Anxiety Disorders

Anxiety Disorders K. Farr, MS, APRN, BC PREVALENCE •Most common diagnosed of all Psychiatric Disorders •Result in considerable distress and functional impairment •Most prevalent disorder: Social Phobia 7.9-13% PTSD: 1% in General Population 20 % in people exposed to traumatic life events NOTE OF CAUTION: Differences in CULTURE May Effect the Manifestation of ANXIETY DISORDERS CULTURAL CONSIDERATIONS •Reliable data on the incidence of anxiety disorders and ritualistic behaviors in this and other countries are SPARSE!!! •Culture–Bound illnesses must be differentiated from anxiety disorders •Hispanics: Susto (fright) •African Americans & Southern Euro-Americans: Nervous Breakdown •ALWAYS REMEMBER: CONTEXT OF CULTURE COMORBIDITY •Anxiety Disorders & Depression occur together frequently •Substance Abuse •Somatization •Other Anxiety Disorders THEORY •There is no doubt that biological correlates predispose some individuals to pathological anxiety states (e.g., phobias, panic attacks). By the same token, traumatic life events, psychosocial factors and sociocultural factors are also etiologicaly significant. GENETIC CORRELATES •Nearly ½ of all clients with Panic Disorder have a relative with the disorder •Studies indicate a genetic component to both Panic Disorder and Obsessive-Compulsive Disorder •Possible relationship between Tourette’s Disorder and OCD GENETIC CORRELATES •Studies indicate that PHOBIAS are mostly accounted for by genetic factors. •Heredity factor was from 30% to 40%, depending on specific phobias •Generalized Anxiety Disorder (GAD)

•19.5 % morbidity risk among relatives of GAD clients compared to 3.5% risks in “normal” control relatives. •VERY COMPLICATED, NOT ONE GENE, NEEDS MUCH MORE RESEARCH!!!! DSM-IV-TR CRITERIA FOR ANXIETY DISORDERS ANXIETY DISORDERS DSM-IV-TR Criteria •PANIC DISORDER

•PHOBIAS •OBSESSIVE-COMPULSIVE DISORDER (OCD) •GENERALIZED ANXIETY DISORDER (GAD) PANIC DISORDER •1. Both A and B A. Recurrent episodes of panic B. At least 1 attack has been followed by 1 month or more of the

attacks following:

Panic Disorder-> •1. Persistent concern about having additional attacks

•2. Worry about consequences (“going crazy”, having a heart attack, losing control)

•3. Significant change in behavior Panic Disorder-> •2. A. Absence of agoraphobia= Panic • B. Presence of agoraphobia= Panic

disorder without agoraphobia. disorder with agoraphobia

PHOBIAS •1. Irrational fear of an object or situation that persists although the person may recognize it as unreasonable. •Types include: •Agoraphobia: Fear of being alone in open or public places where escape might be difficult. May not leave home. Phobias-> ••Social Phobia: Fear of situations where one might be seen and embarrassed or criticized: speaking to authority figures; public speaking, or performing. ••Specific Phobia: Fear of a single object, activity, or situation (e.g., snakes, spiders, closed spaces, or flying). Phobias->

•Anxiety is severe if the activity, object, or situation cannot be avoided. OBSESSIVE COMPULSIVE DISORDER •1. Either obsessions or compulsions •A. Preoccupation with persistent intrusive thoughts, impulses, or images (obsessions). or •B. Repetitive behaviors or mental acts that the person feels driven to perform in order to reduce distress or prevent a dreaded event or situation (compulsion). OCD-> •2. Person knows the obsessions/compulsions are excessive and unreasonable. •3. The obsession/compulsion can cause increased distress and is time consuming. OCD versus OCPD •OCD: Persons performs compulsive behaviors and suffers obsessions as a result of ANXIETY and is trying to RELIEVE ANXIETY.

•OCPD: Revolves around the person’s “PHILOSOPHY” and that which the persons believes to be “Right” or “Wrong” GENERALIZED ANXIETY DISORDER •1. A. Excessive anxiety or worry more months. B. Cannot control the worrying.

days than not over 6

GAD -> •2. Anxiety and worry associated with 3 of the following symptoms: Restless, keyed-up Easily fatigued Difficulty concentrating, mind goes blank Irritability Sleep disturbance Muscle tension DSM-IV-TR CRITERIA FOR ANXIETY DISORDERS: STRESS RESPONSE ANXIETY DISORDERS: STRESS RESPONSE DSM-IV-TR CRITERIA •POSTTRAUMATIC STRESS DISORDER

•ACUTE STRESS RESPONSE POSTTRAUMATIC STRESS DISORDER •1. The person experienced, witnessed, or was confronted with an event that involved actual , threatened death to self or others, responding in fear, helplessness, or horror.

PTSD-> •2. The event is persistently reexperienced by: Recurrent & intrusive recollections of the the event, including images, thoughts, or perceptions Distressing dreams or images Reliving the event through flashbacks, illusions, hallucinations PTSD-> 3. Persistent avoidance of stimuli associated with trauma: Avoidance of thoughts, feelings, conversations Avoidance of people, places, activities Inability to recall aspects of trauma Decreased interest in usual activities Feelings of detachment, estrangement from others Restriction in feelings (love, enthusiasm, joy) Sense of shortened feelings PTSD-> 4. Persistent symptoms of arousal (2 or more) Difficulty falling/staying asleep Irritability/outbursts of anger Difficulty concentrating PTSD-> 5. DURATION OF MORE THAN 1 MONTH: • Acute: Duration less than 3 months •Chronic: Duration 3 months or more •Delayed: If onset of symptoms is at least 6 months after stress ACUTE STRESS RESPONSE 1. The person witnessed or was confronted with an event that involved actual, threatened death to self or others, responding in fear, helplessness or horror. Acute Stress Response-> 2. Three or more of the following dissociative symptoms: Sense of numbing, detachment, or absence of emotional response Reduced awareness of surroundings (e.g., “in a daze”) Derealization Depersonalization Amnesia for an important aspect of the trauma Acute Stress Response-> 3. The event is persistently re-experienced by:

Distressing dreams or images Reliving the event through flashbacks Distress on exposure to reminders of the event Acute Stress Response-> 4. Marked avoidance of stimuli that arouse memory of trauma (thoughts,feelings, people, places, activities, conversations). 5. Marked symptoms of anxiety: Difficulty falling/staying asleep Irritability/outbursts of anger Difficulty concentrating Acute Stress Response 6. Causes impairment in social, occupational, and other functioning, or impairs ability to complete some memory tasks. 7. Not due to drug of abuse/medications or medical condition 8. Lasts from 2 days to 4 weeks, and occurs within 4 weeks of the traumatic event. Anxiety Disorders: TREATMENT Psychopharmacotherapy: •GAD: SSRIs, TCAs, Buspirone (Buspar), SNRIs, Valproic acid (Depakene)

•OCD: SSRIs, especially fluvoxamine (Luvox), TCAs, especially clomipramine (Anafranil)

•Panic Disorder: SSRIs, Benzodiazepines, TCAs, MAOIs, ß-blockers, Valproic acid (Depakote)

•PTSD: SSRIs, TCAs, Benzodiazepines, SNRIs, MAOIs, ß-Blockers, Carbamazepine (Tegretal), Oxcarbazepine (Trileptal)?

•Social Phobia or Social Anxiety D/O: SSRIs, Benzodiazepines, Buspirone, ßBlockers, Gabapentin (Neurontin) PERHAPS: Pregabilin (Lyrica) TBA? Anxiety Disorders: TREATMENT Nursing Interventions •Anxiety Reduction: Observe for verbal and nonverbal signs of anxiety. Instruct in the use of relaxation techniques. Create an atmosphere to facilitate trust Use calm, reassuring approach.

•Coping Enhancement: Provide atmosphere of acceptance. Encourage verbalization of feelings, perceptions, and fears. Acknowledge patient’s spiritual/cultural background. Discourage decision making when the patient is under stress.

•Hope Instillation: Assist to help identify areas of hope in life. Demonstrate hope by recognizing the patients intrinsic worth and viewing the patient’s illness as only one facet of the individual. Avoid masking the truth. Help the patient expand spiritual self..

•Self-Esteem Enhancement: Make positive statements about patient. Monitor frequency of self-negating verbalizations. Explore previous achievements. Explore reasons for self-criticism or guilt.

•Simple Relaxation Therapy: Demonstrate and practice the relaxation technique with the patient. Provide written information about preparing and engaging in relaxation techniques. Anticipate the need for the use of relaxation. Evaluate and document the response to relaxation therapy. K. FARR, MS, APRN, BC 04/11/06