Anxiety Disorders: DSM-5, GAD, and Phobias

Mood & Affect: Anxiety

• Anxiety is an uncomfortable apprehension or dread in response to internal or external stimuli
• It can manifest physically, emotionally, cognitively, and behaviorally
• DSM-5 defines anxiety as the anticipation of a future threat
• Dysregulation of GABA and norepinephrine (NE) is associated with anxiety

Neurotransmitters and Their Impact

• GABA decrease anxiety
• NE increases anxiety

Fear vs. Anxiety

• Fear is an emotional response to a real or perceived imminent threat
• Anxiety disorder involves fear disproportionate to the situation

Generalized Anxiety Disorder (GAD)

• Excessive worry for more than six months causes interference in personal or social life

Phobias

• Irrational fear leads to avoidance of an object, person, place, or situation
• Social phobia involves persistent fear in environments where embarrassment or scrutiny may occur
• Simple phobias involve persistent fear of objects, natural environments, and situations

Panic Disorder

• Involves recurrent panic attacks, which is an extreme, overwhelming response to a perceived or real-life threat

Obsessive-Compulsive Disorder (OCD)

• Characterized by intrusive thoughts, rituals, preoccupations, and compulsions

Stages of Stress Presentation

• Alarm reaction: the body prepares to defend itself, releasing epinephrine and norepinephrine for fuel and liver reconverts glycogen to glucose, resulting in a fight, flight, or freeze response
• Resistance: GI system function decreases, lung capacity and heart rate both increase
• Exhaustion: occurs as a result of a negative response, leading to depleted bodily reserves and fatigue

Levels of Anxiety

• Mild: identifying something is different, attention and focus heighten, which stimulates the ability to learn; restlessness, fidgeting, butterflies, hypersensitivity to noise, and difficulty sleeping
• Moderate: disturbing feeling, nervousness, and agitation sets in, focus falters but is still possible, but may require redirection; muscle tension, sweating, pounding pulse, HA, dry mouth, GI upset, fast talking, frequent urination
• Severe: defensiveness arises, thinking becomes difficult, and completing basic tasks becomes impossible, often with a feeling of horror; severe HR, N/V, diarrhea, trembling, dizziness, tachycardia, chest pain, crying
• Panic: inability to process what is happening and perception becomes distorted with irrationality, person cannot recognize danger, so avoid leaving person alone (10-30 minutes to calm down); immobility or running, speaking being impossible, pupils dilate, elevated BP and HR, fight, flight, or freeze occur

Consequences of Decreased Anxiety

• Utilizing defense mechanisms yields: denial, repression, projection, rationalization, regression, defense mechanism, positive and negative consequences

Anxiety Across the Lifespan

• Children and adolescents with anxiety may mimic cardiac and respiratory issues and may go misdiagnosed and can lead to SI/attempts. Also speech cessation in public, school refusal, acting out, crying, and hiding when caregiver leaves
• Older adults experience mood disorders, decreased functioning and increased somatic and depressive symptoms, and may experience chronic pain

Interventions for Anxiety

• Use calm, concise, clear, and short sentences
• Employ relaxation techniques through deep breathing, progressive muscle relaxation, and meditation

Treatment for Anxiety

• Use Positive reframing by turning negative thoughts or beliefs into positive ones
• Decatastrophizing uses thought stopping and distraction techniques
• Assertiveness uses "I" statements
• CBT

Education/Health Teaching for Anxiety

• Maintain a positive attitude, believe in self, accept what cannot be changed, and learn to relax
• Exercise regularly, eat a healthy diet, limit caffeine and ETOCH, communicate effectively, get enough rest and sleep, set realistic, attainable expectations, and find a pleasurable activity
• Provide community resources, learn relaxation techniques and coping strategies, and engage other healthcare professionals

Additional Information on GAD

• Characterized by excessive worry greater than 6 months, causes interference in personal and/or social life
• Nursing care is to educate and use coping strategies, relaxation strategies, and time management

Phobias

• Irrational fear of objects, natural environmental objects and situations that are social and simple

Panic Attacks

• Extreme, overwhelming response to a perceived or real-life threatening situation that causes abrupt surges of intense fear or discomfort, peaks in minutes, and lasts up to 30 minutes
• Palpitations, chest pain, tachycardia, nausea, sweating, paresthesia (skin burning, tickling sensation), trembling, choking, disorganized thinking, irrational fear, compromised communication, and feeling of impending doom occurs. May mimic s/s of MI

Panic Disorder

• Recurrent, unexpected panic attacks that have remissions and exacerbations
• Can lead to phobias Chest pain, choked feeling, Gl upset, chills, hot flashes, and fearing being “crazy” are signs
• Use CBT, deep breathing and benzos. Also, antihypertensives: catapres (clonidine) and propranolol (inderal)
• Nursing actions: remain with patient, focus on deep breathing/relaxation techniques, ensure a safe and private environment, and reassure with a calm voice

OCD

• Typically presents in late adulthood
• Consists of depression and poor functional abilities, panic, bipolar, eating disorders, impulse control disorders
• Children: grades dropping, concentration difficulties, and performing rituals
• Older adults: increased thought and communication disturbances

OCD Treatment

• Includes: ECT, transcranial magnetic stimulation (TMS), SSRIs (sertraline, fluoxetine, paroxetine, and fluvoxamine - kids), CBT, and thought stopping

OCD Assessment

• Check: skin, GI upset, appearance, joints, social life, family life, mental status (ability to listen, loaded conversation including volume, rate, tone and awareness)

OCD Nursing Interventions

• Establish a rapport, therapeutic techniques (active listening), maintain skin integrity, encourage use of soft soaps, schedule and limit hand washing, note response to meds.
• In inpatient settings: monitor anxiety, explain routines, allow rituals at first, create schedules, identify triggers, point out triggers, positive reinforcement, encourage coping strategies

Medication: Alprazolam (Xanax)

• It is a benzodiazepine that increases GABA effects, suppresses CNS and seizure activity (available in tabs or solution)
• Side effects: sedation, respiratory depression, ataxia, dizziness, forgetfulness, confusion, slurred speech, fatigue
• DO NOT USE WITH OPIODS due to HFR abuse, cease abruptly, and during pregnancy
• May alter liver function

Medication: Buspirone Hydrochloride (HCL)

• Anxiolytic that reduces serotonin turnover
• Has side effects of: dizziness, HA, nervousness, nausea, restlessness, dry mouth, constipation
• Advised not to prescribe in pregnancy, renal and cognitive impairments
• Effects my take weeks to notice, don't take with grapefruit juice or ETOH
• Effects can cause serotonin syndome

Medication: Paroxetine (Paxil)

• It is an SSRI (available in tabs, capsules, suspension) that has side effects of: sedation, dizziness, HA, tremors, sweating, insomnia, GI upset (dry mouth, decrease appetite, diarrhea, constipation)
• Avoid in 1st two months to children, teens, and young adults
• Don't stop abruptly

Medication: Duloxetine (Cymbalta)

• SNRI, capsules with side effects of: SI, nausea, diarrhea, constipation, dry mouth, decreased appetite, insomnia, sedation, dizziness, sweating, increased BP, urinary retention, hypoglycemia
• Can be prescribed to children for GAD (>7yrs) and there is a risk of Sl/behaviors
• Monitor BP, glucose, CNS and do not use with ETOH

Medications: Antihistamines

• Blocks histamine 1 receptors
• Hydroxyzine Hydrochloride (Atarax): IM, syrup, and tabs
• Hydroxyzine Pamoate (Vistaril): capsules, suspension
• Can take weeks if used for chronic conditions

Antihistamine Side Effects

• Sedation, dizziness, dry mouth, tremor, fatigue, pain at injection site, respiratory depression
• Use with caution in the elderly due to HRF for increased anticholinergic effects
• Avoid ETOH, monitor/report palpitations, difficulty breathing, vision changes, difficultly urinating, dizziness, fainting