Anxiety Disorders

Anxiety Disorders

Anxiety can be good.  Your senses and problem solving can be heightened, anxiety is there to protect you.

Common anx d/o: OCD, panic d/o, Generalized Anx d/o, phobias, PTSD

Test: table 21.7: RN interventions for various forms of anx

Discussed; 4 categories of Anxiety manifestations [by physio, psych, cog, and behave]

4 manifestation components of anx. d/o

• Physiological: palpitations, tach, sweating, shaking, nausea/diarrhea, SOB, dizziness, fatigue, chest/stomach pain, higher BP, dry mouth, urinary frequency.
• Psychological: insomnia, depersonalization, fear of death, feelings of doom, helpless, hopeless, fight or flight, mend and tend, irritability
• Cognitive:  judgment and perception errors, poor performance, depth perception issues, tangentiality, distracted, forgetfulness
• Behavioral: restless, rapid speech, withdrawal, pacing, inability to complete tasks, sobbing without tears.

Anxiety:

• Mild/Level 1: helpful motivator; everyday tension, offers alterness.  Tx; eating, TOB, swearing, exercise
• Moderate/ Level 2: High perception, but becomes ‘tunnel visioned’—attention only on stressful situation
• Severe/ Level 3: Perception inaccuracies, problem solving impaired. Needs intervention/help
• Panic/ Level 4: distorted perceptions. Dread and terror. Needs immediate intervention.

PANIC DISORDER

            Panic Attacks

• Can last from 5 mins to one hour,
• It’s a d/o when it becomes recurrent. 
• Sudden, spontaneous. 
• With therapy and training pts can ident their triggers and antecedents.
• Connected to agoraphobia, or not.  In this case agoraphobia is about a physical or social situation [bridges, crowds] where the person feels they cannot escape.
• Symptoms: SOB, tach, smothering or choking sensation, the feeling of dread and doom, fear that you may die from it.  Throat constrixn, parasthesias, derealization [things aren’t real], depersonalization [looking down on yourself, OOBody] non purposeful movement.
• Crying is a good release of the energy

  • Nclexnote

Physical symptoms of panic attack are similar to cardiac emergencies. These symptoms are physically taxing and psychologically frightening to patients. Recognition of the seriousness of panic attacks should be communicated to the patient.

Tx of PA’s and Panic d/o

Reciprocal inhibition: training pt to use coping skills and practices when their panic comes up.  You can use distraction, ask them to walk with you, etc.  Don’t ask questions: they cannot answer you.

Risks: not enough sleep, females, substances, high stress situations, fam history, TOB

 Meds: benzo’s, SSRI’s, SNRI’s

NCLEX-y question: don’t give a long acting benzo to pt with sleep apnea

Phobic d/o’s;  “persistent irrational fear of an object, sitch, activity, and a compelling need to avoid it.”  People will experience panic if they are put in a situation where they cannot avoid their phobia.

A phobia is the displacement of and unconscious conflict onto a symbolically related object.  The fear has to be marked and persistent.

• Social phobia: aka “social anx d/o.” Most common--a fear of scrutiny, embarrassment, or criticism. Fear of appearing inept in front of others.  The person imagines that there will be humiliation and embarrassment.  To be a d/o it has to be irrational and debilitating.  A person can have panic attacks, hates working in groups.  Equal btwn genders.  Usually only one area of concern and is chronic.
• Agoraphobias w/o Hx of panic d/o: place or situation that cannot be escaped
• Specific Phobia: aka simple phobia of an object or situation.

Tx: SSRI’s, SNRI’s, benzo’s. 

Post-traumatic stress disorder:  Can be acute: like the event happened <3mo ago.  Chronic is >3 months.  Delayed can be many months or years after the event.

Range of estrangement: restrictive affect.  A lot of people can no longer have a connected relationship: like wild men living in mountains as hermits. It’s easier for them to connect with people who have been through a similar situation.

PTSD affects roughly 8% of the general population, and women are more likely than men to be affected

 Acute:

Chronic

Delayed onset: if symptoms appear 6 months or more after event

Pts say that ‘anyone who can talk about their experience easily is faking it.’

Nursing Interventions

Nutrition and exercise is common to all these d/os.  Explain to the family what’s going on.  Group therapy can be great for PTSD pts. Hypnosis, abreaction [catharsis].  If you can immediately put pts into therapy and make them talk about the experience, the less likely they are to go PTSD. Cog therapy: thought stopping.

• Exposure to traumatic event
  Witnessed, experienced, or confronted with event(s) involving actual or threatened death or serious injury or threat to physical integrity of self or others
  Response involving intense fear, helplessness, or horror
• Persistent re-experiencing of traumatic event
  Recurrent and intrusive distressing recollections
  Recurrent distressing dreams
  Acting or feeling like traumatic event was recurring
  Intense psychological distress and physiologic reactions when exposed to cues symbolizing or resembling the event
• Persistent avoidance of stimuli associated with trauma with numbing of general responsiveness
  Thoughts, feelings, or conversations associated with the trauma avoided
  Activities, places, or people who arouse recollection of trauma avoided
  Inability to recall important aspects of trauma
  Insignificant decreased interest or participation in activities
  Detachment and estrangement from others
  Restricted range of affect
  Sense of a shortened future
• Persistent symptoms of arousal
  Difficulty falling or staying asleep
  Irritability and anger outbursts
  Difficulty concentrating
  Hypervigilance
  Exaggerated startle response
• Duration of symptoms greater than 1 month (acute: duration less than 3 months; chronic:duration longer than 3 months; with delayed onset: if symptoms appear 6 months or more after event)
• Significant distress or impairment of social, occupational, or other important areas of functioning

Acute stress disorder

A dissociative d/o: there are 5 symptoms: derealism, dissociative amnesia, decreased awareness of surroundings, detachment, depersonalization.

Essential feature of the five disorders in this class involves a failure to integrate identity, memory, and consciousness. This class of disorders includes

• dissociative amnesia, the inability to recall important, yet stressful information;
• dissociative fugue, unexpected travel away from home with the inability to recall one's past and confusion about personal identity or the assumption of a new identity;
• depersonalization disorder, the feeling of being detached from one's mental processes;
• dissociative identity disorder, formerly multiple personality disorder (see Chapter 35); and dissociative disorder not otherwise specified. See Table 21.10 for diagnostic criteria and assessment findings. Persons with dissociative disorders may also have comorbid substance abuse, mood disorders, personality disorders (Cluster B), or PTSD. Treatment options include the use of antidepressants to treat underlying mood and anxiety. Psychotherapy options include hypnotherapy, cognitive-behavioral therapy, and psychoanalytic psychotherapy to discover the triggers that lead to heightened anxiety and dissociation.

Generalized Anxiety disorder: GAD

Pervasive anxiety that interferes w/ life.  Greater than 6 mo.  No phobias, panics, or OCD.  Insomnia, muscle tension, nausea, sweating, irritability, restlessness.

OCD

Movie: As Good as it Gets.  Listed as Anx d/o, b/c anx is at the base of the compulsions.  Obsessions: thoughts that keep intruding into the mind, and in order to keep that at bay, person repeats the act in order to keep the thought at bay.  OCD is “egodystonic;” meaning the person knows their habit is a real problem,  [versus ‘egosyntonic:’ where the person believes they are truly doing the right thing ]  “Rituals” like locking windows and doors and handwashing, lights on and and off, etc, chairs moved into the table, cupboards all closed, etc.

Counting obsessions.

Need for precision or symmetry.

OCD occurs in people with turrets, BUT turrets doesn’t show up in the OCD population.

Obsession

Compulsion: these are not like gambling or shopping compulsions, those are addictions—they feel good.  Compulsions with OCD are to relieve anxiety.

Hoarding is a form of OCD: if those things are taken from the person they feel that they will die.  They won’ t let people near the house.  Financial hoarding might also count.

Right after the ritual is when the person’s anx is at it’s lowest, but the person feels negative due to the egodystonia.

Control issues with OCD: shows up again in personality d/o

Nursing interventions

Good relationship is necessary. Do not interrupt the ritual—you do not want to deal with the person when they are anxious. Intervene only if there is a hazard to the ritual.

Paraphrasing and reflecting—active listening—with these pts will never work b/c you will never get it right enough.

Nursing interventions for all anxiety disorders

Limit CNS stims: caffeine, etc. Distinguish antecedents and behaviors that indicate their anx is on the rise. Distinguish btwn anx w/ a identifiable source and one w/o.  Exercise, diet, imagery.  What’s worked in the past?  Identify support people.  With severe or panic anx: use short directive sentences.

Factitious d/o:

Factitious disorders are conditions in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms. Factitious disorder by proxy is a condition in which a person deliberately produces, feigns, or exaggerates symptoms in a person who is in their care. People might be motivated to perpetrate factitious disorders either as a patient or by proxy as a caregiver to gain any variety of benefits including attention, nurturance, sympathy, and leniency that are unobtainable any other way

Individuals with Munchausen syndrome may produce symptoms by contaminating urine samples, taking hallucinogens, injecting themselves with bacteria to produce infections, and other such similar behaviour. [Factitious disorder by proxy is a condition in which a person deliberately produces, feigns, or exaggerates symptoms in a person who is in their care.—that’s munchausen by proxy]