Anxiety Universal human experience Dysfunctional behavior often defends against anxiety Legacy of Hildegard Peplau (1909-1999) Operationally defined concept and levels of anxiety Suggested specific nursing interventions appropriate to each of four levels of anxiety Anxiety and grief have been described as two major, primary psychological response patterns to stress. A variety of thoughts, feelings, and behaviors are associated with each of these response patterns. Adaptation is determined by the extent to which the thoughts, feelings, and behaviors interfere with an individual’s functioning.

1. Anxiety
Anxiety Disorders
Chapter 8

2. Concept of Anxiety and
Psychiatric Nursing
• Anxiety
– Universal human experience
– Dysfunctional behavior often defends against
anxiety
• Legacy of Hildegard Peplau (1909-1999)
– Operationally defined concept and levels of anxiety
– Suggested specific nursing interventions
appropriate to each of four levels of anxiety

3. Psychological Adaptation to
Stress
• Anxiety and grief have been described as two
major, primary psychological response patterns
to stress.
• A variety of thoughts, feelings, and behaviors
are associated with each of these response
patterns.
• Adaptation is determined by the extent to which
the thoughts, feelings, and behaviors interfere
with an individual’s functioning.

4. Anxiety and Fear
• Anxiety: feeling of apprehension,
uneasiness, uncertainty, or dread resulting
from real or perceived threat whose actual
source is unknown or unrecognized
• Fear: reaction to specific danger
• Similarity between anxiety and fear
– Physiological response to these experiences is
the same (fight-or-flight response)

5. Anxiety
• A diffuse apprehension that is vague in
nature and is associated with feelings of
uncertainty and helplessness.
• Extremely common in our society.
• Mild anxiety is adaptive and can provide
motivation for survival.

6. Types of Anxiety
• Normal
– Motivating force that provides energy to carry out tasks of
living
• Acute or state
– Anxiety that is precipitated by imminent loss or change that
threatens one’s security (crisis)
• Chronic or trait
– Anxiety that persists over time
• Mild
– Occurs in normal everyday living
– Increases perception, improves problem solving
– Manifested by restlessness, irritability, mild tension-relieving
behaviors

7. Types of Anxiety
• Moderate
– Escalation from normal experience
– Decreases productivity (selective inattention) and learning
– Manifested by increased heart rate, perspiration, mild somatic
symptoms
• Severe
– Greatly reduced perceptual field
– Learning and problem solving not possible
– Manifested by erratic, uncoordinated, and impulsive behavior
• Panic
– Results in loss of reality focus
– Markedly disturbed behavior occurs
– Manifested by confusion, shouting, screaming, withdrawal

8. Peplau’s four levels of anxiety
• Mild – seldom a problem
• Moderate – perceptual field diminishes
• Severe – perceptual field is so diminished that
concentration centers on one detail only or on
many extraneous details
• Panic – the most intense state

9. Behavioral adaptation responses
to anxiety
• At the mild level, individuals employ
various coping mechanisms to deal with
stress. A few of these include eating,
drinking, sleeping, physical exercise,
smoking, crying, laughing, and talking to
persons with whom they feel comfortable.

11. Defense Mechanisms
• Help protect people from painful awareness
of feelings and memories that can cause
overwhelming anxiety
– Operate all the time
– Adaptive (healthy) or maladaptive (unhealthy)
• First outlined and described by Sigmund
Freud and his daughter Anna Freud

12. Properties of Defense
Mechanisms
• Major means of managing conflict and affect
• Relatively unconscious
• Discrete from one another
• Hallmarks of major psychiatric disorders
• Can be reversible
• Can be adaptive as well as pathological

13. Healthy, Intermediate, and
Immature Defense Mechanisms
• Healthy
– Altruism, sublimation, humor, suppression
• Intermediate
– Repression, displacement, reaction formation,
undoing, rationalization
• Immature
– Passive aggression, acting-out behaviors,
dissociation, devaluation, idealization, splitting,
projection, denial

14. Defense Mechanisms
– Compensation
– Denial
– Displacement
– Identification
– Intellectualization
– Introjection
– Isolation
– Projection
– Rationalization
– Reaction formation
– Regression
– Repression
– Sublimation
– Suppression
– Undoing

15. • Anxiety at the moderate to severe level that
remains unresolved over an extended
period of time can contribute to a number of
physiological disorders – for example,
migraine headaches, IBS, and cardiac
arrhythmias.
• Extended periods of repressed severe
anxiety can result in psychoneurotic
patterns of behaving – for example, anxiety
disorders and somatoform disorders.

16. Introduction: Anxiety
Disorder
Anxiety provides the motivation for
achievement, a necessary force for survival.
Anxiety is often used interchangeably with the
word stress; however, they are not the same.
Anxiety may be differentiated from fear in that
the former is an emotional process, whereas
fear is cognitive.

17. • Extended periods of functioning at the panic
level of anxiety may result in psychotic
behavior; for example, schizophrenic,
schizoaffective, and delusional disorders.

18. Epidemiological statistics
– Anxiety disorders are the most common of all psychiatric
illnesses
– More common in women than men
– Minority children and children from low socioeconomic
environments at risk
– A familial predisposition probably exists
• How much is too much?
– When anxiety is out of proportion to the situation that is
creating it.
– When anxiety interferes with social, occupational, or other
important
areas of functioning.

19. Predisposing Factors
• Psychodynamic theory
• Cognitive Theory
• Biological aspects
• Transactional Model of Stress
Adaptation

20. Panic Disorders: Panic Attack,
Panic Disorder with Agoraphobia
• Panic attack
– Sudden onset of extreme apprehension or fear
of impending doom
– Fear of losing one’s mind or having a heart
attack
• Panic disorder with agoraphobia
– Panic attacks combined with agoraphobia
• Agoraphobia is fear of being in places or situations
from which escape is difficult or help unavailable
– Feared places avoided, restricting one’s life

21. Phobia
• Phobia: persistent, irrational fear of specific
objects, activities, or situations
• Types of phobias
– Specific: response to specific objects
– Social: result of exposure to social situations or
required performance
– Agoraphobia: fear of being in places/situations
from which escape is difficult or help
unavailable

22. Obsessive-Compulsive Disorder
(OCD)
• Obsession
– Thoughts, impulses, or images that persist and recur
• Ego-dystonic symptom: feels unacceptable to individual
• Unwanted, intrusive, persistent ideas, thoughts, impulses,
or images that cause marked anxiety or distress

23. Compulsions
• Ritualistic behaviors that individual feels driven to
perform
• Primary gain from compulsive behavior: anxiety
relief
• Unwanted repetitive behavior patterns or mental acts
that are intended to reduce anxiety, not to provide
pleasure or gratification

25. Generalized Anxiety Disorder
(GAD)
• Excessive anxiety or worry about numerous things lasting at
least 6 months
• Common symptoms
– Restlessness
– Fatigue
– Poor concentration
– Irritability
– Tension
– Sleep disorders

26. Post-traumatic Stress Disorder
(PTSD)
– Development of characteristic symptoms following
exposure to an extreme traumatic stressor involving a
personal threat to physical integrity or to the physical
integrity of others
– Characteristic symptoms include reexperiencing the
traumatic event, a sustained high level of anxiety or
arousal, or a general numbing of responsiveness.
Intrusive recollections or nightmares of the event are
common.

27. • Psychosocial theory
– The traumatic experience
• Severity and duration of the stressor
• Extent of anticipatory preparation before onset
• Exposure to death
• Numbers affected by life threat
• Extent of control over recurrence
• Location where trauma was experienced
– The individual
• Degree of ego-strength
• Effectiveness of coping resources
• Presence of preexisting psychopathology
– Outcomes of previous experiences with stress/trauma
– Behavioral tendencies
– Current psychosocial developmental stage
– Demographic factors

28. – The recovery environment
• Availability of social supports
• Cohesiveness and protectiveness of family and friends
• Attitudes of society regarding the experience
• Cultural and subcultural influences
• Learning theory
– Negative reinforcement as behavior that leads to a reduction in an
aversive experience, thereby reinforcing and resulting in repetition
of the behavior
– Avoidance behaviors
– Psychic numbing
• Cognitive theory
– A person is vulnerable to post-traumatic stress disorder when
fundamental beliefs are invalidated by experiencing trauma
that cannot be comprehended and when a sense of helplessness and
hopelessness prevails.

29. Treatment Modalities
• Psychopharmacology
– PTSD
• Antidepressants
• Anxiolytics
• Antihypertensives
• Others

30. • Biological aspects
– It has been suggested that a person who has experienced
previous trauma is more likely to develop symptoms after a
stressful life event.
– Disregulation of the opioid, glutamatergic, noradrenergic,
serotonergic, and neuroendocrine pathways may be involved
in the pathophysiology of PTSD.
• Transactional Model of Stress Adaptation
– The etiology of PTSD is most likely influenced by multiple
factors

31. Acute Stress Disorder
• Occurs within 1 month after exposure to highly
traumatic event
• Characterized by at least three dissociative symptoms
during/after event
– Subjective sense of numbing
– Reduction in awareness of surroundings
– Derealization
– Depersonalization
– Dissociative amnesia

32. Anxiety Caused by Medical
Conditions
• Direct physiological result of medical
conditions such as:
– Hyperthyroidism
– Pulmonary embolism
– Cardiac dysrhythmias
• Evidence must be present in history,
physical exam, or laboratory findings in
order to diagnose

33. Nursing Process:
Assessment Guidelines
• Determine if anxiety is primary or
secondary (due to medical condition)
– Ensure sound physical/neurological exam
• Use of Hamilton Rating Scale
– Comprehensive data related to anxiety
• Determine potential for self-harm/suicide
• Perform psychosocial assessment
• Determine cultural beliefs and background

34. Nursing Process: Diagnosis and
Outcomes Identification
• NANDA-International (NANDA-I)
– Nursing diagnoses useful for patient with
anxiety or anxiety disorder
• Nursing Outcomes Classification (NOC)
– Identifies desired outcomes for patients with
anxiety or anxiety disorders

35. Considerations for Outcome Selection
for Patients with Anxiety Disorders
• Reflect patient values and ethical and
environmental situations
• Be culturally relevant
• Be documented as measurable goals
• Include a time estimate of expected
outcomes

36. Nursing Process:
Planning and Implementation
• Planning
– Select interventions that can be implemented in
a community setting
– Include patient in process of planning
• Implementation
– Follow Psychiatric–Mental Health Nursing:
Scope and Standards of Practice (ANA, 2007)

37. Nursing Interventions for Patients
with Anxiety Disorders
• Identify community resources offering
specialized treatments proven as effective
• Identify community support groups
• Use therapeutic communication, milieu
therapy, promotion of self-care activities,
and psychobiological and health teaching
and health promotion

38. Nursing Interventions:
• Milieu Therapy
• Cognitive-Behavioral Therapy (CBT)

39. Common Benzodiazepine
Anxiolytics
Generic
diazepam
lorazepam
alprazolam
clonazepam
chlordiazepoxide
oxazepam
Brand
Valium
Ativan
Xanax
Klonopin
Librium
Serax
*Non- Anxiolytic:
BusSpar
Non-sedating, non habit forming and
not a prn. Good for the elderly

40. Non-benzodiazepine Hypnotic
Generic
Zolpidem
Zalepon
Eszopiclone
Ramelteon
Brand
Ambien, *Ambien CR
Sonata
Lunesta
Rozerem
*contains a two layer coat
One layer releases it simmediataely
and other layer has a slow release
of additional drug

41. The Nursing Process: Antianxiety
Agents
Background Assessment Data
• Indications: anxiety disorders, anxiety symptoms, acute
alcohol withdrawal, skeletal muscle spasms, convulsive
disorders, status epilepticus, and preoperative sedation
• Action: depression of the CNS
• Contraindications/Precautions
– Contraindicated in known hypersensitivity; in combination
with other CNS depressants; in pregnancy and lactation,
narrow-angle glaucoma, shock, and coma
– Caution with elderly and debilitated clients, clients with
renal or hepatic dysfunction, those with a history of drug
abuse or addiction, and those who are depressed or
suicidal

42. • Interactions
– Increased effects when taken with alcohol,
barbiturates, narcotics, antipsychotics
antidepressants, antihistamines, neuromuscular
blocking agents, cimetidine, or disulfiram
– Decreased effects with cigarette smoking and
caffeine consumption
– DO NOT USE WITH ALCOHOL
Nursing Diagnosis
• Risk for injury
• Risk for activity intolerance
• Risk for acute confusion

43. Planning/Implementation
• Monitor client for these side effects
– Drowsiness, confusion, lethargy; tolerance;
physical and psychological dependence;
potentiation of other CNS depressants;
aggravation of depression; orthostatic hypotension;
paradoxical excitement; dry mouth; nausea and
vomiting; blood dyscrasias; delayed onset
(with buspirone only)
• Educate client/family about the drug

44. Common Medications
• BZAs: short-term treatment only
– Causes dependence
• Buspirone: management of anxiety disorders
• Selective serotonin reuptake inhibitors (SSRIs): first-
line treatment for all anxiety disordersSelective
norepinephrine reuptake inhibitors (SNRIs):
venlafaxine approved for panic disorder, GAD, and
SAD
• Tricyclic antidepressants (TCAs): second- and third-
line treatment

45. Nursing Process: Evaluation
– Does patient maintain satisfactory
relationships?
– Can patient resume usual roles?
– Is patient compliant with medications?
– Does patient maintain satisfactory
relationships?
– Can patient resume usual roles?
– Is patient compliant with medications?