anxiety, anxiety disorders and stress-related illness

7/27/2019 Anxiety, Anxiety Disorders and Stress-Related Illness

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Anxiety, Anxiety

Disorders and Stress-

Related Illness


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ANXIETY

This is a vague feeling of dread orapprehension; it is a response to external and

internal stimuli that can have behavioral,

emotional, cognitive and physical symptoms.


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ANXIETY DISORDERS

-comprise a group of conditions that share a

key feature of excessive anxiety with ensuringbehavioral, emotional, cognitive and

physiologic responses.


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ANXIETY AS A RESPONSE TO STRESS

Stress is the wear and tear that life causes on the

body

Han Selye, an endocrinologist, identified the

physiologic aspects of stress, which he labeled the

general adaptation syndrome


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Alarm reaction stage- Stress stimulates the body to send

message from the hypothalamus tothe glands and organs to prepare for

potential defense needs.


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Resistance Stage

- The digestive system reduces function to shunt

blood to areas needed for defense. Lungs take in

more air, and the heart beats faster and harder so it

can circulate this highly oxygenated and highly

nourished blood to the muscles to defend the body

by fight, flight or breeze behaviors.


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Exhaustion stage

- Occurs when the person responded negatively

to anxiety and stress: body stores are depleted or

the emotional components are not resolved,

resulting in continual arousal of the physiologic

responses and little reserve capacity.


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LEVELS OF NXIETYAnxiety Level Psychological

Responses

Physiologic Responses

Mild Wide perceptual field

Sharpened senses

Increased motivation

Increased learning

ability

Irritability

Restlessness

Fidgeting

GI butterflies

Difficulty sleeping

Hypersensitivity to

noise


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Moderate Perceptual field narrowed

to immediate task

Selectively attentiveCannot connect thoughts

or events independently

Increased use ofautomatisms

Muscle tension

Diaphoresis

Pounding pulseHeadache

Dry mouth

High voice pitchFaster rate of speech

GI upset

Frequent urination


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Severe Perceptual field reduced to

one detail or scattered details

Cannot complete tasks

Cannot solve problems orlearn effectively

Behavior geared toward

anxiety relief and is usually

ineffective

Doesnt respond to redirection

Feels awe, dread, or horror

Cries

Ritualistic behavior

Severe headache

Nausea, vomiting and

diarrhea

TremblingRigid stance

Vertigo

Pale

Tachycardia

Chest pain


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Panic Perceptual field reduced to focus

on self

Cannot process any environmental

stimuliDistorted perceptions

Loss of rational thought

Doesnt recognize potential

danger

Cant communicate verbally

Possible delusions and

hallucination

May be suicidal

May bolt and n

OR

Totally immobile and mute

Dilated pupilsIncreased blood pressure

and pulse

Fight, flight, or freeze


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Working with Anxious Clients


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Mild anxiety is asset to the clients and requires

no direct intervention.

Moderate anxiety, the nurse must be certain

that the client is following on what the nurse issaying. The clients attention can wander, and he or

she may have some difficulty concentrating over time.


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When anxiety becomes severe, the client no

longer can pay attention or take information. The nurse

goals must be lower the persons anxiety level to

moderate or mild before proceeding with anything else.

Talking to the client in a low, calm and soothing voice

can help. If the person cannot sit still, walking with

them while talking can be effective.


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During the panic level anxiety, the persons safety is

the primary concern. The nurse must keep talking to the

person in a comforting manner, even though the client

cannot process what the nurse is saying. Going to small,

quiet, and non stimulating environment may help to reduce

anxiety. The nurse should remain with the client until the

panic recedes. Panic level is not sustained independently but

can last from 5- 30 minutes.


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when working with an anxious client,

the nurse must be aware of his or err own

anxiety level..it is easy for the nurse to

become increasingly anxious. Remainingcalm and in control is essential if the nurse

is going to work effectively with the client


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Short term anxiety can be treated with anxiolytic

medications. Most of these are Benzodiazepines, which

are commonly prescribed for anxiety. These drug are

designed to relieve anxiety so that the person can dealmore effectively with whatever crisis or situation is

causing stress


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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 that is repressed can cause eating disorders, such s

anorexia nervosa and bulimia.

Stress can also exacerbate the symptoms of many illnesses, such as

hypertension and ulcerative colitis

Chronic or recurrent anxiety resulting from stress may also be

diagnosed as an anxiety disorder


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ANXIOLYTIC DRUGS


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BENZODIAZEPINES

Diazepam (valium)

Alprazolam(xanax)

Chlordiazepoxide(librium)

Lorazepam(ativan)Clonazepam(klonopin)

Oxazepam(serax)


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NON-BENZODIAZEPINES

Buspirone(buspar)

Meprobamate(miltown,equanil)


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Implementation

NURSINGINTERVENTION

Remain w/ the client atall the times when levels

of anxiety are high.Move the client to a quiet

area w/ minimaldecrease stimuli such as

a small room.

RATIONALE

A highly anxious clientshould not be alone.

In a large area, the clientcan feel lost andpanicked, but a smaller

room can enhance asense of security.


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Cont

PRN medications may beindicated for high levelsof anxiety , delusions,disorganized thoughts

and so forth.

Remain calm in yourapproach to the client.

Medications may benecessary to decreaseanxiety to a level at w/cthe client can feel safe.

The client can feel moresecured if you are calm

and if the client feels youare in control of thesituation.


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Cont

Use short simple andclear statements.

Avoid asking or forcing

the client to makechoices.

Be aware of your own

feelings in level ofdiscomfort.

The client ability to dealw/ abstractions orcomplexity is impaired.

The client may not make

sound decisions or maybe unable to makedecisions.

Anxiety is communicated

interpersonally. Being w/an anxious client can rise

your own anxiety level.


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Cont

Encouraged the clientparticipation inrelaxation exercise such

as deep breathing,progressive musclerelaxation ,meditation ,and imagining being in a

quiet and peaceful place.

Relaxation exercise areeffective, non chemical

ways to reduce anxiety.


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Cont

Teach the client to userelaxation techniquesindependently.

Help the client see thatmild anxiety can be apositive catalyst for

change and does notneed to be avoided.

Using relaxationtechniques can give theclient confidence inhaving control over

anxiety.

The client may feel thatall anxiety is bad and not

useful.


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OVERVIEW OF ANXIETY

DISORDERS


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Anxiety disorders are diagnosed when anxiety

no longer function as a signal of danger or a

motivation for needed change but becomes chronic

and permeates major portions of the persons life,

resulting in maladaptive behaviors and emotional

disability.


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Types of anxiety disorders include the following;

Agoraphobia with or without panic disorder Panic disorder

Specific phobia

Social phobia

OCD Generalized anxiety disorder (GAD)

Acute stress disorder

Posttraumatic stress disorder.


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RELATED DISORDER

Anxiety disorder due to a general medical

condition

-diagnosed when the prominent symptoms of

anxiety are judged to result directly from a

physiologic condition. The person may have panicattacks, generalized anxiety, or obsessions or

compulsions.

Subtance-induced anxiety disorder

-is anxiety directly caused by drug abuse,

medication, or exposure to a toxin .Symptoms

include prominent anxiety, panic attacks, phobias,

obsession, or compulsions


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Separation anxiety disorder

-is excessive anxiety concerning separation

from home or from person, parents, or caregivers towhom the clients is attached. It occurs when it is no

longer developmentally appropriate and before 18

years of age.

Adjustment disorder-is an emotional response to a stressful event,

such as one involving financial issues, medical

illness,or a relationship problem, that result in

clinically significant symptoms such as markeddistress or impaired functioning.


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ETIOLOGY

GENETIC THEORIES

-Anxiety may have an inherited componentbecause the first-degree relatives of clients withincreased anxiety have higher rates of developing

anxiety. Heritability refers to the proportion of adisorder that can be attributed to genetic factors.

High heritabilities are greater than 0.6and indicatethat genetic influences dominate.

Moderate heritabilities are 0.3 to 0.5 and suggestan even greater influence of genetic andnongenetic factors.

Heritabilities less than 0.3 mean that genetics arenegligible as a primary cause of the disorder.


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NEUROCHEMICAL THEORIES

Gamma-aminobutyric acid (y-aminobutyric acid [GABA]is the amino acid neurotransmitter believed to be

dysfunctional in anxiety disorders. GABA , an inhibitorneurotransmitter , functions as the bodys naturalantianxiety agent by reducing cell excitability, thusdecreasing the rate of neuronal firing.

Because GABA reduces anxiety and norepinephrine

increases it, it researchers believe that a problem withthe regulation of these neurotransmitters occurs inanxiety disorders.

Serotonin, the indolamine neurotransmitter usuallyimplicated in psychosis and mood disorders, has many

subtypes. Serotonin is believed to play a distinct role inOCD, panic disorder, and GAD. An excess innorepinephrine is suspected in panic disorder, GAD, andposttraumatic stress disorder.


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PSYCHODYNAMIC THEORIES


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INTRAPSYCHIC/PSYCHOANALYTICTHEORIES

Freud (1936) saw a persons innate anxiety as the

stimulus for behavior. He described defense

mechanisms as the humans attempt to controlawareness of and to reduce anxiety. Some people

overuse defense mechanisms, which stops them

from learning a variety of appropriate methods to

resolve anxiety-producing situations.


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INTERPERSONALTHEORY

HarryStack Sullivan(1952)viewed anxiety as being

generated from problems in interpersonal

relationships. Caregivers can communicate anxiety

to infants or children through inadequate nurturing,agitation when holding or handling the child, and

distorted messages .In adults anxiety arises from

the persons need to conform to the norms and

values of his or her cultural group. The higher the

level of anxiety, the lower the ability tocommunicate and solve problems and the greater

the chance for anxiety disorders to develop.


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Hildegard Peplau (1952) understood that humans

exist in interpersonal and physiologic realms; thus,

the nurse can better help the client to achieve

health by attending to both areas. She identified the

for levels of anxiety and developed nursingintervention and interpersonal view of anxiety


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BEHAVIORALTHEORY

Behavioral theorists view anxiety as being learned

through experiences. Behaviorists believe that

people can modify maladaptive behaviors without

gaining insight into their causes. They contend thatdisturbing behaviors that develop and interfere with

a personslife can be extinguished or unlearned by

repeated experiences guided by a trained therapist.


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SYMPTOMS OF ANXIETY

DISORDERSDSM IV-TR DIAGNOSTIC CRITERIA


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DISORDER SYMPTOMS

AGORAPHOBIA is anxiety about

or avoidance of places or

situations from which escapemight be difficult or in which help

might be unavailable.

Avoids being outside alone or at

home alone, avoids traveling in

vehicles, impaired ability to work,difficulty meeting daily

responsibilities (e.g. grocery

shopping or going to

appointments); knows response is

extreme

PANIC DISORDER is

characterized by recurrent,

unexpected panic attacks that

cause constant concern. Panic

attack is the sudden onset of

intense apprehension, fearfulnessor terror associated with feelings of

impending doom.

A discrete episode of panic lasting

15 to 30 minutes with four or more

of the following, palpitations,

sweating, trembling or shaking,

shortness of breath, choking or

smothering sensation, chest painor discomfort, nausea,

derealization or

depersonalization,fear of dying or

going crazy, paresthesias, chills or

hot flashes.


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SPECIFIC PHOBIA is

characterized by significant anxiety

provoked by a specific feared

object or situation, which oftenleads to avoidance behavior.

Marked anxiety response to the

object or situation, avoidance or

suffered endurance of object or

situation; significant distress orimpairment of daily routine,

occupation, or social functioning;

adolescents and adults recognize

their fear as excessive or

unreasonable.

SOCIAL PHOBIA is characterizedby anxiety provoked by certain

types of social performance

situations, which often leads to

avoidance behavior.

Fear of embarrassment or inabilityto perform; avoidance or dreaded

endurance of behavior or situation;

recognition that response is

irrational or excessive; beliefs that

others are judging him or her

negatively; significant distress or

impairment in relationships, work

or social life, anxiety can be

severe or panic level.


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OBSESSIVE-COMPULSIVE

DISORDER involves obsessions

(thoughts, impulses, or images)

that cause marked anxietyand/or

compulsions (repetitive behaviorsor mental acts) that attempt to

neutralize anxiety.

Recurrent, persistent, unwanted,

intrusive thoughts, impulses, or

images beyond worrying about

realistic life problems; attempts to

ignore, suppress, or neutralizeobsessions with compulsions that

are mostly ineffective; adults and

adolescents recognized that

obsessions and compulsions are

excessive and unreasonable.

GENERALIZED ANXIETY

DISORDER is characterized by at

least 6 months of persistent and

excessive worry and anxiety.

Apprehensive expectations more

days than not for 6 months or

more about several events or

activities; uncontrollable worrying;

significant distress or impaired

social or occupational functioning;

three of the following symptoms;

restlessness, easily fatigue,

difficulty concentrating or mind

going blank, irritability, muscle

tension, sleep disturbance,


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ACUTE STRESS DISORDERis

the development of anxiety,dissociation, and other symptoms

within 1 month of exposure to an

extremely traumatic stressor, it

lasts 2 days to 4 weeks.

Exposure to traumatic event

causing intense fear, helplessness,or horror, marked anxiety

symptoms or increase arousal;

significant distress or impaired

function; persistent re-

experiencing of the event; three of

the following symptoms; sense ofemotional numbness or

detachment, feeling dazed,

derealization, depersonalization,

dissociative amnesia (inability to

recall important aspect of the

events)


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POST TRAUMATIC STRESS

DISORDER is characterized by

the re-experiencing of anextremely traumatic event,

avoidance of stimuli associated

with the event, numbing of

responsiveness, and persistent

increased arousal; it begins within

3 months to years after the eventand may last a few months or

years.

Exposure to traumatic event

involving intense fear,

helplessness, or horror, re-experiencing (intrusive

recollections or dreams,

flashbacks, physical and

psychological distress over

reminders of the event); avoidance

of memory provoking stimuli andnumbing of generalresponsiveness

(avoidance of thoughts, feelings

conversations, people, places,

amnesia, diminish interest

participation in life events, feeling

detached or estranged from

others, restricted affect, sense of

foreboding)


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Treatment Treatment for anxiety disorders usually involves

medication and therapy.

Positive Reframing means turning negative messages intopositive messages.

Decatastrophizinginvolves the therapists use of questionsto more realistically appraise the situation


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Assertiveness Training helps the person take

more control over life situations. Techniques

help the person negotiate interpersonal

situations and foster self- assurance.


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Elder Considerations

Anxiety that starts for the first time in late life is frequentlyassociated with another condition such as depression, dementia,

physical illness, or medication toxicity or withdrawal.

Ruminative thoughts are common in late- life depression and cantake the form of obsessions such as contamination fears, pathologic

doubt, or fear of harming others.

The treatment of choice for anxiety disorder in elderly is selective

serotonin reuptake inhibitor (SSRI) antidepressants.


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Mental Health PromotionTips for managing stress:

Keep a positive attitude and believe in yourself

Accept there are events you cannot control

Communicate assertively with others

Learn to relax Exercise regularly

Eat well- balanced meals

Limit intake of caffeine and alcohol

Get enough rest and sleep

Set realistic goals and expectations and find an activity that is personally meaningful

Learn stress management techniques


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General Appearance and Motor Behavior

Mood and Affect

Thought Processes and Content

Sensorium and Intellectual Processes Judgment and Insight

Self- concept

Roles and Relationships

Physiologic and Self- care Concerns


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The client is anxious, worried, tense, depressed,

serious, or sad. When discussing the panic attacks,

the client may be tearful.

During panic attack, the client may describefeelings of being disconnected from himself or

herself (depersonalization) or sensing that things are

not real (derealization).


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The client is overwhelmed, believing that he or she is

dying, losing control or going insane. It may evenconsider suicide.

Thoughts are disorganized and the client loses the ability

to think rationally.

The client may become confused and disoriented.


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He or she cannot take in environmental cues

and respond appropriately.

The client believe they are helpless and have

no control over their anxiety attacks.

The clients often make self- blaming

statements.


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The client find themselves consumed with

worry about impending attacks and may be

unable to do many things they did before.

The person typically avoids people, places andevents associated with previous panic attacks.

The client often reports problems withsleeping and eating.


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Nursing Interventions

For Panic Disorder Provide a safe environment and ensure clients privacy during a panic

attack.

Remain with the client during a panic attack.

Help client to focus on deep breathing.

Talk to client in calm, reassuring voice.

Teach client to use relaxation technique.

Help client to use cognitive restructuring techniques. Engage client to explore how to decrease stressors and anxiety-

provoking situations.


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Client/ Family Education

For Panic Disorder Review breathing control and relaxation techniques.

Discuss positive coping strategies.

Encourage regular exercise.

Emphasize the importance of maintaining prescribed medicationregimen and regular follow- up.

Describe time- management.

Stress the importance of maintaining contact with community andparticipating in supportive organizations.


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PANICDISORDER


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Composed of discrete episodes of panic attacks,15-30 minutes of rapid, intense, escalating

anxiety in which the person experiences great

emotional fear as well as physiologic

discomfort.


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During the attack the person displays four or more

symptoms:

Palpitations, Sweating

Tremors, SOBSense of suffocation, Nausea

Chest pain Paresthesias

Chills or hot flashes DizzinessAbdominal distress


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Panic disorder is more

common in people who have

not graduated from college andare not married


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CLINICAL COURSE It peaks in late adolescence and id-30s

The person becomes homebound or stays in a limited area near

home such as on the block or within town limits. This behavior

is known as agoraphobia (fear of the marketplace or fear ofbeing outside)

The behavior pattern of people with agoraphobia clearly

demonstrate the concepts of primary and secondary gain

associated with many anxiety disorders


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Primary gain

- The relief of anxiety achieved by performing the specific

anxiety-driven behavior such as 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

behavior


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If the client is anxious, speech may increase in rate,pitch, and volume, and he or she may have

difficulty sitting in a chair.

Automatisms- are automatic, unconscious

mannerisms- may be apparent.


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PHOBIA


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An illogical, intense, and persistent fear of a specificobject or a social situation that causes extreme distress

and interferes with normal functioning.

Usually do not result from past negative experiences.

Person may never have had contact with the object of the

phobia.


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THREE CATEGORIES

Agoraphobia

Specific phobia

Social phobia


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AGORAPHOBIA

Fear of being in open spaces and

situation in which the person thinksthere is no escape or help would be

difficult to obtain.


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SPECIFIC PHOBIA

An irrational fear of an object or situation

Are subdivided into following categories:

> Natural environment phobias: fear of storms, water,heights or other natural phenomena

> Blood injection phobias: fear of seeing ones own

blood, traumatic injury or an invasive medical procedure


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> Situational phobias: fear of being in a specific

situation such as on a bridge or tunnel, elevator, small

room, hospital or airplane

> Animal phobia: fear of animals or insects

> Other types of specific phobias: fear of getting

lost while driving

A A


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SOCIAL PHOBIA

Also known as social anxiety disorder Which is an anxiety provoked by certain social or performance situation

The person becomes severely anxious to the point of panic or

incapacitation when confronting situations involving people.

Examples are making speech, attending social engagement alone,

interacting with opposite sex or strangers and making complaints, etc.

The fear is rooted in low self-esteem and concern about others

judgement.


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ONSET AND CLINICAL COURSE

Specific phobias usually occur in childhood oradolescence.

Social phobia peak age of onset is middle

adolescence. Sometimes emerges in a person who

was shy as a child

TREATMENT


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TREATMENT

Behavioral therapy> Systematic desensitization

> Flooding

> Positive reframing

> Assertiveness training

Therapist initially focus on teaching what anxiety is Help client identify anxiety responses


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Teach relaxation techniques

Help set goals and discuss methods to achieveit

Help client to visualize phobic situations Help client to develop self-esteem and self-

control


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Obsessions


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Are recurrent, persistent, intrusive & unwantedthoughts, images or impulses that cause markedanxiety & interfere with interpersonal, social, oroccupational function.

The persons knows these thoughts are excessive orunreasonable but believes he or she has no controlover them.

CompulsionsA i li i i i b h i l


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Are ritualistic or repetitive behaviours or mentalacts that a person carries out continuously in an

attempt to neutralize anxiety.

Usually the theme of the rituals is associated with

that of the obsession.

OCD can be manifested only when thoughts,images, & impulses consume the person or he/she iscompelled to act out the behaviours to a point atwhich they interfere with personal, social &occupational function

OCD can be manifested through many behaviours,ll f hi h i i i l & diffi l


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all of which are repetitive, meaningless & difficult toconquer .

The persons understands that these rituals areunusual & unreasonable but feel forced to perform

them to alleviate anxiety or to prevent terriblethoughts

Obsessions & compulsions are a source of distress& shame to the person, who may go to treat lengthsto keep them secret.

Onset & Clinical Course


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OCD can start in childhood, especially in males.

In females, it more commonly begins in the 20s.

Overall, distribution between the sexes is equal.

Onset is usually gradual, although there have beencases of acute onset with periods of waxing &waning symptoms.

80% of those treated with behaviour therapy andmedication report success in managing obsessions& compulsions, whereas 15% show p0rogressivedeterioration in occupational and socialfunctioning.

Treatment

Lik f th i t di d ti l t t t f OCD


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Like for other anxiety disorders, optimal treatment for OCDcombines medication & behaviour therapy.

Behaviour therapy specifically includes exposure & responseprevention:

Exposure

Involves assisting the clients to deliberately confront the

situations & stimuli that he or she usually avoids.Response Prevention

Focuses on delaying or avoiding performance of rituals. Theperson learns to tolerate the anxiety & to recognize that it will

recede without the disastrous imagined consequences.

Other techniques discussed previously, such as deep breathing& relaxation, also can assist the person to tolerate & eventuallymanage the anxiety.

GENERALIZED ANXIETY DISORDER


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GENERALIZED ANXIETY DISORDER

A person with GAD worries excessively and feelshighly anxious at least 50% of the time for 6months or more.

Unable to control this focus on worry, the personhas three or more of the following symptoms:uneasiness, irritability, muscle tension, fatigue,difficulty thinking and sleep alterations.

more people with this chronic disorder are seenby family physicians than by psychiatrists.

Buspirone (buSpar) and SSRI antidepressants arethe most effective treatment.

OS C S SS SO


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POSTTRAUMATIC STRESS DISORDER

PSD can occur in a person who has witnessed anextraordinarily terrifying and potentially deadlyevent.

After the traumatic event, the personexperiences all or some of it through dreams orwaking recollections and responds defensively tothese flash backs.

New behaviors develop related to the trauma,such as sleep difficulties, hyper vigilance,thinking difficulties, severe startle response, andagitation.

ACUTE STRESS DISORDER


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ACUTE STRESS DISORDER

ASD similar to post traumatic stress disorder in

that the person has experienced a traumatic

situation but the response is more dissociative.

the person has a sense that the event was unreal,believes he or she is unreal, and forgets some

aspects of the event through amnesia, emotionaldetachment, and muddled obliviousness to the

environment.

anxiety, anxiety disorders and stress-related illness

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