Transcript medications for anxiety - Austin Community College

ANXIETY DISORDERS
WHAT IS ANXIETY?
 SUBJECTIVE EXPERIENCE OF
DISCOMFORT IN RESPONSE TO AN
ACTUAL OR PERCEIVED THREAT OR
LOSS (“STRESSOR”)
 THREAT MAY BE EXTERNAL OR
INTERNAL
 ANXIETY MAY PERSIST EVEN
AFTER THREAT IS GONE
WHAT IS ANXIETY, cont’d
 PERCEPTION OF THREAT
DEPENDS ON THE INDIVIDUAL
 SOMATIC COMPONENT:
AUTONOMIC (SYMPATHETIC)
NERVOUS SYSTEM ACTIVATION
Acute Stress: Activation of the
Hypothalamic-Pituitary-Adrenal Axis

Release of endogenous opiates
Increased TSH
Release of dopamine and serotonin
Physiology of Anxiety: Activation of Sympathetic N.S.
Somatic Symptoms:
Dry mouth
Palpitations, chest tightness
or chest pain
Tachypnea,
breathlessness
Nausea, constipation
or diarrhea
 Energy
Muscle tension,
restlessness
Urinary retention,
or incontinence
Levels of Anxiety

Mild (Stage 1)

Moderate (Stage 2)

Severe (Stage 3)

Panic (Stage 4)
Mild Anxiety
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Increased alertness
Broad field of perception
Enhances learning and performance
Moderate Anxiety
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Perceptual field narrows
Tunes out stimuli
Focused on one task
Decreased attention span
 Problem solving ability
Severe Anxiety
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Narrow or distorted
perception and cognition
Flight of ideas
Physical symptoms
problematic
Behavior directed toward
relief of discomfort
Panic
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Disorganized and irrational
Overwhelmed, out of control
May become violent,
hysterical, or immobilized
“Fight, Flight or Freeze”
Nursing Interventions
for Anxiety: Some Guidelines
Table 9-1: Interventions for Levels of Anxiety, p. 87
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Assess level of anxiety via objective, subjective
data
Assess client’s coping methods and
effectiveness
Planning: can source of client’s stress/anxiety
be managed or not?
Client teaching:
 will not be effective if anxiety is severe or
panic level
 OK for moderate anxiety if it is simple and
step-by-step
ANXIETY DISORDERS
 WHEN ANXIETY INTERFERES WITH
FUNCTIONING AND SELF-CARE
 MOST ARE CHRONIC, BUT MAY BE
IN RESPONSE TO ACUTE
SITUATION
 CHALLENGING TO TREAT/MANAGE
ANXIETY DISORDERS
NIMH 2009:
• Anxiety disorders more prevalent than
mood disorders (40 million)
• 18.1% of US population over age 17
• First episode by age 21.5
• Co-occurrence with depression and
substance abuse
• Common to have more than one
anxiety disorder
UNDERSTANDING ANXIETY:
Primary Gain

Behaviors directed toward relief of the
anxiety, e.g.
 Excessive activities and tasks
 Avoiding the thing(s) that cause the
anxiety
 Using medications to relieve
physiologic discomfort
 Using mood altering substances
UNDERSTANDING ANXIETY:
Secondary Gain

Refers to attention or benefit
the person gets from the illness
Can become more important
than relieving the anxiety
 Decreases motivation to get well
 Others take care of individual
 Complicates treatment

Axis 1 Anxiety Disorders
Generalized Anxiety Disorder (GAD)
Panic Disorder
with Agoraphobia
without Agoraphobia
Obsessive-Compulsive Disorder (OCD)
Phobias
Somatoform Disorders
Acute and Post-Traumatic
Stress Disorders and
Dissociative Disorders
Not in this Module: Will be
covered with Violence, Abuse
and Trauma - Module 8
Etiology/Theories of Anxiety
Disorders

Biological Theories

Defects in Brain Chemistry-Person over-responds to
stimuli
 Neurotransmitter
dysregulation
 Altered # of
benzodiazepine receptors
Genetic Theory

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Some disorders clearly run in families:
e.g. panic, OCD
Inherited trait for shyness has been
discovered
Psychoanalytic/
Psychodynamic Theories

Result of conflict between
instincts and values

Use of Defense Mechanisms
to deal with anxiety:
 Repression
 Displacement
 Conversion
Interpersonal Theory

Anxiety is caused by
threat to self-esteem,
security or self-control
Generalized Anxiety
Disorder (GAD)
Most common type
 Cognitive and physical symptoms
 Chronic and excessive worry ( > 6 months)
 Worry is habitual, cannot be controlled
 Causes impairment

http://www.youtube.com/watch?v=U6QuNjlHsHw&feature=related
Interventions for GAD
Goal: to assist the client to develop adaptive
coping responses
 Assess for level of anxiety = moderate to severe
 Reduce level of anxiety
 Identify and describe feelings
 Assist to identify causes of feelings
Milieu Management for GAD
Calm environment
 Cognitive Behavioral Therapy (CBT)
 Corrects faulty assumptions
 If you change, others will change
 Recreational activities
 Relaxation
 Groups: assertiveness, expressive arts,
etc.
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Panic Disorder

Recurring, sudden,
intense feelings of
 Apprehension
 Terror
 Impending doom
 Losing control
 Going crazy

Somatic Symptoms
Heart Attack
 Dying

Recurrent
 May or may not be
situational
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If situational, will avoid
places or situations
that trigger symptoms
Peaks within 10
minutes
Panic DO
http://www.freefuninaustin.com/2011/09/half-price-texas-jumping-beans.ht
Scenario: Situational Panic
An office worker experienced episodes of
dizziness, nausea and a fear of losing
emotional control in front of his boss and
co-workers whenever the whole staff was
together. He started calling in sick or
skipping staff meetings.
Panic Disorder: Complications

Over time, the fear of situational panic
attacks may cause the person to severely
restrict activities  agoraphobia
Scenario, cont’d: Panic Disorder
with Agoraphobia
The office worker was fired for missing too
much work. He had difficulty finding a new
job, because he would often become
panicked when on an interview. Eventually
he stopped going out to interviews at all.
“I never know when I’ll have an attack and it
is easier to just not put myself through that.”
Etiology of Panic Disorder

Psychological
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Life stresses
 Separation and disruption of attachment in
childhood
Biological
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Heredity
Hyperactivity of Interaction of Cognitive-Sympathetic NS--Endocrine Systems
 Catastrophic thinking (“what if”) triggers
the physiological response
Panic Disorder:
Interaction of Cognitive–ANS–HPA Axis
Nurse-Client Relationship and
Milieu Management: Acute Phase of
Panic Disorder
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Communication: Similar to panic level anxiety,
stay with them, reassure that they are safe
Calm environment,  stimulation
Assess for suicidal ideation: 1 in 5 are suicidal
Use touch carefully
PRN Medications: alprazolam/Xanax,
lorazepam/Ativan
Nurse-Client Relationship
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Client teaching: improvement
often follows
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You are not crazy
Recognize and address triggers
Recognize symptoms
Meds. can help
When is the best time to teach these clients?
Milieu
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Relaxation Exercises
 Stretching
 Yoga
 Soft music
Gross motor activities
 Walking
 Jogging
 Basketball
Outpatient Tx
 Cognitive
Restructuring
Reinterpreting beliefs
Meeting fears
Giving options
Panic Disorder: Medications
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Serotonin Reuptake Inhibitors
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Long-Term treatment
Calcium channel blockers and beta
adrenergic blockers: reduce ANS
symptoms
Benzodiazepines

Immediate effects
Obsessive-Compulsive Disorder
(OCD)

Obsessions
Recurrent and persistent thoughts,
ideas, impulses
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Compulsions
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Repetitive behaviors
 Performed in a particular manner (ritual)
 Response to obsession
 Prevent discomfort
 “Neutralize” anxiety
OCD
http://www.youtube.com/watch?v=44DCWslbsNM&feature=related
http://www.youtube.com/watch?v=Rn1OYlYzgm8&feature=related
OCD: Associated Signs and
Symptoms
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Depression, low self-esteem
Increased anxiety when resist their compulsions
Strong need to control
Rituals interfere with normal routines and
relationships
Magical thinking
 Beliefs that thinking equals doing
OCD
Nurse-Client Relationship
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Assist to meet basic needs
Allow structured time to perform rituals
Explain expectations
Identify feelings--connect to behaviors
Introduce new activities slowly
Reinforce and recognize positives
Milieu
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Relaxation Exercises
Stress management
Recreational and
Social skills
Outpatient
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CBT and ThoughtStopping
OCD: Medications
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Antidepressants
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Tricyclic Antidepresants
 clomipramine (Anafranil)
SSRIs
 fluoxetine (Prozac)
 paroxetine (Paxil)
Phobias/DSM IV
Marked and specific fear that is excessive
and unreasonable, cued by the presence
or anticipation of object.
 Person recognizes fear as unreasonable
 Situation or object is avoided

Phobias-Continued
Agoraphobia without Panic
Disorder: a fear of being in public places
 Social Phobia: e.g. fear of being humiliated

in public, fear of stumbling while dancing,
choking while eating, etc.
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Specific phobia: fear of a specific object
or situation; animals, heights, flying
etc.
Comparison of Panic Disorder
and Specific Phobia
The office worker who
often experiences
episodes of panic when
there is heated debate
and arguing during staff
meetings
The office worker who is
terrified of being inside
enclosed spaces with
no windows
Treatment for Phobias
Outpatient is most common
 Behavior therapy:
systematic desensitizationlike Fear of Flying groups
 Nurse-client relationship and milieu
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Interventions are very similar to GAD
Medications
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No effect on avoidant behaviors
SSRIs
 Reduce anxiety and depression
Somatoform Disorders

Anxiety is relieved by developing physical
symptoms for which no known organic cause
or physiologic mechanism can be determined.
Somatization Disorder
 Pain Disorder
 Hypochondriasis
 Conversion Disorder
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Somatoform Disorders:
Overview
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Client expresses psychological conflict through
symptoms
Client is not in control of symptoms and
complaints
See general practitioners, not mental health
professionals
Repression of feelings, conflicts, and
unacceptable impulses
Denial of psychological problems
Individuals are dependent and needy
1) Somatization Disorder
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Recurrent frequent somatic complaints
for years
Complaints change over time
Onset prior to 30 years old
See many physicians
May have unnecessary surgical
procedures
Impairment
Etiology
 Chronic emotional abuse
 Unable to verbalize anger
2) Pain Disorder

Severe Pain in one or more areas
Significant distress and impairment
 Location or complaint does not
change
 “Doctor Shoppers”
 Pain may allow secondary gain
 Avoidance, e.g.
 Does not have to go to work
 Frequently use pain medication
 If has a physiologic disorder, the
amount of pain is out of proportion

3) Hypochondriasis
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Worry about having a serious illness despite
no medical evidence
Misinterpretation of bodily symptoms
Check for reassurance from doctors and
friends
4) Conversion Disorder
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Sudden onset of deficit or alteration in
voluntary motor or sensory function
Conflicts or stressors proceed symptoms
Symptoms characteristically suggest a
neurological disorder:
 Paralysis, blindness, or seizures
May show little concern or anxiety
Theory is: anxiety is “replaced” by the
physical symptom
Nurse-Client Relationship
and Management of
Somatoform Disorders
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Always rule out the physical
Show acceptance and empathy; do not
challenge or force insight
Encourage identification, appropriate expression
of emotions
Teach adaptive coping e.g. assertiveness skills
Critical Thinking
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
A soldier, who received notice of deployment to
Afghanistan, suddenly developed numbness
and weakness in both lower extremities. After a
medical admission for diagnostic testing, no
physiologic cause was found, and the client
was transferred to the mental health unit.
Critique each statement by the nurse;
suggesting any alternatives.
CRITICAL THINKING
A)
B)
C)
“The doctors have not found anything wrong with you.
You should try to get up and walk.”
“ I notice you were supposed to go overseas. Did that
upset you?”
“As part of your stay here we would like you to attend a
stress management group. You probably have some
stress you are not aware of.”
MEDICATIONS FOR
ANXIETY
BENZODIAZEPINES (BZDs)
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CNS Depressants
Compete for GABA receptors; decrease
response of excitatory neurons
Tolerance, dependence are problems
Cause dizziness, somnolence, confusion
Best for short-term use
Shorter acting BZDs PRN for episodes of
anxiety or panic: clonazepam (Klonopin)
lorazepam (Ativan)
NON-BENZODIAZEPINE
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First line agent: buspirone (BuSpar)
Binds to serotonin and dopamine receptors
No CNS depression
No abuse potential documented
May have paradoxical effects (increased
anxiety, depression, insomnia, etc.)
May not be fully effective for 3-6 weeks
May cause EPS
NON-BENZODIAZEPINES:
ANTIHISTAMINES
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Very sedating
No addiction potential
May be used long-term
Examples: diphenhydramine (Benadryl)
hydroxyzine (Vistaril)
ANTIDEPRESSANTS
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Useful in treatment of panic (with or without
agoraphobia), obsessional thinking
Low abuse potential
SSRI’s: first line drugs due to low sedation
ANTIDEPRESSANTS, CONT’D

SSRI’s and SNRI’s:
fluoxetine (Prozac)
sertraline (Zoloft)
paroxetine (Paxil)
citalopram (Celexa)
escitalopram (Lexapro)
fluvoxamine (Luvox): best for OCD

venlafaxine (Effexor)
duloxetine (Cymbalta)
Antidepressants for Anxiety, cont’d

Tricyclics (TCAs)

Clomipramine (Anafranil)—for OCD
MISCELLANEOUS
propranolol (Inderal)-Beta adrenergic blocker
and clonidine (Catapres)-Alpha 2 agonist
 Decrease autonomic symptoms in panic : e.g.
tachycardia, muscle tremors


gabapentin (Neurontin)
 For OCD and social phobias
GENERAL GUIDELINES FOR
USE OF ANTIANXIETY AGENTS
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Sedation potentiates falls, accidents
Cautious use in elderly, renal, liver
problems
Do not combine with other CNS
depressants or alcohol
Paradoxical effects common: esp.
with BZDs, buspirone, and some
antidepressants
Don’t stop benzodiazepine therapy
abruptly