Anxiety

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 Hear this?
• There is an intense, constant fear that is
hard to describe
• It’s a sinking feeling in your stomach—
almost as if someone is stalking you and
you never know when those arms are going
to wrap around you and drag you away.
• There’s more anxiety today, and that
women, in particular, are feeling it

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 Introduction
• Common in all phases of life
• Most prevalent mental disorders in the U.S.
• Afflicting 28.7% of the population (life span);
19.3% over a 12-month period
• 1 in 4 people with an anxiety disorder is correctly
identified, diagnosed, and treated
• Client’s symptoms are not primarily due to
organic factors
• Stress, fear, anxiety, depression

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 Types of Anxiety (DSM-IV)
• Panic disorder – acute anxiety
• Specific phobia; social phobia;
• Obsessive-compulsive disorder
• Posttraumatic stress disorder
• Generalized anxiety disorder

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Types of Anxiety (DSM-IV) –cont’d
• Acute stress disorder – immediately after the event
• Anxiety disorder due to a general medical
condition
• Substance-induced anxiety disorder
• Others –
– Adjustment disorders featuring anxiety
– Separation anxiety
– Sleep disorder of insomnia

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 Symptoms of Anxiety Disorders
• Motor tension - trembling, feeling shaky,
muscle tension, muscle aches, restlessness
• Autonomic nervous system hyperactivity –
shortness of breath, feeling of being
smothered, heart rate↑, sweating or feel cold,
clammy hands, dry mouth, dizziness,
• Hypervigilance – feeling edgy, difficulty
concentrating, irritability

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 Dynamics of anxiety
• Stress, coping & defense mechanism
• Theories - Freud, Sullivan, Selye
• Primary gain - desire to relieve anxiety
• Secondary gain - attention gained from
others

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Process of Coping
Stressor Anxiety Neurochemical/physiological
reactions

Adaptive
Palliative
Coping Maladaptive
Dysfunctional

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 What is anxiety?
• Anxiety is a normal emotion which helps us
recognize real problems and solve them. In
its healthy form, anxiety helps you perform
at your top form when you’re adjusting to,
say, a new job or a new baby
• Anxiety is not normal when it lasts days
beyond a specific stressful event, or when it
interferes with a person’s life

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 Levels of Anxiety
• Mild +1 - slight fidgeting, alert, feeling
challenged, ready for constructive action,
• Moderate +2 - irritability ↑, confidence ↓
concentrating↓, ready for protective action
• Severe +3 - hypersensitivity, distorted
perceptions, ready for flight or fight,
• Panic +4 - actual flight/fight or
immobilization, rage, disorganized,
distorted sensory awareness
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 Intervention in levels of anxiety
• Mild +1 – take as natural; benefit from it
• Moderate +2 - ↓anxiety by crying,
exercising, refocusing; using medications
• Severe +3 - ↓anxiety & stimuli; use simple
directions, use time out (seclusion); using
medication (IM)
• Panic +4 – guide firmly, restrains if needed,
using medication (IM)
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 Interventions to Reduce Anxiety
• Calm & quiet environment
• To identify what and how they feel
• To describe & discuss their feeling
• To identify the possible causes
• To listen carefully - assess suicidal attempt
• Do something - to release nervous energy;
to discourage preoccupation with the self.

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 Anxiety and other diseases
• Panic disorder occurs in 15-30% of the
major depression cases
• Factitious disorder –deliberately make up
the symptoms
– ie. Munchausen syndrome by proxy
• Malingering – consciously create or
exaggerate false symptoms to avoid work or
other responsibilities
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 Social Phobia –
Most common anxiety disorder
• An extreme fear of being judged by others
• Chr, unremitting, life long disorder.
• begins around age of 13-20
• Prevalence: 13.3% lifetime duration
• Lead to other problems: alcohol (18.8%0,
drug abuse (13.0%), agoraphobia (44.9%)*
• Paralyzed by fears that he will humiliate or
embarrass himself in front of others -> drop
out from school, unemployed, no friends, …
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 Panic disorder (panic attack)
• Happen unexpected or situationally bound
• Spontaneous attacks of intense fear and
discomfort; may last from minutes to an
hour
• Symptoms of anxiety can last for hours
• S & S include heart rate ↑, chest pain, chills
or hot flushes, dizziness, SOB, fear of
losing control, depersonalization
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 Interventions for Panic Attack
• Stay with the pt and acknowledge the pt’s
discomfort
• Maintain calm, keep the environment quiet
• Use simple direction
• Allow pts to pace or cry – to release tension
• Reassure the pt, you are in control
• Use paper bag for hyperventilation pt
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 generalized anxiety disorder
• Persistent, excessive and unrealistic worry
that lasts for 6 months and more
• Worry for everything, irrational concerns,
• S/S: restlessness; difficulty concentrating or
sleeping; irritability; fatigue; muscle tension

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 Obsessive-compulsive Disorder
• Repetitive behaviors or experiencing
recurrent, persistent thought
• Time consuming
• Normal routine was interfered – work,
social functioning and interpersonal
relationships
• Low self-esteem & self-worth →depression
• Thinking process is rigid – right & wrong
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 Interventions for OCD
• Physical care – food, rest, grooming
• Provides pts with time to perform rituals
• Explain expectations, routines, changes
• Be empathic – aware of their needs to perform
rituals
• Help to connect feeling and behaviors
• Structure simple activities – distraction
• Reinforce positive changes
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 Phobic disorders
• Def: intense, irrational fear responses to an
external object, activity, or situation; it
causes severe distress & impair functioning
• Interventions:
– Non-critical attitude
– Provide activities
– Physical care and comfort needs
– Behavior is a method of coping

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 Etiology
• Cognitive theories – neg. thinking, irrational
ideas
• Genetics –
• Biochemical factor –
– epinephrine -> nervous
– Neurotransmitters – excessive serotonin,
norepinephrine, dopamine ->anxiety
– GABA
• Changes in the society, value, culture, IPR,
• Food, exercise 22
 Assessment
• Health history; physical examination
• Medications – amphetamines, anticholinergics,
antihypertensive, epinephrine, OTC drugs, …
• Screening – Mini International Neuropsychiatric
Interview (MINI); Liebowitz Social Anxiety
Scale; Brief Social Phobia Scale; Michigan
Alcoholism Screening Test…

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 Treatment
• Cognitive-behavioral therapy – to reduce
automatic negative perceptions and
irrational beliefs,
• Relaxation training,
• Behavioral approaches- ie desensitization
• Pharmacotherapies – fluvoxamine (Luvox),
Prozac, Paxil, Beta-blockers, MAOIs,
benzodiazepine,
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 Nursing Implications
• Case finding, evaluating, and treating
• Educator – knowledge and skills to cope
with anxiety
• Identifying local resources
• Document and report the anxiety disorder &
advocate for treatment

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 Posttraumatic Stress Disorder
• Traumatic event →PTSD and/or ASD
• S & S: intense fear, horror, sense of helplessness,
dissociative symptoms
• Prevalence: 50-70% - life time
• PTSD can occur 10-20 years later
• Denial, repression, suppression, withdrawal,
feeling of hopelessness, nightmare, illusion,
depression, suicidal ideation, substance abuse

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 Interventions for PTSD
• Nonjudgmental, empathic, honest
• Normal reactions toward the trauma –
connections between experience & feelings
• Safe verbalization of feelings – esp anger
• Adaptive coping strategies – exercise,
relaxation instead of alcohol, drugs
• Progressive review of the trauma event –
grieving process
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 Anxiety related disorder –
Somatoform disorders
(hysteria or Briquet’s syndrome)
• Anxiety is expressed through physical
symptoms
• Caused by an interaction of neurobiological,
psychological and familiar factors
• Doctor shopping without satisfaction
• Meeting needs from physical complaints
unconsciously
• Different from factitious disorder -
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 Anxiety related disorder –
Dissociative disorders
• Anxiety is removed from conscious awareness,
which helps pts to survive extreme emotional pain
• Disruption in the usually integrated functions of
consciousness, memory, identity, or perception
– Depersonalization disorder: outside their mind or body
– Dissociate amnesia: loss of memory
– Dissociative fugue: travel away from home & inability
to remember the past, confused about identity
– Dissociative identity disorder: 2 or more identities or
personality state
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 Mild Moderate Severe

Dissociative Depersonalization Dissociative fugue

Disorder
State DID
Daydreaming Dissociative amnesia

Mohr (2009), p 461 30

 Anxiety related disorder –
Conversion disorder
• Loss of voluntary motor or sensory functions that
appears to represent physiologic pathology but,
instead, relates to psychological conflict or need.
• Symptoms follow a greatly distressing event or
experience to defense against intrapsychic anxiety
• La belle indifference – clients are not disturbed by
their dramatic symptoms

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 Anxiety related disorder –
Hypochondriasis
• Clients fear that they have a serious disease
despite no significant pathology or other reason
for thinking so
• Hypervigilance -> misinterpret and overreact to
physical signs and symptoms
• Preoccupation with bodily distress & needs for
other’s attention-> disrupt social relationships
• Unaware of their anxiety or depression

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 Anxiety related disorder –
Body dysmorphic disorder (BDD)
• Extremely self-conscious about the
imagined defect in appearance
• Thinking that others notice the imagined
flaw
• Retreat from usual activities, socially
isolated, decreased academic and
occupational functions or even house bound
• Severe case -> suicide
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 Conclusion
• Diffuse apprehension – subjective, vague,
uncertainty, helplessness
• Level- mild, moderate, severe, panic
• Responses – physiological, behavioral,
cognitive, affective
• Predisposing factors – multiple; threats to
physical integrity and self-esteem
• Adaptation - coping
• Anxiety is a very real and serious—yet
treatable—disorder
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 Conclusion (II)
• Intervention
– IPR,
– self-awareness,
– protecting the patient,
– modifying the environment,
– encouraging activity,
– medication, and
– learning new ways to cope with stress

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 Joke
• Q: What's the difference between
stress, tension and panic?

A: Stress is when wife is pregnant,

Tension is when girlfriend is pregnant,
and Panic is when both are pregnant.

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