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feeling of apprehension, uneasiness, uncertainty or dread resulting from a real or perceived threat
What is important to remember about anxiety?
- we all face anxiety daily
- Provides motivation for achievement
- But must be kept within normal limits
What is normal anxiety?
- Considered normal reaction to a realistic danger or threat to biological integrity or self concept
- Normal anxiety dissipates when the danger or threat is no longer present
- "Normally" is determined by societal standards
When is Anxiety considered abnormal or pathological?
- Response to greatly disproportionate to risk
- Response continues beyond the existence of danger
- Intellectual, social or occupational functioning is impaired
- Person suffers psychosomatic effects (colitis, dermatitis, etc)
What is the prevalence of anxiety disorders?
- Most common form of psychiatric disorder in the US
- Affects approx 13.3% of the adult population
What are the major comorbidities of anxiety disorders?
- Major depression
- Substance abuse --> self medicate
What are the different levels of panic?
Describe mild anxiety
normal experience to everyday life
Describe Moderate anxiety
person sees, hears and grasps less information
Describe severe anxiety
- Person may focus on 1 detail or may scattered details
- Has difficulty noticing what is going on
- May have somatic symptoms (headache, dizzy)
- hyperventilation and sense of impeding doom
Describe panic anxiety
Most extreme and results in marked disturbance
- Unable to process what is going on in the environment may:
- loose touch with reality
- be vonfused
- hallucinate or have false sensory perceptions
What are some approaches to reduce anxiety?
- Relaxation response --> use regularly
- Meditation + guided imagery
- Therapeutic thought
- Cognitive restructuring and reframing
- Assertive training + progressive relaxation
- Music + Pets + Exercise + Talking with friends
- Breathing exercises
severe anxiety or panic
excessive, irrational fears cause patient to avoid feared object or situation
persistent, reccurent and intrusive thoughts, impulses that cant be dismissed
ritualistic behaviors patient feels driven to do repetitively to reduce anxiety
Define the biochemical factors theory for anxiety disorders
Biological and anatomical changes
Serotonin may have a role in producing symptoms associated with anxiety
Abnormal functioning of GABA (gamma-aminobutyric acid receptors), may also effect anxiety disorders
Behavioral therapy for OCD changes not only behavior by also brain chemistry
Abuse early in life is associated with greater limbic system dysfunction - theory is that abuse affect brain structure by reduction in the hippocampus size.
What role does serotonin have in producing symptoms of anxiety?
Serotonergic antidepressent, Anagranil, has a theraputic effect of OCD
Buspar, a serotonergic receptor antagonist is effective in other anxiety disorders
Describe how abnormal functioning of GABA (gamma-aminobutyric acid receptors) may effect anxiety disorders
- GABA believed to exert a "breaking effect" on anxiety
- Benzodiazepines (valium & xanax) enhance the activity of GABA at receptor recites and reduce anxiety
What are the genetic factors associated with anxiety disorders?
1/2 of a patients with panic disorders have a relative with this disorder
What are the different psycho-social theories for anxiety disorders?
- Interpersonal --> emotional distress in the early years can lead to anxiety
- Learning --> anxiety is learned response that may be unlearned
- Cognitive --> caused by distortions in a persons thinking and perceiving
What are the cultural aspects of anxiety disorders?
- Value conflicts created by immigration and assimilation into new culture may increase anxiety
- In some cultures, panic attacks involve fear of magic of witchcraft
- Phobias are excessive fear in the context of the culture
Name the different anxiety disorders
- Panic Disorder
- Specific (simple)
- Social anxiety disorder
- Obsessive compulsive disorder
- Generalized anxiety disorder
- Posttraumatic stress disorder
- Acute anxiety disorder
Describe a panic disorder without agoraphobia (fear of open spaces)
Panic disorder --> often associates with feelings of impending doom and intense physical discomfort
Symptoms come on unexpectedly --> do not occur immediately before or on exposure to a situation that would cause anxiety
Attack lasts minutes, rarely an hour
Average age onset in late 20's
What are the different symptoms that may be experienced with a panic disorder
How many do they need to have to be diagnosed?
They need to have 4
- Dyspnea or smothering sensation
- Dizziness or faintness
- Palpitations or tachycardia
- Trembling or shaking
- Nausea or abdominal distress
- Depersonalization or derealization
- Numbing or tingling
- Chest pain or discomfort
- Fear of dying
- Fear of going crazy
- Fear of doing something uncontrollable
experience a fear of being in places or situations from which escape might be difficult or embarrassing or in which help might be available
What is important to remember about Agoraphobia without an history of panic disorder?
It is rare!!
What is a social phobia?
AKA Social anxiety disorder
a persistent fear appearing shameful, stupid or inept in the persistence of others
What is a simple phobia?
- Persistent fear of specific object or situation
- Usually NOT associated with other psychiatric Symptoms or disorders
- Sensations can occur in response to person Merely THINKING about phobic stimulus
- Begin at almost any age
- Those in childhood usually disappear without treatment
- Persist into adulthood need treatment
What are the basics of OCD?
Recurrent obsessions or compulsions sufficiently severe to cause
- marked distress
- be time consuming or
- significantly interfere with the person's normal routine, occupations, functioning or usual social activities or relationships
persistent ideas, thoughts, impulses or images. Most common thoughts of violence, contamination or doubt
unwanted repetitive acts of intentional behavior patterns
person recognizes that the behavior is excessive or unreasonable, but is compelled to continue due to relief of discomfort
Can be conditioned response to a trauma
Lesions in hippocampus exibit nonspecific EEG changes
What are the most common compulsions?
When do compulsions typically start?
may begin in childhood, more often in adolescence or early childhood
What may complicate compulsions?
- Major depression
- Substance abuse
What is the goal of the nursing intervention for compulsions?
aimed at helping patient maintain anxiety at manageable level without having to resort to use of ritualistic behavior
What is generalized anxiety disorder?
Chronic, unrealistic and excessive anxiety and worry. Have existed 6 months or more and cannot be attributed to organic factors
Onset usually in the 20s or 30s
Mild depression symptoms common. Most often follow an episode of major depression
Somatic complaints may also be present
Describe the symptom motor tension of generalized anxiety disorder
- trembling, twitching or feeling shaky
- muscle tension, aches or soreness
- easily fatigued
Describe the symptom autonomic hyperactivity of generalized anxiety disorder
- SOB or smothering sensation
- palpitations or tachycardia
- sweating or cold clammy hands
- dry mouth + trouble swallowing
- dizziness or lightheaded
- nausea, diarrhea or abdominal distress
- hot flashes or chills + frequent urination
Describe the symptom of vigilance and scanning of generalized anxiety disorder
- feeling keyed up or on edge
- exaggerated startle response
- difficulty concentrating or "mind goes blank"
- trouble falling asleep or staying asleep
What are the predisposing factors to panic and generalized anxiety disorders?
Psychodynamic --> inability of the ego intervene when conflict between the id & superego which produces anxiety
What is the cognitive theory relating to the predisposing factors to panic and GAD.
- central process in adaptation is cognition or information processing
- disturbance in central mechanism of cognition leading to disturbance of feeling and behavior
What are the biological aspects relating to the predisposing factors to panic and GAD.
Neuroanatomical --> subcortex responsible for initiating and controlling states of physiological arousal and involuntary homeostatic functions
Biochemical --> abnormal elevation of blood lactate noted in patient with panic disorders
- Medical conditions:
- drug intox or withdrawal
- neuro disorders
What are some medical conditions that can cause anxiety?
- pulmonary embolism
- cardiac dysrhythmia
Called Secondary Anxiety
Also include substance induced anxiety
What is the best way to fix secondary anxiety?
Fix the underlying cause
What is PTSD?
Post-traumatic stress disorder --> development of symptoms following: a psychologically distressing event outside the range of usual human experiences
What are the symptoms of PTSD?
- re-experiencing the trauma
- sustained high level of anxiety or arousal
- general numbing of responsiveness
- symptoms of depression are common
- painful guilt about surviving
- can occur at any age
- may begin immediately following trauma or years later
- substance abuse common
What are the examples of trauma associated with PTSD?
- military combat
- flood + earthquake
- tornadoes + fires
- car or airplane crashes
Describe the basics of the traumatic experience that make up the predisposing factors to PTSD
- severity and duration of the stressor
- defree of preparation prior to onset
- exposure of death
- numbers affected by life threat
- degree of control over recurrence
- location of where trauma experienced (at home or in foreign country)
Describe the basics of the individual characteristics that make up the predisposing factors to PTSD
- degree of ego strength
- effective coping resources
- presence of pre-existing psychopathology
- outcome of precious experience with trauma
- current psyco-social developmental stage
- demographics (age, SEC, education, etc)
What is important about the recovery environment for patients with PTSD
- availability of social supports
- cohesiveness and protectiveness of family and friends
- attitude of society regarding the experience
- cultural and subcultural influence
What are the best predictors of PTSD?
- severity of the stressor
- isolation in the recovery period
- if the fundamental beliefs are invalidated by a trauma that cant be comprehended and sense of hopelessness. Sense of hopelessness prevails
Why are vietnam vets and rape victims more prone to PTSD?
environment that is less supportive than other disaster victims, assault or crime
What are the nursing interventions for PTSD
- Reassurance of safety
- Assist in ways to decrease maladaptive symptoms (flashbacks, nightmares)
- Increase more adaptive coping strategies
- Progression through grief process
What are the basics of acute stress disorder?
occurs within 1 month of trauma (shorter duration than PTSD)
Must have 3 dissociative symptoms during or after trauma
What are the dissociative symptoms associated with acute stress disorder?
- numbing, detachment or absence of emotions
- reduced awareness of surroundings
- derealization or depersonalization
- dissociative amnesia (loss of memory)
What is involved in the assessment of acute stress disorder?
- presenting symptoms
- past coping
- patient's goal
What are the nursing diagnosis for Anxiety Stress Disorder?
- Anxiety --> need to stage degree
- Coping, ineffective
- Thought process, Disturbed
- Self-esteem, Chronic low
- Spiritual distress
What is involved in the planning phase of acute stress disorder treatment?
Collaboration with client and other providers
Written in measurable, behavioral terms
What are some examples of measurable goals in the planning phase in the treatment acute stress disorder?
- Pulse and respiration will be within normal limits by friday
- Client will state a decrease in anxiety/panic from 10 to 7 on a scale of 10 by monday
- Identify 5 personal strengths by tuesday
- List 3 new coping skills by wednesday
- Utilize 1 new coping skill listed by monday
What are the basic nursing interventions for anxiety disorders?
- Reduce anxiety
- Enhance coping
- Instill hope
- Enhance self-esteem
- Use relaxation therapy
What is very important to remember about anxiety?
anxiety disorders often exist with depressive disorders therefore, are at risk for suicide.
What are some counseling techniques for anxiety intervention?
- cognitive restructuring (kicking a field goal)
- relaxation training (child birth classes)
- systematic desensitization
- response prevention
- thought stopping
What are some health care activities that are important during the intervention portion of anxiety treatment
What are the pharmaceutical treatments for anxiety?
- Non benzodiazepines
Describe the anziolytics used in anxiety treatment?
) --> used for short term due to dependence
) --> relieve symptoms of anxiety w/o dependence or tolerance
- Non benzodiazepines (buspar) -->
- does NOT produce immediate calm (can't give PRN)
- needs to be taken 2-3 wk for full effect
- good for generalized anxiety disorder
Describe the antidepressants used in anxiety treatment?
Tricyclic (elavil, tofranil) --> take 2-4 week
MAO (nardil) --> must have tyramine free diet or hypertensive crisis
What are the SSRI's used for anxiety disorders?
Prozac, paxil, zoloft
What are the beta blockers used in anxiety treatment and why?
help reduce physical symptoms, especially good with social phobias
What is important to know about somatoform disorders?
- physical symptoms suggest a physical disorder
- diagnostic tests are negative for physical illness
- symptoms are linked to phychobiological factors
What are dissociative disorders?
Disturbances in the normally well=integrated continuum of consciousness, memory, identity, and perception
Name the different somatoform disorders
- somatization disorders
- pain disorder
- body dysmorphic disorder
- conversion disorder
What are the basics of somatoform disorder?
- Chronic syndrome of multiple somatic symtoms that can't be explained medically with psychological distress and log term seeking health care assistance
- Anxiety and depression common as are suicide attempts
- Cultural and enviornmental factors need to be considered
What are the basics of hypochondriasis?
- Unrealistic preoccupation with fear of having a serious illness
- Symptoms are grossly disproportionate to the degree of pathology
- May be an ego defense mechanism for low self-esteem
What are the basics of pain disorder?
- Severe or prolonged pain for which there is no adequate medical explanation
- Need to look at secondary gains
What are the basics of Body Dysmorphic disorder?
- Exaggerated belief that the body is deformed or defective in some way
- Symptoms of depression and OCD are common
- Closely associated with delusional thinking
What are the basics of conversion disorder?
- Loss or change in body functioning resultin from a psychological conflict
- No adequate medical explanation
- May suggest neurological disease and occur after extreme psychological stress
- La Belle indifference --> lack of concern with the severity of the condition
What are the different dissociative disorders?
- Depersonalization disorder
- Dissociative amnesia
- Dissociative fugue
- Dissociative identity disorder
What is important to remember about dissociative disorders?
- essential feature --> disturbance or alteration in normal functions of identity, memory or consciousness
- Anxiety becomes overwhelming
- Statistically quite rare
- Most often with war or during natural disasters or sever psycho-social stress
What are the basics of depersonalization disorder?
- Change in quality of self-awareness, change in body image, feelings of detachment or observing oneself outside of body
- Depersonalization --> out of body experience
- Derealization --> like LSD trip
- Can have the physiological basis (brain tumor, epilepsy) or psychic conflicts
What is dissociative amnesia?
Sudden inability to recall important info that is too extensive to be explained by ordinary forgetfulness or organic disease or drug intoxication - withdrawal
What are the types of dissociative amnesia?
What is localized amnesia?
inability to recall all incidents associated with a trauma for a specific period following the event (few hours or days)
What is selective amnesia?
inability to recall only certain incidents associated with traumatic event for a specific time period after the event
What is generalized amnesia?
inability to recall anything that has happened during the person's entire life, including personal identity
What is continuous amnesia?
inability to recall events occurring after a specific time up to and including the present
Describe a dissociative fugue
Characterized by a sudden, unexpected travel away from home or customary workplace
Unable to recall personal identity and assumption of a new identity is common
What are the basics of Dissociative Identity Disorder?
- Characterized by the existence of 2 or more personalities within a single individual
- Transition from 1 personalty to another is usually sudden, often dramatic and precipitated by stress
- Can also be called Multiple Personality Disorder