As discussed in Chapter 2, Hildegard Peplau had a profound role in shaping the specialty of psychiatric mental health nursing. She identified anxiety as one of the most important concepts and developed an anxiety model that consists of four levels: mild, moderate, severe, and panic (Peplau, 1968). The boundaries between these levels are not distinct, and the behaviors and characteristics of individuals experiencing anxiety can and often do overlap. Identification of the specific level of anxiety is essential because interventions are based on the degree of the patient’s anxiety.

15-1 CASE STUDY AND NURSING CARE PLAN

Severe Level of Anxiety

The following case study describes a man experiencing a severe level of acute anxiety. See if you can match his signs and symptoms with those in Table 15-1.

TABLE 15-1

LEVELS OF ANXIETY

MILD	MODERATE	SEVERE	PANIC
Perceptual Field
Heightened perceptual field	Narrowed perceptual field; grasps less of what is going on	Greatly reduced and distorted perceptual field	Unable to attend to the environment
Focus is flexible and is aware of the anxiety	Focuses on the source of the anxiety; less able to pay attention.	Focuses on details or one specific detail Attention is scattered	Focus is lost; may feel unreal (depersonalization) or that the world is unreal (derealization)
Ability to Problem Solve
Able to work effectively toward a goal and examine alternatives	Able to solve problems but not at optimal ability	Problem solving feels impossible. Unable to see connections between events or details	Completely unable to process what is happening; disorganized or irrational reasoning
Mild and moderate levels of anxiety can alert the person that something is wrong and can stimulate appropriate action.	Severe and panic levels of anxiety prevent problem solving. Unproductive relief behaviors perpetuate a vicious cycle.
Physical or Other Characteristics
Slight discomfort Attention-seeking behavior Restlessness Easily startled Irritability or impatience Mild tension-relieving behavior (foot or finger tapping, lip chewing, fidgeting)	Voice tremors Change in voice pitch Poor concentration Shakiness Somatic complaints, (urinary frequency, headache, backache, insomnia) Increased respiration, pulse, and muscle tension More tension-relieving behavior (pacing, banging of hands on table)	Feelings of dread Confusion Purposeless activity Sense of impending doom More intense somatic complaints (chest discomfort, dizziness, nausea, sleeplessness) Diaphoresis (sweating) Withdrawal Loud and rapid speech Threats and demands	Experience of terror Immobility or severe hyperactivity or flight Unintelligible communication or inability to speak Somatic complaints increase (numbness or tingling, shortness of breath, dizziness, chest pain, nausea, trembling, chills, overheating, palpitations) Severe withdrawal Hallucinations or delusions; likely out of touch with reality

Matt Michaels, a 63-year-old man, comes into the emergency department (ED) with his wife, Anne, who has taken an overdose of sleeping pills and antidepressant medications. Ten years earlier, Anne’s mother died, and since that time she has suffered several episodes of severe depression with suicide attempts. She has needed hospitalization during these episodes. Anne Michaels had been released from the hospital 2 weeks earlier after treatment for depression and threatened suicide.

Matt has a long-established routine of giving his wife her antidepressant medications in the morning and her sleeping medication at night and keeping the bottles hidden when he is not at home. Today he had forgotten to hide the medications before he went to work. His wife had taken the remaining pills from both bottles with large quantities of alcohol. When Matt returned home for lunch, Anne was comatose. In the ED, Anne suffers cardiac arrest and is taken to the intensive care unit (ICU).

Matt is very jittery. He moves about the room aimlessly. He drops his hat, a medication card, and his keys. His hands are trembling, and he looks around the room, bewildered. He appears unable to focus on any one thing. He says over and over, in a loud, high-pitched voice, “Why didn’t I hide the bottles?” He is wringing his hands and begins stomping his feet, saying, “It’s all my fault. Everything is falling apart.”

Other people in the waiting room appear distracted and alarmed by his behavior. Matt seems to be oblivious to his surroundings.

Assessment

Gabriel Brown, the psychiatric nurse clinician working in the ED, comes into the waiting room and assesses Matt’s behavior as indicative of a severe anxiety level. After talking with Matt briefly, Gabriel believes nursing intervention is indicated. Gabriel bases his conclusion on the following assessment of the patient:

Objective data

• Unable to focus on anything

• Engaging in purposeless activity (walking around aimlessly)

• Oblivious to his surroundings

• Showing unproductive relief behavior (stomping, wringing hands, dropping things)

Subjective data

“Everything is falling apart.”

“Why didn’t I hide the bottles?”

“It’s all my fault.”

Diagnosis

• Anxiety (severe) related to the patient’s perception of responsibility for his wife’s coma and possible death, as evidenced by inability to focus, confusion, and the feeling that “everything is falling apart”

Outcomes identification

Patient will demonstrate control of the anxiety response *

Planning

Gabriel thinks that if he can lower Matt’s anxiety to a moderate level, he can work with Matt to get a clear picture of his situation and place the events in a more realistic perspective. He also thinks Matt needs to talk to someone and share some of his pain and confusion to help sort out his feelings. Gabriel identifies two short-term goals:

1. Patient’s anxiety will decrease from severe to moderate by 4 pm.

2. Patient will verbalize his feelings and a need for assistance by 4 pm.

Implementation

Gabriel takes Matt to a quiet room in the back of the ED. He introduces himself to Matt and comments that he notices that Matt is upset. He says, “I will stay with you.” At first, Matt finds it difficult to sit down and continues pacing around the room. Gabriel sits quietly and calmly while listening to Matt’s self-recriminations. He attends carefully to what Matt is saying—and what he is not saying—to identify themes.

After a while, Matt becomes calmer and is able to sit next to Gabriel. Gabriel offers him orange juice, which he accepts and holds tightly.

Gabriel speaks calmly, using simple, clear statements. He uses communication tools that are helpful to Matt in sorting out his feelings and naming them.

DIALOGUE	THERAPEUTIC TOOL/COMMENT
Matt: Yes …. yes …. I forgot to hide the bottles. She usually tells me when she feels bad. Why didn’t she tell me?
Nurse: You think that if she had told you she wanted to kill herself, you would have hidden the pills?	Gabriel asks for clarification of Matt’s thinking.
Matt: Yes, if I had only known, this wouldn’t have happened.
Nurse: It sounds as if you believe you should have known what your wife was thinking without her telling you.	Here Gabriel clarifies Matt’s expectations that he should be able to read his wife’s mind.
Matt: Well …. yes …. when you put it that way …. I just don’t know what I’ll do if she dies.

When Gabriel thinks that Matt has discussed his feelings of guilt sufficiently, he asks Matt to clarify his thinking about his wife’s behavior. Matt is able to place his feelings of guilt in a more realistic perspective. Next, Gabriel brings up another issue—the question of whether Matt’s wife will live or die.

DIALOGUE	THERAPEUTIC TOOL/COMMENT
Nurse: You said that if your wife dies, you don’t know what you will do.	Gabriel reflects Matt’s feelings back to him.
Matt: Oh, God (begins to cry); I can’t live without her …. she’s all I have in the world.
Silence
Nurse: She means a great deal to you.	Gabriel reflects Matt’s feelings back to him.
Matt: Everything. Since her mother died, we are each other’s only family.
Nurse: What would it mean to you if your wife died?	Gabriel asks Matt to evaluate his feelings about his wife.
Matt: I couldn’t live by myself, alone. I couldn’t stand it. (Starts to cry again.)
Nurse: It sounds as if being alone is very frightening to you.	Gabriel restates in clear terms Matt’s experience and feelings.
Matt: Yes …. I don’t know how I’d manage by myself.
Nurse: A change like that could take time to adjust to.	Gabriel validates that if Matt’s wife died, it would be very painful. At the same time, he implies hope that Matt could work through the death in time.
Matt: Yes …. it would be very hard.

Again, Gabriel gives Matt a chance to sort out his feelings and fears. Gabriel helps him focus on the reality that his wife may die and encourages him to express fears related to her possible death. After a while, Gabriel offers to go up to the ICU with Matt to see how his wife is doing. When they arrive at the ICU, although Anne is still comatose, her condition has stabilized, and she is breathing on her own.

After his arrival at the ICU, Matt starts to worry about whether he remembered to lock the door at home. Gabriel suggests that he call neighbors and ask them to check the door. At this time, Matt is able to focus on everyday things. Gabriel makes arrangements to see Matt the next day when he comes in to visit his wife.

The next day, Anne has regained consciousness. She is discharged 1 week later. At the time of discharge, Matt and Anne Michaels are considering family therapy with the psychiatric nurse clinician once a week in the outpatient department.

Evaluation

The first short-term goal is to lower anxiety from severe to moderate. Gabriel can see that Matt has become more visibly calm. His trembling, wringing of hands, and stomping of feet have ceased, and he is able to focus on his thoughts and feelings with Gabriel’s help.

The second short-term goal established for Matt is that he will verbalize his feelings and his need for assistance. Matt is able to identify and discuss with Gabriel his feelings of guilt and fear of being left alone in the world if his wife should die. Both of these feelings are overwhelming him. He is also able to state that he needs assistance in coping with these feelings in order to make tentative plans for the future.

*The expected outcome will be evaluated on a 5-point Likert scale ranging from 1 (never demonstrated) to 5 (consistently demonstrated).

Panic

Panic is the most extreme level of anxiety and results in markedly disturbed behavior. Someone in a state of panic is unable to process what is going on in the environment and may lose touch with reality. The behavior that results may be manifested as pacing, running, shouting, screaming, or withdrawal. Hallucinations, or false sensory perceptions (e.g., seeing people or objects not really there), may be experienced. Physical behavior may become erratic, uncoordinated, and impulsive. Automatic behaviors are used to reduce and relieve anxiety although such efforts may be ineffective. Acute panic may lead to exhaustion.

Review Table 15-1, which distinguishes among the levels of anxiety in regard to their (1) effects on perceptual field, (2) effects on problem solving, and (3) physical and other defining characteristics.

Defenses against anxiety

Sigmund Freud and his daughter, Anna Freud, outlined most of the defense mechanisms we recognize today. Defense mechanisms are automatic coping styles that protect people from anxiety and maintain self-image by blocking feelings, conflicts, and memories. Although they operate all the time, defense mechanisms are not always apparent to the individual using them.

Adaptive use of defense mechanisms helps people lower anxiety to achieve goals in acceptable ways. Maladaptive use of defense mechanisms occurs when one or several are used in excess, particularly in the overuse of immature defenses. Figure 15-1 operationally defines anxiety and shows how defenses come into play.

With the exception of sublimation and altruism, which are always healthy coping mechanisms, most defense mechanisms can be used in both healthy and unhealthy ways. Most people use a variety of defense mechanisms but not always at the same level. Keep in mind that evaluating whether the use of defense mechanisms is adaptive or maladaptive is determined for the most part by their frequency, intensity, and duration of use. Table 15-2 describes defense mechanisms and their adaptive and maladaptive uses.

TABLE 15-2

ADAPTIVE AND MALADAPTIVE USES OF DEFENSE MECHANISMS

DEFENSE MECHANISM	ADAPTIVE USE	MALADAPTIVE USE
Compensation is used to counterbalance perceived deficiencies by emphasizing strengths.	A shorter-than-average man becomes assertively verbal and excels in business.	An individual drinks alcohol when self-esteem is low to temporarily diffuse discomfort.
Conversion is the unconscious transformation of anxiety into a physical symptom with no organic cause.	No example. Almost always a pathological defense	A man becomes blind after seeing his wife flirt with other men.
Denial involves escaping unpleasant, anxiety-causing thoughts, feelings, wishes, or needs by ignoring their existence.	A man reacts to the death of a loved one by saying “No, I don’t believe you” to initially protect himself from the overwhelming news.	A woman whose husband died 3 years earlier still keeps his clothes in the closet and talks about him in the present tense.
Displacement is the transference of emotions associated with a particular person, object, or situation to another nonthreatening person, object, or situation.	A child yells at his teddy bear after being picked on by the school bully.	A child who is unable to acknowledge fear of his father becomes fearful of animals.
Dissociation is a disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself.	An art student is able to mentally separate herself from the noisy environment as she becomes absorbed in her work.	As the result of an abusive childhood and the need to separate from its realities, a woman finds herself perpetually disconnected from reality.
Identification is attributing to oneself the characteristics of another person or group. This may be done consciously or unconsciously.	An 8-year-old girl dresses up like her teacher and puts together a pretend classroom for her friends.	A young boy thinks a neighborhood pimp with money and drugs is someone to look up to.
Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing.	Despite the fact that a man has lost his farm to a tornado, he analyzes his options and leads his child to safety.	A man responds to the death of his wife by focusing on the details of day care and operating the household, rather than processing the grief with his children.
Projection refers to the unconscious rejection of emotionally unacceptable features and attributing them to others.	No example. This is considered an immature defense mechanism	A woman who has repressed an attraction toward other women refuses to socialize. She fears another woman will make homosexual advances toward her.
Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener.	An employee says, “I didn’t get the raise because the boss doesn’t like me.”	A man who thinks his son was fathered by another man excuses his malicious treatment of the boy by saying, “He is lazy and disobedient,” when that is not the case.
Reaction formation is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.	A recovering alcoholic constantly talks about the evils of drinking.	A woman who has an unconscious hostility toward her daughter is overprotective and hovers over her to protect her from harm, interfering with her normal growth and development.
Regression is reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been previously exhibited.	A 4-year-old boy with a new baby brother temporarily starts sucking his thumb and wanting a bottle.	A man who loses a promotion starts complaining to others, hands in sloppy work, misses appointments, and comes in late for meetings.
Repression is an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness.	A man forgets his wife’s birthday after a marital fight.	A woman is unable to enjoy sex after having pushed out of awareness a traumatic sexual incident from childhood.
Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.	No example. Almost always a pathological defense	A 26-year-old woman initially values her acquaintances yet invariably becomes disillusioned when they turn out to have flaws.
Sublimation is an unconscious process of substituting mature and socially acceptable activity for immature and unacceptable impulses.	A woman who is angry with her boss writes a short story about a heroic woman.	The use of sublimation is always constructive.
Suppression is the conscious denial of a disturbing situation or feeling. For example, Jessica has been studying for the state board examination for a week solid. She says, “I won’t worry about paying my rent until after my exam tomorrow.”	A businessman who is preparing to make an important speech is told by his wife that morning that she wants a divorce. Although visibly upset, he puts the incident aside until after his speech, when he can give the matter his total concentration.	A woman who feels a lump in her breast shortly before leaving for a 3-week vacation puts the information in the back of her mind until after returning from her vacation.
Undoing is most commonly seen in children. It is when a person makes up for an act or communication.	After flirting with her male secretary, a woman brings her husband tickets to a concert he wants to see.	A man with rigid, moralistic beliefs and repressed sexuality is driven to wash his hands to gain composure when around attractive women.

Anxiety disorders

Individuals with anxiety disorders use rigid, repetitive, and ineffective behaviors to try to control their anxiety. The common element of such disorders is that those affected experience a degree of anxiety so high that it interferes with personal, occupational, or social functioning. The presence of chronic anxiety disorders may increase the rate of cardiovascular system-related deaths. Anxiety disorders tend to be persistent and often disabling. Chapter 10 offers a more complete description of the debilitating effects of chronic stress and resultant anxiety.

Clinical picture

According to the American Psychiatric Association (2013), the term anxiety disorder refers to a number of disorders, including:

• Separation Anxiety Disorder

• Panic Disorder

• Agoraphobia

• Specific Phobia

• Social Anxiety Disorder (Social Phobia)

• Generalized Anxiety Disorder

• Obsessive-Compulsive Disorder

• Body Dysmorphic Disorder

• Hoarding Disorder

• Hair Pulling and Skin Picking Disorder

Separation anxiety disorder

Separation anxiety is a normal part of infant development; it begins around 8 months of age, peaks around 18 months, and begins to decline after that. People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other (Bostic & Prince, 2010). There may also be fear that something horrible will happen to the other person and that it will result in permanent separation. The anxiety is so intense that it distracts sufferers from their normal activities, causes sleep disruptions and nightmares without the significant other close by, and is often manifested in physical symptoms such as gastrointestinal disturbances and headaches.

This problem is typically diagnosed prior to the age of 18 after about a month of symptoms. Separation anxiety may develop after a significant stress, such as the death of a relative or pet, an illness, a move or change in schools, or a physical or sexual assault (Ursano et al., 2011).

Recently, clinicians have begun to recognize an adult form of separation anxiety disorder that may begin either in childhood or in adulthood. Those who are the subject of the attachment—a parent, a spouse, a child, or a friend—may grow weary of the constant neediness and clinginess. In fact, adults with this disorder often have extreme difficulties in romantic relationships and are more likely to be unmarried (Nichols, 2009). Characteristics of adult separation anxiety disorder include harm avoidance, worry, shyness, uncertainty, fatigability, and a lack of self-direction (Mertol & Alkin, 2012). It is accompanied by a significant level of discomfort and disability that impairs social and occupational functioning and does not respond well to the most popular type of psychotherapy, cognitive-behavioral therapy.

Panic disorders

Panic attacks are the key feature of panic disorder. A panic attack is the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom. The feelings of terror present during a panic attack are so severe that normal functioning is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur. People experiencing panic attacks may believe they are losing their minds or having a heart attack. Uncomfortable physical symptoms such as palpitations, chest pain, breathing difficulties, nausea, and feelings of choking, chills, and hot flashes may occur. Typically, panic attacks come “out of the blue” (i.e., suddenly and not necessarily in response to stress), are extremely intense, last a matter of minutes, and then subside.

Unpredictability is a key aspect of panic disorder in children and adolescents. The attacks of panic seem to come out of nowhere, last about 10 minutes, and then subside. During the attack the young person has much the same symptoms as adults, but is often less able to articulate the psychological aspects, such as fear. They may become avoidant of situations where help is not available, may develop feelings of hopelessness in controlling these attacks, and may become depressed. Alcohol or substance abuse is not uncommon in adolescents with this disorder.

People who experience these attacks begin to “fear the fear” and become so preoccupied about future episodes of panic that they avoid what could be pleasurable and adaptive activities, experiences, and obligations. Table 15-3 outlines a generic nursing care plan for panic disorder, and the Evidence-Based Practice box provides additional information.

TABLE 15-3

GENERIC CARE PLAN FOR PANIC DISORDER

Nursing diagnosis: Severe anxiety as evidenced by sudden onset of fear of impending doom or dying, increased pulse and respirations, shortness of breath, possible chest pain, dizziness, and abdominal distress.
Outcome criteria: Panic attacks will become less intense and time between episodes will lengthen so that patient can function comfortably at the usual level.
SHORT-TERM GOAL	INTERVENTION	RATIONALE
1. Patient’s anxiety will decrease to moderate by (date).	1a. If hyperventilation occurs, instruct patient to take slow, deep breaths. Breathing with the patient may be helpful. 1b. Keep expectations minimal and simple.	1a. Focus is shifted away from distressing symptoms. 1b. Anxiety limits ability to attend to complex tasks.
2. Patient will gain mastery over panic episodes by (date).	2a. Help patient connect feelings before attack with onset of attack: “What were you thinking about just before the attack?” “Can you identify what you were feeling just before the attack?” 2b. Help patient recognize symptoms as resulting from anxiety, not from a catastrophic physical problem. Examples: Explain physical symptoms of anxiety. Discuss the fact that anxiety causes sensations similar to those of physical events, such as a heart attack. 2c. Identify effective therapies for panic episodes. 2d. Teach patient abdominal breathing to be immediately used when anxiety is detected. 2e. Teach patient to use positive self-talk, such as “I can control my anxiety.” 2f. Teach patient and family about any medication ordered for patient’s panic attacks.	2a. Physiological symptoms of anxiety usually appear first as the result of a stressor. They are immediately followed by automatic thoughts, such as “I’m dying” or “I’m going crazy,” which are distorted assessments. 2b. Factual information and alternative interpretations can help patient recognize distortions in thought. 2c. Cognitive-behavioral treatment is highly effective. Antianxiety medication is appropriate. 2d. Breathing exercises break the cycle of escalating symptoms of anxiety. 2e. Cognitive restructuring is an effective way to replace negative self-talk. 2f. Patient and family need to know what the medication can do, what the side effects and toxic effects are, and whom to call if untoward reactions occur.

EVIDENCE-BASED PRACTICE

Using Exercise to Reduce Panic Attack Severity

Stoy, M., Graetz, B., Scheel, M., Wittmann, A., Gallinat, J., Lang, U.E., Dimeo, F., & Hellweg, R. (2010). Acute exercise ameliorates reduced brain-derived neurotrophic factor in patients with panic disorder. Psychoneuroendocrinology, 35(3), 364-368.

Problem

Panic attacks are terrifying and are accompanied by palpitations and feeling sweaty, faint, and weak. They may lead to disability and complete avoidance of normal activities. Medications and cognitive therapy are useful in the treatment of this disorder; the discovery of other natural treatments would be beneficial to sufferers.

Purpose of study

Neurotrophin brain-derived neurotrophic factor (BDNF) is associated with anxiolytic (anxiety reduction) activity and is increased through exercise. The researchers wanted to see if exercise would improve symptoms of panic disorder.

Methods

Twelve patients with panic disorder were matched with 12 healthy control subjects. Serum samples for BDNF analyses were taken before and after either 30 minutes of exercise or 30 minutes of quiet rest. The two conditions were separated by 1 week, and the order of the exercise and rest was done randomly.

Key findings

Prior to the experiment, increased anxiety was associated with reduced BDNF concentrations in all subjects, but for patients with panic disorder the BDNF concentration was significantly reduced. After 30 minutes of exercise there was a significant increase in BDNF concentrations for patients with panic disorder. For the control subjects, the increase in BDNF was not significant.

Implications for nursing practice

Nurses know that 30 minutes of exercise is good for almost anyone. For those who suffer from the overwhelming anxiety of panic disorder, this therapeutic exercise may be essential. Nurses can promote a prescription of daily exercise and can advocate for such equipment as treadmills and stationary bicycles to be included in designs of psychiatric facilities.

Agoraphobia

Agoraphobia is intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available. The feared places are avoided in an effort to control anxiety. Examples of situations that are commonly avoided by patients with agoraphobia are being alone outside; being alone at home; traveling in a car, bus, or airplane; being on a bridge; and riding in an elevator. These situations may be made more tolerable with the addition of a friend. Avoidance behaviors can be debilitating and life constricting. Consider the effect on a father whose agoraphobia renders him unable to leave home and prevents him from seeing his child’s high school graduation or the businesswoman whose avoidance of flying prevents her from attending distant business conferences.

Specific phobias

A specific phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance, or actual avoidance of the object, activity, or situation. Specific phobias are characterized by the experience of high levels of anxiety or fear in response to specific objects or situations, such as dogs, spiders, heights, storms, water, blood, closed spaces, tunnels, and bridges.

Characteristically, phobic individuals experience overwhelming and crippling anxiety when faced with the object or situation provoking the phobic response. Daily functioning is compromised, and phobic people go to great lengths to avoid the feared object or situation. A phobic person may not be able to think about or visualize the object or situation without becoming severely anxious. The life of a phobic person becomes more restricted as activities are given up so that the phobic object can be avoided. All too frequently, complications ensue when sufferers try to decrease anxiety through self-medication with alcohol or drugs.

Consider the case of Daniel, who developed a profound fear of elevators after being trapped in one for 3 hours during a power outage. As his fear and anxiety intensified, it became necessary for him to use only stairs or escalators. He obsesses about the possibility that he will be forced to use an elevator in social situations and avoids attending events where this may occur. It has reached a point where even going inside closets or small storage rooms is unbearable. This fear of enclosed spaces is called claustrophobia. Other common phobias are listed in Table 15-4.

TABLE 15-4

CLINICAL NAMES FOR COMMON PHOBIAS

CLINICAL NAME	FEARED OBJECT OR SITUATION
Acrophobia	Heights
Agoraphobia	Open spaces
Astraphobia	Electrical storms
Claustrophobia	Closed spaces
Glossophobia	Talking
Hematophobia	Blood
Hydrophobia	Water
Monophobia	Being alone
Mysophobia	Germs or dirt
Nyctophobia	Darkness
Pyrophobia	Fire
Xenophobia	Strangers
Zoophobia	Animals

Social anxiety disorder

Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that could be evaluated negatively by others. Situations that trigger this distress include fear of saying something that sounds foolish in public, not being able to answer questions in a classroom, looking awkward while eating or drinking in public, and performing badly on stage. Whenever possible, people with social anxiety disorder avoid these social situations; if they are unable to avoid them, they endure the situation with intense anxiety and emotional distress.

Small children with this disorder may be mute, nervous, and hide behind their parents. Older children and adolescents may be paralyzed by fear of speaking in class or interacting with other children; the worry over saying the wrong thing or being criticized immobilizes them. Conversely, younger people may act out to compensate for this fear making an accurate diagnosis more difficult. This anxiety often results in physical complaints to avoid social situations, particularly school.

Fear of public speaking is the most common manifestation of social anxiety disorder. Interestingly, this disorder has afflicted famous singers and actors such as Barbra Streisand and Sir Laurence Olivier, both of whom were terrified that they might forget the words to songs and scripts.

Generalized anxiety disorder

The key pathological feature of generalized anxiety disorder is excessive worry (Newman & Llera, 2011). Children, teens, and adults may experience this worry, which is out of proportion to the true impact of events or situations. Persons with generalized anxiety disorder anticipate disaster and are restless, irritable, and experience muscle tension. Decision making is difficult due to poor concentration and dread of making a mistake.

Common worries in generalized anxiety disorder are inadequacy in interpersonal relationships, job responsibilities, finances, and health of family members. Because of this worry, huge amounts of time are spent in preparing for activities. Putting things off and avoidance are key symptoms and may result in lateness or absence from school or employment, and overall social isolation. Family members and friends are overtaxed as the person with this disorder seeks continual reassurance and perseverates about meaningless details.

Sleep disturbance is common because the individual worries about the day’s events and real or imagined mistakes, reviews past problems, and anticipates future difficulties. Fatigue is a noticeable side effect of this sleep deprivation. Refer to Table 15-5 for a generic care plan for generalized anxiety disorder.

TABLE 15-5

GENERIC CARE PLAN FOR GENERALIZED ANXIETY DISORDER

Nursing diagnosis: Ineffective coping related to persistent anxiety, fatigue, difficulty concentrating
Outcome criteria: Patient will maintain role performance.
SHORT-TERM GOAL	INTERVENTION	RATIONALE
1. Patient will state that immediate distress is relieved by end of session.	1a. Stay with patient. 1b. Speak slowly and calmly. 1c. Use short, simple sentences. 1d. Assure patient that you are in control and can assist him or her. 1e. Give brief directions. 1f. Decrease excessive stimuli; provide quiet environment. 1g. After assessing level of anxiety, administer appropriate dose of antianxiety agent if warranted. 1h. Monitor and control own feelings.	1a. Conveys acceptance and ability to give help. 1b. Conveys calm and promotes security. 1c. Promotes comprehension. 1d. Counters feeling of loss of control that accompanies severe anxiety. 1e. Reduces indecision. Conveys belief that patient can respond in a healthy manner. 1f. Reduces need to focus on diverse stimuli. Promotes ability to concentrate. 1g. Reduces anxiety and allows patient to use coping skills. 1h. Anxiety is transmissible. Displays of negative emotion can cause patient anxiety.
2. Patient will be able to identify source of anxiety by (date).	2a. Encourage patient to discuss preceding events. 2b. Link patient’s behavior to feelings. 2c. Teach a cognitive therapy principle: Anxiety is the result of automatic thinking with a dysfunctional appraisal of a situation. 2d. Ask questions that clarify and dispute illogical thinking: “What evidence do you have?” “Explain the logic in that.” “Are you basing that conclusion on fact or feeling?” “What’s the worst thing that could happen?” 2e. Have patient give an alternative interpretation.	2a. Promotes future change through identification of stressors. 2b. Promotes self-awareness. 2c. Provides a basis for behavioral change. 2d. Helps promote accurate cognition. 2e. Broadens perspective. Helps patient think in a new way about problem or symptom.
3. Patient will identify strengths and coping skills by (date). Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: The nursing process and standards of care for psychiatric mental health nursing Cultural implications for psychiatric mental health nursing Sleep-wake disorders Biological basis for understanding psychiatric disorders and treatments Stay updated, free articles. Join our Telegram channel Tags: Varcarolis Foundations of Psychiatric Mental Health Nursing Feb 3, 2017 \| Posted by admin in NURSING \| Comments Off on Anxiety and obsessive-compulsive related disorders Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access

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Anxiety and obsessive-compulsive related disorders

Anxiety and obsessive-compulsive related disorders

Anxiety

Levels of anxiety

Mild anxiety

Moderate anxiety

Severe anxiety

Panic

Defenses against anxiety

Anxiety disorders

Clinical picture

Separation anxiety disorder

Panic disorders

Agoraphobia

Specific phobias

Social anxiety disorder

Generalized anxiety disorder

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