Anxiety and Related Disorders

• Notes on anxiety, obsessive compulsive disorders, substance abuse, trauma, personality and other disorders

Four Levels of Anxiety

• Mild anxiety is constructive, heightens perception, focus is flexible and effective and enables problem-solving
• Moderate anxiety is constructive but thinking is hampered, learning is suboptimal, inattention occurs, and sympathetic nervous system symptoms begin
• Severe anxiety reduces perception, makes problem-solving impossible, causes confusion
• Panic results in dysregulation, hallucinations, impulsive behavior, and exhaustion

Anxiety Defense Mechanisms

• Displacement involves redirecting emotions to a safer target, such as yelling at a friend
• Dissociation involves detaching from reality to avoid distress, such as daydreaming during a traumatic event
• Intellectualization involves focusing on facts and logic instead of emotions
• Rationalization involves creating excuses to justify unacceptable behaviors/feelings
• Suppression involves consciously avoiding feelings
• Compensation involves overachieving in one area to make up for a perceived weakness

Specific Phobias

• Specific phobias involve excessive fear with high anxiety levels regarding a specific object, activity, or situation
• An immediate anxiety response occurs and the person avoids the feared thing
• Significant impairment in functioning along avoidance is persistent for at least 6 months
• Risk factors include family history and ACEs
• Examples include acrophobia, agoraphobia, and claustrophobia

Agoraphobia

• Agoraphobia features intense anxiety about being in situations where escape might be hard or help unavailable
• Risk factors include ACEs, family history, and genetics
• Agoraphobia can lead to depressive disorders and alcohol use disorder
• Examples include being alone outside, traveling, or being on a bridge

Generalized Anxiety Disorder

• Excessive anxiety and worry lasting 6 or more months over different issues are present
• Additional symptoms include restlessness, fatigue, irritability, difficulty concentrating, muscle tension
• Risk factors include parental overprotection and genetics

Social Anxiety Disorder

• Severe anxiety occurs due to exposure to social or performance situations, that could be evaluated negatively by others
• Substance use disorders are common
• A risk factor is childhood mistreatment and ACEs

Panic Disorder

• Panic Disorder is characterized by recurrent panic attacks with sudden onset of extreme fear with sense of impending doom, and lasts minutes
• Not necessarily in response to stress; can be random
• Four or more symptoms happen like palpitations, sweating, trembling, SOB, chest pain, nausea, fear of dying
• At least one month of concern about additional panic attacks is observed.

Anxiety Nursing Interventions

• Nursing diagnoses include anxiety, impaired socialization and coping, and chronic low self-esteem
• Outcomes should address the specific problems identified
• For mild to moderate anxiety, therapeutic communication is used
• For severe panic, use clear, short statements
• General interventions include milieu therapy, counseling, relaxation, education, and maintaining a safe environment

Anxiety Disorder Medications

• Benzodiazepines like alprazolam (Xanax) decrease cellular excitation but can cause dependence
• Buspirone (Buspar) takes 2-4 weeks to work and has side effects like dizziness and nausea
• Propranolol decreases physical manifestations of anxiety like HR, blushing, and shaky voice for social anxiety

Obsessive-Compulsive Disorder (OCD)

• Obsessions are thoughts or impulses that persist, recur, and cause anxiety or shame
• Compulsions are ritualistic behaviors the person feels driven to perform to reduce anxiety
• Outcomes include reduced time spent on compulsions and ability to delay/resist them
• Nursing interventions include promotion of self-care and health teaching

OCD medications

• SSRIs are a class of antidepressants
• SNRIs include venlafaxine

OCD Treatments

• Exposure and response prevention involves exposing triggering to OCD symptoms
• The patient refrains performing compulsions
• Flooding involves exposing the patient to a large trigger to extinguish response

Addiction Defined

• Addiction is a chronic condition with cycles of relapse and remission characterized by substance and compulsive behaviors even with adverse effects

Intoxication Defined

• Intoxication is the process of using a substance to excess

Tolerance Defined

• Tolerance means a need for higher doses to achieve initial effect

Withdrawal Defined

• Withdrawal means physiological symptoms that occur when substance stops

Codependence Defined

• Codependence is excessive emotional/psychological reliance on a partner

Opioid intoxication

• Psychomotor retardation, drowsiness, slurred speech, low BP are symptoms of opioid intoxication.

Opioid Overdose

• Low BP, HR, unresponsiveness, sedation, miosis (pin-point pupils), coma, respiratory depression indicate an Opioid overdose
• Miosis, coma, and respiratory depression suggest overdose

Opioid Overdose Treatment

• Naloxone is an opioid antagonist and is administered via IM, IV, SQ, or intranasally routes
• Increased respirations and pupillary dilation should be seen after administration; repeated doses may be needed
• Methadone and Clonidine are used in treatment to blocks sympathetic responses

Sedative/Hypnotic Intoxication and Overdose

• Sedative/Hypnotics: Benzos, z-hypnotics, barbiturates, all prescription sleep meds, are used as treatment
• Intoxication leads to slurred speech, incoordination, unsteady gait, nystagmus, impaired judgment, and potentially death/coma can result
• Overdose is treated with gastric lavage, activated charcoal, mechanical ventilation

Stimulant Intoxication/Withdrawal

• Short-term: Euphoria, high energy, alertness, BP, HR dilated pupils
• Long-term: Chest pain, cardiac arrhythmias, depression, seizures, risk of heart attack, delusions
• Withdrawal: Fatigue, vivid dreams, insomnia/hypersomnia, psychomotor, retardation

Alcohol Use

• Binge drinking occurs when too much alcohol is consumed too quickly and Heavy drinking happen too too often
• Legal definition of intoxication IN TEXAS: 80mg ethanol per deciliter or 0.08/dl

Alcohol Withdrawal

• 6-8 hours: the sakes, nausea, vomitinf, impaired cognition, high HR, BP, Temp.
• 8-10 hours: psychotic/ perceptual symtoms and its a medical emergency
• 12-24 hours: seizures

Alcohol Assessment and Interventions

• Assess with MSE, physical/psychosocial history
• Family needs, codependence, the CIWA and CAGE tools
• Nursing diagnoses include risk for suicide/injury/overdose, withdrawal, impaired sleep, denial, hopelessness
• Interventions include promoting safety and sleep and reintroduce nutrition

Medications for Alcohol disorders:

• Naltrexone helps the patient with both withdrawal and relapse prevention by decreasing craving
• Benzos like Lorazepam, diazepam, chlordiazepoxide act as CNS depressants
• TPAPN (Texas Peer Assistance Program for Nurses) offers early help, monitoring, and advocacy

PTSD Etiology and Symptoms

• PTSD arises from exposure to actual or threatened death, serious injury, or sexual violence with symptoms lasting over 1 month
• Symptoms include intrusion, avoidance, negative alterations in cognition/mood, and hyperarousal
• Somatic symptoms like headaches and loss of interest can occur
• Assessment includes environmental safety, history, MSE, developmental/psychosocial measures, play activities, and interaction observations.

PTSD - Trauma informed care:

• Cultivate a sense of safety, ask for open body position and before touching
• Increase resilience with strength-based approach
• Use clear language and teach back as well as culturally and gender sensitive services

PTSD Interventions for Children:

• Use art and play to help with expression feelings, reduce arousal and ensure safety
• Teach coping skills and techniques to manage triggers and mandated abuse

PTSD Adult Diagnoses:

• Relaxation techniques before exploring trauma to help regulte emptions
• Teach coping, problem solving skills, self-care
• Normalize situation, symptoms doesn't refelct personal failure or weakness

Medications for PTSD

• SSRIs: sertraline and paroxetine have high toxicity: serotonin syndrome, hyponatremia, increased bleeding risk
• Phenelzine (MAOI) has a strict list of diet restrictions and may cause hypertensive crisis, serotonin syndrome.
• EMDR and CBT both used in adults to process and integrate traumatic memories

Acute Stress Disorder

• Acute stress disorder is a condition that arises 3 days to 1 month after a highly traumatic event
• The patient can exhibit include derealization, memory problems, distressing dreams, avoidance, sleep disturbances, and mood changes
• Interventions are the establishment of trust with support/ education about the disorder

Amnesia and Derealization

• Dissociative amnesia involves an inability to recall personal data, often due to trauma
• In depersonalization disorder, the patient experiences feeling detached from self
• In derealization disorder, the patient feels that surroundings are not real

Somatic Symptom Disorder

• Somatic symptom disorder involves physical symptoms with no physical cause
• It features a focus on the symptoms with excessive thoughts and anxieties
• This issue must maintain for over 6 months of elevated time

Illness Anxiety Disorder

• Illness anxiety disorder features a preoccupation with having a serious illness
• Somatic symptoms in this category may not arise, are mild or are non-existent

Somatic / Disorder Nursing Interventions:

• Foster a therapeutic relationship
• Patient is resistant to the concept that no physical cause exists, so maintain a consistent supportive approach

Nursing Assessment Components for Sleep disorders:

• Sleep attern with common decreased concentration, fatigue, mood distrubances and decreased work as complaints
• What is you bedtime routinr, naps during day, stressors tha contribure to difficulties, do you feel refreshed/restored in the morning, are important

Sleep Disorder Health Care:

• Maintain a regular sleep-wake cycle and consistent pre-sleeo routing
• Sleep with a room environment that is conductive to sleep, avoid clock watching, daytime napping, caffeine, stimulants and alcochol

Sleep Disorder Medication:

• The Benzos group of temazapam, restoril is a controlled substance and may need aid from achohol wihdrwal and panic attacks
• Z-hypnotics also used

Psychological treatments for Sleeplessness/Insomnia

• Use behavioral intervention and 5 basic principles to help decrease negative associations:
• Going to bed only when sleepy
• Get out of bed if unable to sleep
• Use bed only for sex and sleep

Eating disorders: Anorexia

• Refrain of caloric energy leads to weight loss as well as a fear of weight gain or becoming fat, body image struggles or lack of recognition

Eating disorders: Bulimia

• Episodes of binge eating happen every week for 3, with lack of control or inappropriate compensatory behavior to prevent weight gain.
• Some may have normal low weight, enlarged parotid glands, dental issues, abnormal labs/callus

Eating disorders: Life threatening conditions and management:

• Life threatening conditions in nursing diagnoses and three realistic patient outcomes and interventions
• Goal: Interupt cycles or binges by normalizing eating, balancing activity or indications for socialization

Disorders: Cycle of Violence for abuse:

• Cycle involves tension building, acute battering, honeymoon stage and that repeat with a fall of safety

Child, Adults, Abuse and Violence

• Offer Privacy, Rapport and trust, how relationships are settled and avoid the use of triggering words
• The use of indicators and assessing patients with responses
• Outcomes includes reversing to problem addressed safety-wise

Personality Disorder A:

• A: Cluster A falls within this category and includes paranoid, schizoid and schizotypal, all eccentric styles who lack the ability to retain relationships

Personality Disorder B:

• The cluster B includes dramatic and antisocial people, narcissitics, histrionic and borderline

Other Personality traits:

• Magical thinking, anxious in social situations and has lack of trust
• All are limited in emotional expression, stubborn and are highly meticulous