irene dunn, ma,msn,rnc

Irene Dunn, MA,MSN,RNC

Physiological Responses to Anxiety

Cardiovascular System

Palpitations Racing heart Increased blood

pressure Faintness*

Actual fainting* Decreased blood

pressure* Decreased pulse rate*


Respiratory System Rapid breathing Shortness of breath Pressure on chest

Shallow breathing Lump in throat

Choking sensation Gasping


Gastrointestinal System Loss of appetite Revulsion toward

food Abdominal

discomfort

Abdominal pain* Nausea* Heartburn Diarrhea*


Neuromuscular System Increased reflexes Startle reaction

Eyelid twitching Insomnia Tremors Rigidity

Fidgeting Pacing Strained face Generalized

weakness Wobbly legs Clumsy movement


Skin

Flushed face

Localized sweating (palms)

Itching

Hot and cold spells Pale face Generalized

sweating


Urinary Tract Pressure to urinate* Frequent Urination* *Parasympathetic response

Behavioral Responses to Anxiety

Restlessness Physical tension Tremors Startle reaction Hypervigilance Rapid speech

Lack of coordination Accident proneness Interpersonal

withdrawal Inhibition Flight Avoidance Hyperventilation

Cognitive Responses to Anxiety

Impaired attention Poor concentration Forgetfulness Errors in judgment Preoccupation Blocking of thoughts Decreased perceptual

filed Reduced creativity Diminished productivity

Confusion Self-consciousness Loss of objectivity Fear of losing control Frightening visual images Fear of injury or death Flashbacks Nightmares

Affective Responses to Anxiety

Edginess Impatience Uneasiness Tension Nervousness Fear Fright Shame

Frustration Helplessness Alarm Terror Jitteriness Jumpiness Numbing Guilt

Medical Disorders Associated with Anxiety


Cardiovascular/Respiratory Asthma Cardiac arrhythmias Chronic obstructive

pulmonary disease Congestive heart

failure Coronary

insufficiency

Hyperfynamic beta-adrenergic state

Hypertension Hyperventilation

syndrome Hypoxia, embolus,

infections


Endocrinology

Carcinoid Cushing’s syndrome Hyperthyroidism Hypoglycemia Hypoparathyroidism

Hypothyroidism Menopause Pheochromocytoma Premenstrual

syndrome

Medical Disorders Associated with AnxietyNeurological

Collagen vascular disease

Epilepsy Huntington’s

disease

Multiple sclerosis Organic brain

syndrome Vestibular

dysfunction Wilson’s disease


Substance Related Intoxications Anticholinergic

drugs Aspirin Caffeine Cocaine

Hallucinogens including phencyclidine (angle dust)

Steroids Sympathomimetics THC


Withdrawal Syndromes Alcohol Narcotics Sedative-hypnotics

Panic Attack Criteria

Palpitations, pounding heart, or accelerated heart rate

SweatingTrembling or shakingSensations of shortness

of breath or smothering

Feeling of choking

Chest pain or discomfortNausea or abdominal

distressFeeling dizzy, unsteady,

lightheaded or faintDerealization (feelings

of unreality) or depersonalization (being detached from oneself)

Panic Attack Criteria

Fear of losing control or going crazy Fear of dying Paresthesias (numbness or tingling

sensations) Chills or hot flashes

Obsession and Compulsion Criteria

Obsession– Recurrent and persistent thoughts, impulses, or

images are experienced during the disturbance as intrusive and inappropriate and cause marked anxiety or distress

– The thoughts, impulses, or images are not simply excessive worries about real-life problems.


– The person attempts to ignore or suppress such thoughts or impulses or to neutralize them with some other thought or action

– The person recognizes that the obsessional thought impulses, or images are a product of one’s own mind.


Compulsion– The person feels driven to perform repetitive

behaviors (such as hand washing, ordering, checking) or mental acts (such as praying, counting, repeating words silently) in response to an obsession or according to rules that must be applied rigidly.


The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

Differences Between Anxiety and Depression

AnxietyPredominantly fear or

apprehensionDifficulty falling asleep

(initial insomnia)Phobic avoidance

behaviorRapid pulse and

psychomotor hyperactivity

Depression Predominantly sad or

hopeless with feelings of despair

Early morning awakening (late insomnia) or hypersomnia

Diurnal variation (feels worse in the morning)

Slowed speech and thought processes


Anxiety Breathing disturbances Tremors and palpitations Sweating and hot or cold

spells Faintness,

lightheadedness, dizziness

Depression Delayed response time Psychomotor retardation

(agitation may also occur) Loss of interest in usual

activities Inability to experience

pleasure


Anxiety Depersonalization

(feeling that one’s environment is strange, unreal, or unfamiliar)

Selective and specific negative appraisals that do not include all areas of life

Depression Thoughts of death or

suicide Negative appraisals

are pervasive, global, and exclusive

Sees the future as blank and has given up all hope


Anxiety Sees some prospects

for the future Does not regard

defects or mistakes as irrevocable

Uncertain in negative evaluation

Predicts that only certain events

may go badly

Depression Regards mistakes as

beyond redemption Absolute in negative

evaluations Global view that

nothing will turn out right

Summarizing the Evidence on Anxiety Disorders

Disorder: Generalized anxiety disorderTreatment: Most treatment outcome studies

have shown active treatments to be superior to nondirective approaches, and uniformly superior to no treatment, however; most of these studies failed to demonstrate differential rates of efficacy among active treatments.

Treatment: Generalized anxiety disorder

Recent studies suggested cognitive-behavior therapy (combining relaxation exercises and cognitive therapy), with the goal of bring the worry process under control, to be most efficaciousThe benzodiazepines reduced the anxiety and worry symptoms of GADBuspirone appeared comparable to the benzodiazepines in alleviating GAD symptomsThe tricyclic antidepressants have been useful in the treatment of GAD

Disorder:Obsessive compulsive disorder

(OCD) Treatment: Cognitive-behavioral therapy

involving exposure and ritual prevention methods reduced or eliminated the obsessions and behavioral and mental ritual of OCD.

Approximately 40% to 60% of OCD patients respond to serotonergic reuptake inhibitors (SRI’s), including clomipramine, fluvoxamine, paroxetine, fluoxetine, and sertraline, with mean improvement in obsessions and compulsions of approximately 20% to 40%.

Disorder: Panic disorder

Treatment: situational in vivo exposure substantially reduced symptoms of panic disorder with agoraphobia.

Cognitive-behavioral treatments that focused on education about the nature of anxiety and panic and provided some form of exposure and coping skills acquisition significantly reduced symptoms of panic disorder without agoraphobia


Tricyclic antidepressants and monoamine oxidase inhibitors reduced the number of panic attacks and also reduced anticipatory anxiety and phobic avoidance, although side effects cause some patients to drop from clinical trials.

The benzodiazepines (e.g. Alprazolam) elinated panic attacks in 55% to 75% of patients.


More recently, serotonin reuptake inhibitors (SRI’s), and selective serotonin reuptake inhibitors (SSRI’s) have produced reductions in panic frequency, generalized anxiety, disability and phobic avoidance.

Disorder: Posttraumatic stress disorder

Treatment: Monoamine oxidase inhibitors (MAO’s) reduced intrusive thoughts, improved sleep, and moderated anxiety and depression in PTSD patients.

Tricyclic antidepressants reduced intrusive thoughts and obsessions and moderated depression in these patients.

Disorder: Posttraumatic stress disorder

Selective serotonin reuptake inhibitors (SSR’s) markedly reduced intrusive thoughts, avoidance, and sleep problems.

Exposure therapies (systematic desensitization, flooding, prolonged exposure and implosive therapy) and , to a lesser extent, anxiety management techniques (using cognitive-behavioral strategies) reduced PTSD symptoms, including anxiety and depression, and increased social functioning.

Antianxiety DrugsBenzodiazepines

Alprazolam (Xanax) Chloridazepoxide

(Librium) Clorezepate

(Tranxene) Diazepam (Valium)

Halazepam (Paxipam) Lorazepam (Ativan) Oxazepam (Serax) Prazepam (Centrax)

Antianxiety Drugs

Antihistamines– Diphenhydramine (Benadryl)– Hydroxyzine (Atarzx)

Beta-Adrenergic Blocker– Propranolol (Inderal)

Anxiolytic – Buspirone (BuSpar)

Antidepressant/Antianxiety Drugs

Citalopram (Celexa) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Praxil) Sertraline (Zoloft)

Other Newer Antidepressants

Mirtazepine (Remerom) Nefazodone (Serzone) Reboxetine (Vestral) Trazodone (Desyrel) Venlafaxine (Effexor)

Tricyclics

Amitiptylene (Elavil) Desipramine (Norpramin) Clomipramine (Anafranil) Imipramine (Tofranil) Nortiptyline (Pamelor)

MAO’s Phenelzine (Nardil)

Cognitive Behavioral Treatment Strategies for Anxiety Disorders

Anxiety Reduction Relaxation training Biofeedback Systematic

desensitation Interoceptive

exposure

Flooding Vestibular

desensitization training Response prevention Eyemovement

desensitization and reprocessing (EMDR)

Cognitive Restructuring

Monitoring thoughts and feelings

Questioning the evidence

Examining alternatives

Decatastrophizing Reframing Thought stopping

Learning New Behavior

Modeling Shaping Token economy Role playing

Social skills training Aversion therapy Contingency

contracting

irene dunn, ma,msn,rnc

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