Anxiety disorders

Anxiety; it occurs more commonly in women (2:1); it has a family predispsition; usually co-occurs/comorbidty

• apprehension, uneasiness, uncertainty, uneasiness, or dread from *real or perceived threat 
• Pathologic: when it is persistant, and not logical
• Fear: a reaction to specific danger 
• It is normal, and necessary for survival

depression (make eachother worse)

• The amygdala; 
• the hypocampus
• the brain stem
• increases rr and hr 
• causes tremors

increase in heart rate and BP, SOB, Palpitations, flushing, sweating, sensation of choking, tremors, nausea vomiting, increased urination

decreased attention, decreased concentration, forgetfulness, thought blocking

Mild: + , person is alert, sees, hears & grasps more than usual; goal oriented learning is enhanced; able to recognize anxiety; *What is experienced in everyday life (nail biting, fidgeting)

• moderate: ++ perceptual field is narrowed, but person can attend to more if directed to do so 
• selective inattention, mild somatic symptoms, problem solving capacity is still available (shaking, Head ache, upset stomach)

• severe: +++ 
• perceptual field greatly reduced
• requires direction to change focus; intense somatic symptoms present; feeling of impending doom; dazed

• Panic level: ++++ attention is severely narrowed or speed of scatter is sharply increased
• feelings of awe, dread, terror, are common;psychosis can occur
• rational communication and behavior disappear, flight/fight takes over
• exhaustion/death can occur if panic continues for prolonged period
• marked disturbed before hallucinations shouting, crying, screaming) *patient cannot stay like this for long, can lead to death

recurrent panic attacks (15-20 minutes duration) at least one attack followed by: persistent concern about having another, worry about losing control; significant change in behavior r/t attacks; can be with or without Agoraphobia

gradual restriction of activities/travel; anxiety about being in places where escape might be difficult; fear of being alone in open or public places; may not leave home ( will not go on a plane, bus, no crowds, won't drive on bridge, worry about having a panic attack

• *stay with the patient during panic attack (safety) 
• maintain calm(anxiety is transferred), supportive attitude, offer reassurance, speak using simple words, brief messages, and a slow delivery; decrease environmental stimuli; slow deep breaths, keep expectations minimal and simple, help connect feelings with attack onset; help client recognize symptoms as anxiety, not a physical problem; identify therapies, teach abdominal breathing and positive self talk

• Benzodiazepines 
• Alprazolam (xanax): 0.75-4mg/day
• Lorazapan (ativan): 2-6:mg/day
• Clonazepam (Klonopin): 1.5-4mg/day
• oxazepam (serax): 30-120mg/day

CNS depressants, decreased RR and HR *do not take with alcohol*

• buspirone (Buspar): 15-30mg/day *most common, no CNS depress, cannot be prn)
• Beta blockers (propranolol, Inderal: 30-80mg/day
• SSRIs: selective seritonin reuptake inhibitors (first line therapy; anti-depress, much more effective long term, can't reallyoverdose less side effects, no sedation) 
• sertraline (zoloft) 
• fluoxetine (prozac) 
• Paroxetine (paxil) 
• Fluvoxamine (luvox) 
• citalopram (celaxa

• excessive worry or anxiety about multiple issues which lingers six or more months and occurs more days then not 
• difficult to control worry
• and has 3 or more of the following: restlessness of feeling on edge
• easily fatigued; irritability; muscle tension; sleep disturbance common**)

• all the symptoms of anxiety, panic attacks, obsessions and compulsions that develop with the use of the substance 
• r/t starting, stopping, and using illegal drugs

• developmentally inappropriate levels of concern over being away from a significant other; typically diagnosed prior to age 18; symptom duration is one month; normal activates and sleep impaired 
• can result in panic disorders/panic attacks

• some are healthy: altruism, sublimination, suppression, humor
• intermediate: repression, displacement, reaction formation, somatization, rationalism, undoing
• never appropriate (immature): passive aggressive, projection, disassociation, denial, splitting ( hallmark of borderline, sees person as all good or all bad)

defense mechs: autonomic coping styles, protect people from anxiety, maintain self-imae by blocking(feelings, conflicts, memories) can be healthy or unhealthy

• fear cued by the presence or anticipation of a specific object o situation. Exposure invariably provokes an immediate anxiety response or a panic attacks, even though he/she recognizes that the fear is excessive or unreasonable. 
• The phobic stimulus is either avoided or endured with marked distress; classified according to the stimulus

• Spotlight shunners: expecting the worst; is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively  
• DSM: marked or persistent fear of one or more social situations
• exposure produces anxiety, person recognized fear is excessive, interferes significantly with person's routine, fear not related to effects of a substance, fear unrelated to general medical or psychiatric conditions

• Systemic desensitization
• in vitro- imagery
• In-vivo-live
• flooding (implosion therapy)
• group therapy
• medication
• cognitive therapy

• OCD: (thought) unfruitful attempt t ignore or suppress thoughts; recognizes thoughts as product of own mind
• Compulsion (act): ritual acts followed according to rigid rules, aimed at preventing or reducing distress or preventing some dreaded event; compulsive act is not realistic to prevent event

Run on rituals: obsessive-compuls. behaviors and activities take up more than 1hr/da. for some, rituals take hours to complete and become a major life activity

• MDD
• Panic disorder, social phobia, eating disorders, substance abuse, personality disorders

• Washers: fear contamination
• Checkers: doubt they have done something important (close/lock door)
• Doubters and sinners: fear of doom of not perfect
• Counters and arrangers: magical thinking/superstition about order, symmetry or number

• Biological: neurotransmitter imbalance (serotonin)
• there is an enlarged basal ganglia
• psychoanalytical: Overuse of defense mechanism "undoing"
• fixation at anal stage, underdeveloped egos, conflict between ID and EGO
• Cog-behavioral: compulsion is reinforced by reduction in anxiety

• difficulty discarding possessions of limited/no value. Marked distress associated with discarding
• Accumulation results in little to no useable personal space
• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others)

• anticipate needs, especially for information
• *focus on client rather than on rituals
• monitor nutrition/sleep; encourage meals/rest
• avoid hurrying client
• *** Do not arbitrarily forbid rituals; give positive reinforcement for non ritualistic activity
• prevent/treat self inflicted injury
• cog therapy: ** thought monitoring/blocking Ex. pivture STOP sign; rubber band on arm)

• Benzos
• SSRIs
• TCA-Clomipramine ( anafranil)

• picture going to fun house with mirrors; **exaggerated belief that body is deformed/flawed/defective in some way
• ex: slight flaws in face, acne, wrinkles, nose
• social and occupational impairment occurs r/t excessive anxiety
• numerous visits to plastic surgeons and dermatologists

• (somatic symptom disorders)
• Conversion disorder
• illness anxiety disorder(hypochondriasis)
• factitious disorders

• hx of many physical complaints
• occurs over a period of years
• results in tx being sought, significant impairment in functioning
• S&S cannot be explained by a medical condition; NOR are the intentionally produced or feigned

• etiology: children learn to gain affection, care, attention through illness; family systems unable to deal with conflict, child becomes ill, focus is on them (learned behavior)
• Outcome: client will demonstrate ability to cope with stress by means other than preoccupation with physical symptoms

• Loss or change in body function; the physical symptoms of which cannot be explained by any medical disorder. ex: paralysis, blindness, deafness, difficulty swallowing
• Primary gain: conversion S &S serve to prevent internal conflict/painful issues from attaining awareness
• secondary goal: enables client to avoid difficult situation or to obtain support that might otherwise not be forthcoming; S & S usually occur after a situation that produces extreme psychological stress
• Goal: client demonstrates more adaptive coping strategies for dealing with stress
• La belle: is a bland affect ex "oh whatever, who cares that I cant see"

• misinterpretation of physical sensations
• over concerned for health and preoccupied with symptoms; extreme worry and fear
• course of illness chronic and relapsing  

• Munchausen syndrome- undergo painful tests even though nothing is wrong to get attention
• Munchausen by proxy- usually in children

malingering

• precipitated by stressful event
• debilitating cognitive, emotional, and behavioral symptoms that negatively impact normal functioning; responses to stressful event may include combinations of depression, anxiety and conduct disturbance

re-experiencing of the trauma; avoidance of stimuli associated with trauma; persistent symptoms of increased arousal; alterations in mood

• Re-experiencing
• avoidance
• physical arousal

• War
• Terrorism
• Natural disasters
• violence/abuse
• accidents/injury

• Therapeutic nurse-client relationship: safe, trusting environment
• Remain with client during flashback; allow client to talk about trauma at own pace; acknowledge themes and validate feelings;
• debriefing: immediately following experience (encourage detailed description of event-multisensory experience)
• grief and loss therapy

• Beta blockers: decrease ANS hyperarousal by inhibiting norepinephrine (Inderal)
• Benzos: increase inhibitory effect of GABA (se prn.. addictive qualities)
• Mood stabilizers: stabilize CNS
• antidepressants: increase serotonin

• occurs after significant adverse experience/trauma; individuals respond to stress with severe interruption of consciousness
• *Unconsciousness defense mechanism
• protects individual against overwhelming anxiety through emotional separating

• diss. amnesia: inability to integrate memories
• diss. fugue: sudden travel away from home with no explanation
• diss. identity disorder: multiple personality disorder

• anger: emotion
• aggression: an action

• Children: anger co-exists with *ADHD, oppositional defiant disorder and impulsivity
• Adults: anger co-exists with *depression, PTSD, mania, Psychotic disorder, and Alzheimer's

• Overcrowding
• inexperienced staff
• provocative or controlling staff
• poor limit setting
• **History of violence is the single best predictor of future violence**

• Substance abusers
• cognitive defects
• those with unreal expectations
• those who feel ignored
• those who feel frightened and/or threatened

• restlessness/ hyperactivity
• signs of anxiety and tension
• profanity, argumentativeness
• loud voice or stony silence
• intense glaring eye contact
• intoxication
• carrying a dangerous object
• recent acts of violence
• challenging and threatening- verbal, written or gestures

• maintain client's dignity and self esteem
• stay calm
• assess situation; identify stressors and what client sees as his need 'use calm voice, non threatening body language
• be empathetic, genuine, honest
• maintain large personal space, don't argue
• give clear options
• assess for own personal safety