ANXIETY

ANXIETY
• Needed in our daily lives to achieve goals
• A feeling of apprehension, uneasiness, uncertainty resulting from a real or perceived threat
whose actual source is unknown or unrecognized.
• Moderate level of anxiety we use defense mechanisms
• Normal anxiety provides the energy needed to carry out the tasks involved in living and
striving toward goals.
• Becomes abnormal when severity is inappropriate or when it occurs in inappropriate
circumstances.*
o Or inappropriate to situation – mildly anxious = defense mechanisms
• A person gets anxiety then the person developes a behavior to get rid of that anxiety –
Then it can become a disorder when a person uses that behavir all the time it interferes
with interpersonal relationships, affects social functioning, or affects job performance.
• The type of maladaptive behavior that occurs is how these are diagnosec. Most of the time
is can be
o Anxiety, avoidance, physical symptoms, memory disturbance.
• Primary gain
o “Reward”
o Relief of anxiety
 When the anxiety is relived so that is a reward
• Secondary gain
o “Fringe benefits of being ill”
o Seen on Somatoform disorders
o Attention, release from responsibility, getting one’s way, dependent”
 Having people taking care of you, Boss or husband
 DO not seek help unless someone demands it
 Feel life is unpleasant living under these conditions

PEOPLE WITH THESE DISORDERS

• Are aware that they are experiencing distress
• Are aware that their behaviors are not rational or maladaptive
• Are unable to identify the specific cause of why there behaviors are ocuring
• Are unaware of any possible psychological causes of the distress
• Feel helpless to change their situation – Not psychotic

PSYCHOPATHOLOGY
• Biochemical
o Neurotransmitters Seritonin and GABA are involved
• Genetics
o Relatives with it
• Psychosocial
o Learned especially phobias. Distorted thinking must always be perfect
o Person thinks they must be approved by everyone in society
• Sociocultural
 o Differentiate what is normal for this culture and anxiety for another culture
GENERALIZED ANXIETY DISORDER
• Chronic, unrealistic, excessive anxiety and worry, motor tension, 6 months
o Always thinking something bad will happen before doing
o Can start in childhood or adolescence
o Early 20’s have mild symptoms
o Can have depression symptoms also
o Meds: Buspar****

PANIC DISORDER WITHOUT AGORAPHOBIA

• Terror, feeling of impending doom, intense physical discomfort, Depression is Common
o Recurrent panic attacks – do not know when they are going to occur
o Can have sumptoms of depression
o Onset – Late 20’s average
o Can last minutes or occasionally hours
o Meds: Antidepresants – IF MAOI TEACH ABOUT TYRAMINE FOODS****

PANIC DISORDER WITH AGORAPHOBIA

• Symptoms of Panic Disorder
o Has panic attacks and that has caused the person to be housebound
o Are afraid if they have a panic attack they would not be able to get out of that
situation.
o Fear of being places from which escape would be difficult
o Feel safe being at home
o Go to extreme measures to avoid a panic attack
o Common Things Avoided:
 Outside home
 Bridge Bus, train, car Crowds
Example: If a woman has this disorder and married the client has a lot of secondary gain
• Woman could not function unless she had a support person to do everything for her
• The husband also has a gain it is Control.

SOCIAL PHOBIA
• Fear of appearing shameful, stupid or inept in the presence of others.
• Avoid any situation that would put them at risk such as:
o Speaking, eating, public restrooms, writing. Avoid these situations.
 Only experience anxiety when they have to do this
 Fine as long as you avoid what you are afraid of
 May affect social or occupation
 If job depends on it, may go to seek help
 Meds:Inderal****

SPECIFIC PHOBIA
• Fear of object or situation
o Snakes, spiders, flying, heights
• Anxiety only in presence or thinking about phobia
 o More common in women as long as it does not interfere in functioning they can lead a
normal life
o Same physical symptoms can occur
o Occurs more in women – Can be learned from parents
o Desensitization Therapy and Relaxation techniques is an effective tx for Phobias***
OBSESSIVE-COMPULSIVE DISORDER
• Obsessions, compulsions, has to do ritual to avoid anxiety.
• Obsessions
o Unwanted thoughts that occur repeadedly
• Compulsions
o The acts you have to do to get rid of the anxiety
 Handwashing, counting, checking, or touching

• A disorder when interferes with client’s life

o Thoughts recurrent in head
o Actions
Main ND for OCD – Ineffective Individual Coping****

POST TRAUMATIC STRESS DISORDER

• Re-experience trauma in dreams, images, flashbacks, survival guilt, anxiety, depression,
numbing of responses.
• Experienced an abnormal trauma that normal people do not experience
• Get depressed and affects their whole life

Wheather or not you develop PTSD depends on your coping skills

o If you are a good coper you are less likely to have traumatic stress disorder

• May unconsciously react

• Rape, military combat, earthquake, tornado
• Trouble with jobs
• Difference in relationships
• People can become numb and do not respond normally to emotion
• May have depression

HEALTHY LIFESTYLE
• Manage Stress
o Relaxation
 If you are relaxed you won’t feel anxious
 Develop your own system of relaxation
 Have to be practiced
 Abdominal breathing
o Nutrition
 Well balanced vitamin B&C and decrease caffeine intake
o Exercise
 Decreases Stress
o Sleep
 8 hours per night
SECONDARY PREVENTION
• Early diagnosis / treatment
o Parents should watch children and notice if they are having any problems with anxiety and
intervene early
o Sooner the better disrupts lives less
• Relaxation techniques
o Deep breathe, abd. Visualize, can be used with all these disorders
• Cognitive restructuring
o Replacing negative. Self talk with positive self talk changes distorted thinking
o Can be used with all disorders
• Behavior Modification – Used in Phobias
o Systematic Desensitization
 First taught relaxation techniques
 Helping person face phobia using gradual exposure
 Done several days a week
o Flooding
 Exposed to large amounts to endure until anxiety decreases
o Response Prevention
 Used with OCD
 Refuse the person of perform their rituals
 Done with a treatment team – the staff sets limits
 They have to be allowed to perform rituals so they can become comfortable with the
environment.
 They become comfortable then they gradually decrease the time they can spend on
their ritual.
 Would not be done by a nurse it would be done as a team approach
o Thought Stopping
 Used for OCD
 Shout stop – or snap rubber band on wrist
• Group Therapy
o PTSD and Some phobias have self help groups
o Self help – leader is a person who has gotten over the disorder

HOSPITALIZATION
o Only in the hospital if they have prolonged or severe anxiety, health is in danger or they are
suicidal.
• Milieu Therapy
o Must have a Structured routine – creates less anxiety
o Activities
 Gets mind off self
o Therapeutic Interactions
 The nurse is very involved in the care of the clients b/c whenever they are anxious
you need to STAY WITH THE CLIENT.
 Support the other therapies they are going to
o Self care activities
 May affect ability to care for themselves
 Hygiene may be affected
 All adl’s affected
 May not eat – Nutrition affects – OCD may not take time to eat, Phobic may be afraid
of germs so will not eat
 May not take time to go the BR – Set a time to go to BR
 OCD – takes hours to dress or perform hygiene
 Most all have trouble sleeping PTSD have nightmares, stay with client until calm
 May wash their hands too much. Watch for physical health also.
MEDICAL PLAN OF CARE
• MEDICATIONS

o Antianxiety
 Usually given for short periods of time in order to engage in other therapies in
order to reduce anxiety.
 Benzodiazepines
• Panic Disorders
• Ativan, Zanax, Tranzene, Valium, Librium, Klonopin
o Supress CNS – Absorbed in the GI tract – DO NOT give
antacids when giving these medications.
o No alcohol
• Common Side Effects:
o Drowsiness
o Ataxia
o Weakenss
o Decrease pulse and BP
o In elderly or debilitated persons there may be an adverse affect
that will make the person more excited
 Miscellaneous
• Vistaril
• Buspar is only used for Generalized Anxiety Disorder ****
• Does not work rapidly, takes 2-3 weeks to work, not sedating, nor will
become dependent
• Less sedation and no dependence

• Beta Blockers – Inderal for Social Phobia

o Works on the physical symptoms of anxiety helps relax the person
o Take only when giving a speech or anything that causes anxiety

• Antidepressants
o All can be used for Panic Attacks
o Tricyclics(TCA)
 Panic
 OCD (Aanfranil)
 PTSD
o SSRI
 Panic
 Phobias
 OCD – Luvox or Prozac
o MOAI
 Panic
 Social Phobias
 PTSD
NURSING PLAN OF CARE
• Anxiety – p460
o If having a panic attack -- Stay with client
o Take to enviroment with decreased stimuli
o Nurse should appear calm – Slow down your breathing they will follow “Breath with
me”
o May have to give an antianxiety agent (PRN Ativan)
o Once calm teach relaxation techniques
o Teach positive self talk
o Increase exercise
o Decrease caffeine
o Discuss what happened so you can ID a pattern
o Keep simple, clear words,
 Take over-tell them what to do

• Ineffective individual coping – Seen in clients with OCD

o Focus on client not symptoms
o Will be uncomfortable in hospital – DO NOT take away their ritual – they must
become accustomed to the environment.
o With a team approach you would begin to limit rituals
o Watch for their physical health – Handwashing – can have hands raw and sore
o Reluctant to get help because rituals are done in secret
o Only time they are in the hospital is because husband or wife is threatening to leave
them or their job depends on it.
o Never hurry them to make a decision – They have to make a “perfect” decision so
give them time.
o Thought stopping, Rubber band
o Medications: Tricyclis (Anafranil), SSRI (Luvox)

• Fear – Clients with Phobias

o Rarely in hospital
o Mainly support their therapy that they are engaging in
o Practice relaxation techniques
o Role model – Do not be afraid
o A nurse does not make a client face a phobic object – it is not in the nurses job
description.
o Listen to their feelings

• Posttraumatic Stress response p 464.

o Assessing patterns of sleep due to nightmares
o If they wake up with nightmares – Stay with Them until they feel better. They may
need to talk, Be there for them
o Often these people will abuse drugs and alcohol to self medicate so assess for
substance abuse
o If a rape client – respect wishes and do not give a male nurse
 SOMATOFORM
DISORDERS
• Anxiety transformed into physical symptoms
• Physical symptoms suggesting medical disease
• Precipitated by psychological factors
• More acceptable than mental illness
• Medical costs – expensive
• Side Effect: Addiction to medications
• Not follow through with psych consult
• Having Physical symptoms (instead of mental) gets sympathy from others

PSYCHOPATHOLOGY
• Biological
• Genetic
o Runs in families - Some type of conflict that is causing anxiety
• Cultural
• Psychosocial
o Psychoanalytical - Repressed Conflict
• Behavioral
o May have learned that if they are helpless they may manipulate others in to doing
what they want them to.

SOMATIZATION DISORDER
• Multiple physical complaints but they don’t focus on one specific disease
• General – Usually Neuro or GI
• Multiple providers (doctors)
• Impairs social and occupational functioning THERE IS NO PHYSICAL
• They have altered their life pattern because they are sick REASON FOR THE
• Chronic, begins before age 30 SYMPTOMS THEY ARE
HAVING
HYPOCHONDRIASIS
• Feel they have a specific serious disease and physical complaints follow that disease
pattern.
• Misinterprets body symptoms
• Over 6 months
• Impairs social and occupational functioning
• May “Doctor shop” they feel they are not getting the proper care
• ND: Ineffective Individual Coping /2nd Gain; Attention and relief from having to go to work***

PAIN DISODERS
• Severe and prolonged pain that is out of the ordinary for their condition
• Impairs social and occupational functioning.
• If there is a physical condition present then the pain is accepted
 • Often the pain will allow the person to avoid unpleasant activities or get support they may
not get otherwise.
• Person might get addicted to pain medication
• May request surgery – Back pain
CONVERSION DISORDER
• Loss of or change in bodily function resulting from a psychological conflict
• Occurs after extreme psychological stress
• Most Conversion reactions resemble a neurological disease
o Ex. Paralysis, seizures, blindness, numbness in different areas of the body
• Sudden onset, after severe stress
• La belle indifference
o If a normal person were to suddenly become blind the would panic
o This disorder is diagnosed by “La belle indifference” apathetic about having this
problem (don’t really care)
o Because being blind has gotten them out of a difficult situation
o A lot of Primary (getting out of that situation) and Secondary gain (all the attention
they would receive)
• Recover
• ND: Ineffective Individual Coping – With these clients you may have physical diagnosis
• Primary Gain: Getting out of the situation
• Secondary Gain: Attention****

SECONDARY PREVENTION
• Healthy lifestyle may help prevent some of this

• Med surg setting rather than psych settings because of their physical symptoms
o Will go through many diagnostic tests trying to rule out things
o Many will have surgery
o Very difficult clients to care for
o They are always on the call light with complaints
o Nurse client relationship is very important
 Have the client trust you, do what you say you are going to do. If you said you
would be there in 10 minutes—Be there in 10 minutes

• Diagnostic tests
o To rule out other disorders

• Difficult clients
o Always have on light always want pain meds every 2-3 hours
o Have Client trust you

• Individual and group therapy

o Will help because in group will talk about how client expresses anxiety through
physical symptoms
o Work on having them directly verbalize their feelings

• Family therapy
 o Important family may reinforce “sick” behavior
o Need to be aware of the secondary gain
o Need to give attention to client when they are not sicki

• Cognitive Restructuring
o Negative self thoughts to positive
MILIEU THERAPY
• Self Care Activities are impaired with these disorders
o Treat them as if they really have that condition
o Expect them to be as independent as they can
o Matter of Fact approach
o Support client self-care
• Relaxation techniques
• Assertiveness Training
o Helps client being able to verbalize to have their needs met rather than getting their
needs met through physical symptoms.
• Biofeedback
o Teach relaxation
• Case Manager
o Help save medical cost
o Govern what providers the patient sees
• Exercise
o Can help the persons self of well-being

MEDICAL PLAN OF CARE

• SSRI for Depression
• Recognize addiction of antianxiety, pain and sedatives

NURSING PLAN OF CARE

• Ineffective individual coping p.490
• Remember with Somataform Disorders there is no physical reason for their problems; once
you have discovered there is no physical reason you don’t keep repeating tests (checking
pulse)
• Spend time with the client other than when they are asking for you to come down for a
physical complaint.
• Do chart about physical complaints but do not spend a lot of time standing there listening to
all their physical complaints
• Make agreement
o “I will stay in your room and talk to you as long as you don’t talk about your physical
complaints”
• Helps them learn to talk about other things
• Encourage to attend Assertiveness training so they know how to ask to get their needs met
• Teach stress reduction techniques
o Distract client
o Involve in other activity
o Talk about something else
o Avoid rejection
o Do what you say you are going to do
 DISSOCIATIVE
DISORDERS
• Disruption in consciousness, memory, identity, or perception of environment
• Person has such an overwhelming anxiety that personality disorganization happens
• Unaware of their overwhelming anxiety
• Anxiety is repressed because what has happened to them is so awful that if they were to
face it, it would be overwhelming
• Causes a person to “tune out” what has happened to them
• Associated with Childhood abuse

DISSOCIATIVE AMNESIA
• Inability to recall important personal information
• Generalized
o Can’t remember anything about their entire life
• Localized
o Memory loss occurs for all incidence associated with a traumatic event for a specific
time period.
• Selective
o Inability to recall incidence associated with a traumatic event.
o Ex. May remember a car accident but cant remember that someone was killed in the
accident”
• Generally this terminates abruptly and the person is completely normal, so they get over it
very quickly and may not have any other episodes.

DISSOCIATIVE FUGUE
• Sudden unexpected travel away from home or the customary work place
• Inability to recall identity and information about their past
• Assume new identity; then all of a sudden they will go back to their original identity and
have Amnesia for the Fugue state.
o EX. You come to school one day
o The next thing you know you are in Dallas
o When you are in Dallas, you assume a new identity and get a job
o All of a sudden the police find you walking down this road and the only thing you can
remember is that you are from Jackson MS and don’t know how you got there.
• No recurrences, Recovery is rapid and complete
• Triggered by a traumatic event

DISSOCIATIVE IDENTITY DISORDER

• Multiple Personality
• Generally there is a “main” personality that is most often in charge; occasionally the
subpersonality will take over the “main” personality
• Each has own memories, behavior patterns, social relationships
 • Most of the time the “Main” personality is not aware of the other personalities but the
subpersonalities are aware of the primary.
• Primary or “Main” personality will have “lost time” due to the take over of the Subpersonality

SECONDARY PREVENTION
• Diagnostic tests
o Will be done to rule out any medical causes for amnesia
• Hospitalized when suicidal
o Try to keep them from Dissociating
 Have them wrap themselves in a blanket
• Reinforces external boundaries
 Hold a handful of ice
• Helps them focus on something real
 Assign a certain chair that is a safe place
• Suicide is a high risk because it is the other personalities that are trying to kill them
• Behavioral therapy
• Family therapy
o Family life is very chaotic

MILIEU THERAPY
• Safe environment
o Very important
o Can be manipulative – They can find the one thing in the room to comit suicide with
o Watch closely
• OT / Art therapy
o Express themselves
• Unit meetings
o Help them feel part of the unit and not so isolated

MEDICAL PLAN OF CARE

• Medication
o Antianxiety – Ativan, Klonopin
 SSRI and Tricylic
o Antidepressants – Despression is a part of this illness
• Hypnotherapy
o Used as an adjunct to counseling – used to meet the other personality
o Have the longest type of talk therapy – May take years for all of the personalities to
become united as one
• Narcotherapy
o Interviewing the client under the influence of Pentathol (like general anesthesia)

NURSING PLAN OF CARE

• Personal identity disturbance p 502
o Provide safe environment
o Don’t push client to regain memory or any lost memory
o Keep envoronment simple
 o Supportive of client
o Work on stress reduction (holding ice in hand, blanket)
o If client does not remember relationships you need to do family intervention
• High risk for violence to self
o Side affect of Depression