Transcript Anxiety
Anxiety Elisa A. Mancuso RNC, MS, FNS Professor Most common mental health problem – 25 % adults Women>men Age <45 – ↑ Divorced/separated – Lower socioeconomic status Vague apprehension and feelings of uncertainty & helplessness Subjective emotional response to a stressor – State of tension, or impending doom Necessary force for survival Mild → Moderate → Severe → Panic Physiologic Responses Hormones & Neurotransmitters “Fight or Flight Response” Depends on degree & duration of anxiety – ↑ Epinephrine (E) – ↑ Norepinphrine (NE) – ↑ Cortisone – ↑ Serotonin (5-HT) – ↓ GABA ↑ HR & ↑ SV =↑ CO ↑ BP ↑ RR & depth = SOB Physiologic Responses Generalized Responses – Restlessness – Irritability – Fainting – Palpitations – ↑ Diaphoresis – ↑ Urination –↑N&V – ↓ Libido Hyperreflexia Impatience Chest Pressure Headache ↑ Muscle tension Gluconeogenesis Dry Mouth Sexual Dysfunction Cognitive Responses Mild (+) – ↑ Sensory awareness ↑ Learning – ↑ Concentration = Optimal Functioning Moderate (++) – ↓ Perceptual field Impaired attention – ↓ Concentration & Problem Solving Severe (+++) – Limited Perceptual field – Disorganized processing Panic (++++) – – – – Closed perceptual field ↓ Contact with reality Impaired thinking/function Unable to process stimuli Selective inattention Time distorted Behavioral Responses Mild (+) – Learn new skills – ↑ Startle reaction Moderate (++) – ↑ Competitive activity – Frequent topic ▲s – Focus on immediate events Alert & Confident ↑ Speech & Coping Skills ▲ Body position frequently ↑ Defense mechanisms Severe (+++) – ↑ Feeling of threat & tremors “Overload” – ↓ Coordination Neurosis Panic (++++) – – – – Total loss of control Cling to source of safety Helplessness Psychosis May strike physically or withdraw Completely disorganized Anxiety Disorders A group of symptoms & impaired reality testing. Panic Disorder – Sudden onset – Multiple attacks – Intense & escalating apprehension – Poor judgment, confused & disoriented – Feelings of impending doom – Fears losing control or going insane – Lasts 15-30 minutes or (rarely) hours Panic Disorder Intense Physical discomfort – Palpitations Chest pain ↑HR – Dyspnea Choking/Smothering SOB Hyperventilation ↑ RR Dizziness – Diaphoresis Chills/Hot flashes – Tremors & Shaking – GI distress Nausea Diarrhea – Fear of dying and/or going crazy – Depersonalization Nursing Interventions Stay with Pt and remain calm – Assess own level of anxiety Ensure safety and reassure Pt Pt take slow, deep breaths Quiet environment – Focus on a single object in the room Speak in short, simple sentences – Low, calm and soothing voice Encourage verbalization of concerns, feelings and symptoms – Identify precipitating event Sort term use of anxiolytics Generalized Anxiety Disorder Chronic unrealistic and excessive worry – Regarding several events the Pt can’t control Symptoms last > 6 months Impaired social & occupational functioning – Interferes with daily life Symptoms – Autonomic Hyperactivity Jumpiness, tremors, ↑ muscle tension ↑ HR ↑ RR – – – – Feeling on edge Restlessness ↓ Concentration Easily fatigued Hypervigilence Irritability “Mind going blank” Obsessive-Compulsive Disorder Recurrent obsessions & compulsions ↑↑ Time consuming Gradual conditioned response RT traumatic event Obsessions – Unwanted intrusive, persistent images or impulses – Recurrent thoughts of violence, contamination, doubt or need for specific order. Compulsions – Ritualized acts of behavior to neutralize/control obsessions Touching Washing hands Rearranging Counting Opening & Closing Checking – Pt aware behavior is excessive, yet continues to engage to seek relief and ↓ anxiety/tension – Interferes with usual routine Defense Mechanism – Undoing – Displacement OCD Nursing Interventions Initiate conversation as ritual is performed Allow behavior but set limits Identify behavioral cues of ↑ anxiety Present distracting stimulus @ ↑ frequency Substitute socially acceptable behavior Phobias Persistent or irrational fear of specific object, activity or situation that causes avoidance. Exposure to stimulus = immediate anxiety response. – Blushing, Vomiting, Humiliation, Tremors, ↑HR ↑BP ↑RR Agoraphobia – Fear of being alone in public place. No escape Social Phobia – Fear of appearing embarrassed or evaluated negatively by others. Simple Phobia (Specific object or situation) – Acrophobia = Fear of heights – Claustrophobia = Fear of closed in places – Mysophobia = Fear of dirt, germs Nursing Interventions – 1st accept Pt’s fear as real – Relaxation techniques – Behavior Modification – Desensitization Post Traumatic Stress Disorder Extreme stressor and threat to physical integrity. Characteristic symptoms after exposure to traumatic life experience – 9-11, war, earthquakes, airplane crash Symptoms – Re-experiencing event (Flashback) – Avoidance of thoughts, emotions or conversations – Sustained ↑ Anxiety – Angry Outbursts – Hypervigilence Nightmares Sleep Disturbances – Survivor Guilt Depression Substance Abuse – Psychic Numbing Feel detached from others PTSD Nursing Interventions – ↓ Environmental Stimuli – Reorient to reality – Reassure Pt is safe – Encourage verbalization of event and feelings – Facilitate grief process – Adaptive coping techniques – Anxiolytic meds during flashback Somatoform Disorders Physical symptoms without any organic pathology Women> men Onset before age 30 Somatization – Anxiety transformed into physical illness – No labs, diagnostic tests support DX – Chronic course without structural ▲s Conversion Disorder-Hysteria Loss or alteration in physical functioning – Voluntary motor/sensory Abrupt onset after a psychological conflict Symptom – Impaired sense (blind/deaf) or paralysis – “La belle indifference” Pt demonstrates no concern for symptoms Defense Mechanism – Repression Conversion Disorder-Hysteria Primary Gain – Relief via repressing conflict – Anxiety converted to symptoms Secondary Gain – Sympathy, support, ↑↑ attention – avoid activities & responsibilities Nursing Interventions – Focus on ↑↑ anxiety, NOT symptoms – Encourage verbalization Identify conflicts ↓↓ stress & ↑↑ relaxation – Alternative coping skills Hypochondriasis Unrealistic preoccupation/fear of having or getting a serious illness – Specific organ, bodily function or minor alteration Misinterpretation of symptoms – Cough = Lung CA – HA = Brain tumor Symptoms – C/O Multiple symptoms & Persist > 6 months – Dr. Shopping – Demand diagnostic testing & invasive procedures Nursing Interventions – Review objective data, symptoms & interpretation – Set limits on “whining” – ↑ Self-worth and resolve internal anger Dissociative Disorders Severe precipitating stressor. Splitting off an idea or emotion from one’s consciousness. Psychological flight from anxiety Psychogenic Amnesia – Sudden inability to recall important extensive personal information. Psychogenic Fugue – Sudden unexpected travel away from home or usual workplace – Begin new job, relationships (Unaware of true life) – Assumes new identity – Escapes from overwhelming stress or rejection Dissociative Disorders Multiple Personality Disorder – Dissociative Identity Disorder (DID) – Existence of 2 or more distinct personalities within an individual. – Transition from 1 to another personality Sudden & dramatic Precipitated by stress – One personality is dominant – Usually RT sexual child abuse. Dissociative Disorders Depersonalization Disorder – Change in quality of self-awareness – Feelings of unreality, ▲s in body image. – Detachment Sense of observing oneself (from outside of body) Not in touch with body No somatic sensations Anxiety Nursing Interventions # 1 is Patient safety! Remain with Pt & provide support Deep breathing – Controlled slow – Deep & regular abdominal breathing. Progressive muscle relaxation Guided imagery – Visualize favorite place – Embrace scenes, sounds, aromas, textures. Distraction – Music, card games, reading Anxiety Nursing Interventions Journals – ↑↑ Self awareness – Make entries when calm & anxious qd Identify anxiety cues & behavior responses Self-Help Skills – + Coping techniques – Assertiveness Role playing Problem solving Set limits on inappropriate behavior Social Skills Group – ↑ Socialization = ↓Self absorption Daily Schedule Planning – ↑ Autonomy Support System – Family, friends, neighbors, pets Anxiety Nursing Interventions Cognitive–Behavioral Therapy – Positive Reframing Turn negative messages into positive ones. – Decatastrophizing A more realistic appraisal of situation – Assertiveness Training Learn to negotiate interpersonal situations Anxiolytics Anti-Anxiety Meds Used short term basis < 1 month Symptomatic relief only Potentiates GABA = ↓↓ CNS Caution – Do not use ETOH or meds that ↑ CNS – Do not stop med abruptly = Severe Withdrawal CNS agitation ↓BP ↑Temp & Fatal Gran Mal seizures! – Takes 7-10 days for steady effect – Elderly have ↓ hepatic & ↓renal function ↑↑ risk for toxic effect Anxiolytics Anti-Anxiety Meds Benzodiazepines Alprazolam (Xanax) Lorazepam (Ativan) Chlordiazepoxide (Librium) Diazepam (Valium) Clonazepam (Klonopin) Clorazepate (Tranxene) – ↑ Risk for physical dependence & tolerance – Lipophilic & cross blood-brain barrier Side effects – Drowsiness – ↓ Concentration – Clouded Sensorium Sedation Impaired memory Anxiolytics Anti-Anxiety Meds Azaspirodecanediones Buspirone (Buspar) 5-HT receptor antagonist Takes 2-4 weeks to be effective ↓ potential for abuse Propanediols Meprobamate (Equanil/Miltown) ↓ Thalamus & Limbic system response Sedating Antihistamines Hydroxyzine (Vistaril/Atarax) CNS depressant effect Anxiolytics Anti-Anxiety Meds Selective Serotonin Reuptake Inhibitors (SSRIs) Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac/ Serafem Puvules-weekly) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Only prevents 5-HT reuptake ↑↑ 5-HT available = ↑ regulation of emotions, wakefulness No other neurotransmitters affected ↓↓ E & NE Side effects Anxiety Agitation Nausea Insomnia Sexual Dysfunction Akathisia (Use Propanolol) Anxiolytics Anti-Anxiety Meds Side Effects Anticholinergic: – Daytime sedation, Drowsiness, Dry mouth, – HA, Lethargy, Ataxia, Blurred vision, N & V Tolerance, physical & psychological dependence Potentiates other CNS depressants Orthostatic Hypotension Blood Dyscrasias Abrupt Withdrawal Syndrome – Flumazenil (Romazicon) – Benzodiazepam antagonist Reverse CNS effects Must gradually taper down Defense Mechanisms Protect the ego & cope with anxiety unconsciously Denial – Refuse to acknowledge the problem – Substance abuse Regression – Return to an earlier level of development – Holding teddy bear Displacement (3 way) – Transfer feelings from 1 person, object or situation to less threatening person – Angry @ boss → yell @ kids or kick the dog Reaction-Formation – Prevent unacceptable thoughts/behaviors from being expressed by developing opposite thoughts/behaviors – Unwanted pregnancy → New mom overprotective of baby Defense Mechanisms Projection (2 way) – Unacceptable feelings/impulses are attributed to another person – I’m needy but claim my husband is demanding Repression – Involuntary blocking of unpleasant feelings and experiences – No memory of sexual abuse as a child Suppression – Conscious voluntary denial of unpleasant feelings and experiences – Put away NCP & focus on studying for exam Identification – ↑ Self worth by acquiring certain attributes & characteristics of an admitted individual – Gang members Defense Mechanisms Rationalization – Attempting to form logical reasons to justify unacceptable feelings – “Not getting accepted to Harvard I didn’t want to leave home” Sublimation – Substituting constructive/socially acceptable activity for inappropriate impulses. – Aggressive person becomes hockey player Compensation – Covering up a real or perceived weakness by emphasizing/excelling in another area – Poor in sports → Excell in chess Conversion – Unconsciously transforming anxiety into a physical symptom – Paralysis/Blind Undoing – Symbolically negate or cancel out a previous intolerable action – Man has an affair then buys his wife a new car.