Anxiety Disorders

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www.davaar.com.au - wendy@davaar.com.au

1 CNE point

ObjectivesUnderstand anxietyDiscuss generalised anxiety disorderDiscuss panic attacksIdentify signs and symptoms of

generalised anxiety disorder panic attacks

Discuss nursing interventionsDiscuss management

“People are disturbed not by things, but by the views they take of them”

- Epicetetus (Greek Philosopher)

Moreno (1972) understood anxiety as the absence of spontaneity

Consider a time when have you felt anxious:

• crossing the road a car appears from nowhere

• sitting an exam

• attending a job interview

• being part of this group

What were the…thoughts you had (cognitions)(e.g. “I am not safe”

Bio -physiological Symptoms(e.g Heart rate)

Emotional Reactions(e.g. fear)

Behavioral responses(e.g. did not move)

Discuss in small groups

We all have our own coping mechanisms when wefeel under threat.

Who assess or judges that they are “dysfunctional / non coping?”

Anxiety disorders one of the most common behavioural / mental health problems in childhood & adolescence (Puskar, et al, 2009)

Between 8-12% of children experience some kind of anxiety disorder (Bernstein, et al 1996; Muris & Steerneman, 2001)

13 out of every 100 children are affected by an anxiety disorder

Anxiety disorders often occur with another mental illness / physical illness

High correlation between substance use and anxiety in adolescents (SAMHSA, 2007)

Famous People:

Abraham LinconAnthony HopkinsAretha FranklinEric ClaptonSir Issac NewtonSigmund Freud

Anxiety explained• most basic of all emotions all people and animals experience anxiety term anxiety used to describe all feelings & symptoms that arise when an individual perceives a threat or danger anxiety is a natural, normal feeling that is necessary for survival differs in duration and in strength and varies from mild

uneasiness to extreme distress is protective (while it can be unpleasant anxiety cannot

harm an individual)

Functions of Anxiety

first function of anxiety is to alert the individual threat

second function - to motivate the individual into mobilising his/her defences ready for action

DSMIV: anxiety disorder – chronic condition characterized by an excessive and persistent sense of apprehension

Generalized Anxiety Disorder

Panic Attacks

Phobias (overwhelming sense of fear):•Agoraphobia•Social Anxiety Disorder•Zoophobia•Mysophobia

Obsessive/Compulsive disorder

P.T.S.D.SeparationAnxiety

This session will address two anxiety disorders:

Panic Attack Generalised Anxiety

Disorder (GAD)

But first a review………….

An important point to remember whatever the anxiety disorder …FLIGHT/FIGHT/FREEZE response will be present:

this is a primitive mechanism that brings about physical changes which are necessary in order to prepare individuals to fight / run away /stay still … this response controls anxiety whether it is a mild or extreme response

when an individual perceives a threat the body releases adrenalin to activate the autonomic nervous system

Flight / Fight / Freeze Response Useful - highly effective when our life is in danger and we

need tor respond… it motivates and protects us. It is controlled automatically and we don’t have to think about it

Not useful when:

• it is set off in response to a perceived threat rather than an actual one

• there is an impairment in thinking and problem-solving ability

• there is interference with sleep

• there is a disruption in memory and concentration

• the symptoms are unpleasant and prolonged and when they interfere with one’s daily living

Normal response to threat

Perception of threat

Limbic system

Amygdala Signals Alarm

Hypothalamus

SNS

Adrenal Glands

Epinephrine/Norepinepine

Prepare for fight/flight

Corticotropin-releasing factor

Pituitary gland

Adrenocorticotropic hormone (CRF)

Cortisol (Hydrocortizone)

Inhibits Alarm Reaction

PTSD Response

Perception of threat

Limbic system

Amygdala Signals Alarm

Hypothalamus

SNS

Adrenal Glands

Epinephrine/ Norepinepine

Prepare for flight/fight

Mobilization Persists

PTSD symptoms

Corticotropin-releasing factor

Pituitary gland

Adrenocorticotropic hormone (CRF)

Cortisol (Hydrocortizone)

Not able to halt alarm reaction

Generalised Anxiety Disorder• Approx 5% Australian population experience GAD

(beyondblue)

• free floating anxiety accompanied by autonomic symptoms such as tremor in hands (Moore, 2008)

• onset is gradual and may initially occur in teenage or early adult years

• chronic pervasive sense of anxious apprehension & tension

• individuals with GAD often worry every day about

• routine life circumstances i.e. job responsibilities,

• financial situation, health of family members, household chores, care repairs, being late for appointments

• anxiety / worry is associated with three or more of the following: being easily fatigued irritability muscle tension

• difficulty concentrating or mind going blank

• sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

• the anxiety/worry/physical symptoms are not due to direct

• physiological effects (medications), medical condition (hyperthyroidism) and does not exclusively occur during

• a psychotic episode, mood disorder

• the anxiety/worry/physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning (Antai-Otong, 2003; Kettler, et al, 2005)

Essential features:

•“excessive anxiety and worry (apprehensive expectation), occurring more days than not”

•difficult to control the worry

Physical symptoms

feeling cold, clammy hands, dry mouth, sweating, nausea, or diarrhoea, urinary frequency, trouble swallowing “lump in throat”, easily startled

In clinical settings GAD is diagnosed more frequently in women than in men

Why might this be the case?

Panic Attack• often accompanied by a sense of imminent

danger or impending doom• palpitations, pounding heart, or accelerated

heart beat, sweating, trembling/shaking• sensations of shortness of breath or

smothering• feeling of choking• chest pain/discomfort• nausea/abdominal distress• feeling dizzy, unsteady, light headed or faint

• derealisation or depersonalization• fear of losing control or going crazy• feat of dying• paresthesias (numbing/tingling sensations)

chills or hot flushes

• Individuals seeking care for unexpected panic attacks will describe the fear as intense, & state that they “thought they were going to die”, “having a heart attack” “going crazy” and report experiencing an urgent desire to flee

• Approx 3 out of 10 people in Australia will experience at least one panic attack in their lifetime

• Approx 3% of population have a panic attack disorder

Causes

• Multifaceted neurobiological neurotransmitter involvement –

norepinephrine, serotonin, GABA atrophy to both amygdala (Massana et al, 2003b)

• Hereditary

• Psychosocial (Role modelling)

• Environmental

Strategies…..

Nursing in the moment:

• stay calm, regulate own breathing• whatever the wish… resist the temptation to

abandon the client• work with the client to regulate their breathing

(may have to demonstrate)• talk in a calm, firm and reassuring tone• (the client needs to be able to hear you and

needs to have a sense that you know what you are doing and that you can contain their overwhelming fear/ terror)

Longer term...

•work with client to recognise their own strengths and resilience

•facilitate their self appreciation (they got this far, what enabled that?)

•be clear about your boundary issues in terms of the clients capabilities

•work with the client to develop a hierarchy of symptoms and interventions

Interventions / Treatments

Solution Focused Approach Cognitive Behavioural Therapy

Stop, Think, Go Group Therapy Relaxation / meditation Counselling (narrative, gestalt, client centred) Medications

Antidepressants - SSRI’s, Tricyclics, MAOI’s Benzodiazepines - Diazepam Inositol – naturally occurring isomer of glucose,

participates in the action of serotonin

What other interventions can you identify to:

• assist decrease the symptoms of anxiety?• manage long term anxiety?

Discuss in small groups

Questions?

References

Antai-Otong, D. (2003). Current treatment of Generalized Anxiety Disorder. Journal of psychosocial nursing, 41 (12), 20-29

Bernstein, G., Borchardt, C., & Perwien, A. (1996). Anxiety disorders in children and adolescents: A review of the past ten years. Journal of the American Academy of Child and Adolescent Psychiatry, 35 (9), 1110-1119.

Frances,A., Pincus, H.A, & First, M.B. (1994). Diagnostic & Statistical Manual of Mental Disorders 4rth Edition. American Psychiatric Association: Washington 393-444

Kessler, R.C., Chiu, W.T., Demler, O., & Walters, E.E., (2005). Prevalence, severity and comorbidity of twelve-month DSMIV disorders in the National Co morbidity Survey Replication (NCS-R). Archives of General Psychiatry 62 (6), 617-27.

Moore, D. P. (2008). Textbook of clinical neuropsychiatry (2nd edition). Hodder Arnold: London.

Muris, P., & Steerman, P. (2001). The revised version of the screen for child anxiety, related emotional disroders (SCARED-R): First evidence for its reliability and validity in a clinical sample. British Journal of Clinical Psychology, 40, 35-44

Puskar, K., Berndao, L.M., Ren, D., Stark, K.M., & Lester, S. (2009). Sex differences in self-reported anxiety in rural adolescents. International Journal of Mental Health Nursing, 18, 417-423.

Substance Abuse and Mental Health Service Administration (SAMHSA). (2007). Children’s mental health facts: Children and adolescents with anxiety disorders. (Cited 10.12.2009) Available from: http://mentalhealth.samhsa.gov/publications/allpubs?CA-0007/defaultasp