Anxiety disorders

95 Anxiety disorders




Overview/pathophysiology


Anxiety is a diffuse response to a vague threat, as opposed to fear, which is an acute response to a clear-cut external threat. Anxiety often precedes significant changes, for example, beginning new employment. When it is prolonged or excessive, crippling physical or psychologic symptoms may develop. The anxiety disorders are a group of conditions characterized by anxiety symptoms and behavioral efforts to avoid these symptoms. They are the most common psychiatric disorders in the United States, affecting more than 40 million people or about 18.1% of American adults aged 18 and older. Acute anxiety creates physical sensations of arousal (fight or flight), an emotional state of panic, decreased cognitive problem-solving ability, and altered spiritual state with hopelessness and/or helplessness. Anxiety is considered abnormal when reasons for it are not evident or when manifestations are excessive in intensity and duration. Psychologic stress refers to the response of an individual appraising the environment and concluding that it exceeds his or her resources and jeopardizes well-being. Some stressors are universal, whereas others are person specific because of highly individual interpretations of events.


Anxiety is always part of the stress response and has four levels, ranging from mild to panic. Normally, a person experiencing mild-to-moderate anxiety uses voluntary behaviors called coping skills, that is, distraction, deliberate avoidance, and information seeking. Another common response is use of unconscious defense mechanisms, including repression, suppression, projection, introjection, reaction formation, undoing, displacement, denial, and regression. If stress continues at an unbearable level or if the individual lacks sufficient biologic mechanisms for coping, an anxiety disorder may develop. There are eight major categories.




Generalized anxiety disorder:


Characterized by excessive, uncontrollable worrying over a period of at least 6 months. Symptoms include motor tension (trembling; shakiness; muscle tension, aches, soreness; easy fatigue), autonomic hyperactivity (shortness of breath, palpitations, sweating, dry mouth, dizziness, nausea, diarrhea, frequent urination), and scanning behavior (feeling on edge, having an exaggerated startle response, difficulty concentrating, sleep disturbance, irritability).



Panic disorder:


Characterized by a specific period of intense fear or discomfort with at least four of the following symptoms: palpitations or pounding heart, sweating, trembling or shaking, sensations of smothering or difficulty breathing, feeling of choking, chest pain, nausea, feeling dizzy or faint, feeling of unreality or losing control, numbness, and chills or flushes.



Phobias:


Characterized by a persistent and severe fear of a clearly identifiable object or situation despite awareness that the fear is unreasonable. There are two types, specific and social. Specific phobias are subdivided into five types: animals, natural environment (e.g., lightning), blood-injection-injury type, situational (e.g., flying), and other (situations that could lead to choking or contracting an illness). Social phobia relates to profound fear of social or performance situations in which embarrassment could occur.



Obsessive-compulsive disorder (OCD):


Characterized by a preoccupation with recurrent, ritualistic thoughts or actions. Obsessions are persistent thoughts, ideas, impulses, or images that are intrusive and cause marked anxiety. Compulsions are repetitive acts that follow an obsession, are performed according to strict rules, and are aimed at decreasing the feeling of distress/anxiety caused by the obsessions.



Posttraumatic stress disorder:


Results from a pathologic response to a devastating event such as war, natural disaster, or rape. The person continues to reexperience the event through intrusive thoughts or nightmares. Memories of the trauma occur randomly, or symptoms may emerge when the person is exposed to situations that resemble or symbolize the original trauma. Fear and persistent states of arousal lead to difficulty falling asleep or remaining asleep. Hypervigilance with an exaggerated startle response may occur, resulting in problems concentrating and completing tasks. The duration of the symptoms is at least 1 month, and the syndrome may emerge many months after the event. On the other hand, some victims may have no memories of the trauma for a period of time. They may complain of feeling detached or separate from others and lose the ability to enjoy pleasurable events, reflecting “psychic numbing.” In both cases, anger, sadness, rage, depression, or stoicism may be demonstrated.



Acute stress disorder:


Like posttraumatic stress disorder (PTSD), the problem begins with exposure to a traumatic event, with a response of intense fear, helplessness, or horror. In addition, the person shows dissociative symptoms, that is, subjective sense of numbing, feeling “in a daze,” depersonalization, or amnesia and clearly tries to avoid stimuli that arouse recollection of the trauma. But just like PTSD, the victim reexperiences the trauma and shows functional impairment in social, occupational, and problem-solving skills. The key difference is that this syndrome occurs within 4 wk of the traumatic event and only lasts 2 days to 4 wk.



Anxiety disorder caused by medical condition:


May be characterized by severe anxiety, panic attacks, or obsessions or compulsions, but the cause is clearly related to a medical problem, excluding delirium. History, physical examination, and laboratory findings support a specific diagnosis, for example, hypoglycemia, pheochromocytoma, or thyroid disease.



Anxiety disorder not otherwise specified:


Describes individuals with significant anxiety or phobic avoidance but not enough symptoms to meet the criteria for a particular anxiety or adjustment disorder diagnosis. The patient may show a mixed anxiety-depressive picture or demonstrate social phobic symptoms related to having another medical problem, for example, Parkinson’s disease, or present with insufficient data to rule out a general medical condition or substance abuse.



Health care setting


Depends on the type of anxiety disorder. Primary (outpatient) care is likely for most categories, and possibly emergency department care for panic disorders. If the patient has developed panic disorder with agoraphobia, psychiatric home care may be the best care option. Some patients may be hospitalized for physiologic problems.



Assessment




Physical indicators:


Dry mouth, elevated vital signs, diarrhea, increased urination, nausea, diaphoresis, hyperventilation, fatigue, insomnia, sexual dysfunction, irritability, tenseness.



Emotional indicators:


Fear, sense of impending doom, helplessness, insecurity, low self-confidence, anger, guilt.



Cognitive indicators:


Mild anxiety produces increased awareness and problem-solving skills. Higher levels produce narrowed perceptual field, missed details, diminished problem-solving skills, and deteriorated logical thinking.



Social indicators:


Marital and parental functioning may be adversely affected by anxiety and therefore should be assessed.



Spiritual indicators:


Patient may exhibit hopelessness/helplessness, feeling of being cut off from God, anger at God for allowing anxiety.



Suicidality:


Suicide assessment is critical with anxious patients, especially those with panic disorder. For patients suffering dual diagnoses of depression and substance abuse or even other anxiety disorders, risk of self-injury is even greater. Suicidal assessment includes questions to determine presence of suicidal ideation and the lethality of any plan. Essential questions to ask include:


• Have you thought of hurting yourself?

• Are you presently thinking about hurting yourself?

• If you have been thinking about suicide, do you have a plan?

• What is the plan?

• Have you thought about what life would be like if you were no longer a part of it?

A previous history of suicide attempts combined with depression places the patient at high risk in the present. A patient whose depression is lifting is at higher risk for suicide than a severely depressed individual. The improvement may result in an increase in energy. This increased energy is not enough to make the patient feel well or hopeful, but it is enough to carry out a suicidal plan.



Diagnostic tests


There is no specific diagnostic test for anxiety disorders. The diagnosis of anxiety is made through history, interview of patient and family, and observation of verbal and nonverbal behaviors. A number of effective scales are available to quantify the degree of anxiety, such as the Yale-Brown Obsessive Scale, the Yale-Brown Obsessive Compulsive Scale, Hamilton Rating Scale for Anxiety, Panic Attack Cognitions Questionnaire, State-Trait Anxiety Inventory, Sheehan Patient Rated Anxiety Inventory, and the Beck Anxiety Inventory.





Nursing diagnosis:



Deficient knowledge


related to unfamiliarity with causes, signs and symptoms, and treatment of anxiety or specific anxiety disorder


Desired Outcome: By discharge (if inpatient) or after 2 wk of outpatient treatment, patient and/or significant other verbalize accurate information about at least two of the possible causes of anxiety, four of the signs and symptoms of the specific anxiety disorder, and the available treatment options.



















ASSESSMENT/INTERVENTIONS RATIONALES
Assess patient’s understanding about anxiety, its signs and symptoms, and its treatment. This assessment helps the nurse reinforce, as needed, information about anxiety and correct any misunderstanding. Many people lack understanding about the physiologic basis for anxiety and that feeling a little worry is different from the overwhelming anxiety experienced by those who have an anxiety disorder.
Inform patient and significant other that anxiety disorders are physiologic disorders caused by the interplay of many factors, such as stress, imbalance in brain chemistry, psychodynamic factors, faulty learning, and genetics. Many people who suffer from anxiety disorders accept that they are just “nervous worriers” and lack the knowledge that anxiety disorders represent a complex interplay of treatable biologic, genetic, and environmental factors.
Inform patient and significant other about the holistic nature of anxiety, which produces physical, emotional, cognitive, social, and spiritual symptoms. Many people believe that anxiety equates with nervousness and fail to recognize the many other signs and symptoms that make this a holistic disorder.
Inform patient and significant other that anxiety disorders are treatable. Medications are usually indicated for treatment of these disorders and may include antidepressants and anxiolytics or a combination of medications. In addition, other interventions are useful, including dietary interventions (e.g., elimination of caffeinated products), breathing control, exercise program, relaxation techniques, and psychological interventions (i.e., distraction, positive self-talk, psychoeducation, exposure therapy, systematic desensitization, implosive therapy, social interventions, cognitive therapy, stress and time management interventions).
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Anxiety disorders

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