 2 - Worry about consequences, e.g. heart attack
• 3 - Significant change in behavior

With or without Agoraphobia

i.e. without a history of PD (Panic Disorder) occurs rarely, and if it does then early in Pt's history.

Over time, agoraphobia with PA usually develops.

Social phobias (fear of being seen, embarrassed or criticized)

It is β-blocker, generic Propranolol

lightning storms

talking

germs or dirt

night

strangers

Do you use any prescriptions, drugs or alcohol to decrease your anxiety associated with the fear?

reducing anxiety

The reason for the anxiety is that the obsessions driving the compulsions seem senseless to the individual and this creates anxiety.

A) 6 months

• B) Restlessness
• Fatigue
• Poor concentration
• Irritability
• Tension
• Sleep disturbance

C) out of proportion

• a) duration less than 3 months
• b) 3 months or more
• c) onset of symptoms delayed at least 6 months after stress

• A) within 3 months after the trauma
• B) months or years
• C) re-experiencing
• D) intrusive recollections
• E) dreams
• F) flashbacks - dissociative experiences in which the event is relived.
• G) 1 month

• A) 1 month
• B) is resolve within 2 days to 4 weeks

• alcohol
• cocaine
• heroin
• hallucinogens

• Chronic obstructive pulmonary
• Pulmonary embolism
• Asthma
• Hypoxia
• Pulmonary edema

1. Ensure that a sound physical and neurological examination is performed to help determine whether the anxiety is primary or secondary to another psychiatric disorder, medical condition, or substance use.

2. Determine current level of anxiety (mild, moderate, severe, or panic).

3. Assess for potential for self-harm and suicide; people suffering from high levels of intractable anxiety may become desperate and attempt suicide.

4. Perform a psychosocial assessment. Always ask the person, "What is going on in your life that maybe contributing to your anxiety?" The patient may identify a problem that should be addressed by counseling (stressful marriage, recent loss, stressful job or school situation).

5. Note: Culture can affect how anxiety is manifested.

• A) more rapid onset
• B) fewer problematic side effects

• Celexa
• Lexapro
• Prozac
• ***Luvox*** (OCD)
• ---more calming than the above are:
• Paxil
• ***Zoloft*** (agoraphobia)

• Cymbalta
• Effexor

• Elavil
• Anafranil
• Norpramine
• Adapin, Sinequan
• Tofranil
• Aventyl, Pamelor

• Nardil
• Parnate

• Xanax
• Librium
• Klonopin
• Valium
• Ativan

BuSpar - has no dependence issues and so can be taken long term, but it does takes 2-4 weeks to reach full effects.

• Atarax
• Vistaril

• FDA: none
• Off-label: GAD

• Tenormin
• ***Inderal*** (social phobia)

• Tegretol
• Neurotin
• Depakote

• an antibiotic for TB
• It also helps learning or "unlearning" as in fears (phobias)
• Also helpful with OCD