ANXIETY DISORDERS

An emotional response as apprehension, tension etc. to anticipation of danger. Regarded as

pathologic when it interferes with effectiveness in living, achievement of desired goals or
satisfaction, or reasonable emotional comfort. Normal reaction to a realistic danger or threat to
biological integrity or self-concept, considered abnormal if:
− Is out of proportion to the situation that is creating it
− Interferes with social, occupational, or other important areas of functioning
It is the most common psychiatric illness, more common in women
Levels of anxiety:
 Normal- experience periodic warnings of a threat- prompt the client take necessary steps
to prevent a threat or lessen its consequences
 Mild anxiety- increased alertness to inner feelings, has an increased ability to learn,
feelings or restlessness
 Moderate anxiety- sensory perceptions are limited, decreased concentration, pacing,
voice tremors, decreased problem solving
 Severe anxiety- perception further reduced, focus on one detail, inability to communicate,
lack of determination or ability to perform, sense of impending doom
 Panic state- complete disruption of ability to perceive, difficulty verbalizing, unable to
function normally, unable to focus on reality, loss of control
Clinical symptoms:
Physiologic-
 Increased P, BP, R
 Dyspnea or hyperventilation
 Diaphoresis
 Vertigo or lightheadedness
 Blurred vision
 Anorexia, N/V
 Frequency of urination
 Headache
 Insomnia or sleep disturbances
 Weakness or muscle tension
 Tightness in the chest
 Sweaty palms
 Dilated pupils
Physiological or emotional-
 Withdrawal
 Depression
 Irritability
 Crying
 Lack of interest or apathy
  Hypercriticism
 Anger
 Feelings of worthlessness, apprehension, or helplessness
Behavioral symptoms-
 Pacing
 Inability to sit still
 Fingering hair or other nervous habit
 Hypervigilance
Intellectual or cognitive-
 Decreased interest, concentration
 Nonresponsiveness to external stimuli
 Decreased productivity
 Preoccupation
 Forgetfulness
 Orientation to past rather than present or future
Panic disorder:
 A sudden overwhelming feeling of terror or impending doom
 Severe form of emotional anxiety accompanied by behavioral, cognitive, and
physiological signs and symptoms
 Attack usually lasts minutes
 Onset is usually in late teens or early twenties, women twice likely than men
Clinical symptoms:
 Palpitations, pounding heart, increased heart rate
 Diaphoresis, tremors
 Shortness of breath
 Feeling of choking
 Chest pain or discomfort
 Nausea, abdominal discomfort, vertigo
 Derealization, depersonalization
 Fear of loosing control or going crazy
 Fear of dying
 Numbness or tingling sensation
 Chills or hot flashes
Diagnostic characteristics:
 Period of intense fear or discomfort
 Evidence of at least four clinical symptoms
 Sudden onset of symptoms peaking within 10 minutes
Panic disorder with agoraphobia:
 Individual experiences fear of being in places or situations from which escape might be
difficult (or embarrassing) or in which help might not be available
  Individual exhibits concern about having additional panic attacks, consequences, or
change in behavior
 Fear may severely restrict travel or leaving home unaccompanied
Phobia disorder
Irrational fear of an object, activity, or situation that is out of proportion to the stimulus and
results in avoidance of the objects, activity or situation. Fear cued by the presence or anticipation
of a specific object, exposure to which almost invariably provokes an immediate anxiety
response or panic attack even though the subject recognizes that the fear is excessive or
unreasonable. Anxiety is intermittent, arising in particular situation
Agoraphobia:
Fear of being alone in public places from which either escape is not possible or help cannot be
sought promptly. The situations may cause anticipatory anxiety. Seen more commonly in women.
Onset may be sudden or gradual, in 20s or 30s. Comorbid conditions- depression, fatigue,
tension may also be present.
Diagnostic criteria:
- Presence of agoraphobia related to fear of developing panic-like symptoms
- Criteria for panic disorder have never been met
- Disturbance is not due to the direct physiological effects of a substance
- If an associated general medical condition is present, the fear is clearly in excess of that
usually associated with the condition
- Eg- being outside the home, standing in a line, being on a bridge, being in a crowd,
travelling
Social phobia:
Also known as social anxiety disorder. The client desires to avoid situations in which others may
criticize. Begins in childhood or adolescence, interferes with development. Predisposes to other
disorders or comorbidly present with depression, substance abuse etc. more common in first
degree relatives (3 times more likely). Eg.- fear of performing in public, public speaking, eating
etc, may be specific to general. Person recognizes the fear as excessive or disproportionate but is
rarely incapacitating daily functioning. Equally common in men and women. Impairment
interferes with social or occupational functioning causing marked distress to the client. Blushing
and trembling are frequent in social situations.
Diagnostic criteria:
- A marked and persistent fear of one or more social or performance situations in which the
person is exposed to unfamiliar people or to possible scrutiny from others.
- The individual fears that he or she will act in a way that will be humiliating or embarrassing
- Exposure to the feared social situation almost invariably provokes anxiety, which may take
the form of a panic attack
- The person recognizes that the fear is excessive or unreasonable
Specific phobia:
Excessive fear of an object, an activity, or a situation that leads to avoidance of the cause of that
fear. Women are twice likely to suffer than men.
Diagnostic criteria:
- Marked and persistent fear that is excessive or unreasonable when specific object or
situation is present or anticipated
- Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response,
which may reach upto panic attack
- The person recognizes the fear as excessive or unreasonable
- The phobic situation is avoided or else is endured with intense anxiety or distress
- The avoidance, anxious anticipation, or distress in the feared situation interferes
significantly with the person’s normal routine, occupational (academic) functioning,
social activities, relationships or there is marked distress about having the phobia
- In individuals under 18 years of age, duration is at least 6 months
- The anxiety, panic attacks, or phobic avoidance associated with the specific object or
situation are not better accounted for by another mental disorder
Generalized anxiety disorder:
Unrealistic or excessive worry, anxiety and tension the duration of which should be for 6 months
or more that cannot be attributed to specific organic factors. Anxiety interferes with social,
occupational or other important areas of functioning. It can begin across the life cycle, but
highest between childhood and middle age. More common in women.
Clinical features:
- Symptoms are persistent and are not restricted to, or markedly increased in, any particular
set of circumstances
- Excessive anxiety and worry about a number of events that the individual finds difficult to
control
- Restlessness, feeling keyed up or being on edge
- Being easily fatigued
- Difficulty concentrating or mind “going blank”
- Irritability, muscle tension
- Hyperventillation
- Sleep disturbances
Obsessive-compulsive disorder:
Recurrent obsessions (a persistent, painful, intrusive thought, emotion or urge that one is unable
to suppress or ignore) or compulsions (the performance of a repetitious, uncontrollable, but
seemingly purposeful act to prevent some future event or situation) or a combination of both that
interferes with normal life. Mean age of onset- 20 years, as early from 2 years. The person resists
to perform the act which further increases anxiety. They have considerable insight but they are
not able to control their thoughts or behaviors. Usually comorbid with- major depressive disorder,
alcohol use disorder, eating disorder, personality disorder. Equally common in men and women.
Begins in adolescence or early adulthood, but may begin in childhood
Clinical features:
- Obsessional thoughts, sense of compulsion and efforts at resistance
- Obsessional ruminations- internal debates for and against everyday actions
- Obsessional rituals- recurring thoughts
- Obsessional slowness- extreme slowness that is out of proportion to other symptoms
- Obsessional phobias-avoiding situations that may cause distress
- Anxiety
- Depression
- depersonalization
Diagnostic criteria:
- Either obsessions or compulsions
- At some point during the course, the person has recognized that they are excessive or
unreasonable
- They cause marked distress, are time consuming, or significantly interfere with the
normal routine
- The disturbance is not due to the direct physiological effect of any substance use or
general medical condition
Post traumatic stress disorder:
Is a syndrome that develops after an individual sees, is involved in, or hears about a traumatic
experience. Most prevalent in young adults, but can appear at any age. Usually follows sexual
abuse, assaultive violence, accidents, traumatic loses, disasters etc. Women are more susceptible
as they are exposed to more personal violence.
Clinical features:
- Recurrent and intrusive distressing recollection of past events
- Recurrent distressing dreams
- Acting or feeling as if the event were recurring
- Intense psychological distress to internal or external cues symbolizing an aspect of the
event
- Avoidance of thoughts, feelings, or conversations associated with trauma
- Avoidance of activities, places, or people associated with trauma
- Inability to recall an important aspect of the trauma
- Feeling of detachment from others
- Insomnia, labile emotion, decreased concentration, hypervigilance
- Exaggerated startle response
- Depression
- Substance abuse
The full symptom picture must be present for at least 1 month and cause significant interference
with social, occupational and other areas of functioning
Diagnostic criteria:
- The person has been exposed to traumatic event with
 - The person experienced, witnessed event(s) that involved actual or threatened
death or serious injury, or a threat to the physical integrity or self or others
- The person’s response involved intense fear, helplessness, or horror
- The traumatic event is persistently re-experience in one or more of following ways-
- Recurrent and intrusive distressing recollections of the event, including images,
thoughts or perceptions
- Recurrent distressing dreams of the event
- Acting or feeling as if the traumatic event were recurring
- Intense psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event
- Physiological reactivity on exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event
- Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness as indicated by three or more of the following-
- Efforts to avoid thoughts or feelings associated with the trauma
- Efforts to avoid activities, places, or people that arouse recollection of the trauma
- Inability to recall an important aspect of the trauma
- Markedly diminished interest or participation in significant activities
- Feeling of detachment from others
- Restricted range of affect (unable to have loving feelings)
- Sense of foreshortened future (does not expect to have a career, marriage or
normal life span)
- Persistent symptoms of increased arousal as indicated by 2 or more of the following-
- Difficulty falling or staying asleep
- Irritability or outbursts of anger
- Difficulty concentrating
- Hypervigilance
- Exaggerated startle response
- Duration of the disturbance for more than one month
- Disturbance that cause clinically significant distress or impairment in social, occupational,
other important areas of functioning
Predisposing factors:
Psychosocial theory-
- The traumatic experience- severity and duration, degree of anticipatory preparation,
exposure to death, numbers affected by life threat, amount of control over recurrence,
location where the trauma was experienced
- The individual- degree of ego strength, effectiveness of coping stress, presence of
preexisting psychopathology, outcome of previous experience, behavioral tendencies,
current psychosocial developmental stage, demographic factors
 - The recovery environment- availability of social supports, cohesiveness and
protectiveness of family and friends, attitude of society, cultural and subcultural
influences
THE NURSING PROCESS
 Assessment
 Level of anxiety, threat of harm to self or others
 Screening tool or assessment scale can be used-
 Yale-Brown Obsessive Compulsive Scale
 Beck Anxiety Inventory
 Fear Questionnaire
 Faces Anxiety Scale
 Hamilton Anxiety Rating Scale etc.
 Appearance-
 severe distress
 feelings of dread or terror
 express fear of “loosing control”
 self-harm or to others
 Communication or cognitive ability-
 explore the cause in terms of patient’s own view
 any stressors
 coping skills and abilities
 Mood, affect and feelings-
 ask direct questions
 Assess verbal and nonverbal cues
 Past history- duration, onset, coping skills
 Behavior- pacing, inability to sit still, hypervigilance
 Sleep disturbances- sleep onset, sleep maintenance, reexperience
symptoms (nightmares), hyperarousal state (difficulty initiating and
maintaining)
 Presence of nervous habits (nail biting, finger tapping)
 Exaggerated startle response
 Avoidance behavior
 impact on functional areas
 Nursing diagnoses
 Anxiety related to impending ….as evidenced by client’s apprehension, lack of self
confidence
 Impaired verbal communication related to decreased attention secondary to obsessive
thoughts
 Ineffective coping related to poor self-esteem and feelings of hopelessness secondary
to chronic anxiety
  Posttrauma syndrome related to physical assault
 Powerlessness related to obsessive-compulsive behavior
 Disturbed sleep pattern related to hyperactivity secondary to recurring episodes of
panic
 Impaired social interaction related to high anxiety secondary to fear of open places
 Outcome identification
 Consider client’s physical status, activity tolerance, severity of clinical symptoms,
presence or absence of support systems, clinical setting
 The client will
 verbalize feelings related to anxiety
 relate decreased frustration with communication
 demonstrate an improved ability to express self
 express optimism about the present
 socialize with at least one peer daily
 express confidence in self
 verbalize a reduction in frequency of flashbacks
 identify factors that can be controlled by self
 Planning interventions
 Are planned based on severity of symptoms
 Presence of comorbid conditions
 Client’s motivation and preference for treatment
 Acceptance that the experience of anxiety is natural and inevitable
 Understanding that one’s level of anxiety may fluctuate
 Understanding that shame is a self-imposed response to anxiety
 Ability to learn and apply self-help techniques to reduce anxiety
 Ability to remain calm in anxiety producing situations
 Development of problem solving and coping skills
 Implementation
 Maintain a calm, nonjudgmental approach, minimal stimulation
 Use short, simple sentences while communicating
 Assistance in meeting basic needs- proper nutrition, prevention of harm, engaging in
physical activities
 Medication management- also for comorbid conditions, observe for drug interactions
commonly used- benzodiazepines, antidepressants, beta-blockers, anticonvulsants,
antipsychotics etc.
 Interactive therapies-
 Offering emotional support and empathy
 Mobilizing coping skills
 Facilitating positive clinical outcomes
 Increasing functional status
  Improving quality of life (QOL)
 Cognitive behavioral therapy-
 educating the client to recognize and change negative or faulty cognitions and acts
by using behavioral techniques to desensitize fears
 Listen, educate and encourage client to express feelings, thoughts teach relaxation
techniques
 Individual psychotherapy- educational and supportive counseling- providing literature,
teaching relaxation techniques, participate in diversional activities or hobbies,
encourage to express feelings and concerns, help develop strong social support and
resilience
 Insight-oriented psychotherapy- helping clients understand meaning of anxiety,
avoidance behavior, repressed impulses
Alternative and behavioral therapies:
 Visual imagery- relaxing and engaging in fantasy to visualize cause of anxiety,
unresolved conflict
 Eye movement desensitization and reprocessing- allowing to watch rapid movement of
hands, or lights
 Change of pace or scenery- engaging in hobbies, having a pet etc.
 Exercise or massage
 Transcendental meditation- quiet environment, passive state of mind, comfortable
position, ability to focus on a specific word
 Systematic desensitization- exposure to a fear producing situation in a systematized
manner/in a hierarchy
 exposure and response prevention- like in OCD
 Relaxation exercises- deep breathing, tensing and relaxing muscles, imagining
peaceful scenes
 Hypnosis
 Implosion therapy (flooding)- the client imagines or participates in real-life situations
 Yoga
 Group therapy, family therapy, play therapy
 Client education
 Education regarding disease conditions, treatments
 Realistic goals and expectations of treatment
 One-to-one, educational class, support groups
 Prompt feedback
 Self-help techniques, problem-solving, coping skills
 Evaluation
 Client’s response to treatment
 Better understanding of the disease
 Exhibit coping skills
  Medication management

SOMATOFORM AND DISSOCIATIVE DISORDERS

Somatoform disorders are reflected in disordered physiologic complaints or symptoms
suggesting medical disease, not under voluntary control, do not demonstrate organic findings

Dissociative disorder- Disruption in the usually integrated functions of consciousness, memory,

identity, or perception. Individuals are separated from the reality. This aspect is thought to be a
coping mechanism. The disorder may be equally prevalent but less frequently diagnosed in men.
Common somatoform disorders:
• Body dysmorphic disorder
• Somatization disorder
• Conversion disorder
• Pain disorder
• hypochondriasis
Predisposing factors:
• Genetic- more common in first degree relatives
• Biochemical- decreased level of serotonin and endorphins- pain disorder
• Family dynamics- difficulty expressing emotions openly or resolving conflicts verbally-
internalization by the physical symptoms- positive reinforcement
• Psychodynamic- physical complaints are the expression of low self-esteem, ethically or
morally unacceptable emotions are converted into physical symptoms
• Learning theory- sick role relieves from the need to resolve conflicts
▫ Primary gain-avoid stressful situations, eg. excused from duties
▫ Secondary gain-eg. becomes prominent focus of attention
▫ Tertiary gain-eg. relieves the conflict
Common dissociative disorder:
• Dissociative amnesia
• Dissociative fugue
• Dissociative identity disorder
• Depersonalization disorder
Predisposing factors:
• Genetic- first degree relatives, seen in more than one generation
• Psychodynamic theory- occurs when distressing mental contents are repressed from
conscious awareness
• Psychological trauma- trauma overwhelms the capacity to cope by any means other than
dissociation (DID)

Conversion disorder:
 • Loss of or change in body function resulting from a psychological conflict, symptoms
affect voluntary motor or sensory functioning suggestive of neurological disease. Eg.
Paralysis, anosmia, blindness, deafness, pseudocyesis etc.
• Presence of primary (avoid activities)and secondary gain (obtain attention)
• Symptoms follows extreme psychological stress, appear suddenly but the individual lack
concern of the symptoms despite its severity because anxiety provoked by any situation
of stress has been relieved by the disorder
• More common in adolescents and young adults
Features:
• With motor symptom or deficit- impaired coordination, balance, paralysis, localized
weakness, difficulty swallowing, aphonia
• With sensory symptom or deficit- loss of touch or pain sensation, double vision,
blindness, deafness, hallucinations
• With seizures or convulsions
• With mixed features
Diagnostic criteria:
• One or more symptoms or deficits affecting voluntary motor or sensory function
suggesting neurological or other general medical condition
• Psychological factors associated with the symptoms as are preceded by conflicts or
stressors
• The symptoms are not intentionally produced
• The symptoms are not explainable in terms of any medical condition, substance use
• Causes clinically significant impairment requiring medical evaluation
• Is not limited to pain or sexual dysfunction and cannot be accounted for any other mental
disorder
Epidemic hysteria:
• Disorder spreads within a group of people as an “epidemic” mostly in closed groups of
young women.
• Heightened anxiety due to some threat starts from one person who is highly suggestible,
histrionic, and a focus of attention which later on passes to the less susceptible
individuals
• Fainting and dizziness most common symptoms
THE NURSING PROCESS
Assessment-
 general appearance, communication skills, observable behaviour, psychosocial and
cultural history
 all the obtained information should be validated from significant others
 Detailed medical assessment, past medical history
  Assess for presence of mood disorders, substance use, anxiety disorders, self-harm or
suicidal ideation, functional capacity, visits to physician, admissions, surgical
interventions, current medications
 Level of orientation, ability to maintain contact with reality
 History of emotional trauma, ability to recall events
 Level of anxiety, existence of depression
 Impairment in daily functioning
 History of impulsivity, self-mutilation, suicidal tendency
 Depersonalization, derealization
 Presence of nightmares, flashbacks, intrusive images
 Unexplained changes in home environment
Nursing diagnoses-
 Activity intolerance related to increased physical complaints secondary to
hypochondriasis
 Acute confusion related to amnesia secondary to dissociative fugue
 Ineffective health maintenance related to lack of motivation secondary to chronic pain
disorder
 Fatigue related to extreme stress secondary to imagined defect in body
 Impaired physical mobility related to leg pain secondary to conversion disorder
Outcome identifications-
 The client will report a reduction in symptoms of activity intolerance secondary to
multiple somatic complaints
 The client will have diminished episodes of confusion related to amnesia as fugue
improves
 The client will increase social relatedness as amnesia improves
 The client will demonstrate a decrease in exaggerated GI physical complaints
 The client will verbalize decrease in the level and frequency of pain.
Planning interventions-
 Individualized approach
 Safe environment
 Bed rest, proper nutrition, physical therapy, pain medication psychotropic medication
 Develop insight,
 effective coping, problem solving skills
Implementation-
 Should focus on-
 Providing safe environment
 Stabilizing and resolving crises
 Managing symptoms
 Identifying and modifying maladaptive coping skills
 Teaching effective self-management
  Improving lifestyle
 Assist in ADL until physical symptoms are stabilized
 Educate on importance of medication adherence, proper nutrition, other form of
therapies
 Provide reality orientation
 Involve family members or significant others in therapy
 Medications- for comorbid conditions
 Show concerns, should be positive, supportive, provide a socially acceptable
environment
 Interactive therapies-
 Individual- focus on personal and social difficulties rather than somatic
complaints
 Group- provides social support and interaction
 Cognitive behavioral therapy- focuses on teaching individuals self-sufficiency and
independence
 Amobarbital or thiopental induced hypnosis to retrieve memories, supportive or group
psychotherapy more helpful in Dissociative amnesia
 DID- uncovering underlying conflicts, gain insight, synthesize various personalities into
one integrated personality
 Abreaction- remembering with feeling, recall events in detail and reexperience
 Separating the client from any stressor
 Assisting the client to identify personal strengths and weaknesses
 Assisting the client identify positive or alternate coping mechanisms, express himself
 Helping the client identify support systems
 Teaching the client relaxation techniques
 Provide access to interventions specific to client’s culture
 Providing family education, administering medications
Evaluation-
 Symptoms improvement pre and post nursing interventions
 Clients will be able to identify anxiety provoking stressors, demonstrate insight
 Effective coping skills