ANXIETY
Anxiety – feeling, mood, emotional response, syndrome, symptom, or an illness
– diffuse apprehension – vague nature
– assoc with feelings of uncertainty, hopelessness, uneasiness – anticipation of danger
from unknown source (Fear – has known source)
– ubiquitous, common to everyone
– of intra-psychic origin; can become psych emergency
Low levels – adaptive, provide motivation for survival
Anxiety – Problematic – unable to prevent anxiety from escalating to a level that interferes with ability to meet basic needs
4 Levels of Anxiety (Peplau):
1. Mild – seldom a problem
– tension of everyday living
– prepares people for action; sharpens senses
– inc motivation for productivity; inc perceptual ability and awareness of env’t
– learning enhanced
– function @ optimal level
2. Moderate – extent of perceptual field diminishes
– less alert, attention span and ability to concentrate dec
– assistance with prob solving needed
– inc muscular tension and restlessness
3. Severe – greatly diminished perceptual field
– focus on 1 particular detail or on many extraneous details
– attention span extremely limited
– much difficulty completing simplest task
– physical & emotional Sx
4. Panic – most intense; unable to focus even on 1 detail
– misperceptions – hallucinations/delusions
– loss of contact with reality
– wild & desperate actions / extreme withdrawal
– feelings of terror; fear of going crazy, losing control or emotionally weak
– prolonged-emotional exhaustion, life-threatening
Behavioral Adaptation Responses: (Menninger 1963)
Mild – sleeping, eating, phys exercise, smoking, crying, yawning, drinking, daydreaming, laughing, cursing, pacing, foot swinging, fidgeting, nail biting, finger tapping, talking to someone.
Moderate – use of ego defense mech
– maladaptive use-interference w/ ability to deal with: Reality, Interpersonal Relations, Occupational Performance
Compensation Intellectualization Restitution
Conversion Introjection Splitting
Denial Projection Sublimation
Displacement Rationalization Substitution
Dissociation Reaction-formation Suppression
Fixation Regression Symbolization
Identification Repression Undoing
Moderate to Severe – anxiety levels that remain unresolved contribute to physio disorders
(DSM IV-TR) – presence of 1/more specific psycho or behavioral factors that adversely
affect general condition
– psycho factors may exacerbate sx of delay recovery from or interfere
with tx of med condition
– condition may be initiated by envtl situation perceived as stressful
Severe – extended periods can result to psychoneurotic patterns of behaving
Neuroses – excessive anxiety expressed directly or altered thru defense mechanism
– appear as Sx: obsession-compulsion, phobia, sexual dysfunction
Characs of people with Neuroses:
- Aware they are experiencing distress
- Aware that their behavior is maladaptive
- Unaware of any possible psychological cause of distress
- Feel helpless to change their situation
- Experience no loss of contact with reality
Panic – extreme level of anxiety; not capable of processing what is happening in env’t
– lose contact w/ reality
Psychoses – loss of ego boundaries / gross impairment of reality testing
– delusions, hallucinations, impairment of interpersonal functions
Characs of people with Psychoses:
Exhibit minimal distress Unaware that their behavior is maladaptive Unaware of any psychological problem Exhibit flight from reality into a less stressful world
Types of Anxiety:
*Normal – normal response to observable threat/fear
*Pathologic – response to internal/external threat, real/imagined, during w/c person experiences
a “felt” unpleasant emotional state
Other terms:
>Signal Anxiety – response to anticipated event
>Anxiety Trait – component of personality that has been present over a long period
– measurable by observing person’s physio, emo & cognitive behavior
>Anxiety State – result of stressful situation in w/c person loses control of his emotions
>Free-floating Anxiety – always present; accompanied by feeling of dread
Coping mech – MILD
Ego defense mech – MODERATE
Psycho-physiological response - MODERATE TO SEVERE
Psychoneurotic – SEVERE
Psychotic response – PANIC
PD – MILD->MODERATE
Mood disorders – MOD->SEVERE
Thought disorders – SEVERE->PANIC
Anxiety Disorders
*Phobia – most common mental health d/o in US
*Women – more often dx w/ AD
*OCD – equal in both sexes
Etiology:
1. Genetics
2. Neuroanatomical – brain pathology (limbic system-control mood, behavior; emotional)
– cerebral ventricles, defects in R temporal lobe; asymmetrical R & L
hemispheres; abnormality in frontal lobe & basal ganglia
3. Neurotransmitter Hypothesis – malfunctioning of noradrenergic system
– dysregulation in NE, Serotonin, GABA
4. Possible Endocrine Correlation – inc levels of TSH, Prolactin, Cortisol
5. Medical Conditions – Abnormality in HPA (hypothalamus[ANS], pituitary [master gland,
hormones], adrenal) & HPT (thyroid) axes
– Acute MI
– Pheochromocytomas – tumor of adrenal gland
– Substance Intoxication & withdrawal
– Hypoglycemia
– Caffeine Intoxication
– Mitral Valve Prolapse
– Complex partial seizures
6. Psychodynamic Theory – inability of ego to intervene w/ conflict bet. id & superego-anxiety
– response of ego to unconscious, unacceptable thoughts & impulses
that threaten to emerge into consciousness
– delayed ego dev’t (unsatisfactory relationship)
7. Behavioral Theories – all behavior is learned
– conditioned response to perceived threat/stimuli in env’t
8. Cognitive Theory – faulty, distorted or counterproductive thinking accompany or precede
maladaptive behavior & emotional disorders (irrational)
9. Others:
*Temperament – more than 50% of children experience normal fears & anxieties before 18y.o.
(innate fears)
– innate fears don’t reach phobic intensity but may have capacity for dev’t if
reinforced by events in later life
*Life Experiences – Early – symbolic of repressed original anxiety-provoking object/situation
GENERAL ANXIETY DISORDER
W – worries excessively
O – out of control, out of proportion worry
R – restlessness
R – rigidity / inflexibility
I – irritability
E – easy fatigability
R – r/o substance abuse or other med condition as cause
S – sleep disturbances
PANIC DISORDER
-> discrete period of intense fear/discomfort in absence of real danger
-> develops abruptly – peak w/in 10 minutes
-> Autonomic Hyperactivity (Sympathetic NS)
-> 4/more of the ff:
A – abdominal distress, accelerated HR
B – breathlessness (smothering)
C – choking feeling, chills, chest pain
D – dizziness, derealization, depersonalization
F – fear of losing control, dying; flushes (hot)
S – shaking, sweating
T – tingling sensation (paresthesia)
OCD
Obsessions: I – intrinsic to person rather than effect of insertion
I – inappropriate & irrational
I – ignoring attempts to obliterate thoughts but failing to dismiss them completely
I - intrusive
Compulsion: R – repetitive or routinely done
R – reduction of obsession is the goal
R – ritualistic performance
POST TRAUMATIC STRESS DISORDER
T – tragic exposure
R – re-experiencing the episode
A – avoidance of recall
U – unable to function or the Sx interfere with daily functioning
M – month long duration of Sx
A – arousal experiences
S – sleep pattern disturbance
SOCIAL PHOBIA
F – fear (marked/persistent) of 1/more social/performance situations; not due to physiological effects of substance, GMC, mental d/o
E – exposure to unfamiliar people/posible scrutiny – anxiety Sx that are humiliating; situationally-bound/predisposed panic attack
A – avoidance of feared situations
R – recognized excessive & unreasonable fear & marked distress about having phobia
S – significant interference with normal routine, occupational or academic func, social activity
SPECIFIC PHOBIA
F – fear (marked/persistent) & cued by presence/anticipation of specific object/situation
E – exposure to phobic stimulus
A – avoidance of feared situations
R – recognize fear as excessive & unreasonable
S – significant interference with normal routine & functioning
*Animal Type, Natural Env’t, Blood Injection, Situational Type, Others
PHOBIAS
| Acrophobia Agoraphobia Algophobia Androphobia Astrophobia Autophobia Aviophobia Claustrophobia Entomophobia Hematophobia Hydrophobia | Heights Open places Pain Men Storms,lightng,thunder Being alone Flying Enclosed places Insects Blood Water | Iarrophobia Necrophobia Nyctophobia Ochlophobia Ophidiophobia Pathophobia Pyrophobia Sitophobia Thanatophobia Topophobia Zoophobia | Doctors Dead bodies Night Crowds Snakes Disease Fire Flood Death Particular space Animals |
Nsg Dx:
>Mod to Severe Anxiety >Ineffective Individual Coping
>Fear >Impaired Adjustment
>Powerlessness >Social Isolation
>Acute Confusion >Risk for self-directed violence
>Alt Thought Process >Self-esteem disturbances
>Alt Role Performance >Alt Health Maintenance
>Alt Family Processes >Impaired Verbal Communication
Interdisciplinary Plan:
*Assess anxiety thru physio, emotional & behavioral cues.
*Encourage verbally to recognize & verbalize feeling.
*Explore thoughts & circumstances.
*Help cope with what is now an identified specific threat.
*Maintain calm, non-stimulating env’t.
-> Stay w/ person; establish & maintain eye contact; speak clearly, slowly & briefly.
*Use touch if appropriate & helpful.
*Orient.
*If hyperventilating: Instruct to change breathing patterns. Stand close, breathe w/ him.
*If patient shows by behavior but denies verbally: Give feedback.
Individual Psychotherapy – insight-oriented to help pt understand unconscious meaning of anxiety, symbolism of avoided situation, need to repress impulses & 2o gain from Sx.
Cognitive Therapy – reduce anxiety by altering cognitive d/o
– brief; time-limited; structured & orderly; focus - solving current probs
Behavior Therapy
*Systematic Desensitization – relaxation tech; progressive exposure to hierarchy of fear stimuli when in relaxed state
*Implosion Therapy (Flooding) – client must imagine extremely frightening situations for prolonged time; best w/ specific phobias
Group/Family Therapy – for clients w/ PTSD; emphasis on shared experiences; may be informal or led by experienced group therapists
Counseling Intervention
PHOBIA – In vivo desensitization; Cognitive reframing; Social skills training
OCD – Exposure & response prevention; Role model appropriate behavior; Thought stopping
ANXIOLYTICS
Benzodiazepines – as needed basis; brief use (physical dependence, tolerance)
*Buspirone (Buspar) -> 10-14 day delay in alleviating Sx
Caution not to: Handle mech equipment; Drink alcohol/caffeinated beverages; Get pregnant; Breastfeed; Drink on empty stomach or with antacids
ANTIDEPRESSANTS
*Tricyclics – Clomipramine, Imipramine
*SSRIs – Paroxetine, Sertraline
ANTIHYPERTENSIVES
*Ameliorate Anxiety Sx
*Propanolol – potent effects on somatic Sx
*Clonidine – block acute anxiety effects
PANIC – TCA, MAOI, SSRI, Benzodiazepines, Beta-blockers
OCD – TCA, SSRI
Social Phobia – MAOI, Benzodiazepine
GAD – Benzodiazepine, Azapirone
>Milieu (Envt) Therapy – emotionally safe & supportive envt
- goal- oriented contarcting
– structured activities (wake to sleep)
- daily log of anxiety triggers & rxns
– reinforcement of learnings from individual/group therapies
(for improvement)
>Self-Care Activities
- nurse assists the client with self care needs
– OCD -> help decrease lengthy handwashing
ADLs: D - dressing
E - eating
A - ambulating
T - toileting
H - hygiene
Health Education – Focus: Individual’s strengths & coping skills
Families: Do not tell person to be calm, relax or that she is being ridiculous.
With OCD – don’t stop their behavior, it will increase anxiety.
ANXIETY-RLTD D/O:
Psychophysiological Responses – those in w/c it has been determined that psycho factors contribute to initiation or exacerbation of phys condition
PF: mental d/o; psycho sx; personality traits/coping style; maladaptive health behavior; stress-related physio responses
Psychosomatic D/O – physical condition caused by mental illness
Etiology: Selye’s GAS – fight-flight rxn; 3 stages: alarm, resistance, exhaustion
Emotional Specificity Theory
*Shapiro & Crider – effects of emotions to physiologic func
*Friedman & Rosenman – health risks due to personality types
Charac. of stress-prone personalities:
| 1. Always focusing on personal problems 2. Often feeling trapped 3. Feeling of inadequacy 4. Spreading oneself “too thin” 5. Overly competitive 6. Overly critical of self and others
| 7. Always trying to better oneself 8. Being impatient & easily frustrated 9. Multi tasking @ onetime 10. Constantly watching time 11. Talking quickly during conversation 12. Taking multiple jobs 13. Constantly dealing with deadlines
|
Organ Specificity Theory
*Lacey, Bateman, Van Lehn – stress response-organ specific-susceptibility to disease
Familial Theory
*Salvador Minuchin – family dynamics influence dev’t of medical d/o
– psychosomatogenic family
Learning Theory
Physiologic response learned – reward, attention, reinforcement
Asthma – excessive dependency needs
Cancer – (Hafen, et.al) Type C personality; “nice guy’s disease”
– repression of negative emotions; passivity, apologetic, overly cooperative
– calm, placid exterior
– unrealistic standards; inflexible; resent others for perceived wrongs
CAD – Type A
– excessive competitive drive; very aggressive, ambitious
– easily roused hostility
– no time for hobbies
– seldom feel satisfied w/ accomplishments
– measure achievements in numbers produced
– appear extroverted, outgoing, often concealing deep-seated insecurity
Peptic Ulcer – hostility, resentment, guilt, frustration -> inc gastric secretion & motility
– unhealthy attachment to others; excessive worriers, pessimists
Essential HPN – appear congenial, compliant, compulsive
– anger not openly expressed, rage handled poorly
Migraine HA – perfectionist, overly conscientious, inflexible; intelligent
– delegation of responsibility -> difficult
Rheumatoid Arthritis – self-sacrificing, masochistic, conforming, self-conscious, inhibited,
perfectionist
Ulcerative Colitis – predominance of OC traits
– neat, orderly, punctual, difficulty expressing anger
