Anxiety Disorders

Biological Findings
 GAD and Panic D/o
 GABA Theory

? problem binding to the BZD receptors

? Altered receptor sensitivity

Abnormal NE and 5-HT neurotransmission

Studies have shown CO2 inhalation precipitates
panic attacks
 OCD
 ? if obsessions are r/t a defect in neural
inhibition of dominant frontal systems
 5-HT neurotransmission is dysregulated
Biological Findings (cont)
 PTSD
 Extreme stress is assoc with
damaging effects to the brain
 Abuse causes reduction in the
hippocampus (Bremner, et al 1997)
Psychological Factors
 Psychodynamic
 Anxiety results from breakthrough of
repressed ideas and emotions
 Ego defense mechanisms are used to
help manage anxiety
 Interpersonal
 Anxiety is linked to the emotional
distress caused when early needs go
unmet
Psychological Factors
(cont)
 Learning Theories
 Anxiety is a learned response that
can be unlearned
 Learn to be anxious through modeling
 Cognitive Theories
 Anxiety is caused by distortions in
thinking and perceiving
Major Anxiety Disorders
 Panic disorder with or without
agoraphobia
 Generalized anxiety disorder (GAD)
 Obsessive-compulsive disorder
(OCD)
 Phobias
 Post traumatic stress disorder
(PTSD)
Panic Disorder
Panic
 Panic attacks—alone are not listed in
the DSM IV classification as psychiatric
illnesses
 A discrete period of intense fear or
discomfort in which 4 or more of the
following sx develop abruptly and reach a
peak within 10 minutes:

Palpitations, pounding heart, accelerated heart
rate
 Sweating
 Trembling or shaking
 Sensations of SOB or choking

Chest pain or discomfort

Nausea or abdominal distress

Dizziness, lightheadedness, unsteadiness

Derealization, depersonalization

Fear of losing control or going crazy
DSM IV Criteria—Panic
Disorder
 Recent and unexpected panic
attacks
 At least one of the attacks has
been followed for 1 or more
months by 1 or more of the
following:
1. Persistent concern about having
additional attacks
2. Worry about the implications of the
attack or its consequences (losing
control; having a heart attack; going
Panic D/O Without
Agoraphobia
 The previous 2 criteria are met as
well as:
 The individual is free from
agoraphobic sx
 The panic attacks are not r/t direct
effects of a substance (illicit drugs or
medications)
 The panic attacks are not due to a
physiologic condition
 The panic attacks are not better
accounted for by another mental d/o
Panic D/O With
Agoraphobia
 To meet this criteria, the individual
must meet the criteria for panic
d/o as well as experience
debilitating agoraphobic sx
 Agoraphobia—fear of being in any
situation where escape might be
difficult or help unavailable in the
event of a panic attack
Treatment
 Interdisciplinary care is needed.
 Priority care issues include:
 Depression associated with panic disorder.
 Suicide needs to be assessed.
Nursing Management:
Biologic Domain
Assessment
 Ruling out of other disorders
 Assessment questions

Common features of panic attack (Table 21.5)
 Careful review of events prior to attack

 Substance use
 Sleep patterns
 Physical activity
Nursing Diagnosis:
Biologic Domain
 Anxiety
 Risk for self-harm
 Risk of suicide
Biologic Interventions
 Breathing control – Reduce hyperventilation,
and interrupt a panic attack. Practice.
 Nutritional planning
 Reduce anxiety-provoking substances, such as
caffeine, food coloring or MSG.
 Monitor symptoms after eating.
 Relaxation techniques
 Increase physical activity.
Psychopharmacologic
Treatment
Selective serotonin reuptake inhibitors (SSRIs)
 Fluoxetine and sertraline – can cause feelings of
overstimulation, slow titration
 Side effects – anticholinergic, dizziness, anxiety, nervousness
and sexual dysfunction
 Interact with MAOIs
 Fluoxetine interacts with flecainid, warfarin, phenytoin,
carbamazepine and vinblastine.
 Paroxetine interacts with cimetidine, decrease digoxin levels,
phobarbitol and phenytoin.
 Sertraline interacts with diazepan, tolbutamide and warfarin.
 Teaching points:
– Avoid over-the-counter medications.
– Sedative effects may impede judgment while operating machinery.
 Psychopharmacologic
Treatment
Tricylcic antidepressants
 Imipramine and clomipramine reduce panic attacks.
 Therapeutic effects usually occur in three to four weeks.
 Single bedtime doses help deal with sedation.
 EKG before initiation (cardiac conduction)
 Taper discontinuation to avoid cholinergic rebound.
 Observe for anticholinergic effects.
 Start at low doses and gradually increase.
 Interacts with several medications (MAOIs and CNS
depressants)
 Teaching points
– Take medication as prescribed.
– Avoid OTC medications without checking first.
– Warn about sedation; avoid operating machinery.
 Psychopharmacologic
Treatment
Benzodiazepines
 Used during periods of extreme stress and for
immediate symptom release
 Alprazolam, lorazepam and clonazepam
 Initiate benzodiazepines until antidepressants begin
working.
 Short-acting, associated with rebound anxiety
( alprazolam, lorazepam). Give in divided doses.
 Avoid if patient has sleep apnea.
 Withdrawal symptoms can occur.
 Side effects include: headache, confusion, dizziness,
disorientation, sedation and visual disturbances.
 Interactions with TCAs, digoxin, alcohol and other CNS
depressants. Avoid histamine blockers. Cigarette
smoking increases clearance.
 Teaching points: Avoid alcohol, sedative effects
Psychopharmacologic
Treatment
 Monoamine Oxidase Inhibitors
 Phenelzine (Nardil) has been used effectively.
Probably won’t be used because of safer medication
 Can take three to eight weeks to produce effects
 Side effects: sedation, weight gain, hypertension,
hypotension, dizziness, edema, agranulocytosis
 Interacts with food and drugs
 Teaching points: Inform patient of side effects.
Nursing Management:
Psychological Domain
Assessment
 Determining patterns of panic attack, symptoms and responses
 Mental status: restlessness, irritability, watchful or worried facial
expression, decreased attention span, difficulty problem solving,
apprehensive or helpless
 Suicidal assessment
 Cognitive thought patterns
 Avoidance behavior patterns
 Self-concept
 Risk assessment
 Rating scales
Nursing Diagnoses:
Psychological Domain
 Anxiety
 Risk for self-harm
 Powerlessness
Psychological
Interventions
 Help patient attend to and react to input other than
subjective experience. Provide patient with
information.
 Distraction
 Positive self-talk “I will get through this”
 Panic control treatment: structured exposure to
internal sensations
 Exposure therapy
 Systematic desensitization
 Implosive therapy
 Cognitive-behavioral therapy
 Psychoeducation
Nursing Management:
Social Domain
Assessment
 Family functioning
 Cultural factors
Social Interventions
 Stress time management
 Family support
 Help with communication
Emergency Care
Interventions for Panic
Attack
 Stay with the patient.
 Reassure him/her that you will not leave.
 Give clear directions.
 Assist patient to an environment with minimal
stimulation.
 Walk with the patient.
 Administer PRN anxiolytic medications.
Phobias
Phobias
 Specific phobia  Agoraphobia
 marked and  Anxiety about being in
persistent fear; places or situations
where escape may be
excessive and difficult or
unreasonable; embarrassing, and a
cued by presence panic attack may
or anticipation of occur
object  Avoided or endured
under stress
 Social phobia  There are those
 marked and persistent without a diagnosis of
fear of social or panic attack
performance
Post Traumatic Stress
Disorder (PTSD)
PTSD
 1st described in soldiers to explain the
pattern of responses following traumatic
events
 Recently investigators have begun to
adapt the PTSD model to other
traumatic events in human experience
 Adult and child sexual abuse
 Physical abuse
 Disasters
To Be Diagnosed With
PTSD….
A. The person has been exposed to
a traumatic event in which both
of the following were present:
1. The person witnessed, experienced,
or was confronted with an event or
events that involved actual or
threatened death or serious injury,
or a threat to the physical integrity
of self or others
2. The person’s response involved
To Be Diagnosed With
PTSD….
B. The traumatic event is
persistently reexperienced in 1
(or more) of the following ways:
1. Recurrent and intrusive distressing
recollections of the event
2. Recurrent distressing dreams of the
event
3. Acting or feeling as if the traumatic
event were recurring
To Be Diagnosed With
PTSD….
4. The experience of psychologic
distress when internal or external
cues resemble the event
5. Physiologic reactivity on exposure to
internal or external cues resembling
the event
To Be Diagnosed With
PTSD….
C. Persistent avoidance of stimuli
associated with the trauma and
numbing of general responsiveness as
indicated by 3 (or more) of the
following:
1. Efforts to avoid thoughts, feelings, or
conversations about the trauma
2. Efforts to avoid persons or places that
evoke memories of the trauma
3. An inability to remember certain aspects of
the trauma
4. Diminished interest or participation in
To Be Diagnosed With
PTSD….
5. A feeling of estrangement or detatchment
from others
6. Restricted range of affect
7. Sense of a foreshortened future
To Be Diagnosed With
PTSD….
D. Persistent sx of increased arousal
as indicated by 2 (or more) of the
following:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilence
5. Exaggerated startle response
To Be Diagnosed With
PTSD….
D. Duration of disturbance is more
than 1 month
E. The disturbance causes
significant impairment in social or
occupational functioning
Generalized Anxiety
Disorder (GAD)
GAD
 Characterized by excessive anxiety
and worry that occurs more days
than not, for at least 6 months
 This anxiety involves concerns
about a number of events and
activities
 The individual finds it difficult to
control the worry
GAD (cont)
 3 of the following 6 sx must be present
to some degree for a period of a least 6
months:
 Restlessness or feeling on edge
 Being easily fatigued
 Difficulties with concentration
 Irritability
 Muscle tension
 Sleep disturbance
 Anxiety or worry interferes with normal
social or occupational functioning
 Anxiety is not due to the effects of a
Obsessive Compulsive
Disorder (OCD)
OCD
 Characterized by the presence of either
obsessions or compulsions
 Obsessions—recurrent and persistent
thoughts, impulses, or images that are
experienced at some time during the
disturbance as intrusive and inappropriate
and cause marked distress or anxiety
 The individual attempts to suppress or
ignore these thoughts or to neutralize them
with some other thought or action
 Individual recognizes that the obsessional
thoughts are a product of his or her own
mind
OCD
 Compulsions are repetitive
behaviors that the person feels
driven to perform in response to
an obsession
 The behaviors are an attempt to
prevent or reduce the distress
invoked by the obsession
Treatment Modalities
Nursing Management:
Biologic Domain
 Assessment for multiple physical symptoms
 Physical fears
 Physical consequences of compulsions
 Nutrition and sleep status
 Dermatologic lesions secondary to hand
washing
 Head trauma
 Biologic Interventions
 Electroconvulsive therapy
 Psychosurgery
 Maintaining skin integrity
 Psychopharmacologic treatment
 SSRI and TCA
 Antidepressants given in higher doses than for treatment of
depression
 Side effect monitoring a problem for those preoccupied with
somatic concerns
 Teaching points: Manage medication; do not stop prescribed
medications abruptly; avoid OTC medications; and consider
sedative effect.
Nursing Management
Psychological Assessment
 Type and severity of obsessions and
compulsions
 Degree to which the OCD symptoms interfere
with patient’s daily functioning
 Consider using rating scales
 Suicide assessment
Psychological
Interventions
 Response prevention
 Thought stopping
 Relaxation techniques
 Cognitive restructuring
 Cue cards
 Psychoeducation (See Psychoeducation
Checklist.)
Nursing Management:
Social Domain
 Consider sociocultural factors and patient’s
ability to relate to others.
 In the hospital, unit routines are carefully and
clearly explained to decrease patient’s fear of
unknown.
 Recognize significance of rituals.
 Assist patient in arranging schedule.
 Marital and family support are important.
Nursing Management
 Social interventions
 Milieu interventions
 Personal and environmental protective
measures
 Family interventions
 Evaluation
 Continuum of care
Biologic interventions
 Pharmacologic interventions alone
or in combination with cognitive
interventions are among the most
successful treatments for anxiety
and related disorders
Examples of Benzos
 Aprazolam (Xanax)
 Dose/day 0.75-4 mg
 Chlordiazepoxide (Librium)
 Dose/day 25-200 mg
 Clonazepam (Klonopin)
 Dose/day 1-6 mg
 Diazepam (Valium)
 Dose/day 2-40 mg
 Lorazepam (Ativan)
 Dose/day 0.5-10 mg
Examples of Benzos (cont)
 Oxazepam (Serax)
 Dose/day 30-120 mg
 Prazepam (Centrax)
 Dose/day 20-60 mg
 Temazepam (Restoril)
 Dose/day 15-30 mg
Mechanism of Action of
Bezos
 Exert their effect through GABA
 Benzos facilitate the transmission of
GABA by binding to GABA-A receptors
and opening chloride channels
Side Effects of Benzos
 Sedation
 Fatigue
 Reduced motor coordination
 Impaired memory
 Cognitive dysfunction
Serious Side Effects of
Benzos
 Can lead to tolerance, abuse, and
dependence
 Rapid d/c produces withdrawal sx:
 Insomnia
 Diaphoresis
 Autonomic stimulation
 Irritability
 Seizures
Nonbenzodiazepine
Anxiolytic
 Buspirone (BuSpar)
 Antianxiety effects occur gradually over the
first 2 weeks of therapy
 Mechanism of action is unknown—it is a
partial agonist at the 5-HT receptor
 Indicated for the Rx of anxiety d/os
(specifically GAD)
 Side effects include:

Dizziness

H/A

Drowsiness
 CNS sedation and cognitive impairment
occur much less frequently with Buspar
Complementary Medicine
 Kava (50-75 mg tid)
 An herb with antianxiety effects
 SE—GI c/o, H/As, dizziness, and
allergic skin reactions
 Does not impair motor or mental fx
when taken in normal doses
Biologic interventions
 GAD
 SSRIs have found to be effective
 Venlafaxine (Effexor)
 Buspirone (Buspar)
 Panic Disorder
 TCAs—imipramine (Tofranil)
 SSRIs have also found to be effective
 OCD
 TCAs—clomipramine (Anafranil)
 SSRIs—fluvoxamine (Luvox)
Therapy
 Systematic desensitization
 Among the most effective treatments
for panic d/o with agoraphobia
 Cognitive Behavioral Therapy
 Widely used in the Rx of anxiety
disorders
 The client and the therapist identify
target sx and then examine the
circumstances associated with the sx
 Together they devise strategies to
change either the cognitions or the