ANXIETY

DISORDERS
ANXIETY
Is a defuse apprehension that is
vague in nature and associated
with feelings of uncertainty and
helplessness.

The word anxious is related to

the Latin word Angere which
means to struggle and to
distress
ANXIETY DISORDERS
Comprise a group of conditions that share a
key feature of excessive anxiety with
ensuing behavioral, emotional and
physiologic responses
> Unusual behaviors include: panic without
reason, unwarranted fear of objects, and
uncontrollable overwhelming worry.
>It significantly impairs daily routine, the
social life and occupational functioning .
>It is diagnosed when anxiety no longer
function as a signal of danger or
motivation for needed change, but
becomes chronic and permeates major
portions of a persons life, resulting in
Defining Characteristics of Anxiety:
1. Anxiety is an emotion:
it is a subjective individual experience
2. It is an energy:
it cannot be directly observed. It will
require the nurse to infer with patient the
existence of anxiety
3. It is an emotion without specific object:
it is provoked by the unknown
It usually precedes all new experiences
It is an emotional response from the intellectual
appraisal of fear, and fear produces anxiety
4. Anxiety is communicated
interpersonally:
a nurse talking with an anxious
patient within short time will
experience feelings of anxiety and
vice versa
5. Anxiety is part of everyday life:
it is basic to the human condition
and necessary for survival
6. The crux of anxiety is self-
preservation:
Self preservation from selfhood, self-
Common Types of Anxiety Idiom:
a. Signal Anxiety: an anxiety in response to an
anticipated event
Example: a father who normally is relaxed
exhibits tachycardia, dizziness and insomnia
when his child attends school for the first time.
b. Anxiety Trait: anxiety that has become a
component of personality (has been present
over a long period) and is observable in the
persons physiologic, emotional and cognitive
behavior.
Example: a person who responds to non-
stressful situation with anxiety
c. Anxiety State: anxiety which is a result of
stressful situation in which the person losses
control on his emotion.
Example: a mother who has been told her son
has been injured in a basketball game exhibits
anxiety state by becoming hysterical,
complaining chest tightness and insists in
seeing her injured son.
d. Free-floating Anxiety: anxiety that is always
present and accompanied by a feeling of dread.
Example: a woman unable to sleep at night
because she is certain someone will break into
her home goes through a complicated ritual of
checking all the windows several times
Levels of Anxiety by Peplau
Symptoms of Anxiety range from a state of
Euphoria to panic
a. Level zero: Euphoria this is an exaggerated
feeling of wellbeing that is not proportionate to a
specific circumstance or situation. Euphoria
usually precedes the onset of level 1 (mild
anxiety)
b.. Level one:
Mild Anxiety: it is associated with tension of day
to day living.
The person is alert and his perceptual field is increased
The person sees, hears, and grasps more than before
Anxiety seems to motivate learning and produces
growth and creativity
c. . Level two:
Moderate Anxiety: state of anxiety in which the
person focuses only on immediate concerns,
involving narrowing of perceptual field.
The person sees, hears and grasps less
The person blocks selected areas but can attend
more if directed to do so.
d. Level three:
Severe Anxiety: anxiety state marked by
significant reduction in the perceptual field
The person tends to focus on a specific detail and
not think about anything else
All behavior is aimed at relieving anxiety and much
direction is needed to focus on another area
e. Level four:
Panic Anxiety: Anxiety state associated
with awe, dread and terror. The person is
not able to do things even with direction
There is disorganization of personality and can
be life threatening
There is increased motor activity, decreased
ability to relate, distorted perceptions and loss
of rational thought
It is a frightening and paralyzing experience
Prolonged period of panic is incompatible with
life, thus it will result in exhaustion and death.
Physiologic Response to Anxiety:
Is modulated by the brain through the ANS

Two Types of Autonomic

Responses
A. Parasympathetic Response: acts
to conserve body responses
B. Sympathetic Response: activation of body
processes in order to prepare the body to deal
with emergency by fight or flight response
The cortex of the brain perceives a threat
Sends stimulus to the sympathetic branch of ANS
Adrenal glands will release epinephrine
Epinephrine has the following effects:
Respiration becomes deep
Rapid heart beat

Increase arterial pressure

Blood shift from stomach and intestines to the

heart, CNS, muscles and major organs
Glycogenesis

For some people however, the

parasympathetic reaction may coexist or
predominate and produce the opposite effects
Common Clinical
A. Physiologic Symptoms:
Symptoms of Anxiety
Elevated pulse, BP and RR
Dyspnea, hyperventilation
Diaphoreses
Vertigo or light-headedness
Blurred vision
Anorexia, nausea and vomiting
Frequency of urination
Headache
Insomnia, sleep disturbance
Weakness and muscle tension
Tightness in chest
Sweaty palm
Dilated Pupils
B. Psychological / Emotional Symptoms
Withdrawal
Depression
Irritability
Crying
Lack of interest or apathy
Hypercriticism
Anger
Feeling of worthlessness
Apprehension and helplessness
c. Behavioral Symptoms
Pacing
Inability to sit still
Hyper vigilance
D.Intellectual or Cognitive
Symptoms:
Decreased interest
Inability to concentrate
Non-responsiveness to external
stimuli
Decreased productivity
Preoccupation
Etiology of Anxiety Disorders:
A. Psychoanalytic Theory
According to Freud, it is the result of unresolved
unconscious conflict between impulses for
aggressive or libidinal gratification.
Example:

Unconscious conflict of childhood like fear of

losing a parents love or attention may
emerge of feeling of anxiety in childhood,
adolescence, or early adulthood.
Freud contested that innate anxiety is the
stimulus for behaviors. Defense Mechanisms is an
attempt to control awareness of anxiety or to
reduce anxiety.
B. Cognitive Behavioral Theory
Aaron Beck Cognitive Behavioral
Theory : anxiety is learned or
conditional response to a stressful
event or perceived danger.
Example: A student received
probationary notice because of a
failing grade. His unable to sleep,
had headache, light-headedness
and doubts his ability to continue
college.
C. Biologic Theory:
Neurochemical: Gamma-Amino
Butyric Acid (GABA) Is an amino acid
neurotransmitter believed to be
dysfunctional in anxiety disorder.
GABA is an inhibitory
neurotransmitter that functions as
the bodys natural anti-anxiety agent
by reducing cell excitability thus
decreasing the rate of neuronal firing.
Norepinephrine & Serotonin
D. Genetic Theory
First degree relatives of clients
with anxiety disorders have
higher concordance rate of
developing anxiety disorders
E. Neuroanatomical: Neuroimaging
studies suggest:
Abnormalities in glucose metabolism
in the frontal & prefrontal cortex
among patients with Panic & OCD
Abnormalities in the basal ganglia
and ventral prefrontal cortex among
OCD patients
Decreased blood flow in the anterior
temporal lobes among patients with
PTSD
F. Genetic Theory:
Genetic factors are traced:
Strong familial patterns with GAD
Genetic predisposition supported by
twin studies
G. Social-cultural Theory:
Socio-cultural factors cause
anxiety. They are stressful stimuli
of modern society and ones
culture pose a psychological
threat resulting in maladaptive
behavior development.
Types of Anxiety Disorders:
1. Panic Disorder without
Agoraphobia
A panic attack of a discrete
period of intense fear and
discomfort of abrupt onset,
building to maximum
intensity within 10 to 15
minutes
What do Panic Patients Report as Symptoms?
Fear of dying , being crazy or fear
of losing control
Strong urge to escape or flee the
place
The feeling is associated with
chest pain, shortness of breath.
Panic Attack Criteria:

Discrete period of intense fear or discomfort

At least 4 of the following symptoms develops
abruptly and reach peak within 10 minutes:
1. Palpitations, pounding heart or accelerated heart
rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath (smothering)
5. Feelings of choking
6. Chest pain or chest discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheadedness
9. Derealization (feelings of unreality)
 10. Depersonalization (feeling being detached from
the self)
11. Fears of losing control or going crazy
12. Fear of dying
13. Paresthesia
14. Chills or hot flushes
Recurrent unexpected panic attack with
at least one of the attacks followed by a
month of persistent concern about
having additional attack.
Worry about implications of the attacks
and consequences
Significant change in behavior related to
the attack
Nursing Care for Panic
A. Promote safety and comfort
During panic attack, nurses first
concern is to provide safe environment
and ensure the clients privacy
Environment should be less
stimulating: quiet room
Remain with the client and help calm
him down
Talk to client in calm, reassuring voice
Teach client to use relaxation
techniques
Help the client to use cognitive
B. Use therapeutic communication
Use simple and calm communication

Nurse can walk with client who feels

unable to sit and talk

Evaluate carefully the use of touch

because client with high anxiety may

interpret touch by a stranger as a
threat
If anxiety has subsided to a

manageable level, use open-ended

communication technique to discuss
experience
C. Manage anxiety
Teach relaxation technique:
deep breathing
Guided imagery: imagining
safe, enjoyable place to relax
Teaching progressive
relaxation: progressively
tightening, holding, then
relaxing muscle groups while
letting tension flow from the
body through rhythmic
2. Panic with Agoraphobia:
AGORAPHOBIA is translated from
Greek as fear of open market
places
- A severe and pervasive anxiety
about being in situations from
which escape is difficult or
avoidance of situation such as
being alone outside of the home,
traveling in a car, bus or airplane
or being in a crowded area (DSM-
Panic with Agoraphobia
Criteria:
Meets the criteria with panic
Presence of Agoraphobia anxiety being
in places or situations of which help may
not be available in event of panic attack
Agoraphobia fears are clustered in the
following areas:
Fear of being outside the home alone

Fear being in crowd or standing in a

line
Fear being on bridge

Fear in traveling in a bus, train or car

3. Agoraphobia without
History of Panic Disorder
Presence of agoraphobia
without meeting the
criteria for panic disorder
4. Specific Phobias
Existence of a condition
characterized by marked fear of
specific objects or situations
Exposure either in real life or via
imagination or video invariably
elicits intense anxiety
Specific Phobia Criteria
Marked and persistent fear that is
excessive and unreasonable, cued by
presence of anticipation of a specific
object or situation
Criteria:
Exposure to phobic stimulus invariably
provokes immediate anxiety response
The person recognizes that fear is
excessive
The distress and avoidance interferes
with the persons normal routine
5. Social Phobia
Persistent anxiety in social situations including
performances and public speaking (Ballenger 1998)
The critical element is fear of public embarrassment
and ridicule.
The fear is likewise recognized by the person as
excessive and unreasonable
It is associated with fears of fainting, losing bowel and
bladder control, or having ones mind going blank
It is associated with anticipatory anxiety before event
Social Phobia Criteria:
Marked and persistent fear of social
performance in which the person is
exposed to unfamiliar people or to scrutiny
Criteria:
The person fears that he will act in a way that
will be humiliating or embarrassing
Exposure to feared situation invariably
provokes anxiety
The person recognizes that fear is excessive

Distress avoidance interferes with persons

normal routine
6. Obsessive-Compulsive Disorder
Obsession: recurrent and persistent and
intrusive thoughts, impulses or images
experienced during the disturbance as
intrusive and inappropriate and causes
marked anxiety
The obsessions are ego-dystonic because
contents are unlike the thoughts the
person usually has.
Has a clear familial pattern and specificity
Key Features:
The person attempts to ignore / suppress
such thoughts or impulses with another
thought or action
The person recognizes that his obsessions
are product of his own mind
Examples of common Obsessions:

Obsession of fear of dirt and germs

Obsession of fear of burglary (theft) or

robbery
Worries about discarding something

important
Concerns about contracting a serious

illness
Worries that things must be symmetrical
Compulsion: the person is driven to
perform repetitive behaviors or mental
acts in response to an obsession.
The behaviors and mental acts are

aimed at preventing or reducing

distress
Behaviors and mental acts are not

connected in realistic way with

what they are designed to
neutralize and are clearly excessive
Examples of compulsions:
Excessive hand washing

Repeated checking of doors

and locks
Mental acts of Counting

Recording

Hording of objects

Excessive straightening,

ordering, or arranging of
things

7. Post-Traumatic Stress Disorder

The person has been exposed to traumatic event
with the following key features:
The person experienced, witnesses, been confronted
with an event like threatened death, serious injury,
threat to physical integrity
The persons response involved intense fear,
helplessness, and terror
Symptoms may occur immediately after the event or
later, and endure for longer than one month
The traumatic event is re-experienced in the mind
The person avoids stimuli associated with trauma
Treatment: Eye-movement desensitization and
reprocessing
8. Acute Stress Disorder: Meets criteria
for exposure to traumatic event
The person experiences 3 of the
following symptoms:
Sense of detachment
Reduced awareness to
surroundings
Derealization
Depersonalization
Dissociated amnesia
9. Generalized Anxiety Disorder
A protracted period of anxiety
accompanied by associating
symptoms of muscle tension,
easy fatigability, poor
concentration, insomnia and
irritability
An essential feature of
Generalized Anxiety Disorder is
that anxiety and worry cannot be
attributed by focal distress, rather
on many areas including work,
relationships, finances, potential
misfortunes, impending deadlines
Diagnostic Criteria:
1. Excessive anxiety and worry occurring
for more days than not, for at least 6
months involving a number of events or
activities:
Restlessness or feeling keyed up or on

edge
Being easily fatigued

Difficulty in concentrating / mind going

blank
Irritability

Muscle tension

Sleep disturbance
2. Difficulty controlling the worry
3. Focus of anxiety and worry not
confined to another psychiatric
disorders
4. Clinically significant distress /
impairment of functioning
resulting from anxiety
5. Not a direct physiologic effect of
a substance or medical condition
6. Does not occur exclusively
during mood disorder, psychotic
disorder, or pervasive
Treatment of Anxiety Disorders:
1. Psychotherapy (talking therapy):
has been found effective in
specific phobias
2. Medications:
a. Anti-anxiety Medications: does
not cure, they keep symptoms
under control leading to
normal life or fulfilling life:
Anxiolytics: Beta-blockers
b. Antidepressants: Also effective for
anxiety disorders
Needs several weeks before symptoms
will fade away
Newest antidepressants are called
SSRT (Selective Serotonin Reuptake
Inhibitors). It acts in the brain along
chemical messengers called Serotonin
Example of SSRI indicated to conditions
of Panic, OCD, PTSD, Social Phobia:
Fluoxetine * Paroxetine
Setraline * Gitalopram
Fluvoxamine
c. Tricyclic antidepressants: used
in co-occurring anxiety
disorders and depression
d. MAOIs: Oldest class of
antidepressants
Phenelzine: indicated for

panic and social phobia

Patients are placed on

restricted diet because the

drug interacts with cheese,
red wine or food chemical
with tyramine
e. High Potency
Benzodiazepines: are drugs
with quick action and few side
effects
Drowsiness is a common side

effect
Tolerance can easily develop

and withdrawal symptoms do

occur.
The Role of the Nurse
Generalist
- Understanding the basis of anxiety
Identifying mental health needs
Major Intervention:
Establishment of rapport
Enhancing present coping skills
Assessing maladaptive responses
Promoting health maintenance

Advanced Practitioner Psychiatric Nurse

Applying advanced clinical skills
Determining differential diagnosis
Psychotherapy, case management