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NCM 11 7 LEC
REVIEWER / SECOND SEMESTER
ANXIETY AND ANXIETY DISORDERS
ANXIETY
- A vague feeling of dread or apprehension
- A response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms.
- It is distinguished from fear.
- Is unavoidable in life and can serve many positive functions such as motivating the person to take action to solve a problem or to resolve a crisis.
- It is considered normal when it is appropriate to the situation and dissipates when the situation has been resolved. ASSESSMENT 1 Decreased attention span 2 Restlessness, irritability 3 Poor impulse control 4 Feelings of discomfort, apprehension, or helplessness 5 Hyperactivity, pacing 6 Wringing hands 7 Perceptual field deficits 8 Decreased ability to communicate verbally
ANXIETY DISORDERS
- Comprise a group of conditions that share a key feature of excessive anxiety with ensuing behavioral, emotional, cognitive, and physiological responses.
- Client suffering can demonstrate unusual behaviors such as: 1 Panic without reason 2 Unwarranted fear of objects or life conditions 3 Unexplainable or overwhelming worry
- They experience significant distress over time, and the disorder significantly impairs their daily routines, social lives, and occupational functioning. NURSING INTERVENTIONS ❑ Remain with the client at all times when levels of anxiety are high (severe or panic). The client’s safety is a priority. A highly anxious client should not be left alone; his or her anxiety will escalate. ❑ Move the client to a quiet area with minimal or decreased stimuli such as a small room or seclusion area. Anxious behavior can be escalated by external stimuli. In a large area, the client can feel lost and panicky, but a smaller room can enhance a sense of security. ❑ PRN medications may be indicated for high levels of anxiety, delusions, disorganized thoughts, and so forth. Medication may be necessary to decrease anxiety to a level at which the client can feel safe.
❑ Remain calm in your approach to the client. The client will feel more secure if you are calm and if the client feels you are in control of the situation. ❑ Use short, simple, and clear statements. The client’s ability to deal with abstractions or complexity is impaired. ❑ Avoid asking or forcing the client to make choices. The client may not make sound decisions or may be unable to make decisions or solve problems. ❑ Be aware of your own feelings and level of discomfort. Anxiety is communicated interpersonally. Being with an anxious client can raise your own anxiety level. ❑ Encourage the client’s participation in relaxation exercises such as deep breathing, progressive muscle relaxation, meditation, and imagining being in a quiet, peaceful place. Relaxation exercises are effective, nonchemical ways to reduce anxiety. ❑ Teach the client to use relaxation techniques independently. Using relaxation techniques can give the client confidence in having control over anxiety. ❑ Help the client see that mild anxiety can be a positive catalyst for change and does not need to be avoided. useful. ❑ Encourage the client to identify and pursue relationships, personal interests, hobbies, or recreational activities that may appeal to the client. The client’s anxiety may have prevented him or her from engaging in relationships or activities recently, but these can be helpful in building confidence and having a focus on something other than anxiety. ❑ Encourage the client to identify supportive resources in the community or on the internet. Supportive resources can assist the client in the ongoing management of his or her anxiety and decrease social isolation. INCIDENCE ❑ Both children and adults. ❑ One in four adults in the United States ❑ Women ❑ People younger than 45 years of age ❑ People who are divorced or separated. ❑ People of lower socioeconomic status ONSET AND CLINICAL COURSE The onset and clinical course of anxiety disorders are extremely variable, depending on the specific disorder. RELATED DISORDERS ❑ Selective mutism is diagnosed in children when they fail to speak in social situations even though they are able to speak. They may speak freely at home with parents but fail to interact at school or with extended family. Lack of speech interferes with social communication and school performance. There is a high level of social anxiety in these situations.
- An endocrinologist identified the physiological aspects of stress, which he labeled general adaptation syndrome (GAS).
- He identified three stages of reaction to stress: ALARM REACTION STAGE
- Stress stimulates the body to send messages from the hypothalamus to the glands (such as the adrenal gland, to send out adrenaline and norepinephrine for fuel) and organs (such as the liver, to reconvert glycogen stores to glucose for food) to prepare for potential defense needs. RESISTANCE STAGE
- The digestive system reduces the function to shunt blood to areas needed for defense.
- The lungs take in more air, and the heart beats faster and harder so that it can circulate this highly oxygenated and highly nourished blood to the muscles to defend the body by fight, flight, or freeze behaviors.
- If the person adapts to stress , the body responses relax , and the gland, organ, and systemic responses abate. EXHAUSTION STAGE
- Occurs when the person has responded negatively to anxiety and stress. - Body stores are depleted, or the emotional components are not resolved, resulting in continual arousal of the physiological responses and little reserve capacity. Autonomic nervous system responses to fear and anxiety generate the involuntary activities of the body that are involved in self-preservation. Sympathetic nerve fibers “ charge up ” the vital signs at any hint of danger to prepare the body’s defenses. The adrenal glands release adrenaline (epinephrine ), which causes the body to take in more oxygen, dilate the pupils, and increase arterial pressure and heart rate while constricting the peripheral vessels and shunting blood from the gastrointestinal (GI) and reproductive systems and increasing glycogenolysis to free glucose for fuel for the heart, muscles, and central nervous system. When the danger has passed , parasympathetic nerve fibers reverse this process and return the body to normal operating conditions until the next sign of threat reactivates the sympathetic responses. PHYSIOLOGICAL RESPONSE Anxiety causes uncomfortable cognitive, psychomotor, and physiological responses,
such as difficulty with logical thought, increasingly agitated motor activity, and elevated vital signs. To reduce these uncomfortable feelings, the person tries to reduce the level of discomfort by implementing new adaptive behaviors or defense mechanisms. Adaptive behaviors can be positive and help the person learn. Negative responses to anxiety can result in maladaptive behaviors such as tension headaches, pain syndromes, and stress- related responses that reduce the efficiency of the immune system. People can communicate anxiety to others both verbally and nonverbally. They can experience anxiety nonverbally through empathy , which is the sense of walking in another person’s shoes for a moment in time (Sullivan, 1952). LEVELS OF ANXIETY Anxiety has both healthy and harmful aspects, depending on its degree and duration as well as on how well the person copes with it. Each level causes both physiological and emotional changes in the person. MILD ANXIETY ❑ Is a sensation that something is different and warrants special attention. ❑ Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect him or herself. ❑ Often motivates people to make changes or engage in goal-directed activity. ❑ Can learn and solve problems and are even eager for information. ❑ Mild anxiety is an asset to the client and requires no direct intervention. NURSING INTERVENTION ❑ Teaching can be effective. MODERATE ANXIETY ❑ Is the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated. ❑ The person can still process information, solve problems, and learn new things with assistance from others. ❑ He or she has difficulty concentrating independently but can be redirected to the topic. NURSING INTERVENTION ❑ The nurse must be certain that the client is following what the nurse is saying. ❑ The client’s attention can wander, and he or she may have some difficulty concentrating over time. Speaking in short, simple, and easy-to- understand sentences is effective.
BENZODIAZEPINES
- Commonly prescribed for anxiety.
- Have a high potential for abuse and dependence, however; so, their use should be short term , ideally no longer than 4 to 6 weeks.
- To relieve anxiety so that the person can deal more effectively with whatever crisis or situation is causing stress. STRESS-RELATED ILLNESS
- Is a broad term that covers a spectrum of illnesses that result from or worsen because of chronic, long-term, or unresolved stress. CHRONIC STRESS
- It is repressed and can cause eating disorders , such as anorexia nervosa and bulimia. TRAUMATIC STRESSORS
- Can cause a short , acute stress reaction or, if unresolved , may occur later as PTSD. SOMATIC SYMPTOM DISORDERS
- Stress that is ignored or suppressed can cause physical symptoms with no actual organic disease. Stress can also exacerbate the symptoms of many medical illnesses, such as hypertension and ulcerative colitis. Chronic or recurrent anxiety resulting from stress may also be diagnosed as anxiety disorder. ANXIETY DISORDERS
- Are diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change but becomes chronic and permeates major portions of the person’s life, resulting in maladaptive behaviors and emotional disability.
- Anxiety disorders have many manifestations, but anxiety is the key feature of each. TYPES OF ANXIETY 1 Agoraphobia 2 Panic disorder 3 Specific phobia 4 Social anxiety disorder (social phobia) 5 Generalized anxiety disorder (GAD) PANIC DISORDER ❑ composed of discrete episodes of panic attacks, that is, 15 to 30 minutes of rapid, intense, escalating anxiety. ❑ The person experiences great emotional fear as well as physiological discomfort. ❑ During a panic attack, the person has overwhelmingly intense anxiety and displays four or more of the following symptoms: 1 Palpitations 2 Sweating 3 Tremors 4 Shortness of breath 5 Sense of suffocation 6 Chest pain
7 Nausea 8 Abdominal distress 9 Dizziness 10 Paresthesias 11 Chills 12 Hot flashes Panic disorder is diagnosed when the person has recurrent, unexpected panic attacks followed by at least 1 month of persistent concern or worry about future attacks or their meaning or a significant behavioral change related to them. Panic disorder is more common in people who have not graduated from college and are not married. There is an increased risk of suicidality in persons with panic disorder. Studies show suicidal ideation prevalent in 17% to 32% of those with panic disorder, while one-third had a history of suicide attempts (De La Vega, Giner, & Courtet, 2018). ONSET ❑ Late adolescence (mid-30s) AGROPHOBIA ❑ the person becomes homebound or stays in a limited area near home. ❑ fear of the marketplace or fear of being outside ❑ Some people with agoraphobia fear stepping outside the front door because a panic attack may occur as soon as they leave the house. ❑ Others can leave the house but feel safe from the anticipatory fear of having a panic attack only within a limited area. ❑ can also occur alone without panic attacks. PRIMARY GAIN ❑ is the relief of anxiety achieved by performing the specific anxiety-driven behavior ❑ staying in the house to avoid the anxiety of leaving a safe place. SECONDARY GAIN ❑ the attention received from others as a result of these behaviors. ❑ For instance, the person with agoraphobia may receive attention and caring concern from family members who also assume all the responsibilities of family life outside the home (e.g., work and shopping). Essentially, these compassionate significant others become enablers of the self-imprisonment of the person with agoraphobia. TREATMENT ❑ CBTs ❑ deep breathing and relaxation ❑ medications such as: 1 benzodiazepines 2 SSRI antidepressants 3 tricyclic antidepressants 4 Antihypertensives such as clonidine (Catapres) and propranolol (Inderal). NURSING DIAGNOSES 1 Risk for injury 2 Anxiety
social phobia social anxiety disorder, the person becomes severely anxious to the point of panic or incapacitation when confronting situations involving people. The fear is rooted in low self-esteem and concern about others’ judgments. The person fears looking socially inept, appearing anxious, or doing something embarrassing such as burping or spilling food. A person may have one or several social phobias ; the latter is known as generalized social phobia. ONSET AND CLINICAL COURSE ❑ Childhood or adolescence ❑ Merely thinking about or handling a plastic model of the dreaded object can create fear. ❑ Specific phobias that persist into adulthood are lifelong 80% of the time. ❑ The peak age of onset for social phobia is middle adolescence; it sometimes emerges in a person who was shy as a child. ❑ The course of social phobia is often continuous , though the disorder may become less severe during adulthood. TREATMENT ❑ Behavioral therapy ❑ Positive reframing and assertiveness training ❑ Systematic (serial) desensitization , in which the therapist progressively exposes the client to the threatening object in a safe setting until the client’s anxiety decreases. During each exposure, the complexity and intensity of exposure gradually increase, but the client’s anxiety decreases. The reduced anxiety serves as a positive reinforcement until the anxiety is ultimately eliminated. ❑ Flooding is a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety. The goal is to rid the client of the phobia in one or two sessions. This method is highly anxiety producing and should be conducted only by a trained psychotherapist under controlled circumstances and with the client’s consent. GENERALIZED ANXIETY D. ❑ worries excessively and feels highly anxious at least 50% of the time for 6 months or more. ❑ Unable to control this focus on worry, the person has three or more of the following symptoms: 1 Uneasiness 2 Irritability 3 Muscle tension 4 Fatigue 5 Difficulty thinking 6 Sleep alterations The quality of life is diminished greatly in older adults with GAD.
Buspirone (BuSpar ) and SSRI or serotonin–norepinephrine reuptake inhibitor antidepressants are the most effective treatments (Ravindran & Stein, 2017). NURSING INTERVENTION
- Remember that everyone occasionally suffers from stress and anxiety that can interfere with daily life and work.
- Avoid falling into the pitfall of trying to “fix” the client’s problems.
- Discuss any uncomfortable feelings with a more experienced nurse for suggestions on how to deal with your feelings toward these clients.
- Remember to practice techniques to manage stress and anxiety in your own life.
