Anxiety Disorders

PREPAREDAND PRESENTED
BY
RICHARD OPOKUASARE
COLLEGE OF NURSING, NTOTROSO
SCHOOL OFALLIED HEALTH SCIENCES, UDS,TAMALE
asareor@gmail.com ©20161
ANXIETY DISORDERS

INTRODUCTION
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Anxiety is an essential part of being human. It is a survival
instinct that has evolved over millions of years, automatic
mind and body reactions that help us to deal with danger
or avoid it altogether. It is a phenomenon that
humankind has always recognized, since everyone feels
anxious at times. But for some of us things change...
anxiety grows stronger.An undercurrent of
apprehension flows through our thoughts, we become
more sensitive, more uptight, always‘on-edge’ to some
degree.

INTRODUCTION
Over time this anxiety can build up and become so
powerful that it gives rise to other problems such as:
excessive nervousness and worrying, attacks of
anxiety or panic, obsessive thoughts and compulsive
behaviours, irrational fears and phobias, even severe
depression.These problems can overwhelm us and
leave us feeling out of control.We feel as though we
are driven to act like this, strengthen with every
‘attack’ and lead to constant searching for reasons
and answers.

INTRODUCTION
Involving self-doubt, insecurity and fear, anxiety can
appear too powerful to deal with. Indeed, it can begin to
feel like there is no way out of the anxious cycle of
thinking, feeling and behaving in which we find
ourselves.
Anxiety is a complaint of most hospitalized patients. It is seen
as a feeling, a mood, an emotional response, a syndrome, a
symptom, or an illness. It is generally an unpleasant
experience that is similar to fear.

INTRODUCTION
This presentation focuses on some definitions of anxiety, the
differences between normal anxiety and pathological anxiety.
The presentation would further explore the following anxiety
disorders:
 Phobia
 Obsessive-Compulsive Disorder
 PostTraumatic Stress Disorder, and
 GeneralizedAnxiety Disorder
These are types of anxieties indicated in the curriculum for the
Registered General Nursing (RGN) Programme (Nursing and
Midwifery Council, Ghana, October, 2015) for students to know.

DEFINITIONS
 Anxiety: “a feeling of worry, nervousness, or unease about
something with an uncertain outcome.”
 Anxious: “feeling or showing worry, nervousness, or unease”
(Oxford English Dictionary)
 Anxiety Disorders: “Self-damaging ways of thinking, feeling
and behaving characterized by anxiety as a central or core
symptom.”
 Anxiety is defined as a feeling of apprehension and/or tension
that some described as an exaggerated feeling of impending doom,
dread, or uneasiness.
 It is a reaction to an internal threat, such as unacceptable impulse
or a repressed thought that’s straining to reach a conscious level.

FORMS OF ANXIETY
There are two main forms of anxiety.These are:
 Normal Anxiety
 Pathological (or Neurotic) Anxiety.
 Normal Anxiety:This is a normal response to an observable threat, which
some call fear. Fear is a reaction to danger from a specific external source.
 Pathological/Neurotic Anxiety:This is an
affective/cognitive/behavioral/physiological response to an internal or
external threat, real or imagined, during which the person experiences a
“felt” unpleasant emotional state.Thus, it is an inappropriate reaction to a
given stimulus; it is the form of anxiety experienced by those with anxiety
disorders and is different from fear.

DIFFERENTIATING NORMAL ANXIETY
FROM PATHOLOGICAL ANXIETY
NORMAL ANXIETY PATHOLOGICAL/NEUROTIC
ANXIETY
Less intense More intense
May lead to phobias that do not
interfere with life
May lead to phobias that interfere with
life
Identifiable threat or stimuli; cause is
known
Unidentified threat or stimuli;
Psychogenic cause
Does not last longer; may not persist for
months
Last longer; may persist for months
Rational fear of a stimulus Irrational fear of a stimulus

CHARACTERISTICS OF ANXIETY
DISORDERS
1) Excessive worry
2) Fear of illness or impending doom
3) Multiple somatic complaints
4) Avoidant behavior of anxiety-provoking stimuli

EXPLANATION
A phobia is a persistent, and irrational fear of a specific object,
situation, or activity, under ordinary circumstances, should not
provoke fear. Usually, the phobic person is aware that the fear is
unrealistic but still avoids its target.This reaction is beyond the
voluntary control of the person. Encountering what is feared leads to
severe anxiety.
PHOBIC DISORDERS
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EXPLANATION – Cont’d
 Thus, a phobia is an excessive and irrational fear
reaction usually connected to something specific.
 People with phobias often realize their fear is
irrational, but they are unable to do anything about
it. Such fears can interfere with the individual’s
work, school, and personal relationships.
 In sum, phobia is an illogical, intense, persistent fear
of a specific object or a social situation that causes
extreme distress and interferes with normal
functioning.

CAUSES
 Genetics: Children who have a close relative with an anxiety
disorder are at risk for developing a phobia.
 Distressing events: Events such as nearly drowning can
bring on a phobia.
 Exposition: Exposure to confined spaces, extreme heights,
and animal or insect bites can all be sources of phobias.
 Medical condition: People with ongoing medical
conditions or health concerns often have phobias.
 Injuries: There is a high incidence of people developing
phobias after traumatic brain injuries.

CAUSES – Cont’d
 Substance Abuse and depression are also connected to
phobias.
 Ego defense mechanism: According to psychoanalytic
theory, a phobia is a defensive reaction in which the patient
tries to deal with his anxiety by disassociating it from the
original cause (be it a person, place or object) and associating
the anxiety with another person, place or object.The phobic
reaction is unconscious.This is why the sufferer cannot
control the fear whenever s/he is near the stimulus, despite
being aware that the feared object is harmless.

TYPES OF PHOBIC DISORDERS
 There are three forms of phobic disorders.These are:
 AGORAPHOBIA
 SOCIAL PHOBIA
 SPECIFIC PHOBIA

AGORAPHOBIA
Agoraphobia is a fear of places or situations that one cannot
escape from.The word itself refers to “fear of open spaces.”
People with agoraphobia fear being in large crowds or
trapped outside the home.They often avoid social situations
altogether and stay inside their homes.
People with agoraphobia fear they may have a panic attack in a
place where they cannot escape.Those with chronic health
problems may fear they will a medical emergency in a public
area or where no help is available.

SOCIAL PHOBIA
Social phobia is also referred to as “Social anxiety disorder.”
This is extreme worry about social situations that can lead to self-
isolation.A social phobia can be so severe that the simplest
interactions, such as ordering at a restaurant or answering the
telephone, can cause panic.Those with social phobia will often go out
of their way to avoid public situations.
Thus, in social phobia individuals fear that if they attempt to do things
in public they will appear inept, foolish, or inadequate and suffer
shame, embarrassment, or humiliation. Feeling this way, individuals,
although admitting that the fears are irrational and groundless,
nevertheless become intensely anxious upon approaching these
situations and may go to great lengths to avoid them.

Other examples of social phobia
 Individuals may be fearful of answering questions in class.
 Fear of asking others out of date.
 Fear of attending meetings or, in severe cases, of interacting
socially at all.
 Fear of trembling when writing in public.
 Fear of chocking when eating in public, and being unable to
urinate when others are around.
 NB: It is not so much the act itself that is feared, but rather,
it is the doing of the act in public which arouses the fear.

SPECIFIC PHOBIA
Specific phobia, also called simple phobia, is a condition where
an individual experiences extreme anxiety when approaching
something that for others arouses little or no apprehension. It
is therefore an excessive fear of an object, activity, or a
situation, which leads a person to avoid the cause of that fear.
To be a true phobia, the fear must seriously disrupt a person’s
life-style. Common among the phobias are the fears of
snakes, spiders, air travel, train travel, being in closed spaces,
heights, darkness, storms, sight of blood, marriage, and
examinations.

SOME COMMON PHOBIAS AND THEIR
MEANINGS
PHOBIA MEANING
Acrophobia Fear of heights and high places
Aerophobia Fear of air or draughts
Aichmophobia Fear of knives
Amaxophobia Fear of vehicles, driving
Androphobia Fear of men
Bathophobia Fear of depths and deep places
Belonephobia Fear of needles
Bibliophobia Fear of books
Botanophobia Fear of plants

MEANINGS
PHOBIA MEANING
Ceraunophobia Fear of thunder
Chrematophobia Fear of money
Claustrophobia Fear of confined spaces or enclosed places
Dementophobia Fear of insanity
Dromophobia Fear of crossing a street
Erotophobia Fear of sexual activity
Erythrophobia Fear of the colour red, or of blushing
Gamophobia Fear of marriage
Gephryrophobia Fear of crossing bridge or river

MEANINGS
PHOBIA MEANING
Gynophobia Fear of women
Haemophobia Fear of blood
Herpetophobia Fear of reptiles
Hierophobia Fear of sacred objects or rituals
Hodophobia Fear of travel
Ithyphallophobia, medorthophobia Fear of an erect penis
Kenophobia Fear of empty spaces
Mikrophobia Fear of germs, bacteria, or small objects
Molysmophobia, molysomophobia Fear of contamination or infection.

MEANINGS
PHOBIA MEANING
Necrophobia Fear of corpses or death
Neophobia Fear of new situations, places, or objects
Nomatophobia Fear of names
Nosophobia Fear of disease
Ochlophobia Fear of crowds
Oikophobia Fear of one’s surroundings
Ornithophobia Fear of birds
Pantophobia Fear of everything
Pentheraphobia Fear of a mother in law

MEANINGS
PHOBIA MEANING
Phagophobia Fear of food or eating
Phallophobia Fear of penises
Phengophobia Fear of daylights
Pneumatophobia Fear of spirits or noncorporeal beings
Politicophobia Fear of politicians
Scotophobia Fear of the dark
Selenophobia Fear of the moon
Sitophobia Fear of food or eating
Soceraphobia Fear of parents in law

MEANINGS
PHOBIA MEANING
Thanatophobia Fear of death
Theophobia Fear of God
Topophobia Fear of places
Toxiphobia Fear of poisoning
Trichophobia Fear of hair
Triskaidekaphobia Fear of number thirteen
Venerophobia Fear of venereal diseases
Xenophobia Fear of or hostility of foreigners
Zoophobia Fear of animals

SYMPTOMS OF PHOBIA
The most common and disabling symptom of a phobia is a panic attack.
Features of a panic attack include:
 Pounding or racing heart
 Shortness of breath
 Rapid speech or inability to speak
 Dry mouth
 Upset stomach or nausea
 Elevated blood pressure
 Trembling or shaking
 Choking sensation
 Dizziness or lightheadedness
 Profuse sweating
 Sense of impending doom

TREATMENT FOR PHOBIAS
 Cognitive BehaviouralTherapy (CBT): This therapy
focuses on identifying and changing negative thoughts,
dysfunctional beliefs, and negative reactions to fear. It
involves exposure to the source of the fear, but in a
controlled setting.This treatment can decondition people and
reduce anxiety.
 Medications: Antidepressants (e.g., fluoxetine,
imipramine) and anti-anxiety drugs (e.g., chlordiazepoxide,
diazepam, lorazepam) can both help calm both emotional and
physical reactions to fear.
 Hypnosis and Relaxation techniques

NURSING MANAGEMENT
 Provide for the patient’s safety and comfort and monitor fluid and
food intake as needed. Certain phobias may inhibit food or fluid
intake, disturb hygiene, and disrupt the patient’s ability to rest.
 Avoid the urge to trivialize his fears, no matter how illogical the
patient’s phobia seems. Remember that this behavior represents an
essential coping mechanism.
 Encourage him to verbalize and explore his personal strengths and
resources with you (nurse) by asking the patient how he normally
copes with the fear (when he’s able to face the fear).
 Don’t let the patient withdraw completely. If he’s being treated as an
outpatient, suggest small steps to overcome his fears such as planning
a brief shopping trip with a supportive family member or friend.

NURSING MANAGEMENT – Cont’d
 Encourage him to interact with others and provide continuous
support and positive reinforcement; because in social phobias,
the patient fears criticism.
 Support participation in psychotherapy, including
desensitization therapy. However, don’t force insight.
Challenging the patient may aggravate his anxiety or lead to
panic attacks.
 Teach the patient specific relaxation techniques, such as
listening to music and mediating.
 Suggest ways to channel the patient’s energy and relieve stress
(such as running and creative activities).

EXPLANATION
Obsessive-compulsive disorder (OCD), once known as “obsessive-
compulsive neurosis,” is an anxiety disorder characterized by
two main clinical features, namely:
•Recurrent obsessions, or
•Compulsions.
These features interfere with normal life of the individual.
OBSESSIVE-COMPULSIVE
DISORDERS

OCD is characterised by unreasonable thoughts and fears (obsessions) that
lead the individual to do repetitive behaviours (compulsions).
• An obsession is a persistent, painful, intrusive thought, emotion, or
urges that one is unable to suppress or ignore. Common obsessive
thoughts include topics such as religion, sexuality, violence, and
contamination. Everyone has experienced recurrent thoughts at one time
or another.
For example, lines of a song or poem may invade one’s thoughts and
continually run through one’s mind. Obsessions are considered senseless
or repugnant and they cannot be eliminated by logic or reasoning.A
repetitive thought of killing, stabbing, shooting, hitting, or maiming
someone is an example of a violent obsession.Thoughts of contamination
include images of dirt, germs, or faeces.

 A compulsion is the performance of a repetitious,
uncontrollable but seemingly purposeful act to prevent some
future event or situation. Resistance to the act increases
anxiety.Yielding to the compulsion decreases anxiety.The
person is aware of the senselessness of the behaviour and does
not derive pleasure from performing the act. Examples
include repetitive touching, counting, checking, and hand
washing; such actions are not uncommon in children and
adolescents.

AETIOLOGY
 Biochemical influence, e.g., dysregulation of serotonin.
 genetic component, e.g.,Approximately 35% of first-degree
relatives are also affected by OCD; Monozygotic twins have a
higher concordance rate for OCD than dizygotic twins.
 Traumatic injury, e.g., OCD is seen more frequently after brain
injuries or neurological disease such as Huntington’s.
 Infections have been implicated to trigger OCD.
 Behavioural theory suggests that obsessions result from
classical conditioning. Neutral stimuli become paired with
emotional responses of anxiety, and compulsions are a learned
patterned of behaviour that becomes fixed as anxiety is reduced.

Obsession Themes
 Fear of contamination or dirt
 Having things orderly and symmetrical
 Aggressive or horrific thoughts about harming yourself or
others
 Unwanted thoughts, including aggression, or sexual or
religious subjects

Obsession Signs and Symptoms
 Fear of being contaminated by shaking hands or by touching
objects others have touched.
 Doubts that you’ve locked the door or turned off the stove (i.e.,
repetitive checking of doors, etc.).
 Intense stress when objects are not orderly or facing a certain way.
 Images of hurting yourself or someone else.
 Thoughts about shouting obscenities or acting inappropriately.
 Avoidance of situations that trigger obsessions, such as shaking
hands.
 Distress about unpleasant sexual images repeating in your mind.

Compulsion Themes
 Washing and cleaning
 Counting
 Checking
 Demanding reassurances
 Following a strict routine
 Orderliness (arranging and rearranging of items)
 Praying or chanting
 Touching, rubbing, or tapping
 Hoarding
 Aggressive urges (for instance, to kick a colleague, etc.)

Compulsion Signs and Symptoms
 Hand-washing until your skin becomes raw or bruise.
 Checking doors repeatedly to make sure they are locked.
 Checking the stove repeatedly to make sure it is off.
 Counting in certain patterns.
 Silently repeating a prayer, word or phrase.
 Arranging your canned goods to face the same way.

COMPLICATIONS
 Inability to attend work, school or social activities
 Troubled relationships
 Overall poor quality of life
 Anxiety disorders
 Depression
 Eating disorders
 Suicidal thoughts and behaviour
 Alcohol or other substance abuse
 Contact dermatitis from frequent handwashing

TREATMENT
 Psychotherapy
a) Exposure and Response Prevention (ERP):This involves
gradually exposing the individual to a feared object or obsession,
such as dirt, and having him/her learn healthy ways to cope
his/her anxiety.
b) Flooding:This frequent full-intensity exposure (through the use
of imagery) to an object that triggers a symptom must be used
with caution because it produces extreme discomfort.
c) Implosion therapy:A form of desensitization, implosion therapy
calls for repeated exposure to a highly feared object.

TREATMENT –cont’d
 Medications
a) Clomipramine (Anafranil)
b) Fluvoxamine (Luvox)
c) Fluoxetine (Prozac)
d) Paroxetine (Paxil, Pexeva)
e) Sertraline (Zoloft)
 ElectroconvulsiveTherapy
 Psychosurgery as a last resort. In this procedure, a surgical
lesion is made in an area of the brain (the cingulate cortex).
Deep-brain stimulation (DBS) and vagus nerve stimulation are
possible surgical options that do not require destruction of brain
tissue.

NURSING MANAGEMENT
 Approach the patient unhurriedly.
 Provide an accepting atmosphere; don’t show shock,
amusement, or criticism of the ritualistic behaviour.
 Keep the patient’s physical health in mind. For example,
compulsive hand washing may cause skin breakdown, and
rituals or preoccupations may cause inadequate food and fluid
intake and exhaustion.
 Provide for basic needs, such as rest and nutrition, if patient
becomes involved in ritualistic thoughts and behaviours to
the point of self-neglect.

 Let the patient know you (nurse) are aware of his behaviour. For
example, you might say,“I noticed you’ve made your bed three
times today; that must be very tiring for you.”
 Help the patient explore feelings associated with the behaviour.
For example, ask him,“What do you think about while you are
performing your chores?”
 Make reasonable demands and set reasonable limits; make their
purpose clear.Avoid creating situations that increase frustration
and provoke anger, which may interfere with treatment.
 Explore patterns leading to the behaviour or recurring problems.
Listen attentively, offering feedback.

 Encourage the use of appropriate defense mechanisms to
relieve loneliness and isolation.
 Engage the patient in activities to create positive
accomplishments and raise his self-esteem and confidence.
 Encourage active diversional resources, such as whistling or
humming a tune, to divert attention from the unwanted
thoughts and to promote a pleasurable experience.
 Identify insight and improved behavior (reduced compulsive
behavior and fewer obsessive thoughts). Evaluate behavioural
changes by your own and the patient’s reports.

 Identify disturbing topics of conversation that reflect underlying
anxiety or terror.
 Observe when interventions do not work; re-evaluate and
recommend alternative strategies.
 Help the patient identify progress and set realistic expectations of
himself and others.
 Assist the patient with new ways to solve problems and to develop
more effective coping skills by setting limits on unacceptable
behaviour (for example, by limiting the number of times per day
he may indulge in obsessive behaviour). Gradually shorten the
time allowed. Help him focus on other feelings or problems for
the remainder of the time.

 Explain how to channel emotional energy to relieve stress
(for example, through sports).Also teach the patient
relaxation and breathing techniques to help reduce anxiety.
 Work with the patient and other treatment team members to
establish behavioural goals and to help the patient tolerate
anxiety in pursuing these goals

EXPLANATION
Posttraumatic stress disorder (PTSD), formerly known as
“traumatic neurosis,” may occur in practically anyone who has
been exposed to an overwhelmingly traumatic event. Subsequent to
the trauma, whether it be a life-threatening accident, torture, a
natural disaster, or some other extraordinary calamity, such as rape,
patients re-experience the event over and over again as if
unable to lay it to rest.
POST TRAUMATIC STRESS
DISORDER

A general withdrawal from present life occurs, and
patients tend to be anxious and easily startled.They
may have recurrent dreams of the event or
experience intrusive recollection of it during the
day. In extreme instances patients seem in fact to be
actually reliving the event, and they may act
accordingly. For example, a combat veteran (soldier)
may dive for cover if a child sets off a firecracker in
the park (Moore & Jefferson, 2004).

In other words, PTSD occurs after a person has been
exposed to a severe traumatic stressor that involved the
threat of death.The person then persistently re-
experiences the trauma and associated symptoms of
anxiety and arousal.
In sum, PTSD is a mental health condition that is triggered
by a terrifying event – either experiencing it or
witnessing it. Symptoms may include flashbacks,
nightmares and severe anxiety, as well as uncontrollable
thoughts about the event (Mayo, 2014).

DEFINITION
 PTSD is characterised by the re-experiencing of an
extremely traumatic event, avoidance of stimuli
associated with the event, numbing of responsiveness,
and persistent increased arousal; it begins within 3
months to years after the event and may last a few
months or years (Videbeck, 2008, page 246).
 Acute Stress Disorder is also a PTSD, but the
associated symptoms of anxiety must occur within 1
month of experiencing the traumatic stressor; it last 2
days to 4 weeks.

CAUSES
 Products of human cruelty, such as torture,
incarceration in a death camp, sexual and child abuses,
etc.
 Events that catch persons by surprise and then leave
them with no social support afterward, such as typhoon,
earthquakes, landslides, etc. that devastates a
community.
 Lorry/car accidents are less likely to produce PTSD.
 Life experiences, including the amount and severity of
trauma one has gone through since early childhood.

CAUSES – Cont’d
 Heredity:
a) Twin studies have suggested a genetic susceptibility.
b) Inherited aspects of one’s personality – often called your
temperament.
c) Inherited mental health risks, such s increased risk to
anxiety and depression.
 Biochemical and Endocrinologic factors:
a) Studies of these chemicals have shown that alterations in
the production of these substances can lead to “flashbacks.”
b) The way one’s brain regulates the chemicals and hormones
one’s body releases in response to stress.

COMMON TRAUMATIC EVENTS
 Combat exposure (War)
 Childhood neglect and physical abuse
 Sexual assault
 Physical attack (such as armed robbery invasion)
 Being threatened with a weapon

CLINICAL FEATURES
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PTSD symptoms are generally grouped into four (4) types:
 Intrusive memories
 Avoidance
 Negative changes in thinking
 Mood or changes in emotional reactions.

Symptoms of Intrusive Memories
 Recurrent, unwanted distressing memories of the
traumatic event.
 Reliving the traumantic event as if it were
happening again (flashbacks).
 Upsetting dreams about the traumatic event.
 Severe emotional distress or physical reactions to
something that reminds the individual of the
event.

Symptoms of Avoidance
 Trying to avoid thinking or talking about the
traumatic event.
 Avoiding places, activities or people that remind
the individual of the traumatic event.

Symptoms of Negative Changes in
Thinking and Mood
 Negative feelings about oneself or other people.
 Inability to experience positive emotions.
 Feeling emotionally numb.
 Lack of interest in activities the individual once
enjoyed.
 Hopelessness about the future
 Memory problems, including not remembering
important aspects of the traumatic event.
 Difficulty maintaining close relationships.

Symptoms of Changes in Emotional Reactions
(also called Arousal Symptoms)
 Irritability, angry outburst or aggressive
behaviour.
 Always being on guard for danger.
 Overwhelming guilt or shame.
 Self-destructive behaviour, such as drinking too
much or driving too fast.
 Trouble concentrating.
 Being easily startled or frightened.

COMPLICATIONS
 Suicidal thoughts and actions
 Depression
 Anxiety
 Drugs and alcohol use
 Eating disorders
 Marital and other relationship problems
 May tend not have children
 Difficulty coping with work

TREATMENT
 Supportive psychotherapy with an emphasis on
developing effective coping strategies is used.
 Cognitive therapy:This type of talk therapy helps the
patient recognise his/her ways of thinking that are
keeping him/her stuck – for example, negative or
inaccurate ways of perceiving normal situations.
 Exposure therapy:This behavioural therapy helps the
patient face what s/he find frightening so that s/he can
learn to cope with it effectively. One approach to
exposure therapy uses “virtual reality” programs that
allow the patient to re-enter the setting in which s/he
experienced the trauma.

TREATMENT – Cont’d
 Eye movement desensitization and reprocessing (EMDR):
This combines exposure therapy with a series of guided eye
movements that help the patient process traumatic memories
and change how s/he react to traumatic memories.
 Drug treatment is usually with imipramine or amitriptyline
for at least one year.
 *SSRIs, *MAOIs,Trazodone, and Benzodiazepines are also
used.
 *SSRIs = Selective Serotonin Re-uptake Inhibitors
 *MAOIs = Monoamine Oxidase Inhibitors

NURSING CONSIDERATIONS
 Encourage the patient to express his/her grief,
complete the mourning process and gain coping
skills to relieve anxiety and desensitize him/her to
the memories of the traumatic event.
 Examine your (i.e., nurse) feelings about the event
(war or other trauma) so you won’t react with
disdain and shock. Reacting this way hampers the
relationship with the patient and reinforces his/her
typically poor self –image and sense of guilt.

NURSING CONSIDERATIONS – Cont’d
 Encourage him/her to move from physical to verbal
expression of anger.
 Help the patient relieve shame and guilt precipitated
by actions (such as killing or mutilation) that violated
a moral code.
 Help patient put his/her behaviour into perspective,
recognize his/her isolation and self-destructive
behaviour as forms of atonement, and accept
forgiveness. Refer patient to clergy or spiritual leader
as appropriate.

NURSING CONSIDERATIONS – Cont’d
 Practice crisis intervention techniques as
appropriate.
 Accept the patient’s level of functioning; assume a
positive, consistent, honest, and non-judgemental
attitude.
 Provide a safe, staff-monitored room in which the
patient can deal with urges to commit physical
violence or self-abuse by displacement (such as
pounding and clay).
 Provide for or refer the patient to group therapy.

EXPLANATION
Generalized Anxiety Disorder (GAD), also known as “chronic
anxiety neurosis,” is characterized by chronic “free-floating
anxiety,” (i.e., excessive worry and anxiety) for a period of 6-
months accompanied by such autonomic symptoms as tremors,
tachycardia, and diaphoresis as well as somatic complaint of
muscle tension.
GENERALIZED ANXIETY
DISORDER

EXPLANATION
 Free-floating Anxiety is that anxiety that is always
present and accompanied by a feeling of dread,
e.g., failing to sleep at night for fear of something
bad happening such as thieves breaking into one’s
apartment and thereby checking windows daily,
etc.
 In short, GAD is characterized by at least 6
months of persistent and excessive worry and
anxiety.

AETIOLOGY
 Personality: A person whose temperament is timid or
negative or who avoids anything dangerous may be more
prone to generalized anxiety disorder than others are.
 Genetics: GAD may run in families.
 Biochemical factors: Alteration in GABA, noradrenaline,
and serotonin levels may lead to production of clinical
anxiety.
 Learned behaviour: An internal conditioned responses to
a perceived threat or stimuli in the environment, as explained
by behaviour theory.
 Faulty or distorted thinking patterns that occur or
precede maladaptive behaviors and emotional disorders
(Refer CognitiveTheory).

AETIOLOGY – Cont’d
 PsychodynamicTheory: This school of thought
proposes that anxiety is the response of the ego to
unconscious, unacceptable thoughts, feelings, and impulses
that threaten to emerge into consciousness.
 Stressful life events: These are events that occur in
childhood.Threat of harm to the patient or his family, such
as war, abuse, or violent crime (such as witnessing the
death or serious injury of another person) or disaster
(natural/artificial) may trigger anxiety.
 Brain lesions: Organic brain syndrome may set the tone
for anxiety (Refer MedicalTheory).

SIGNS AND SYMPTOMS
 Fatigue
 Irritability
 Muscle tension or muscle aches
 Trembling, feeling twitchy
 Being easily startled
 Trouble sleeping
 Sweating
 Nausea, diarrhoea, constipation or
irritable bowel syndrome
 Headaches
 Palpitations
 Interpersonal withdrawal
 Choking
 Frequency/hesitation of
urination
 Sexual dysfunction
 Tinnitus
 Feeling dread (Feeling of
something terrible about to
happen)
 Feeling of restlessness
 Poor concentration
 Increased consumption of
alcohol/tobacco
 Frequent nail biting

COMPLICATIONS
 Depression
 Substance abuse
 Insomnia
 Digestive or bowel problems
 Heart-health issues, e.g., tachycardia.
 Accident prone behaviour

TREATMENT
A. Chemotherapy:
 Benzodiazepines (e.g. alprazolam, clonazepam)
 Antidepressants (e.g., imipramine)
 Beta blockers to control severe palpitations that have not responded to
anxiolytics (e.g., propanonol)
B. Behavioral therapies:
 Bio-feedback
 Hyperventilation control
C. Other psychological therapies:
 Supportive and Group psychotherapy
 Jacobson’s progressive muscle relaxation technique, yoga, pranayama,
meditation and self-hypnosis

NURSING MANAGEMENT
 NursingAssessment –Assessment should focus on
collection of physical, psychological and social data.
The nurse should be particularly aware of the fact that
major physical symptoms are often associated with
autonomic nervous system stimulation. Specific
symptoms should be noted, along with statements
made by the client about subjective distress.The nurse
must use clinical judgement to determine the level of
anxiety being experienced by the client.
 Other nursing interventions include the following:

 Stay with the client and offer reassurance of safety and
security.
 Maintain a calm, non-threatening matter-of-fact
approach.
 Use simple words and brief messages, spoken calmly
and clearly to explain hospital experiences.
 Keep immediate surroundings low in stimuli (dim
lighting, few people).
 Administer tranquilizing medication as prescribed by
physician.Assess for effectiveness and for side-effects.

 Teach signs and symptoms of escalating anxiety and ways to
interrupt its progression (relaxation techniques, deep-breathing
exercises and meditation, or physical exercise like brisk walks
and jogging).
 Allow patient to take as much responsibility as possible for self-
care activities, provide positive feedback for decisions made.
 Assist patient to set realistic goals.
 Help identify life situations that are within client’s control.
 Help client identify areas of life situation that are not within his
ability to control. Encourage verbalization of feelings related to
this inability.

THANK
YOU
END OF PRESENTATION

Anxiety Disorders

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