Anxiety Disorders

Anxiety Disorders

Anxiety disorders can be a very nebulous phenomenon to recognize and therefore treat Is anxiety a disorder/pathological?
No!!!!!! Some anxiety is advantageous. Anxiety often produced in response to new situations, stress, confusion, etc. Anxiety can heighten ones awareness, therefore ones caution in a threatening situation- improve survival

Anxiety Disorders

If anxiety reaches level where it impairs ones function, may have a disorder Freud wrote extensively about anxiety, often in a sexual context What are normal anxiety symptoms?

Perspiration Headache Palpitations Restlessness GI upset

LEVELS OF ANXIETY
By Peplau Mild Moderate Severe Panic

MILD ANXIETY

Alertness Optimum ability to solve problems and make independent decisions Enhanced learning Nursing Management: Help client identify and describe feelings,develop the capacity to tolerate mild anxiety and use it consciously and constructively

MODERATE ANXIETY

Perception narrowed Selective inattention Physical discomforts Nursing Management: Provide outlet for tension such as walking ,crying,use of appropriate relaxation exercises

SEVERE ANXIETY

Severely impaired problem solving skills. Inability to grasp meaning of communications,engage in self directed activity,or make decisions. Nursing Management: Link clients behavior with feelings.Remain with the patient and provide constant attention until anxiety diminishes.Administer medications as needed.

PANIC

Overwhelmed, inability to function or communicate Possible bodily harm to self or others Loss of rational thought. Nursing Management: Provide nonstimulating,structured environment ,avoid touching,stay with client,speak in quiet tones,medicate with tranquilizers if necessary.

Anxiety Disorders

What are the anxiety disorders?

Panic disorder with and without agoraphobia Agoraphobia without panic Social phobia Specific phobia Generalized anxiety disorder Obsessive compulsive disorder Post traumatic stress disorder Acute stress disorder Anxiety disorder due to medical conditions Substance induced anxiety disorder

Anxiety Disorders

Overall, anxiety disorders may be one of most prevalent psychiatric disorders

Up to 25% of Americans will meet diagnostic criterion for an anxiety disorder at some point in their life Women have higher incidence of anxiety disorders There is some genetic component to anxiety disorders

Anxiety Disorders

What are some of the medical problems which can look like anxiety disorders?

Tumors (including pheochromocytoma) MS Migraine headaches Seizures Stroke Hyperthyroid Hypoxia Lupus Hypoglycemia Medications Many others!!!

Anxiety Disorders

What substances can make you feel/look anxious?

First question, should be is it intoxication or withdrawal

Alcohol/sedative withdrawal Cocaine/stimulant intoxication Cannabis intoxication Caffeine intoxication and withdrawal

PANIC DISORDERS
Panic

disorder with/without agoraphobia

3-5% lifetime prevalence of panic d/o, but 5-8% lifetime prevalence of panic attacks, female to male ratio is 3:1, usually in young adulthood Up to 85-90% of patients with panic d/o will have another co-morbid psychiatric disorder

TREATMENT

Treatment is usually multi-modal Psychoanalytical psychotherapy is indicated only if personality problems exist. Supportive psychotherapy is used either alone or in combination with drug therapy. Relaxation Techniques CBT,bio feedback and hyperventilation control are therapies which can also be used

PANIC DISORDERS

What is a panic attack?

Palpitations Sweating Trembling Choking sensation,sensations of shortness of breath Chest pain GI complaints-nausea or abdominal distress Fear of dying or going crazy Derealization Paresthesias Chills or hot flushes

Attacks come out of the blue, last about 10 minutes, often not in response to stress, need repeated attacks and fear of having another

CHARACTERISTIC FEATURES OF PHOBIA

Presence of the fear of an object ,situation or activity. Fear is out of proportion of the dangerousness perceived. Patient recognizes the fear as irrational and unjustified (insight is present) Unable to control the fear and is very distressed by it. Leads to phobic avoidance.

AGORAPHOBIA

Very common for someone to develop a fear of being away from home, going in publicsomewhere they cannot get help This is known as agoraphobia Common enough with panic disorder that to diagnose panic disorder, you must specify either with or without agoraphobia Responds well to cognitive behavioral therapy, as well as other forms of therapy

SOCIAL PHOBIA
Lifetime prevalence of 2-3%, initially thought to be more prevalent in females, but clinically is equal sex distribution Demonstrate a marked fear of being in situations where they will be scrutinized by others, fear they will be embarrassed, recognize fear is excessive e.gs-public speaking ,public performance,eating in public,participating in groups,speaking to strangers,etc. Can lead them to have a panic attack

PHOBIC DISORDERS

So, how do you differentiate social phobia and panic disorder with agoraphobia?
Agoraphobia has a fear of being somewhere they cannot get help, so if someone were with them, they would feel reassured Social phobia has a fear of being scrutinized and being embarrassed, so if someone accompanies them, they will feel worse

SPECIFIC (SIMPLE) PHOBIA

Irrational fear of a specified object or situation.Anticipatory anxiety leads to persistent avoidance behavior,while confrontation with the avoided object or situation leads to panic attack e.gs-acrophobia-fear of high places zoophobia-fear of animals xenophobia -fear of strangers algophobia -fear of pain claustrophobia-fear of closed places

PHOBIAS( contd.)
Secondary defense mechanism is displacement. Management: Behavior therapy in the form of Flooding Systematic desensitization Relaxation techniques Drug therapy in the form of Benzodiazepines-to reduce anticipatory anxiety.Alprazolam is the drug of choice Antidepressants-to control the panic attacks

GENERALIZED ANXIETY DISORDER

Lifetime prevalence of 4-6% Females to Male ratio is 2:1 Difficult to diagnose as definition is

Excessive worry/anxiety occurring more days than not for 6 months about many areas of ones life (school, work, money, relationships) Three or more of the following six symptoms.Only one required in children Symptoms consist of restlessness, easily fatigued, difficulty concentrating, irritable, muscle tension, sleep problems

GENERALIZED ANXIETY DISORDERS

These patients will often seek out primary care doctors for physical complaints first So, primary docs must be aware of this illness and the somatic complaints the patients present with This illness is very likely to be co-morbid with other psychiatric illnesses, i.e. up to 25% of GAD patients will have panic attacks at one point in their illness, also likely to experience major depression at some point

OBSESSIVE COMPULSIVE DISORDER

What is an obsession?

Recurrent and intrusive thought, feeling, or sensation

Conscious behavior to reduce anxiety

What is a compulsion?

Lifetime prevalence estimated at 2-3% Females=males Frequently co-morbid with other illnesses, i.e. major depression, social phobia

OBSESSIVE COMPULSIVE DISORDERS

Most common obsessions are

Fear of contamination Pathological doubt (forgot to turn off stove) Somatic Need for symmetry

To diagnose OCD, need either obsessions or compulsions which are recognized as excessive by patient, take more than 1 hour/day or interfere with functioning

OBSESSIVE COMPULSIVE DISORDERS

Obsessions
Must have repetitive thoughts, sensations, feelings which intrude into mind and cause anxiety Person must try to neutralize/ignore them Recognize as excessive Not just worrying about life stressors

Compulsions
Repetitive behaviors or mental acts person feels driven to perform by obsessions Behaviors supposed to reduce anxiety of obsessions, but are not realistically connected or are excessive

TREATMENT OF OCD
Poor prognosis is yielding to obsessions/compulsions, childhood onset, bizarre compulsions, co-morbid major depressive disorder, delusional beliefs, personality disorder presence, need for hospitalization Treatment is not just meds OCD responds well to therapy, i.e. cognitive behavioral therapy In severe cases, will do psychosurgery

Typically is cingulotomy (25-30% success rate)

POST TRAUMATIC STRESS DISORDER

Develops after experiencing/witnessing a stressful/life threatening event to you or loved one which led to intense fear, helplessness, or horror Been mentioned in literature since Civil War, described as irritable heart, then shell shock in WW I, combat neurosis in WW II, then PTSD in Vietnam era Lifetime prevalence of PTSD is 1-3%. About 30% Vietnam vets experience PTSD Can occur after natural disaster, wars, rapes, assault, motor vehicle accidents

PTSD

To diagnose PTSD, need 4 things

Traumatic event Re-experience traumatic event through nightmares, flashbacks, recurrent disturbing thoughts of event Attempts to avoid stimuli associated with event, i.e. avoid going to places which remind you of event, avoid talking about events, cannot recall important parts of event, feeling detached/estranged from others, sense of foreshortened future Increased autonomic arousal, i.e. difficulty falling asleep, outbursts of anger, hypervigilance, exaggerated startle response, difficulty concentrating

PTSD
About 30% of patients with PTSD recover completely, 40% have mild symptoms over time, 20% have moderate symptoms, 10% stay unchanged or worsen Treatment is with meds, group participation, as well as individual therapy