NR202 Test 4 Anxiety disorders

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Define anxiety: Anxiety is an uncomfortable feeling of apprehension or dread that occurs in response to internal or external stimui and can result in physical, emotional, cognitive, and behavioral symptoms
What is normal anxiety: 1. It is a healthy adaptive response
2. Serves to alert a person of impending threat
3. Intensity and duration is proportional to situation
4. followed by relief behaviors (coping) intended to reduce or prevent more anxiety
What is maladaptive anxiety: Exaggerated intense response that is pervasive and interferes with functioning
What are some anxiety-related disorders: 1. Generalized anxiety disorder (GAD)
2. Panic disorder
3. Phobias
4. Obsessive compulsive disorder (OCD)
5. Post traumatic stress disorder (PTSD)
Anxiety disorders: info -incidence: higher incidence in women than men
Can be acute, time limited of persistent and severely disabling
Comorbid incidence with depression is high
NIMH estimates that only 1 in 5 persons with anxiety will seek medical attention
May result in repeated physician visits with wide variety of complaints or self medication.
Generalized anxiety disorder-characteristics: Chronic, unrealistic, excessive anxiety and uncontrolled worry.
Panic disorder: Recurrent acute attacks manifested by intense apprehension, fear, and terror often accompanied by feelings of impending doom and intense physical symptoms
1. Dyspnea
2. Palpitations and chest pain or discomfort
3. Diaphoresis
4. Trembling
5. Hot and cold flashes
6. Fear of losing control, going crazy or dying.
Panic disorder with Agoraphobia: Recurrent panic attacks combined with intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurred
Phobia:: Excessive irrational fears that result in avoidance of feared object or situation
1. Social
2. Specific object or situation
Obsessive Compulsive disorder (OCD):: Persistent, recurrent, intrusive thoughts, impulses, or images that can not be dismissed from the mind and ritualistic behaviors that one is driven to perform.
-Counting, compulsions,
Could be depressed/anxious
Posttraumatic Stress disorder PTSD:: A constellation of symptoms of anxiety that persist after a traumatic event involving actual or threatened death or serious injury to self or others
- Re-experiencing the trauma through intrusive recollections, dreams, and/or flashbacks
- Avoidance of stimuli associated with trauma
- Persistent numbing or detachment/ estrangement
-Persistent increase arousal-
e/b irritability, difficulty sleeping, difficulty concentrating, hypervigilance,
Acute stress disorder: A PTSD type response which lasts less than 3 months and occurs within four weeks of the traumatic event.
Anxiety disorder due to General medical condition:: Anxiety symptoms as a result of physiological consequences of a medical condition
Substance induced Anxiety disorder: Anxiety caused by direct physiological effects of a substance during intoxification or withdrawal.
Clinical symptoms of anxiety disorders: 1. Elevated pulse, BP, and R
2. Dyspnea or hyperventilation
3. Diaphoresis
4. Vertigo or light-headedness
5. Blurred vision
6. Anorexia, nausea, and vomiting
7. Frequency of urination
8. Headache
9. Insomnia or sleep disturbance
10. Weakness or muscle tension
11. Tightness in the chest
12. Sweaty palms
13. Dilated pupils
Clinical symptoms Psychologic Anxiety disorders: 1. Withdrawal
2. Depression
3. Irritability
4. Crying
5. Lack of interest or apathy
6. Hypercritical
7. Anger
8. Feelings of worthlessness, apprehension, or helplessness
Clinical symptoms cognitive: Anxiety disorders: 1. Decreased interest
2. inability to concentrate
3. Nonresponsiveness
4. Dereased productivity
5. preoccupation
6. Forgetfulness
7. Orientation to past rather than future
8. Ruminition
9. Reduction of perceptual field.
Defense mechanisms Associated with phobia: Displacement
- Purpose - in phobias, anxiety is reduced when strong feelings about the original object are directed at less threatening object and that object is avoided
Defense mechanisms associated with compulsions: Undoing
- Purpose- Performing a symbolic act cancels out an unacceptable act or idea
Defense mechanisms associated with obsession: Reaction formation
Purpose- Anxiety-producing unacceptable thoughts or feelings are kept out of awareness by the opposite feeling or idea
Defense mechanisms associated with PTSD: Repression
-purpose- Repression unconsciously pushes an idea or feeling out of awareness
what questions do you ask when giving a symptom assessment to a person who has an anxiety disorder: What do you experience preceding and during severe anxiety, including physical symptoms, feelings, thoughts, and behaviors?
when did the symptoms begin?
Have you experienced this in the past? (Circumstances?)
What actions have relieved these symptoms?
What do you check for in a psychological assessment for a person with an anxiety disorder-: 1. Mental status: Check for disorganized thinking, irrational fears, decreased ability to communicate verbally and suicidal tendencies.
2. Cognitive Thought Patterns: Check for catastrophic thinking and fears regarding losing control. Assessfor external locus of control
3. Avoidance behavior Patterns: Identify those behaviors or events that precede anxiety (antededents) and consequences of behaviors that have developed. Does avoidance affect ability to function? Do any behaviors interfere with accessing needed treatment?
Social assessment for a person with an axiety disorder?: Support: To what degree are interpersonal relationships affected
Activities of daily living: Can patient complete a self-care and use community resources effectively
Coping strategies: What does patient do to manage symptoms?
Nursing diagnoses for those who have anxiety disorders: 1. Panic disorder and GAD
-Anxiety (assessed level)
-powerlessness
2. Phobic disorders
-fear
-social isolation
-altered role performance
4. OCD
-Altered role performance
-ineffective individual coping
5. PTSD/Acute stress DO
-Post trauma response
-Dysfunctional grieving
6. Other
-Sleep pattern disturbance
-Self esteem disturbance
-Altered nutrition
-Knowledge deficit
Treatments for anxiety: Name 9 with explanation: Cognitive Restructuring
-Correct cognitive errors made by patient
-Identify and reframe negative self-talk

Flooding/Implosion
-Exposure to large amounts of undesirable stimulus

Health teaching
-Signs and symptoms
-Effects on the body
-Effective coping strategies
-Healthy lifestyle practice

Inpatient hospitalization-For those with prolonged and severe anxiety
-For those with physical health complications
-For those who are suicidal-establish a safe and predictable daily routine, prevent constant focus on anxiety or symptoms, Supportive interactions, and assure self care by maintaining a good nutrition and fluid intake, personal hygiene/grooming, and allow rest for sleep pattern disturbance

Modeling
-Provide examples of healthy coping with an object or situation

Relaxation training
-Tension reduction
-Learning to activate relaxation response to offset anxiety
Response prevention
-Not permitting the individual to perform a compulsive behavior
Systematic Desensitization
-Gradual exposure to phobic object or situation
Thought stopping
-Interruption of obsessive thought
-Loud verbal command such as â€œStop!â€
-Negative physical stimulus (snapping with rubber band)
Nursing interventions -For anxiety disorders: Mild degree of anxiety Moderate degree of anxiety: 1. Mild degree of anxiety
-Learning is possible
-Nurse assists patient to use energy anxiety provides to encourage learning
2. Moderate degree of anxiety
-Nurse to check own anxiety
-Encourage patient to talk
*Have patient focus on one experience, describe it fully, then formulate generalizations about the experience.
Nursing interventions -For anxiety disorders: Severe Degree of anxiety: -Learning is less possible
-Allow relief behaviors to be used but do not ask about them
-encourage patient to talk
*Ventilation of random ideas is likely to reduce anxiety to moderate level
* When anxiety is reduced, proceed with interventions used with moderate degree of anxiety
anxiolytic drugs-general information: 1. Used to treat the somatic and psychological symptoms of anxiety disorders
2. Benzodiazepines are an example and have a quick onset of action. However, the drugs have the potential for dependence. So, Benzodiazepines should only be used for short periods of time.
BuSpar is an alternative drug that does not cause dependence.
Nursing interventions -For anxiety disorders: 4. Panic level of anxiety: Panic level of anxiety
-Learning is impossible
-Nurse to stay with patient
-Allow pacing and walk with the patient
-No content inputs to the patient's thinking should be made
* This is a burden to the patient who will distort them.
-Do not touch the patient
-Use the fewest possible statements and the fewest words
* Giving liquids to replace lost fluids - "drink this"
* Encouraging ventilation- "Say what's happening to you" or "Tell me what you feel now"
* Respond to patient's statements with short statements that are to the point.
*Responses should match the patient's attention span.
Medication treatments for anxiety: Benzodiazepines: Benzodiazepines
G: generic, T:Trade names
G: Alprazolam T: Xanax
G: Clonazepam T: Klonopin
G: Diazepam T: Valium
G: Lorazepam T: Ativan
G: Oxazepam T: Serax
Action and indications
Increase GAPA release and receptor binding at synapses. Show preferential effect on limbic system. Useful for short term treatment of anxiety, dependence, and tolerance can develop
Antianxiety medication teaching: what would you teach someone on antianxiety meds?: 1. Do not increase the dose of frequency
2. Be aware of reduced ability to handle mechanical equipment
3. Do not mix with alcohol
4. Risk of congenital anomalies
5. Excreted in breast milk
6. Abrupt stoppage may result in life threatening withdrawal symptoms
7. Drug interactions with tagament and Dilantin.
More antianxiety meds: Nonbenzodiazepine antianxiety agent: G: Buspirone hydrochloride T: BuSpar
Actions and Indications: Alleviates anxiety. Less sedating than the benzodiazepines. Does not appear to produce physical/psychological dependence. Requires 3 weeks or more to be effective. BuSpar is an antianxiety med that does not depress the CNS but works with norepinephrine seretonin
Meds to relieve symptoms of anxiety: Beta blockers: G: Propanolol T: Inderal
Actions and Indications: Used to relieve physical symptoms of anxiety. Acts by attaching to sensors that detect arousal messages.
-For social anxiety disorder.
-Lowers the heart rate.
-Provides some relief, but not for acute attack.
Meds for long term management of anxiety: SSRIâ€™s: SSRIâ€™s
G: Seritraline T: Zoloft
G: Fluoxetine T: Prozac
G: Paroxetine T: Paxil
G: Fluvoxamine T: Luvox

Action and Indication: Used to treat OCD, panic, agoraphobia, and generalized anxiety disorder. Few anticholinergic effects
Medication treatment: MAOIs: G: Phenelzine T: Nardil
Action and indications: Used to treat panic disorders, phobias, and PTSD. Acts by blocking reuptake of norepinephrine and serotonin in central nervous system.
Medication treatment: Tricyclics and others: G: Clomipramine T: Anafranil
Actions and Indications: Antidepressants used to manage anxiety symptoms
T:Celexa
Actions and Indications: Regulation of serotonin and norepinephrine
T: Lexapro and Effexor
Actions and Indications: Nonaddictive
When do dissociative responses occur?: They occur when anxiety becomes overwhelming and a disorganization of personality ensues.
Name some dissociative disorders: -Dissociative Amnesia
-Dissociative fugue
-Dissociative identity
-Depersonalization disorder
What are the features of dissociative disorder: Itâ€™s a disturbance or alteration in the normally integrative functions of
-Identity
-Memory
-Consciousness
-Perception of the environment
Define dissociative amnesia: Sudden inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness and which is not due to the direct effects of substance use or a general medical condition
Generalized amnesia-unable to recall info about his or her lifetime
Localized amnesia-client is unable to remember all events in a certain period
Selective-The client is able to recall some but not all events in a certain period
Define and explain Dissociative fugue: Characterized by a sudden unexpected travel away from home or customary workplace and inability to recall identity and information about some or all of the past.
The fugue state can involve assumption of a new identity
During a fugue state, individuals tend to lead rather simple lives, rarely calling attention to themselves
Spontaneous loss of memory usually preceded by a severely traumatic event
After a few weeks to a few months, a person in a fugue state may remember their former life and identity but become amnesic for the time spent in the fugue
Define and explain Dissociative Identity disorder: -The presence of two or more distinct alternate personality or subpersonality states that recurrently take control of behavior
-Each alternate or subpersonality has its own pattern of perceiving, relating to, and thinking about the self and the environment
-The transition from one personality to another is usually sudden, often dramatic, and usually precipitated by stress
-It is believed that severe sexual, physical, or psychological trauma in childhood predisposes a person in this condition.
How do dissociative identities develop?: -A young child is confronted with an intolerable terror-producing event in time when defenses are inadequate to handle the intense anxiety.
-The child dissociates the event and the feelings associated with the event.

The dissociated processes are split off from the memory or the primary personality
-The dissociated part of the personality takes on an existence of its own, becoming a subpersonality.

-The subpersonality learns to deal with feelings and emotions that could overwhelm the primary personality
-This process may occur several times, creating one or several sub-personalities
-When the individual is faced with an anxiety producing situation, one of the subpersonalities takes over to protect the primary personality from disorganization and disintegration
-Each alternate personality or subpersonality is a complex unit with its own memories, behavioral patterns, and social relationships that dictate how the person acts when that personality dominates
-Subpersonalities may think of themselves as being different in age, sex, race, religion, or sexual orientation.
Define and Describe Depersonalization disorder: 1. Persistent or recurrent alteration in the perception of the self to the extent that the sense of oneâ€™s own reality is temporarily lost while reality testing remains intact.
2. Body feels mechanical, dreamy, or detached from the body
a. Sense of deadness of the body
b. Sense of seeing self from a distance
c. Perception that limbs are smaller or longer than normal
3. Derealization is described as an alteration in the perception of the external environment
Nursing diagnoses for dissociative disorders: 1. Risk for violence: self-directed related to lack of impulse control of subpersonality
2. Altered thought processes related to repression of anxiety
3. Altered role performance related to disturbances in memory or identity
4. Anxiety related to alterations in memory, identity, or depersonalization episodes
5. Personal identity disturbance related to a traumatic event
6. Others
a. Social isolation
b. Powerlessness
c. Sleep pattern disturbance
Nursing interventions for Dissociative disorders: 1. Establishing a trusting relationship
2. Meeting safety and security needs
3. Offering emotional presence during the recalling of painful experiences
4. Confirm Identity and orient to time and place
5. Use behavioral methods to help patient focus on the present
a. Wrapping self in a blanket
b. Going to a safe place
c. Counting
6. Providing a quiet, supportive, structural environment
7. Teach coping strategies to prevent dissociative episodes.
Medication management for people who have dissociative disorders: Antianxiety medication such as clonazepam (Konopin) and Lorazepam (Ativan) for short periods to treat anxiety states.
SSRIs, tricyclic antidepressants, or antipsychotics to treat severe psychiatric symptoms
Narcotherapy which is interviewing under the relaxing influence of thiopental sodium (Pentothal) given IV-(truth serum) gives the therapist access to memories, conflicts, or other personalities.
Characteristics of Somatoform disorders: Somatoform disorders are characterized by physical symptoms suggesting medical disease, but no demonstrable organic pathology or known pathophysiological mechanism can be found to account for them.
Somatization refers to all those mechanisms by which anxiety is translated into physical illness or bodily complaints
Key points of Somatoform disorder Anxiety can be out of an individuals conscious awareness and can result in physical symptoms including pain Certain individuals because of neurobiological makeup may be more vulnerable to heightened awareness o: Key points of Somataform disorder
Clients with somatoform disorders truly experience suffering even though there is no â€œorganicâ€ reason for their symptoms
Depression, substance abuse, anxiety, and personality disorders are often comorbid conditions and require treatment
Diagnosis is essential to initiate appropriate treatment and to prevent continued unnecessary medical treatment
When are Somatoform disorders diagnosed?: Somatoform disorders are diagnosed when behavior patterns interfere with the individualâ€™s ability to function and are generally chronic, ongoing patterns of behavior.
Name the different types of Somatoform disorders:: Somatization disorder
Pain disorder
Hypochondriasis
Conversion disorder
Body dysmorphic disorder
How is Somatization disorder diagnosed?: The client has a history of many physical complaints that cannot be explained by a medical condition. It begins before age 30, occurring over a period of years with treatment being sought, there is significant impairment in social, occupations, or other areas of functioning. Must have complaint of pain in four different areas, and 2 GI, 1 reproductive and 1 neurological symptom
How is Pain disorder diagnosed?: Pain is a predominant feature of the disorder
Pain must be of sufficient severity to cause distress and impaired functioning
Psychological factors are judged to play an important role in the onset, severity, exacerbation or maintenance of pain.
If medical condition is present, it plays a minor role. The condition does not explain the amount of pain experienced by the patient.
How is Hypochondriasis diagnosed?: Hypochondriasis is Non-delusional preoccupation with having a serious disease or the fear of having a serious disease. There is a misinterpretation of bodily symptoms despite medical evaluation and reassurance. This condition has lasted longer than 6 months. Significant impairment in social, occupations, or other areas of functioning.
How is conversion disorder diagnosed?: Conversion disorder is characterized by one or more symptoms that suggest the presence of a neurological disorder that cannot be explained medically.
Psychological factors are present and are associated with the onset or exacerbation of the symptoms.
How is Body dysmorphic disorder diagnosed?: Body dysmorphic disorder involves preoccupation with an imagined defect in appearance that causes significant distress or impairment in social or occupational functioning
Typical concerns focus on imagined or minor flaws of the face or head, wrinkles, freckles, excessive or thinning hair, asymmetry of the face. Other part of the body may be the focus: breasts, genitals, body size and shape.
Clients are tormented by the supposed defect and spend inordinate amounts of time in their preoccupation: checking defect, avoiding reflections, or in grooming rituals.
May emerge in adolescence
Treatment approaches for those who have a somatoform disorder: 1. The development of a trusting, ongoing relationship with the nurse allows the client to learn about the diagnosis and the connection of mind to body
2. Clients with somatoform disorders are likely to experience exacerbation of symptoms when stressed. Education can lessen intensity of response
3. Treatments known to improve ability to function:
a. Antidepressant meds
b. Stress management techniques
c. Biofeedback
d. Group therapy
e. Socialization
Clinical Management tips for those who have a somatoform disorder: 1. Avoidance or rejection may result in increase anxiety levels causing intensification of somatic complaints
2. Avoid reinforcing the somatic symptoms by focusing on the pain or other somatic symptom
3. Always ask the client what is going on emotionally when complaining of somatic symptoms
4. Reflect back to the client the feeling that you see displayedâ€¦â€you must have felt very lonely during that timeâ€ when the client describes a situation involving physical symptoms.
5. Avoid assumptions that all somatic complaints are invalid
6. Do frequent self assessment tips for personal responses to the clients concerns
7. Avoid punitive attitude. Give physical care that is required with the same gentle approach you would use with any client and same attitude of concern
8. involve client in his/her care as much as possible through teaching about personal responses to stress
9. Limit time spent discussing physical concerns. Seek out the client and direct positive attention at times when physical symptoms are not the focus of concern.
10. Recognize the value of supportive therapy that increases the clientâ€™s functional level rather than aim for â€œcure.â€
What meds do you give to a person who has somatoform disorder?: Tricyclic and SSRI antidepressants may be used to treat chronic pain &/or associated depression
Clients rarely profit from antianxiety medication.
*If used, careful monitoring is needed because of addiction potential.
what does somatization mean: The expression of psychological stress through physical symptoms.
explain malingering disorders, factitious disorders, and psychosomatic illness as it contrasts to somatoform disorders: Somatoform disorders are not intential or under conscious control of the client, unlike in malingering or factitious disorders. Malingering involvs a conscious process of intentially producing symptoms for an obvious environmental goal. Factitious disorder refers to deliberate fabrication of symptoms or self inflicted injury with the goal of assuming the sick role. Psychosomatic illness-there is evidence of a general medical condition that may be affected by stress or psychological factors.

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