Management of patient with GAD

1. GENERALIZED ANXIETY DISORDER
PREPARED BY
MRS. DIVYA PANCHOLI
ASSISTANT PROFESSOR, SSRCN, VAPI

2. DEFINITION OF ANXIETY
• An emotional (e.g. apprehension,
tension, uneasiness) to anticipation
of danger, the source of which is
largely unknown or unrecognized.
• Anxiety may be regarded as
pathologic when it interferes with
effectiveness in living,
achievement of desired goals of
satisfaction or reasonable
emotional comforts. MRS. DIVYA PANCHOLI 2

3. GENERALIZED ANXIETY DISORDER
• INTRODUCTION
• Generalized anxiety disorders
are those in which anxiety is
unvarying & persistent (unlike
phobic anxiety disorders where
anxiety is intermittent & occurs
only in the presence of a
particular stimulus.
• Irrational excessive anxiety
• Constantly for more than 6
months
MRS. DIVYA PANCHOLI 3

4. INCIDENCE
• It is the most common
neurotic disorder & it
occurs more frequently in
women than men.
• The prevalence rate of
generalized anxiety
disorders is about 2.5-8%
COURSE
•The disorder may
begin in childhood or
adolescence, but onset
is not common after
age 20.
MRS. DIVYA PANCHOLI 4

5. ETIOLOGY
GENETIC THEORY
• Anxiety disorder is most frequent
among relatives of patients with
this condition.
• About 15 to 20% of the first
degree relatives of patients with
anxiety disorder exhibit anxiety
disorder themselves.
• The concordance rate in
monozygotic twins of patients
with panic disorders is 80%MRS. DIVYA PANCHOLI 5

6. BIOCHEMICAL FACTORS
• Serotonin is thought to be decreased in anxiety disorders.
• Nor epinephrine is thought to be increased in anxiety
disorders.
• GABA is the major inhibitory neurotransmitter in the
brain. It is involved in reduction & slowing of cellular
activity. It is synthesized from glutamic acid, with
vitamin B6 as a cofactor.
• It is found in almost every region of the brain.
• GABA is thought to be decreased in anxiety disorders
(allowing for increased cellular excitability).
MRS. DIVYA PANCHOLI 6

7. PSYCHODYNAMIC THEORY
• The psychodynamic view focuses on the inability of the ego to
intervene when conflict occurs between the id and the super ego,
providing anxiety.
• For various reasons (unsatisfactory parent-child relationship,
conditional love) ego development is delayed.
• When developmental defects in ego functions compromise the
capacity to modulate anxiety, the individual resorts to
unconscious mechanisms to resolve the conflict. Overuse or
ineffective use of ego defense mechanisms results in maladaptive
responses to anxiety. MRS. DIVYA PANCHOLI 7

8. BEHAVIORAL
THEORY
•Anxiety is viewed
as an unconditional
inherent response of
the individual to a
painful stimulus.
COGNITIVE
THEORY
•According to this
theory anxiety is
related to cognitive
distortions & negative
automatic thoughts.
MRS. DIVYA PANCHOLI 8

9. CLINICAL FEATURES
MOTOR SYMPTOMS
Tremors
Restlessness
Fearful
facial expression
Muscle twitches
MRS. DIVYA PANCHOLI 9

10. CLINICAL FEATURES
PSYCHOLOGICAL
• Fearful anticipation
• Irritability
• Sensitivity to noise
• Restlessness
• Poor concentration
• Worrying thoughts &
apprehension
PHYSIOLOGICAL
MRS. DIVYA PANCHOLI 10

11. DIAGNOSIS
•Anxiety is a central feature of many
mental disorders, psychiatric evaluation
to rule out phobias, OCD, depression &
acute schizophrenia.
•Based on ICD 10 criteria.
MRS. DIVYA PANCHOLI 11

12. TREATMENT- ANXIOLYTIC MEDICATIONS
GROUP ACTION SIDE-EFFECTS
BENZODIAZE
PINES
Increases the affinity of the
GABA receptor for GABA.
Sedation, dizziness, weakness, ataxia,
decreased motor performance,
dependence, withdrawal.
SSRIS, SNRIS SSRIS block reuptake of
serotonin into the pre-synaptic
nerve terminal, increasing
synaptic concentration of
serotonin.
SNRIS inhibit reuptake of
neuronal serotonin & nor
epinephrine, mild reuptake of
dopamine.
SSRIS- nausea, diarrhea, insomnia,
headache, somnolence, sexual dysfunction
SNRIS- headache, dry mouth, nausea,
somnolence, dizziness, insomnia, asthenia
(loss of tone), constipation, diarrhea
MRS. DIVYA PANCHOLI 12

13. NORADRENERGIC AGENTS
(E.G. PROPRANOLOL,
CLONIDINE)
Prpranolol- blocks beta-adrenergic
receptor activity
Clonidine- stimulates alpha-
adrenergic receptors.
Propranolol- bradycardia,
hypotension, weakness, fatigue,
impotence, upset, bronchospasm
Clonidine- dry mouth, sedation,
fatigue, hypotension
BARBITURATES CNS depression, also produces effects
in the hepatic & cardiovascular
systems.
Somnolence, agitation, confusion,
ataxia, dizziness, bradycardia,
hypotension, constipation
BUSPIRONE Partial agonist of 5-HT1A receptor Dizziness, drowsiness, dry mouth,
headache, nervousness, nausea,
insomnia
MRS. DIVYA PANCHOLI 13

14. BEHAVIOR THERAPY
• Biofeedback to decrease physical symptoms of anxiety by
teaching the patient how to become aware of & then
consciously control various body functions (including
blood pressure, heart & respiratory rates, skin temperature
& perspiration)
• Relaxation techniques- Jacobson’s progressive muscle
relaxation, yoga, pranayama, meditation & self hypnosis.
• Supportive psychotherapy
MRS. DIVYA PANCHOLI 14

15. COGNITIVE THERAPY
• To reduce cognitive distortions by teaching the patient how
to restructure her thoughts & view her worries more
realistically.
• In one approach patient taught to record worries & list
evidence that justifies or contradicts each one.
• Patient learns that ‘worrying about worry’ maintain anxiety.
Avoidance & procrastination are ineffective problem
solving techniques.
MRS. DIVYA PANCHOLI 15

16. NURSING DIAGNOSIS
• Panic anxiety related to real or perceived threat to biological
integrity or self-concept, evidenced by various physical &
psychological manifestation.
• Powerlessness related to impaired cognition evidenced by verbal
expression &lack of control over life situations & non-participation
in decision making related to own care or significant life issues.
• Impaired virtual communication related to anxiety unrealistic
thinking as evidenced by loosening of association, echolalia,
verbigeration.
MRS. DIVYA PANCHOLI 16

17. NURSING DIAGNOSIS
•Risk for injury related to extreme hyper-activity, impulsive
behavior as evidenced by lack of control, injurious
movements.
• Altered family process related to euphoric mood,
delusion grandiosity as evidenced by refused to accept
responsibility for own activity.
•Anxiety evidenced by muscle tension, hyper vigilance,
distractibility, increased vital signs, insomnia to stress threat
to self-concept loss.
MRS. DIVYA PANCHOLI 17

18. 18
DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE
Powerlessness related to
impaired cognition evidenced
by virtual expression of lack
of contraction of control over
life situation and non-
participation in delutions
making related to own care.
Patient will able to
effectively solve
problems and take
control of his life.
 Allow the patient to take
as possible for self care
activities.
 Assist patient to set
realistic goals.
 Help identify life situation
that are within patients
control.
 Encourage the
verbalization of feeling
related to this inability.
 Provide chouis will
increase patient feeling of
control.
 Unrealistic goals set the
patient up for failure and
reinforce feeling of
powerlessness.
MRS. DIVYA PANCHOLI

19. 19
DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE
Panic anxiety related to real or
perceived threat to biological
integrity to self concept
evidenced by various physical
and psychological
manifestations.
Patient will be able to
recognize symptoms of unset
on anxiety and intervene
before reaching panic level.
 slay with the patient and
offer reassurance of safety
and security
 Maintain a clam non
thretening matter of fact
approach.
 Keep immediate
surrounding low in stimuli
 Administer tranquilizing
medication as per
physicians order.
 Presence of trusted
individuals provide feeling
of security and
reassurance
 Anxiety is contagious and
may be transferred from
staff to patient and vice
versa.
 A stimulating
environment may
increase of anxiety level.
 Provide relief from
immobilizing effect of
anxiety.
MRS. DIVYA PANCHOLI

20. 20
DIAGNOSIS OBJECTIVE INTERVENTION RATION
ALE
Anxiety evidenced by
muscle tension hyper
vigilance
distractibility
increased vital signs,
insomnia to stress,
threat to self concept
, loss
 Express feeling calmer.
 Verbalises greater
sense of control over
stressors.
 Interact with client in a calm manner
using a soft voice and reassuring
approach.
 Listens to the clients concern &
allows expressions of feeling
 Teach relaxation technique such as
deep breathing, muscles relaxation
etc.
 Determine the factors causing
anxiety.
 Administer anti-anxietic mediations.
MRS. DIVYA PANCHOLI

21. 21
DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE
Ineffective individual coping
evidenced by fear, phobic
response to events or objects,
irrational thoughts related to
phobia, extreme guilt.
 Demonstrate increased ability
to think rationally
 Tolerate feared objects,
events.
 Understand that phobic
response are irrational and
will not be changed by logical
explanations
 Approach the client in a calm
non authoritarian’s manner
using soft voice.
 Assist the client to clarify
thoughts & avoid
misinterpretations of events.
 Assist the clients to develop
coping mechanism to control
anxiety response.
MRS. DIVYA PANCHOLI

22. You can refer following link also
• https://www.youtube.com/watch?v=9mPwQTiMSj8
• https://www.youtube.com/watch?v=oEpOK9fWmmI
• https://www.youtube.com/watch?v=4WJS0O1llUo
• https://www.youtube.com/watch?v=8jR9cehXrpE
MRS. DIVYA PANCHOLI 22