Anxiety Disorder

Definitions
Anxiety is a diffuse, vague apprehension associated with
feelings on uncertainty and helplessness. This
emotion has no specific object. It is subjectively
experienced and communicated interpersonally. It is
different from fear, which is the intellectual appraisal of
danger. Anxiety is the emotional response to that
appraisal. The capacity to be anxious is necessary for
survival, but severe levels of anxiety are incompatible
with life. Anxiety disorders are the most common
. psychiatric problems in the United States

Type
:Panic disorder without agoraphobia- 1
Recurrent unexpected panic attacks and at least
one of the attacks has been followed by a month
: (or more) of
A> Persistent concern about having additional
. attacks
B> Worry about the implications of the attack or its
.consequences, or
C> A significant change in behavior related to the
.attacks. Also the absence of agoraphobia

:Panic disorder with agoraphobia- 2

Meets the above criteria. In addition, the presence of
agoraphobia, which is anxiety about being in places or
situations from which escape might be difficult (or
embarrassing) or in which help may not be available in the
event of having an unexpected or situationally predisposed
panic attack. Agoraphobic fears typically involve
characteristics clusters of situations that include being
outside the home alone; being in a crowd or standing in a
line; being on a bridge; and traveling in a bus, train, or car.
Agoraphobic situations are avoided, or are endured with
marked distress or with anxiety about having a panic
. attack, or require the presence of a companion

Agoraphobia without history of panic- 3

:disorder
Present of agoraphobia and has never met
. criteria for panic disorder

:Specific phobia

-4

Marked and persistent fear that is excessive

or unreasonable, cued by the presence or
anticipation of a specific object or situation
(e.g., flying, heights, animals, receiving an
injection, seeing blood). Exposure to the
response. The person recognizes the fear
is excessive, and the distress or
avoidance interferes with the person's
.normal routines

: Social phobia- 5
Marked and persistent fear of one or more social or
performance situations in which the person is
exposed to unfamiliar people or to possible
scrutiny by others. The individual fears that he or
she will act in a way (or show anxiety symptoms)
that will be humiliating or embarrassing.
Exposure to the feared situation almost invariably
provokes anxiety. The person recognizes the fear
is excessive, and the distress or avoidance
. interferes with the person's normal routine

: Obsessive-compulsive disorder- 6
Either obsessions or compulsions are
recognized as excessive and interfere with
. the person's normal routine

: Posttraumatic stress disorder- 7

The person has been exposed to a traumatic event in
: which both the following occurred
A> The person experienced, or was confronted with an
event or events that involved actual or threatened
death or serious injury or a threat to the physical
. integrity of self or others
B> The person's response involved intense fear,
helplessness, or horror. The person experiences the
traumatic event, avoids stimuli associated with the
trauma, and experiences a numbing of general
. responsiveness

: Acute stress disorder- 8

Meets the above criteria for exposure to a traumatic
event, and the person experiences three of the
following symptoms: sense of detachment, reduced
awareness of surroundings, derealization,
. depersonalization, and dissociated amnesia

: Generalized anxiety disorder- 9

Excessive anxiety and worry, occurring more
days that not for at least 6 months, about a
number of events or activities. The person
finds it difficult control the worry and
experiences at least three of the following
six symptoms: restlessness or feeling keyed
up or on edge, being easily fatigued,
difficulty concentrating or mind going blank,
irritability, muscle tension, and sleep
. disturbance

:Classification of anxiety disorder

Mild anxiety: is associated with the tension of.1

daily living and makes a person alert and
increases the person's perceptual field. This
anxiety can motivate learning and produce
. growth and creativity

Moderate anxiety: allows a person to.2

focus on immediate concerns and blocks
out the periphery. It narrows the person's
perceptual field. The person thus
experiences selective inattention but can
. focus on more areas if directed to so do

Severe anxiety: greatly reduces a person's.3

perceptual field. The person tends to focus on
a specific detail and not think about anything
else. All behavior is aimed at obtaining relief.
The person needs much direction to focus on
. any other area
Panic level of anxiety: is associated with awe,.4
.dread, and terror

Risk Factors:

:Physiological responses to anxiety

Body system

Responses
Cardiovascular

Palpitations
Heart "racing"
Increased blood pressure
Faintness
Actual fainting
Decreased blood pressure
Decreases pulse rate

Respiratory

Rapid breathing
Shortness of breath
Pressure on chest
Shallow breathing
Lump in throat
Chocking sensation
Gasping

Neuromuscular

Increased reflexes
Startle reaction
Eyelid twitching
Insonia
Tremors
Figidity
Ridgeting, pacing
Strained face
Generalized weakness
Wobbly legs
Clumsy movement

Gastrointestinal

Loss of appetite
Revulsion toward food
Abdominal pain
Nausea
Heartburn
Diarrhea

Cont
Body system

Responses
Gastrointestinal

Loss of appetite
Revulsion toward food
Abdominal discomfort
Abdominal pain
Nausea
Heartburn
Diarrhea

Urinary tract

Pressure to urinate
Frequent urination
Face flushed

Skin

Localized sweating (palms0

Itching
Hot and cold spells
Face pale
Generalized sweating

Behavioral, cognitive and effective responses

System

Responses
Behavioral

Restlessness
Physical tension
Tremors
Startle reaction
Rapid speech
Lack of coordination
Accident proneness
Interpersonal withdrawal
Inhibition
Flight
Avoidance
Hyperventilation
Hypervigilance

Cognitive

Impaired attention
Poor concentration
Forgetfulness
Errors in judgment

Behavioral, cognitive and effective responses to anxiety

System

Responses
Cognitive (continued)

Preoccupation
Blocking of thoughts
Decreased perceptual field
Reduced creativity
Diminished productivity
Confusion
Hypervigilence
Self-consciousness
Loss of objectivity
Fear of losing control
Freighting visual images
Fear of injury or death
Flashbacks
Nightmares

Affective

Edginess
Impatience
Uneasiness
Tension
Nervousness
Fearfulness
Alarm
Terror
Jitteriness
Jumpiness
Numbness
Guilt
Shame

:Nursing Care Plan

:Nursing Diagnosis
Sarah, a 47-year old woman, presented to the
employee health department of a teaching
hospital after walking there from her office. She
was complaining of chest pain and shortness of
breath. Sarah's medical history included
psoriasisl. Her vital signs were remarkable for a
pulse of 116; her electrocardiogram and
laboratory work were within normal limits. Sarah
mentioned to the staff that her son had died 3
. months ago

During her evaluation Sarah and the nurse

explored her symptoms of anxiety and
depression, the exacerbation of her psoriasis,
and her chronic headaches, which had become
worse since her son's death. In addition to
concern about financial matters and her son's
alcoholism, she now worried frequently about
her performance at work. The nurse
recommended a medication trial. Sarah refused
because of her fears of addition and loss of
. control

Anxiety related to change in role functioning,

recent loss of son (dysfunctional grieving)
threat to socioeconomic status, and stressors
exceeding ability to cope, as evidenced by
uncertainty, intermittent sympathetic nervous
system stimulation, restlessness, and
. exacerbation of medial condition (psoriasis)

Client outcomes

Nursing interventions

Evaluation

Sarah will identify common

situations that provoke anxiety.

Assign "homework" to client (e.g.,

keeping a panic attack and headache
diary). Documenting anxiety
responses helps client link symptoms
with precipitating events.

Sarah identifies returning home after

work as a critical time for symptoms to
develop. She reports that she visits her
mother or does errands daily.

Sarah will describe early

warning symptoms of anxiety.

Assist Sarah in associating her panic

attach symptoms with thoughts about
separation from her husband. This
will help illustrate to Sarah specific
situations in her life that result in
panic anxiety.

Sarah reports that she does not

experience headaches when her husband
is traveling.

Sarah will report willingness to

tolerate mild to moderate levels
of anxiety.

In weekly sessions, explore with Sarah

the advantages and disadvantages of
separation and divorce. These
discussions will help Sarah problem
solve viable options that may offer
some control over her anxiety.

Sarah reveals unwillingness to live alone.

Sarah will demonstrate

adaptive coping mechanisms.

During weekly sessions discuss options

that will allow Sarah maximum
control over her choices. Increased
choices over life situations tend to
minimize anxiety response to some
degree.

Sarah informs her husband that she

wants a trial separation. The husband
moves into their son's former room.

: Nursing Interventions
A> Assess own level of anxiety and make a conscious
effort to remain calm. Anxiety is readily transferable from
. one person to another
B> Recognize the client's use of relief behaviors (pacing,
wringing of hands) as indicators of anxiety. Early
interventions help to manage anxiety before symptoms
. escalate to more serious levels
C> Inform the client of the importance of limiting caffeine,
nicotine, and other central nervous system stimulants.
Limiting these substances, prevents/ minimizes physical
symptoms of anxiety such as rapid heart rate and
. jitteriness

D> Teach the client to distinguish between

anxiety that can be connected to
identifiable objects of sources (illness,
prognosis, hospitalization, know stressors)
and anxiety for which there is no
immediate identifiable object of source.
Knowledge of anxiety and its related
components increase the client's control
. over the disorder

E> Instruct the client in the following anxietyreducing strategies, which help reduce anxiety in
a variety of ways and distract the client from
. focusing on the anxiety
. Progressive relaxation technique -1
Slow deep-berating exercises -2
. Focusing on a single object in the room -3
. Listening to soothing music or relaxation tapes -4
Visual imagery -5

:Medication
In recent years, there has been a growing
interest in Eastern techniques of
medication. Experimental evidence of the
efficacy of medication is still in its infancy,
but it seems to have a striking effect on
physiological functions as measured by
. oxygen composition

Tricyclics: Several studies have demonstrated that

imipramine is effective in the treatment of panic
disorder. The presumed mechanisms of action is
impipramine's apparent ability to block panic attacks.
Starting does not imipramine should be somewhat
lower than the typical starting doses prescribed in the
treatment of depression. This conservative approach
is recommended because many anxiety patients,
particularly those with panic disorder. The
relationship between plasma levels of imipramine
and the antipanic efficacy of imipramine is poorly
understood. Although imipramine has been the most
systematically studied tricyclic in the treatment of
panic disorder, an increasing number of case reports
and clinical studies suggest that other tricyclic
. antidepressants may be equally effective

:MAO inhibitors
Like tricyclic antidepressants, MAO
inhibitors appear to be quite effective in
the treatment of panic disorder. Some
investigators have suggested that MAO
inhibitors may be slightly more effective
. than imipramine

:Antihypertensive agents
There is some evidence to suggest that blockers possess anxiolytic properties.
Clinical experience, however, suggests
that -blockers may be less effective in the
treatment of panic disorder than tricyclic
. antidepressants

:Benzodiazepines
Many investigators have suggested that
benzodiazepines are effective in the treatment of
generalized anxiety but fail to prevent panic
attacks. Recent research ahs cast doubt on this
popular but unsubstantiated notion. Despite the
ongoing controversy regarding this issue, many
patients with panic disorder achieve inadequate
relief with low to moderate doses of traditional
benzodiazepines. Emerging data suggest that this
relative lack of response to many benzodiazepines
may be related to issues of potency. Consistent
with this concept, two high-potency
benzodiazepines and clonazepam have been
found to be effective in the treatment of panic
. disorder