I. Anxiety
- Anxiety is a normal response to stress
- It is a subjective experience that includes feelings of apprehension, uneasiness, uncertainty, or dread
- Anxiety occurs because of a threat that may be misperceived or misinterpreted or of a threat to identity or self-esteem.
- Anxiety may result when values are threatened or preceding new experiences
II. Anxiety as a Response to Stress
Stress is viewed as a nonspecific body response to any demand
General adaptation syndrome: an automatic physical reaction to stress mediated by the sympathetic nervous system; has three distinct stages — alarm, resistance, and exhaustion
1. Alarm is the initial response to a stressor
- As a result of hormonal activity, generalized physical arousal develops and physical and psychological defenses are mobilized
- The "fight-or-flight" reaction, an automatic psychological state of high anxiety mediated by the sympathetic nervous system, occurs
- Increased alertness is focused on the immediate task or threat
- The level of anxiety is mild to moderate
2. Resistance occurs when the body mobilizes resources to combat stress
- The body stabilizes and adapts to stress, but functions below optimal level
- Used of Coping and Defense Mechanism
- Coping mechanisms- efforts to manage specific demands that are appraised as threatening
- Defense mechanisms - unconscious psychological responses designed to diminish or delay anxiety and protect the person
- Psychosomatic symptoms begin to develop
- The level of anxiety is moderate to severe
3. Exhaustion occurs when adaptational resources are depleted
- Results from inability to cope with overwhelming or long-lasting stress
- Thinking becomes disorganized and illogical
- The person may experience sensory misperceptions, delusions, hallucinations, and/or reduced orientation to reality
- The level of anxiety is severe to panic
III. Levels of anxiety
- Mild
- associated with the tension of everyday life
- The individual is alert
- The perceptual field is increased
- can be motivating, produce growth, enhance creativity, and increase learning.
- Moderate
- The focus is on immediate concerns.
- narrows the perceptual field.
- Selective inattentiveness occurs.
- Learning and problem solving still occur.
- Severe
- a feeling that something bad is about to happen.
- A significant narrowing in the perceptual field occurs.
- Focus is on minute or scattered details.
- All behavior is aimed at relieving the anxiety.
- Learning and problem solving are impossible.
- The individual needs direction to focus.
- Panic
- associated with dread and terror and a sense of impending doom.
- The personality is disorganized.
- The individual is unable to communicate or function effectively.
- Increased motor activity occurs.
- Loss of rational thoughts with distorted perception occurs.
- Inability to concentrate occurs.
- If prolonged, panic can lead to exhaustion and death.
IV. Etiology
A. Biological factors
- Anxiety results from improper functioning of the body systems involved in the normal stress response
- Predisposition to the development of anxiety appears to be partially related to genetic factors
- Hyperactivity of the autonomic nervous system is associated with anxiety
- Several neurotransmitters have been associated with anxiety
- A low level of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits the reactivity of neurons, is associated with anxiety
- High levels of Norepinephrine. Norepinephrine is associated with the "fight-or-flight" reaction.
- Panic attacks, sudden episodes of symptoms such as dizziness, dyspnea, tachycardia, palpitations, and feelings of impending doom and death (high levels of Norepinephrine)
- High levels of serotonin - Obsessive-compulsive disorder
V. Management of Anxiety Disorders
PRIORITY NURSING ACTIONS
A. Actions to Take for a Client Experiencing Anxiety
- Provide a calm environment, decrease environmental stimuli, and stay with the client.
- Ask the client to identify what and how he or she feels.
- Encourage the client to describe and discuss his or her feelings.
- Help the client to identify the causes of the feelings if he or she is having difficulty doing so.
- Listen to the client for expressions of helplessness and hopelessness.
- Document the event, significant information, actions taken and follow-up actions, and the client’s response.
B. General nursing measures
Interventions: Mild to moderate levels
- Help the client identify the anxiety.
- Encourage the client to talk about feelings and concerns.
- Help the client identify thoughts and feelings that occurred before the onset of anxiety.
- Encourage problem solving.
- Encourage gross motor exercise.
Interventions: Severe to panic levels
- Reduce the anxiety quickly.
- Use a calm manner.
- Always remain with the client.
- Minimize environmental stimuli.
- Provide clear, simple statements.
- Use a low-pitched voice.
- Attend to the physical needs of the client.
- Provide gross motor activity.
- Administer antianxiety medications as prescribed.
C. Psychopharmacology
ANTI-ANXIETY OR ANXIOLYTIC MEDICATIONS
- Antianxiety medications depress the CNS, increasing the effects of GABA, which produces relaxation and may depress the limbic system.
- Benzodiazepines
- the most commonly used and most effective medications for treatment of the symptoms of anxiety
- have anxiety-reducing (anxiolytic), sedative-hypnotic, muscle-relaxing, and anti-convulsant actions
- are contraindicated in clients with acute narrow-angle glaucoma and should be used cautiously in children and older adults
- interact with other CNS medications, producing an additive effect.
- Abrupt withdrawal of benzodiazepines can be potentially life-threatening, and withdrawal should occur only under medical supervision.
Side effects:
- Daytime sedation
- Ataxia
- Dizziness
- Headaches
- Blurred or double vision
- Hypotension
- Tremor
- Amnesia
- Slurred speech
- Urinary incontinence
- Constipation
- Paradoxical CNS excitement
- Lethargy
- Behavioral change
Acute toxicity
- Somnolence
- Confusion
- Diminished reflexes and coma
- Flumazenil (Romazicon), a benzodiazepine antagonist administered intravenously, reverses benzodiazepine intoxication in 5 minutes.
- A client being treated for an overdose of a benzodiazepine may experience agitation, restlessness, discomfort, and anxiety.
Nursing Responsibilities (Benzodiazepine)
- Monitor for motor responses such as agitation, trembling, and tension.
- Monitor for autonomic responses such as cold clammy hands and sweating.
- Monitor for paradoxical CNS excitement during early therapy, particularly in older adults and debilitated clients.
- Monitor for visual disturbances because the medications can worsen glaucoma.
- Monitor liver and renal function test results and complete blood cell counts.
- Reduce the medication dose as prescribed for the older adult client and for the client with impaired liver function.
- Initiate safety precautions because the older adult client is at risk for falling when taking the medication for sleep or anxiety.
- Assist with ambulation if drowsiness or lightheadedness occurs.
- Instruct the client that drowsiness usually disappears during continued therapy.
- Instruct the client to avoid tasks that require alertness until the response to the medication is established.
- Instruct the client to avoid alcohol.
- Instruct the client not to take other medications without consulting the physician.
- Instruct the client not to stop the medication abruptly (can result in seizure activity).
Withdrawal
- To lessen withdrawal symptoms, the dosage of a benzodiazepine should be tapered gradually over 2 to 6 weeks.
- Abrupt or too rapid withdrawal results in the following:
- Restlessness
- Irritability
- Insomnia
- Hand tremors
- Abdominal or muscle cramps
- Sweating
- Vomiting
- Seizures
2. Non-benzodiazepine: Buspirone (Buspar) is a serotonin and dopamine antagonist used in the short-term treatment of anxiety
- Buspirone is well-absorbed orally
- It generally takes 2 to 3 weeks for the anti-anxiety effects to become apparent and 4 to 6 weeks or longer for the drug to become fully effective
- Side effects of buspirone rarely occur
Common side effects include dizziness, drowsiness, headache, nausea, nervousness, light-headedness, and excitement
- Side effects generally decrease over time as the body adapts to the medication
- not habit forming and does not potentiate the depressant effects of alcohol, barbiturates, and other central nervous system (CNS) depressants
- Due to its short half-life, buspirone must be administered three times daily
- Because buspirone does not induce an immediate calming effect it shouldn’t be used as a prn medication for anxiety
- Withdrawal symptoms do not occur when the drug is discontinued
3. Beta blockers: have a calming effect on the CNS
- are effective in treatment of physical symptoms of anxiety, such as tremors and tachycardia
VI. Specific Disorders
- Generalized Anxiety Disorder
- unrealistic anxiety about everyday worries that persists over time and is not associated with another psychiatric or medical disorder.
- Physical symptoms occur.
Assessment
- Restlessness and inability to relax
- Episodes of trembling and shakiness
- Chronic muscular tension
- Dizziness
- Inability to concentrate
- Chronic fatigue and sleep problems
- Inability to recognize the connection between the anxiety and physical symptoms
- Client is focused on the physical discomfort.
!!! Nurses should encourage clients with generalized anxiety disorder to rethink their perceptions of the stressor, recognize that some anxiety is a normal part of life, and learn new coping mechanisms
2. Panic disorder
- produces a sudden onset of feelings of intense apprehension and dread.
- The cause usually cannot be identified.
- Severe, recurrent, intermittent anxiety attacks lasting 5 to 30 minutes occur.
Assessment
- Choking sensation
- Labored breathing
- Pounding heart
- Chest pain
- Dizziness
- Nausea
- Blurred vision
- Numbness or tingling of the extremities
- Sense of unreality and helplessness
- Fear of being trapped
- Fear of dying
Interventions
- Remain with the client.
- Attend to physical symptoms.
- Assist the client to identify the thoughts that aroused the anxiety and identify the basis for these thoughts.
- Assist the client to change the unrealistic thoughts to more realistic thoughts.
- Use cognitive restructuring to replace distorted thinking.
- Administer anti-anxiety medications if prescribed.
3. Post-traumatic Stress Disorder
- After experiencing a psychologically traumatic event, the individual is prone to re-experience the event and have recurrent and intrusive dreams or flashbacks.
Stressors:
- Natural disaster
- Terrorist attack
- Combat experiences
- Accidents
- Rape
- Crime or violence
- Sexual, physical, and emotional abuse
- Re-experiencing the event as flashbacks
Assessment
- Emotional numbness
- Detachment
- Depression
- Anxiety
- Sleep disturbances and nightmares
- Flashbacks of event
- Hypervigilance
- Guilt about surviving the event
- Poor concentration and avoidance of activities that trigger the memory of the event
Interventions for Posttraumatic Stress Disorder
- Be nonjudgmental and supportive.
- Assure client that his or her feelings and behaviors are normal reactions.
- Assist client to recognize the association between his or her feelings and behaviors and the trauma experience.
- Encourage client to express his or her feelings; provide individual therapy that addresses loss of control or anger issues.
- Assist client to develop adaptive coping mechanisms and to use relaxation techniques.
- Encourage use of support groups
- Facilitate a progressive review of the trauma experience.
- Encourage client to establish and re-establish relationships.
- Inform client that hypnotherapy or systematic desensitization may be used as a form of treatment.
4. Phobias
- Irrational fear of an object or situation that persists, although the person may recognize it as unreasonable
- Associated with panic level anxiety if the object, situation, or activity cannot be avoided
- Defense mechanisms commonly used include repression and displacement.
Types
Interventions
- Identify the basis of the anxiety.
- Allow the client to verbalize feelings about the anxiety-producing object or situation; frequently talking about the feared object is the first step in the desensitization process.
- Teach relaxation techniques, such as breathing exercises, muscle relaxation exercises, and visualization of pleasant situations.
- Promote desensitization by gradually introducing the individual to the feared object or situation in small doses.
- Always stay with the client experiencing anxiety to promote safety and security.
- Never force the client to have contact with the phobic object or situation.
5. Obsessive-Compulsive Disorder
Obsessions: Preoccupation with persistently intrusive thoughts and ideas
Compulsions: The performance of rituals or repetitive behaviors designed to prevent some event, divert unacceptable thoughts, and decrease anxiety.
- Obsessions and compulsions often occur together and can disrupt normal daily activities.
- Anxiety occurs when one resists obsessions or compulsions and from being powerless to resist the thoughts or rituals.
- Obsessive thoughts can involve issues of violence, aggression, sexual behavior, orderliness, or religion and uncontrollably can interrupt conscious thoughts and the ability to function.
Compulsive behavior patterns (behaviors or rituals)
- Compulsive behavior patterns decrease the anxiety.
- The patterns are associated with the obsessive thoughts.
- The patterns neutralize the thought.
- During stressful times, the ritualistic behavior increases.
- Defense mechanisms include repression, displacement, and undoing.
Interventions for Obsessive-Compulsive Disorder
- Ensure that basic needs (food, rest, grooming) are met
- Identify situations that precipitate compulsive behavior; encourage client to verbalize concerns and feelings.
- Be empathetic toward client and aware of his or her need to perform the compulsive behavior
- Do not interrupt compulsive behaviors unless they jeopardize the safety of client or others (provide for client safety related to the behavior).
- Allow time for client to perform the compulsive behavior, but set limits on behaviors that may interfere with client’s physical well-being to protect client from physical harm.
- Implement a schedule for client that distracts from the behaviors (structure simple activities, games, or tasks for client).
- Establish a written contract that assists client to decrease the frequency of compulsive behaviors gradually.
- Recognize and reinforce positive non-ritualistic behaviors
