UNDERSTANDING ANXIETY

WHAT IS ANXIETY?

Anxiety is one of the most simple of emotions; common to everyone.

Normal anxiety: can be good, it gives you the energy and focus to overcome a task. It is necessary for survival. (Fight or Flight) (Butterflies before a race)

Many times dysfunctional behavior is a defense against anxiety

STRESS LEADS TO ANXIETY

ANXIETY VS FEAR

Anxiety has an unknown source

Fear is a reaction to a specific threat

CATEGORIES OF ANXIETY

Normal Anxiety

Healthy life force necessary for survival

Acute Anxiety (State)

Crisis threatens sense of security

Chronic Anxiety (Trait)

Long term anxiety

Discomfort in relationships

LEVELS OF ANXIETY

Mild Moderate

Severe Panic

INTERVENTIONS

Mild to Moderate

Assist with regaining focus

Recognize distress

Listen

Clarify

Ask open-ended ?

Provide calm presence

Severe to Panic

Safety of client and others

Quiet environment

Medications

Point out reality

Meet physical needs

Use short, simple statements

DEFENSE MECHANISMS

Manage Conflict and affect

Relatively unconscious

Discrete from one to another

Hallmarks for psych syndromes (reversible)

Adaptive as well as pathological

DEFENSES

Healthy (altruism, sublimation, humor, suppression)

Intermediate (repression, displacement, reaction formation, somatization, undoing, rationalization)

Immature (passive aggressive, acting out, dissociation, idealization, splitting, projection)

ANXIETY DISORDERS

ANXIETY DISORDERS

13% of the US adult population are affected by anxiety. It is the most common psychiatric disorder in the US.

The level of anxiety is so high in these client’s that it interferes with personal, occupational, and social functioning.

Caused by : genetics, psychosocial factors, cultural factors, and traumatic life events

THEORY

Genetic: cluster in families

Biological: Limbic system irregularities

Psychological: (Freud, Learning theories, cognitive theories, Sullivan)

Cultural

PANIC DISORDERS

Panic without agoraphobia: panic attack , unexpected

Panic with agoraphobia: recurrent panic attacks with fear of being out in public when it happens.

Agoraphobia: fear of being out and people seeing the attack, these clients may not leave home due to this fear

GENERALIZED ANXIETY DISORDER

Excessive worrying about numerous things; this can last for months or even longer

DSM –IV-TR criteria (p565)

PHOBIAS

What is phobia?

A persistent irrational fear of an object, activity, or situation that leads to the desire for avoidance.

PHOBIAS

Specific types ( snakes, bridges, small spaces)

Social Anxiety Disorder (SAD)

Severe anxiety provoked by exposure to a social situation

Overwhelming and crippling anxiety when facing the situation

OBSESSIVE-COMPULSIVE

DISORDER (OCD)

Obsessions

Thoughts, impulses, or images that persist and recur, so that they can not be dismissed from the mind

Compulsions

Ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety

These can be seen separately but usually they go hand in hand!

OCD

DSM- IV-TR criteria see pg 572 for criteria

Common Obsessions:

Doubt..need to double check everything (Did I..??)

Sexual imagery ( You see a man and want to rub his arm repetitively , uncontrollably)

Need for order (Felix )

Violence

Germs/ Dirt

POST TRAUMATIC STRESS DISORDER

Flashbacks

Avoidance with stimuli associated with trauma

Numbing of responses persistently

Persistent symptoms of increased arousal

These symptoms usually begin within 3 months of disturbance

See page 574 for criteria

ACUTE STRESS DISORDER

Usually occurs within 1 month after disturbance

To be dx with this the pt must have at least 3 symptoms:

Subjective sense of numbing

Amnesia

Detachment

Reduction in awareness of surroundings

Depersonalization(sense of unreality)

Usually resolves within 4 weeks

SUBSTANCE –INDUCED ANXIETY

Anxiety

Panic attacks

Obsession

Compulsion

These develop either due to substance use or after stopping the chronic use of substances

ANXIETY DUE TO MEDICAL CONDITIONS

Anxiety can be the direct result of medical diagnosis

Cardiac History

Strokes

Trauma that effects cognition or mobility

BASIC NURSING INTERVENTIONS

Reduce anxiety

Enhance coping/Instill hope

Psychopharmacological Interventions

Enhance self esteem

Use relaxation techniques

Locate community resources

Support groups / counseling/ Milieu Therapy

Medication Education

ADVANCED PRACTICE INTERVENTIONS

Cognitive therapy

Cognitive restructuring

Behavioral Therapy

Relaxation

Modeling/ Desensitization

Flooding/ Response prevention

Thought stopping

MEDICATIONS

Antidepressants

SSRI’s * / Tricyclics/ MAOI inhibitors/ Serotonin-norepinephrine reuptake inhibitors

Anxiolytics

Benzodiazepines

Buspar (nonbenzodiazeoine) increase available serotonin/ not a strong sedative

Antihistamines

Beta Blockers

Anticonvulsants

FAMILY AND CLIENT TEACHING

Nurse should include:

Do not change dose without discussing with MD

The meds will reduce your ability to handle mechanical equipment; cars, machinery

No alcohol.. No caffeine

If taking MAOI instruct about tyramine free diet

Can cause congenital abnormalities in fetus, do not breast feed

Meds need to be taken with Meals to avoid GI upset

After taking Benzos for 3-4 months, you may experience withdrawal signs if stopped abruptly

SOMATOFORM AND DISSOCIATIVE DISORDERS

SOMATOFORM DISORDERS

Physical symptoms suggest a physical disorder

Diagnostic tests are NEGATIVE for illness

Symptoms are linked to Psychobiological factors

Many times this disorder will co-exist with another Psychological disturbance

SOMATOFORM DISORDERS

Somatization Disorder

Hypochondriasis

Pain Disorder

Body Dysmorphic Disorder

Conversion Disorder

SOMATOFORM D/O VS OTHER DISORDERS:

Malingering

Intentionally producing symptoms to produce a goal

Factitious Disorder

Fabrication of symptoms to assume the “sick role”

Psychosomatic Illness

General medical condition affected by stress or psychological factors

ASSESSMENT

Overall assessment

Voluntary control?

Secondary gains

Cognitive style

Ability to communicate feelings and emotional needs

Dependence on Medications

BASIC NURSING INTERVENTIONS

Promotion of self care activities

Health teaching

Case Management

Psychobiological Interventions: Anxiolytics (short term) , antidepressants (greatest help, SSRI’s)

ADVANCED: PSYCHOTHERAPY

DISSOCIATIVE DISORDERS

Disturbances in the normally well integrated continuum of consciousness, memory, identity, and perception

Dissociation is an unconscious defense mechanism that protects the person from overwhelming anxiety

We all dissociate: do you remember every minute of driving here today? But this client spends their life in that psychological state.

DISSOCIATIVE DISORDERS

Depersonalization

Dissociative Amnesia

Dissociative Fugue

Dissociative Identity Disorder

ASSESSMENT

Identity and Memory

Disorientation vs A and O x 3; do they remember the past?

Client History: memories from childhood?

Moods: depressed..anxious

Use of ETOH and other drugs

Impact on client? Family?

Miss a lot of work especially DID due to multiple personalities being in control

Suicide Risk?

BASIC LEVEL INTERVENTIONS

Milieu Therapy

SAFETY SAFETY!!!

Simple routines, nondemanding

Don’t flood client with past events

Stress reduction, coping mechanisms

Health Teaching

Psychobiological Interventions : no specific meds; but antidepressants vs anxiolytics as needed

ADVANCED PRACTICE

Cognitive-behavioral therapy: find a logical reason for the behavior then work to develop alternative coping mechanisms

Psychodynamic Psychotherapy: group therapy

MOVIE TIME!!!

If you are looking for other movies that portray DID check out Sybil, Three Faces of Eve, or Identity