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ANXIETY DISORDERS Slide 2 WHAT IS ANXIETY? SUBJECTIVE EXPERIENCE OF DISCOMFORT IN RESPONSE TO AN ACTUAL OR PERCEIVED THREAT OR LOSS (STRESSOR) THREAT MAY BE EXTERNAL OR INTERNAL ANXIETY MAY PERSIST EVEN AFTER THREAT IS GONE Slide 3 WHAT IS ANXIETY, contd PERCEPTION OF THREAT DEPENDS ON THE INDIVIDUAL SOMATIC COMPONENT: AUTONOMIC (SYMPATHETIC) NERVOUS SYSTEM ACTIVATION Slide 4 Acute Stress Involves Activation of the Hypothalamic-Pituitary-Adrenal (HPA) Axis Release of dopamine and serotonin Release of endogenous opiates Increased TSH Slide 5 Physiology of Anxiety: Activation of Sympathetic N.S. Somatic Symptoms: Dry mouth Palpitations, chest tightness or chest pain Tachypnea, breathlessness Nausea, constipation or diarrhea Temp. energy, then exhaustion Muscle tension, restlessness Urinary retention, or incontinence Slide 6 Levels of Anxiety Mild (Stage 1) Moderate (Stage 2) Severe (Stage 3) Panic (Stage 4) Slide 7 Mild Anxiety Increases alertness & attention Broad field of perception Enhances learning and performance Slide 8 Moderate Anxiety Perceptual field narrows Tunes out stimuli Focused on one task Decreased attention span Problem solving ability Slide 9 Severe Anxiety Narrow or distorted perception and cognition Flight of ideas Physical symptoms problematic Behavior directed toward relief of discomfort Slide 10 Panic Disorganized and irrational Overwhelmed, out of control May become violent, hysterical, or immobilized Fight, Flight or Freeze Slide 11 Nursing Interventions for Anxiety: Some Guidelines See Table 9-1 (10-1): Levels of Anxiety, p. 87 (122) Assess level of anxiety via objective, subjective data Assess clients coping methods and effectiveness Planning: can source of clients stress/anxiety be managed or not? Client teaching: will not be effective if anxiety is severe or panic level OK for moderate anxiety if it is simple and step- by-step Slide 12 ANXIETY DISORDERS WHEN ANXIETY INTERFERES WITH FUNCTIONING AND SELF-CARE MOST ARE CHRONIC, BUT MAY BE IN RESPONSE TO ACUTE SITUATION CHALLENGING TO TREAT/MANAGE Slide 13 ANXIETY DISORDERS NIMH 2009: Anxiety disorders more prevalent than mood disorders (40 million) 18.1% of US population over age 17 First episode by age 21.5 Co-occurrence with depression and substance abuse Common to have more than one anxiety disorder Slide 14 UNDERSTANDING ANXIETY: Primary Gain Behaviors directed toward the individuals desire to relieve the anxiety to feel better, e.g. Excessive activities and tasks Avoiding the thing(s) that cause the anxiety Using medications to relieve physiologic discomfort Using mood altering substances Slide 15 UNDERSTANDING ANXIETY: Secondary Gain Refers to attention or benefit the person gets from the illness Can become more important than relieving the anxiety Decreases motivation to get well Others take care of individual Complicates treatment Slide 16 Axis 1 Anxiety Disorders Generalized Anxiety Disorder (GAD) Panic Disorder with Agoraphobia without Agoraphobia Obsessive-Compulsive Disorder (OCD) Phobias Somatoform Disorders Slide 17 Acute and Post-Traumatic Stress Disorders and Dissociative Disorders Not in this Module: Will be covered with Violence, Abuse and Trauma - Module 8 Slide 18 Etiology/Theories of Anxiety Disorders Biological Theories Defects in Brain Chemistry-- Person over-responds to stimuli Neurotransmitter dysregulation Altered # of benzodiazepine receptors Slide 19 Genetic Theory Some disorders clearly run in families: e.g. panic, OCD Inherited trait for shyness has been discovered Slide 20 Psychoanalytic/ Psychodynamic Theories Result of conflict between instincts and values Use of Defense Mechanisms to deal with anxiety: Repression Displacement Conversion Slide 21 Interpersonal Theory Anxiety is caused by threat to self-esteem, security or self-control Slide 22 Generalized Anxiety Disorder (GAD) Most common type Cognitive and physical symptoms Chronic and excessive worry ( > 6 months) Worry is habitual, cannot be controlled Causes impairment Slide 23 http://www.youtube.com/watch?v=U6QuNjlHsHw&feature=related http://www.youtube.com/watch?v=2TwvYtLeIKo&feature=related GAD Slide 24 Interventions for GAD Goal: to assist the client to develop adaptive coping responses Assess for level of anxiety = moderate to severe Reduce level of anxiety Identify and describe feelings Assist to identify causes of feelings Slide 25 Slide 26 Milieu Management for GAD Calm environment Cognitive Behavioral Therapy (CBT) Corrects faulty assumptions If you change, others will change Recreational activities Relaxation Groups: assertiveness, expressive arts, etc. Slide 27 Panic Disorder Recurring, sudden, intense feelings of Apprehension Terror Impending doom Losing control Going crazy Somatic Symptoms Heart Attack Dying Recurrent May or may not be situational If situational, will avoid places or situations that trigger symptoms Peaks within 10 minutes Slide 28 http://www.youtube.com/watch?v=eQgxdrPb3DM Panic DO Slide 29 Slide 30 Panic Disorder: Complications Over time, the fear of situational panic attacks may cause the person to severely restrict activities agoraphobia Slide 31 Etiology of Panic Disorder Psychological Life stresses Separation and disruption of attachment in childhood Biological Heredity Hyperactivity of Interaction of Cognitive-- Sympathetic NS--Endocrine Systems Catastrophic thinking (what if) triggers the physiological response Slide 32 Panic Disorder: Interaction of CognitiveANSHPA Axis Slide 33 Nurse-Client Relationship and Milieu Management: Acute Phase of Panic Disorder Communication: Similar to panic level anxiety, stay with them, reassure that they are safe Calm environment, stimulation Assess for suicidal ideation: 1 in 5 are suicidal Use touch carefully PRN Medications: alprazolam/Xanax, lorazepam/Ativan Slide 34 Nurse-Client Relationship Client teaching: improvement often follows You are not crazy Recognize and address triggers Recognize symptoms Meds. can help When is the best time to teach these clients? Slide 35 Milieu Outpatient Tx Relaxation Exercises Stretching Yoga Soft music Gross motor activities Walking Jogging Basketball Cognitive Restructuring Reinterpreting beliefs Meeting fears Giving options Slide 36 Panic Disorder: Medications Serotonin Reuptake Inhibitors Long-Term treatment Long-Term treatment Calcium channel blockers and beta adrenergic blockers: reduce ANS symptoms Benzodiazepines Immediate effects Immediate effects Slide 37 Obsessive-Compulsive Disorder (OCD) Obsessions Recurrent and persistent thoughts, ideas, impulses Compulsions Repetitive behaviors Performed in a particular manner ( ritual ) Response to obsession Prevent discomfort Neutralize anxiety Slide 38 http://www.youtube.com/watch?v=44DCWslbsNM&feature=related http://www.youtube.com/watch?v=Rn1OYlYzgm8&feature=related OCD Slide 39 OCD: Associated Signs and Symptoms Depression, low self-esteem Increased anxiety when resist their compulsions Strong need to control Rituals interfere with normal routines and relationships Magical thinking Beliefs that thinking equals doing Slide 40 OCD Nurse-Client Relationship Assist to meet basic needs Allow structured time to perform rituals Explain expectations Identify feelings--connect to behaviors Introduce new activities slowly Reinforce and recognize positives Slide 41 Milieu Outpatient Relaxation Exercises Stress management Recreational and Social skills CBT and Thought- Stopping Slide 42 OCD: Medications Antidepressants Tricyclic Antidepresants Tricyclic Antidepresants clomipramine (Anafranil) SSRIs SSRIs fluoxetine (Prozac) paroxetine (Paxil) Slide 43 Phobias/DSM IV Marked and specific fear that is excessive and unreasonable, cued by the presence or anticipation of object. Person recognizes fear as unreasonable Situation or object is avoided Slide 44 Phobias -Continued Agoraphobia without Panic Disorder : a fear of being in public places Social Phobia : e.g. fear of being humiliated in public, fear of stumbling while dancing, choking while eating, etc. Specific phobia : fear of a specific object or situation; animals, heights, flying etc. Slide 45 Comparison of Panic Disorder and Specific Phobia The office worker who often experiences episodes of panic when there is heated debate and arguing during staff meetings The office worker who is terrified of being inside enclosed spaces with no windows Slide 46 Treatment for Phobias Outpatient is most common Behavior therapy: systematic desensitization ; like Fear of Flying groups Nurse-client relationship and milieu Interventions are very similar to GAD Slide 47 Medications No effect on avoidant behaviors SSRIs Reduce anxiety and depression Reduce anxiety and depression Slide 48 Somatoform Disorders Anxiety is relieved by developing physical symptoms for which no known organic cause or physiologic mechanism can be determined. Somatization Disorder Pain Disorder Hypochondriasis Conversion Disorder Slide 49 Somatoform Disorders: Overview Client expresses psychological conflict through symptoms Client is not in control of symptoms and complaints See general practitioners, not mental health professionals Repression of feelings, conflicts, and unacceptable impulses Denial of psychological problems Individuals are dependent and needy Slide 50 1) Somatization Disorder Recurrent frequent somatic complaints for years Complaints change over time Onset prior to 30 years old See many physicians May have unnecessary surgical procedures Impairment Etiology Chronic emotional abuse Unable to verbalize anger Slide 51 2) Pain Disorder Severe Pain in one or more areas Significant distress and impairment Location or complaint does not change Doctor Shoppers Pain may allow secondary gain Avoidance, e.g. Does not have to go to work Frequently use pain medication If has a physiologic disorder, the amount of pain is out of proportion Slide 52 3) Hypochondriasis Worry about having a serious illness despite no medical evidence Misinterpretation of bodily symptoms Check for reassurance from doctors and friends Slide 53 4) Conversion Disorder Sudden onset of deficit or alteration in voluntary motor or sensory function Conflicts or stressors proceed symptoms Symptoms characteristically suggest a neurological disorder: Paralysis, blindness, or seizures Paralysis, blindness, or seizures May show little concern or anxiety Theory is: anxiety is replaced by the physical symptom Slide 54 Nurse-Client Relationship and Management of Somatoform Disorders Always rule out the physical Show acceptance and empathy; do not challenge or force insight Encourage identification, appropriate expression of emotions Teach adaptive coping e.g. assertiveness skills Slide 55 Critical Thinking A soldier who received notice of deployment to Afghanistan, suddenly developed numbness and weakness in both lower extremities. After a medical admission for diagnostic testing, no physiologic cause was found, and the client was transferred to the mental health unit. Critique each statement by the nurse; suggesting any alternatives. Slide 56 CRITICAL THINKING A) The doctors have not found anything wrong with you. You should try to get up and walk a little. B) I notice you were supposed to go overseas. Did that upset you? C) As part of your stay here we would like you to attend a stress management group. You probably have some stress you are not aware of. Slide 57 MEDICATIONS FOR ANXIETY Slide 58 BENZODIAZEPINES (BZDs) CNS Depressants Compete for GABA receptors; decrease response of excitatory neurons Tolerance, dependence are problems Cause dizziness, somnolence, confusion Best for short-term use Shorter acting BZDs PRN for episodes of anxiety or panic: clonazepam (Klonopin) lorazepam (Ativan) Slide 59 NON-BENZODIAZEPINE First line agent: buspirone (BuSpar) Binds to serotonin and dopamine receptors No CNS depression No abuse potential documented May have paradoxical effects (increased anxiety, depression, insomnia, etc.) May not be fully effective for 3-6 weeks May cause EPS Slide 60 NON-BENZODIAZEPINES: ANTIHISTAMINES Very sedating No addiction potential May be used long-term Examples: diphenhydramine (Benadryl) hydroxyzine (Vistaril) Slide 61 ANTIDEPRESSANTS Useful in treatment of panic (with or without agoraphobia), obsessional thinking Low abuse potential SSRIs: first line drugs due to low sedation Slide 62 ANTIDEPRESSANTS, CONTD SSRIs and SNRIs: fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) fluvoxamine (Luvox): best for OCD venlafaxine (Effexor) duloxetine (Cymbalta) Slide 63 Antidepressants for Anxiety, contd Tricyclics (TCAs) Clomipramine (Anafranil)for OCD Slide 64 MISCELLANEOUS propranolol (Inderal)-Beta adrenergic blocker and clonidine (Catapres)-Alpha 2 agonist Decrease autonomic symptoms in panic : e.g. tachycardia, muscle tremors gabapentin (Neurontin) For OCD and social phobias Slide 65 GENERAL GUIDELINES FOR USE OF ANTIANXIETY AGENTS Sedation potentiates falls, accidents Cautious use in elderly, renal, liver problems Do not combine with other CNS depressants or alcohol Paradoxical effects common: esp. with BZDs, buspirone, and some antidepressants Dont stop benzodiazepine therapy abruptly