1. UNDERSTANDING ANXIETY

2. WHAT IS ANXIETY?
 Anxiety is one of the most simple of emotions;
common to everyone.
 Normal anxiety: can be good, it gives you the energy
and focus to overcome a task. It is necessary for
survival. (Fight or Flight) (Butterflies before a race)
 Many times dysfunctional behavior is a defense
against anxiety
 STRESS LEADS TO ANXIETY

3. ANXIETY VS FEAR
 Anxiety has an unknown source
 Fear is a reaction to a specific threat

4. CATEGORIES OF
ANXIETY
 Normal Anxiety
 Healthy life force necessary for survival
 Acute Anxiety (State)
 Crisis threatens sense of security
 Chronic Anxiety (Trait)
 Long term anxiety
 Discomfort in relationships

5. LEVELS OF ANXIETY
 Mild
 Moderate
 Severe
 Panic

6. INTERVENTIONS
 Mild to Moderate  Severe to Panic
 Assist with regaining  Safety of client and
focus others
 Recognize distress  Quiet environment
 Listen  Medications
 Clarify  Point out reality
 Ask open-ended ?  Meet physical needs
 Provide calm presence  Use short, simple
statements

7. DEFENSE MECHANISMS
 Manage Conflict and affect
 Relatively unconscious
 Discrete from one to another
 Hallmarks for psych syndromes (reversible)
 Adaptive as well as pathological

8. DEFENSES
 Healthy (altruism, sublimation, humor, suppression)
 Intermediate (repression, displacement, reaction
formation, somatization, undoing, rationalization)
 Immature (passive aggressive, acting out,
dissociation, idealization, splitting, projection)

9. ANXIETY DISORDERS

10. ANXIETY DISORDERS
 13% of the US adult population are affected by
anxiety. It is the most common psychiatric disorder in
the US.
 The level of anxiety is so high in these client’s that it
interferes with personal, occupational, and social
functioning.
 Caused by : genetics, psychosocial factors, cultural
factors, and traumatic life events

11. THEORY
 Genetic: cluster in families
 Biological: Limbic system irregularities
 Psychological: (Freud, Learning theories, cognitive
theories, Sullivan)
 Cultural

12. PANIC DISORDERS
 Panic without agoraphobia: panic attack ,
unexpected
 Panic with agoraphobia: recurrent panic attacks
with fear of being out in public when it happens.
 Agoraphobia: fear of being out and people seeing
the attack, these clients may not leave home due
to this fear

13. GENERALIZED ANXIETY
DISORDER
 Excessive worrying about numerous things; this
can last for months or even longer
 DSM –IV-TR criteria (p565)

14. PHOBIAS
What is phobia?
A persistent irrational fear of an object, activity, or
situation that leads to the desire for avoidance.

15. PHOBIAS
 Specific types ( snakes, bridges, small spaces)
 Social Anxiety Disorder (SAD)
 Severe anxiety provoked by exposure to a social
situation
 Overwhelming and crippling anxiety when facing
the situation

16. OBSESSIVE-COMPULSIVE
DISORDER (OCD)
 Obsessions
 Thoughts, impulses, or images that persist and
recur, so that they can not be dismissed from the
mind
 Compulsions
 Ritualistic behaviors that an individual feels
driven to perform in an attempt to reduce
anxiety
 These can be seen separately but usually they go
hand in hand!

17. OCD
 DSM- IV-TR criteria see pg 572 for criteria
 Common Obsessions:
 Doubt..need to double check everything (Did I..??)
 Sexual imagery ( You see a man and want to rub his
arm repetitively , uncontrollably)
 Need for order (Felix )
 Violence
 Germs/ Dirt

18. POST TRAUMATIC STRESS
DISORDER
 Flashbacks
 Avoidance with stimuli associated with trauma
 Numbing of responses persistently
 Persistent symptoms of increased arousal
 These symptoms usually begin within 3 months
of disturbance
 See page 574 for criteria

19. ACUTE STRESS
DISORDER
 Usually occurs within 1 month after disturbance
 To be dx with this the pt must have at least 3
symptoms:
 Subjective sense of numbing
 Amnesia
 Detachment
 Reduction in awareness of surroundings
 Depersonalization(sense of unreality)
 Usually resolves within 4 weeks

20. SUBSTANCE –INDUCED
ANXIETY
 Anxiety
 Panic attacks
 Obsession
 Compulsion
 These develop either due to substance use or after stopping the chronic
use of substances

21. ANXIETY DUE TO MEDICAL
CONDITIONS
 Anxiety can be the direct result of medical diagnosis
 Cardiac History
 Strokes
 Trauma that effects cognition or mobility

22. BASIC NURSING
INTERVENTIONS
 Reduce anxiety
 Enhance coping/Instill hope
 Psychopharmacological Interventions
 Enhance self esteem
 Use relaxation techniques
 Locate community resources
 Support groups / counseling/ Milieu Therapy
 Medication Education

23. ADVANCED PRACTICE
INTERVENTIONS
 Cognitive therapy
 Cognitive restructuring
 Behavioral Therapy
 Relaxation
 Modeling/ Desensitization
 Flooding/ Response prevention
 Thought stopping

24. MEDICATIONS
 Antidepressants
 SSRI’s * / Tricyclics/ MAOI inhibitors/ Serotonin-norepinephrine
reuptake inhibitors
 Anxiolytics
 Benzodiazepines
 Buspar (nonbenzodiazeoine) increase available serotonin/ not
a strong sedative
 Antihistamines
 Beta Blockers
 Anticonvulsants

25. FAMILY AND CLIENT
TEACHING
 Nurse should include:
 Do not change dose without discussing with MD
 The meds will reduce your ability to handle mechanical equipment;
cars, machinery
 No alcohol.. No caffeine
 If taking MAOI instruct about tyramine free diet
 Can cause congenital abnormalities in fetus, do not breast feed
 Meds need to be taken with Meals to avoid GI upset
 After taking Benzos for 3-4 months, you may experience withdrawal
signs if stopped abruptly

26. SOMATOFORM AND
DISSOCIATIVE DISORDERS

27. SOMATOFORM
DISORDERS
 Physical symptoms suggest a physical disorder
 Diagnostic tests are NEGATIVE for illness
 Symptoms are linked to Psychobiological factors
 Many times this disorder will co-exist with another
Psychological disturbance

28. SOMATOFORM
DISORDERS
 Somatization Disorder
 Hypochondriasis
 Pain Disorder
 Body Dysmorphic Disorder
 Conversion Disorder

29. SOMATOFORM D/O
VS OTHER DISORDERS:
 Malingering
 Intentionally producing symptoms to produce a goal
 Factitious Disorder
 Fabrication of symptoms to assume the “sick role”
 Psychosomatic Illness
 General medical condition affected by stress or
psychological factors

30. ASSESSMENT
 Overall assessment
 Voluntary control?
 Secondary gains
 Cognitive style
 Ability to communicate feelings and emotional
needs
 Dependence on Medications

31. BASIC NURSING
INTERVENTIONS
 Promotion of self care activities
 Health teaching
 Case Management
 Psychobiological Interventions: Anxiolytics (short term) ,
antidepressants (greatest help, SSRI’s)
 ADVANCED: PSYCHOTHERAPY

32. DISSOCIATIVE
DISORDERS
 Disturbances in the normally well integrated
continuum of consciousness, memory, identity, and
perception
 Dissociation is an unconscious defense mechanism
that protects the person from overwhelming anxiety
 We all dissociate: do you remember every minute of
driving here today? But this client spends their life in
that psychological state.

33. DISSOCIATIVE
DISORDERS
 Depersonalization
 Dissociative Amnesia
 Dissociative Fugue
 Dissociative Identity Disorder

34. ASSESSMENT
 Identity and Memory
 Disorientation vs A and O x 3; do they remember the
past?
 Client History: memories from childhood?
 Moods: depressed..anxious
 Use of ETOH and other drugs
 Impact on client? Family?
 Miss a lot of work especially DID due to multiple
personalities being in control
 Suicide Risk?

35. BASIC LEVEL
INTERVENTIONS
 Milieu Therapy
 SAFETY SAFETY!!!
 Simple routines, nondemanding
 Don’t flood client with past events
 Stress reduction, coping mechanisms
 Health Teaching
 Psychobiological Interventions : no specific meds; but
antidepressants vs anxiolytics as needed

36. ADVANCED PRACTICE
 Cognitive-behavioral therapy: find a logical
reason for the behavior then work to develop
alternative coping mechanisms
 Psychodynamic Psychotherapy: group therapy

37. MOVIE TIME!!!
 If you are looking for other movies that
portray DID check out Sybil, Three Faces of
Eve, or Identity