Anxiety

1. Anxiety Elisa A. Mancuso RNC, MS, FNS Professor

2. Most common mental health problem 25 % adults Women>men Age <45 ↑ Divorced/separated Lower socioeconomic status Vague apprehension and feelings of uncertainty & helplessness Subjective emotional response to a stressor State of tension, or impending doom Necessary force for survival Mild→ Moderate → Severe → Panic

3. Physiologic Responses Hormones & Neurotransmitters “Fight or Flight Response” Depends on degree & duration of anxiety ↑ Epinephrine (E) ↑ HR & ↑ SV =↑ CO ↑ Norepinphrine (NE) ↑ BP ↑ Cortisone ↑ RR & depth = SOB ↑ Serotonin (5-HT) ↓ GABA

4. Physiologic Responses Generalized Responses Restlessness Hyperreflexia Irritability Impatience Fainting Chest Pressure Palpitations Headache ↑ Diaphoresis ↑ Muscle tension ↑ Urination Gluconeogenesis ↑ N & V Dry Mouth ↓ Libido Sexual Dysfunction

5. Cognitive Responses Mild (+) ↑ Sensory awareness ↑ Learning ↑ Concentration = Optimal Functioning Moderate (++) ↓ Perceptual field Impaired attention ↓ Concentration & Problem Solving Severe (+++) Limited Perceptual field Selective inattention Disorganized processing Time distorted Panic (++++) Closed perceptual field ↓ Contact with reality Impaired thinking/function Unable to process stimuli

6. Behavioral Responses Mild (+) Learn new skills Alert & Confident ↑ Startle reaction ↑ Speech & Coping Skills Moderate (++) ↑ Competitive activity ▲ Body position frequently Frequent topic ▲s ↑ Defense mechanisms Focus on immediate events Severe (+++) ↑ Feeling of threat & tremors “Overload” ↓ Coordination Neurosis Panic (++++) Total loss of control Cling to source of safety Helplessness Psychosis May strike physically or withdraw Completely disorganized

7. Anxiety Disorders A group of symptoms & impaired reality testing. Panic Disorder Sudden onset Multiple attacks Intense & escalating apprehension Poor judgment, confused & disoriented Feelings of impending doom Fears losing control or going insane Lasts 15-30 minutes or (rarely) hours

8. Panic Disorder Intense Physical discomfort Palpitations Chest pain ↑HR Dyspnea Choking/Smothering SOB Hyperventilation ↑ RR Dizziness Diaphoresis Chills/Hot flashes Tremors & Shaking GI distress Nausea Diarrhea Fear of dying and/or going crazy Depersonalization

9. Nursing Interventions Stay with Pt and remain calm Assess own level of anxiety Ensure safety and reassure Pt Pt take slow, deep breaths Quiet environment Focus on a single object in the room Speak in short, simple sentences Low, calm and soothing voice Encourage verbalization of concerns, feelings and symptoms Identify precipitating event Sort term use of anxiolytics

10. Generalized Anxiety Disorder Chronic unrealistic and excessive worry Regarding several events the Pt can’t control Symptoms last > 6 months Impaired social & occupational functioning Interferes with daily life Symptoms Autonomic Hyperactivity Jumpiness, tremors, ↑ muscle tension ↑ HR ↑ RR Feeling on edge Hypervigilence Restlessness Irritability ↓ Concentration“Mind going blank” Easily fatigued

11. Obsessive-Compulsive Disorder Recurrent obsessions & compulsions ↑↑ Time consuming Gradual conditioned response RT traumatic event Obsessions Unwanted intrusive, persistent images or impulses Recurrent thoughts of violence, contamination, doubt or need for specific order. Compulsions Ritualized acts of behavior to neutralize/control obsessions Touching Rearranging Opening & Closing Washing hands Counting Checking Pt aware behavior is excessive, yet continues to engage to seek relief and ↓ anxiety/tension Interferes with usual routine Defense Mechanism Undoing Displacement

12. OCD Nursing Interventions Initiate conversation as ritual is performed Allow behavior but set limits Identify behavioral cues of ↑ anxiety Present distracting stimulus @ ↑ frequency Substitute socially acceptable behavior

13. Phobias Persistent or irrational fear of specific object, activity or situation that causes avoidance. Exposure to stimulus = immediate anxiety response. Blushing, Vomiting, Humiliation, Tremors, ↑HR ↑BP ↑RR Agoraphobia Fear of being alone in public place. No escape Social Phobia Fear of appearing embarrassed or evaluated negatively by others. Simple Phobia (Specific object or situation) Acrophobia= Fear of heights Claustrophobia= Fear of closed in places Mysophobia= Fear of dirt, germs Nursing Interventions 1st accept Pt’s fear as real Relaxation techniques Behavior Modification Desensitization

14. Post Traumatic Stress Disorder Extreme stressor and threat to physical integrity. Characteristic symptoms after exposure to traumatic life experience 9-11, war, earthquakes, airplane crash Symptoms Re-experiencing event (Flashback) Avoidance of thoughts, emotions or conversations Sustained ↑ Anxiety Angry Outbursts Hypervigilence Nightmares Sleep Disturbances Survivor Guilt Depression Substance Abuse Psychic Numbing Feel detached from others

15. PTSD Nursing Interventions ↓ Environmental Stimuli Reorient to reality Reassure Pt is safe Encourage verbalization of event and feelings Facilitate grief process Adaptive coping techniques Anxiolytic meds during flashback

16. Somatoform Disorders Physical symptoms without any organic pathology Women> men Onset before age 30 Somatization Anxiety transformed into physical illness No labs, diagnostic tests support DX Chronic course without structural ▲s

17. Conversion Disorder-Hysteria Loss or alteration in physical functioning Voluntary motor/sensory Abrupt onset after a psychological conflict Symptom Impaired sense (blind/deaf) or paralysis “La belle indifference” Pt demonstrates no concern for symptoms Defense Mechanism Repression Conversion

18. Conversion Disorder-Hysteria Primary Gain Relief via repressing conflict Anxiety converted to symptoms Secondary Gain Sympathy, support, ↑↑ attention avoid activities & responsibilities Nursing Interventions Focus on ↑↑ anxiety, NOT symptoms Encourage verbalization Identify conflicts ↓↓ stress & ↑↑ relaxation Alternative coping skills

19. Hypochondriasis Unrealistic preoccupation/fear of having or getting a serious illness Specific organ, bodily function or minor alteration Misinterpretation of symptoms Cough = Lung CA HA = Brain tumor Symptoms C/O Multiple symptoms & Persist > 6 months Dr. Shopping Demand diagnostic testing & invasive procedures Nursing Interventions Review objective data, symptoms& interpretation Set limits on “whining” ↑ Self-worth and resolve internal anger

20. Dissociative Disorders Severe precipitating stressor. Splitting off an idea or emotion from one’s consciousness. Psychological flight from anxiety Psychogenic Amnesia Sudden inability to recall important extensive personal information. Psychogenic Fugue Sudden unexpected travel away from home or usual workplace Begin new job, relationships (Unaware of true life) Assumes new identity Escapes from overwhelming stress or rejection

21. Dissociative Disorders Multiple Personality Disorder Dissociative Identity Disorder (DID) Existence of 2 or more distinct personalities within an individual. Transition from 1 to another personality Sudden & dramatic Precipitated by stress One personality is dominant Usually RT sexual child abuse.

22. Dissociative Disorders Depersonalization Disorder Change in quality of self-awareness Feelings of unreality, ▲s in body image. Detachment Sense of observing oneself (from outside of body) Not in touch with body No somatic sensations

23. Anxiety Nursing Interventions # 1 is Patient safety! Remain with Pt & provide support Deep breathing Controlled slow Deep & regular abdominal breathing. Progressive muscle relaxation Guided imagery Visualize favorite place Embrace scenes, sounds, aromas, textures. Distraction Music, card games, reading

24. Anxiety Nursing Interventions Journals ↑↑ Self awareness Make entries when calm & anxious qd Identify anxiety cues & behavior responses Self-Help Skills + Coping techniques Role playing Problem solving Assertiveness Set limits on inappropriate behavior Social Skills Group ↑ Socialization = ↓Self absorption Daily Schedule Planning ↑ Autonomy Support System Family, friends, neighbors, pets Nutrition Balanced diets : NO CAFFEINE, CHOCOLATE, ETOH

25. Anxiety Nursing Interventions Cognitive–Behavioral Therapy Positive Reframing Turn negative messages into positive ones. Decatastrophizing A more realistic appraisal of situation Assertiveness Training Learn to negotiate interpersonal situations

26. Anxiolytics Anti-Anxiety Meds Used short term basis < 1 month Symptomatic relief only Potentiates GABA = ↓↓ CNS Caution Do not use ETOH or meds that ↑ CNS Do not stop med abruptly = Severe Withdrawal CNS agitation ↓BP ↑Temp & Fatal Gran Mal seizures! Takes 7-10 days for steady effect Elderly have ↓ hepatic & ↓renal function ↑↑ risk for toxic effect

27. Anxiolytics Anti-Anxiety Meds Benzodiazepines Alprazolam (Xanax) Lorazepam (Ativan) Chlordiazepoxide (Librium) Diazepam (Valium) Clonazepam (Klonopin) Clorazepate (Tranxene) ↑ Risk for physical dependence & tolerance Lipophilic & cross blood-brain barrier Side effects Drowsiness Sedation ↓ Concentration Impaired memory Clouded Sensorium

28. Anxiolytics Anti-Anxiety Meds Azaspirodecanediones Buspirone (Buspar) 5-HT receptor antagonist Takes 2-4 weeks to be effective ↓ potential for abuse Propanediols Meprobamate (Equanil/Miltown) ↓ Thalamus & Limbic system response Sedating Antihistamines Hydroxyzine (Vistaril/Atarax) CNS depressant effect

29. Anxiolytics Anti-Anxiety Meds Selective Serotonin Reuptake Inhibitors (SSRIs) Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac/ Serafem Puvules-weekly) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Only prevents 5-HT reuptake ↑↑ 5-HT available = ↑ regulation of emotions, wakefulness No other neurotransmitters affected ↓↓ E & NE Side effects Anxiety Agitation Nausea Insomnia Sexual Dysfunction Akathisia (Use Propanolol)

30. Anxiolytics Anti-Anxiety Meds Side Effects Anticholinergic: Daytime sedation, Drowsiness, Dry mouth, HA, Lethargy, Ataxia, Blurred vision, N & V Tolerance, physical & psychological dependence Potentiates other CNS depressants Orthostatic Hypotension Blood Dyscrasias Abrupt Withdrawal Syndrome Flumazenil (Romazicon) Benzodiazepam antagonist Reverse CNS effects Must gradually taper down

31. Defense Mechanisms Protect the ego & cope with anxiety unconsciously Denial Refuse to acknowledge the problem Substance abuse Regression Return to an earlier level of development Holding teddy bear Displacement (3 way) Transfer feelings from 1 person, object or situation to less threatening person Angry @ boss → yell @ kids or kick the dog Reaction-Formation Prevent unacceptable thoughts/behaviors from being expressed by developing opposite thoughts/behaviors Unwanted pregnancy → New mom overprotective of baby

32. Defense Mechanisms Projection (2 way) Unacceptable feelings/impulses are attributed to another person I’m needy but claim my husband is demanding Repression Involuntary blocking of unpleasant feelings and experiences No memory of sexual abuse as a child Suppression Conscious voluntary denial of unpleasant feelings and experiences Put away NCP & focus on studying for exam Identification ↑ Self worth by acquiring certain attributes & characteristics of an admitted individual Gang members

33. Defense Mechanisms Rationalization Attempting to form logical reasons to justify unacceptable feelings “Not getting accepted to Harvard I didn’t want to leave home” Sublimation Substituting constructive/socially acceptable activity for inappropriate impulses. Aggressive person becomes hockey player Compensation Covering up a real or perceived weakness by emphasizing/excelling in another area Poor in sports → Excell in chess Conversion Unconsciously transforming anxiety into a physical symptom Paralysis/Blind Undoing Symbolically negate or cancel out a previous intolerable action Man has an affair then buys his wife a new car.