Anxiety disorder

1. ANXIETY DISORDERS
PRESENTED BY : BURHAN HADI

2. anxiety
 is abnormal response to threatening situation.
anxiety disorder
 Are often the most common of all psychiatric disorder and result
in considerable distress and functional impairment.
 As Anxiety disorders, as the term suggests, has an unrealistic,
irrational fear or anxiety of disabling intensity at its core and its
principal and most obvious manifestation.

3. Level of anxiety
• Mild
( increase alertness , motivation and attentiveness restlessness ,difficulty
sleeping ,hypersensitivity to noise )
• Moderate
(perception narrowed ,selective inattention and physical discomfort, muscle
tension, dry mouth , headache )
• Sever
(impaired learning ability , cannot complete task ,crying ,tachycardia , chest pain )
• Panic
( unable to function, unable to communicate , mute voice ,increase B/P and pulse)

4. TYPES OF ANXIETY DISORDER
• Panic disorder
Panic disorder with agoraphobia or without agoraphobia
• Phobic disorder
Specific Phobias
Social Phobias
• Generalized Anxiety Disorder (GAD)
• Obsessive Compulsive Disorder (OCD)
• Post-traumatic Stress Disorder (PTSD)
• Acute Stress Disorder (ASD)

5. PANIC DISORDER
 Panic disorder defined as the occurrence of
unexpected panic attacks.
Panic disorder with agoraphobia characterized by
both recurrent unexpected panic attacks and
agoraphobia.
 Panic disorder without agoraphobia characterized
by recurrent unexpected panic attacks.
 Symptoms: 1. persistent concern of having attack.
2. Worry about the implications of attack.
3. A significant change in behavior related to attack.

6. Panic Attacks
– Palpitations
– Chest pain
– Sweating
– Trembling
– SOB
– Nausea
– Feeling dizzy
– Fear of going crazy/dying
– Numbness /tingling
– Chills/hot flushes
4 or more of below symptoms, develop
suddenly & peak within 10 minutes

7. • COURSE AND PREVALENCE:
• Age at onset for panic disorder varies but lay between
late adolescence and mid-30s.
• Lifetime prevalence of panic disorder reported to be
high as 3.5% and one year prevalence rate are
between 0.5% and 1.5%.
• Duration: at least one month

8.  A persistent and disproportionate fear of some specific
object or situation that presents little or no actual danger
to person.
Specific phobias: is characterized by clinically significant
anxiety provoked by exposure of specific feared object or
situation, often leading to avoidance.
 Specific types:
Animal type: feared cued by animal or insect
Natural Environment type: feared cued by object in natural environment like
storm, water or height.
Blood Injection type: fear cued by receiving injection or seeing blood.
Situational type: fear cued by situation such as tunnels bridges, elevator.
Other type: fear of choking, vomiting, contracting illness.
Phobic disorder

9. Course and Prevalence
• Age onset for specific phobia lay between childhood
to mid-20s.
• In community samples current prevalence rate
ranges from 4% to 8.8% and lifetime prevalence rates
ranges from 7.2% to 11.3%.
• Duration: at least 6 months.

10. SOCIAL PHOBIA
 Is characterized by clinically significant anxiety provoking by
exposure to certain types of social or performance situation,
which people exposed to unfamiliar people or to scrutiny by
others.
 The individual fears that he or she will act in a way that will be
humiliating or embarrassing.
 Duration: at least 6 months.
Course and Prevalence:
It has an onset in the mid-teens.
 Studies have reported a lifetime prevalence of social phobia
3% to 13%.

11. OBSESSIVE COMPULSIVE DISORDER
 Obsessive Compulsive Disorder characterized by obsessions(which
cause marked anxiety) and by compulsions( which serve to
neutralize anxiety)
Obsession: are persistent thoughts, ideas, impulses, or images that
seem to invade a person’s consciousness.
 Compulsions: repeat or rigid behavior or mental act that a person
feels compelled to perform to reduce distress or anxiety. :
Types
 Verbal compulsion: compel them to repeat expressions, phrases.
 Touching : must touch or avoid touching certain items
 Counting compulsion: driven to count the things they see around them.

12. Course and Prevalence
Community studies have a lifetime prevalence of 2.5% prevalence
of 0.5%-2.1% in adults. OCD prevalence is similar in many different
cultures.
 Age onset is earlier in males than females: between age 6 and 15
for males and between age 20 and 29 years for females.

13. GENERALIZED ANXIETY DISORDER
 Excessive anxiety and worry occurring more days
than not for at least 6 months about number of
events and activities.
 Symptoms:
• Restlessness or feeling keyed up or on edge
• Being easily fatigue
• Irritability & muscle tension
• Sleep disturbance
• Difficulty concentrating or mind going blank
 Course and prevalence:
• Onset occurring after age 20 years.
• prevalence rate for GAD was 3% - 5%.

14. Posttraumatic Stress Disorder
 PTSD is characterized by the re-experiencing of an
extremely traumatic event accompanied by the
symptoms of increased arousal and by avoidance of
stimuli associated with trauma.
 Symptoms:
• Nightmares
• Sleep disturbances
• Startle responses
• Anger outburst
• Regressive behavior
• Detachment
• Avoidance of trauma recollections
• Avoidance of talk of trauma
• Distress at exposure to similar stimuli

15. Course and Prevalence
 PTSD can occur at any age, including childhood.
 Community based studies prevalence for PTSD 8% of
adult population in United States.
 Duration:
Acute: duration of symptoms less than 3 months.
Chronic: duration of symptoms last 3 months or longer.
With Delayed onset: 6 months have passed between the traumatic
event and the onset of symptoms.

16. ACUTE STRESS DISORDER
 Acute Stress Disorder (ASD) is characterized by
symptoms similar to those PSTD that occur immediately
in the aftermath of an extremely traumatic event.
 Symptoms:
• Depersonalization.
• Dissociative amnesia (inability to recall traumatic events).
• Subjective sense of numbing, detachment or emotional responsiveness.
• De realization.
 Traumatic event is persistently re-experienced
• Thoughts.
• Recurrent images.
• Flashback episode.
• Sense of reliving the experience.
• Distress on exposure to reminders of traumatic events.

17.  Marked symptoms of anxiety or increased arousal
• difficulty in sleeping.
• irritability
• poor concentration
• hyper vigilance
• motor restlessness
• exaggerated startle response
 Course and Prevalence
• Symptoms experienced during or immediately after the trauma,
last for at least 2 days, and maximum 4 weeks and occur within 4
weeks of the traumatic event.
• ASD in few available studies, rates ranging from 14% to 33% have
been reported in individuals exposed to severe trauma.

18. Treatment
The most effective treatment of AD is probably one that combines
psychotherapy , pharmacotherapy and supportive therapy.
• Psychotherapy:
1. Cognitive-behavioral therapy.
2. Insight oriented therapy.
• Supportive therapy.
• Pharmacotherapy: antianxiety drug
1. Benzodiazepines.
2. Serotonergic agents: buspirone.
3. Other drugs: tricycles antidepressants, adrenergic receptor
antagonists like propranolol.
Other therapies :
• electroconvulsive therapy (ECT), Psychosurgery , Psychoanalysis.
These treatments are used in resistant cases.

19. NURSING Process
Nursing assessment:
• Assessment parameters focus on physical symptoms,
precipitating factors, avoidance behavior with phobia,
impact of anxiety on physical functioning etc.
• History & MSE:
• Assess for communication patterns
• Ability to perform or complete the task.
• Attention to anxiety reducing behaviors such as going to
bathroom, leaving group therapy.

20. NURSING DIAGNOSIS
1. Powerlessness
2. Sleep pattern disorder
3. Low self-esteem
4. Ineffective coping, individual or family
5. Impaired skin integrity or other diagnoses related to specific compulsion
6. Anxiety
7. Ineffective Individual Coping
8. Impaired Social Interaction
9. Fear
10. Hopelessness
11. Social Isolation
12. Risk for Injury

21. Nursing intervention for Panic Disorder
1. Provide for client’s safety (e.g., a secure environment, staying with the client,
letting the nurse will provide for safety).
2. Suggest that the client substitute positive thoughts for negative ones.
3. Discuss the process of thinking about the feared object/situation before it occurs.
4. Encourage client to share the seemingly unnatural fears and feelings with others,
especially the nurse therapist..
5. Share own experience with client as indicated after relationship has been
established.
6. Encourage to stop, wait, and not rush out of feared situation as soon as
experienced. Support use of relaxation exercises (e.g., breath control, muscle
relaxation, self-hypnosis).
7. Involve in interceptive exposure therapy as appropriate, with client holding breath,
hyperventilating and inhaling CO2, or receiving sodium lactate injections as
indicated.
Nursing intervention

22. Interventions for phobia disorder.
1. Encourage the client to discuss the feared object or situation.
2. Identify whether the client is depressed, and intervene.
3. Teach the client that the phobia is a symbolic representation (an object or a
situation that is a substitution) of anxiety.
4. assure the client that safety will be maintained.
5. Establish a systematic desensitization program.
6. Collaborate with the health care team to determine the appropriateness of other
behavior modification techniques, such as reciprocal inhibition and implosion
(see Behavior Modification Techniques Used in Treatment of Phobias).
7. Teach coping skills, such as assertiveness, thought-stopping techniques, and
problem solving.
8. Have the client learn and practice relaxation exercises and guided imagery.
9. Work with client to identify the real source of anxiety that's been displaced as a
phobia.

23. Interventions for Generalized Anxiety Disorder
1. Observe the client for overt signs of anxiety.
2. Give the client the information needed to help identify physical, emotional, and
behavioral symptoms as being anxiety-related.
3. Work with the client to identify sources of stress.
4. Advise the client not to use caffeine, nicotine, or alcohol to cope with anxiety
5. Teach the client problem-solving skills, such as formulating a goal and devising a
plan to meet that goal.
6. Encourage the client to use a journal to record feelings, behaviors, stressful events,
and coping strategies used to address the anxiety.
7. Provide the client with telephone numbers for mental health clinics or hot line
services for crisis situations.
8. Administer ant anxiety medication as prescribed when the client's symptoms are
interfering with ability to function, dedications can decrease physical symptoms and
enhance the ability to deal with stress.
9. Work with the client to establish a support system, including friends, family,
community mental health facilities, and support groups.
10.Teach the client anxiety-reduction techniques, such as affective coping methods
(hoping things can be changed, crying to release tension, working off tension, or
obtaining help or comfort from others) and problem-focused coping methods (trying
to maintain some control over the situation, getting another opinion, drawing on
experience, or trying different ways of solving the problem).
11.Encourage the client to establish a routine for daily activities.

24. Interventions Obsessive-Compulsive Disorder
1. Encourage the client to express feelings and concerns about life stressors,
fears, and anxieties.
2. Help the client identify how the disruptive thoughts and compulsive behaviors
affect physical, emotional, and social functioning.
3. Explore the difference between thoughts and actions, and discuss the social
consequences of the compulsive actions.
4. Help the client assess how ritualistic behavior impairs daily functioning.
5. Help the client identify the situations that promote anxiety and precipitate
ritualistic behaviors.
6. Teach the client thought-stopping skills and relaxation techniques to decrease
the incidents of obsessive thoughts and compulsive behaviors.
7. Have the client attend a support or therapy group.
8. Help the client discuss feelings and reactions about personal life situations and
social events.
9. Help the client recall times when anxiety was handled in a satisfactory manner. .
10.Encourage the client to participate in treatment activities, interactions, and social
events.

25. Nursing intervention for Posttraumatic Stress Disorder
1. Assess degree of anxiety/fear present, associated behaviors, and reality of threat
perceived by client.
2. Maintain and respect client’s personal space boundaries (approximately 4-foot circle
around client).
3. Develop trusting relationship with the client.
4. Identify whether incident has reactivated preexisting or coexisting situations
(physical/psychological).
5. Observe for and elicit information about physical injury, and assess symptoms such
as numbness, headache, tightness in chest, nausea, and pounding heart.
6. Evaluate social aspects of trauma/incident (e.g., disfigurement, chronic conditions,
permanent disabilities).
7. Identify psychological responses (e.g., anger, shock, acute anxiety [panic],
confusion, denial).Note laughter, crying, calm or agitation, excited (hysterical) behavior,
expressions of disbelief and/ or self-blame. Record emotional changes.
8. Determine degree of disorganization. Indicator of level of intervention that is required
(e.g., may need to be hospitalized when disorganization is severe). Note signs of
increasing anxiety (e.g., silence, stuttering, inability to sit still/pacing).
9. Administer medications as indicated, e.g.: Antidepressants: fluoxetine (Prozac),
amoxapine (Asendin), doxepin (Sinequan), imipramine (Trofranil), MAO inhibitor
phenelzine (Nardil)

26. Implementation
 Establish trusting relationship
 Monitor self-awareness
 Protect the patient
 Modify the environment
 Encourage activity
 Administer medication
 Recognize anxiety
 Utilize pt insight to cope with threats
 Promote relaxation response

27. Evaluation
 Patient Outcome/Goal
 Patient will demonstrate adaptive ways of coping with stress
 Nursing Evaluation
 Was nursing care adequate, effective, appropriate, efficient, and
flexible?

28. References
 Basavanthappa,BT psychiatric mental health nursing (1 st Ed)
Jaypee Brothers medical publishers. 2007
 Videbeck, Sheila L. Psychiatric Mental Health Nursing.
Lipincolt Williams and wilkins.2007
 Varcarolis ,E, ,manual psychiatric nursing care planning,4thed
,saunder , USA 2011