Classification and Manifestations of Anxiety Disorders .docx

Classification and Manifestations of Anxiety Disorders Objectives ========== At the end of the session participants will be able to: 1) Overview of Anxiety Disorders 2\) Define the terms (a) Anxiety (b) Fear (c) anxiety disorders 3\) Discuss the Levels of Anxiety 4\) Discuss the Epidemiology of...

Classification and Manifestations of Anxiety Disorders Objectives ========== At the end of the session participants will be able to: 1) Overview of Anxiety Disorders 2\) Define the terms (a) Anxiety (b) Fear (c) anxiety disorders 3\) Discuss the Levels of Anxiety 4\) Discuss the Epidemiology of common anxiety disorders 5\) Discuss the Causes of Anxiety Disorders 6\) Discuss Complications of Anxiety Disorders 7\) Outline the Classification of Anxiety disorders according the DSM-5 criteria 8\) Describe Clinical Symptoms and Diagnostic Characteristics 9\) Outline Medical and Nursing Management of persons diagnosed with anxiety disorders Overview ======== Everyone can feel anxious sometimes, but people with anxiety disorders often experience fear and worry that is both intense and excessive. These feelings are typically accompanied by physical tension and other behavioral and cognitive symptoms. They are difficult to control, cause significant distress and can last a long time if untreated. Anxiety disorders interfere with daily activities and can impair a person\'s family, social and school or working life. An estimated 4% of the global population currently experience an anxiety disorder. In 2019, three hundred and one million people in the world had an anxiety disorder, making anxiety disorders the most common of all mental disorders Although highly effective treatments for anxiety disorders exist, only about 1 in 4 people in need (27.6%) receive any treatment. Barriers to care include lack of awareness that this is a treatable health condition, lack of investment in mental health services, lack of trained health care providers, and social stigma. Definition: =========== Anxiety ------- Is a state of feeling apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized Fear ---- An emotional response to real or perceived imminent threat Anxiety Disorder ---------------- Is a type of mental health condition where you may respond to certain things and situations with fear and dread. You may also experience physical signs of anxiety, such as a pounding heart and sweating. An Anxiety Disorder occurs when - Anxiety interferes with your ability to function - You often overreact when something triggers your emotions - You cannot control your responses to situations. ### Levels of Anxiety Levels of anxiety can be influenced by personality, coping strategies, life experiences, and gender. Anxiety levels are typically classified by the level of distress and impairment experienced into four categories: - Mild - Moderate - Severe - Panic #### Levels of Anxiety: Mild Although often described as sub-clinical or clinically non- significant, mild anxiety can impact emotional, social, and professional functioning., Mild anxiety symptoms may present as social anxiety or shyness and can be experienced in early childhood through to adulthood If left unaddressed, mild anxiety can lead to maladaptive coping strategies or more severe mental conditions. #### Levels of Anxiety: Moderate People with this level of anxiety have more frequent or persistent symptoms than those with mild anxiety, but still have better daily functioning than someone with severe anxiety or panic disorder. For example, individuals may report experiencing symptoms such as feeling on edge, being unable to control their worrying or being unable to relax the majority of days in a week, but not every day. Although moderate anxiety symptoms are disruptive, people with moderate anxiety may have success in managing their anxiety with the help of a doctor or self- help strategies. Levels of Anxiety: Severe Severe anxiety is intensely debilitating, and symptoms of severe anxiety meet key diagnostic criteria for clinically- significant anxiety disorder. People with severe anxiety typically score higher on scales of distress and lower on functioning. Severe anxiety symptoms also frequently co-occur with major depression, which can contribute to greater disability. Symptoms of severe anxiety are frequent and persistent and may include increased heart rate, feelings of panic and social withdrawal. These symptoms can result in loss of work and increased health care costs. In addition, individuals with severe anxiety may turn to alcohol and drugs as a means to cope with their symptoms. #### Levels of Anxiety: Panic Panic level anxiety, or panic disorder, is characterized by frequent, recurring, and unexpected panic attacks. A panic attack can include symptoms such as: - Rapid onset of extreme fear - Heart palpitations - Rapid breathing - Nausea or dizziness - Fear of death Panic attacks usually last around 10 minutes. The triggers for panic attacks vary from person to person, and the cause of an attack may be familiar to the person or unknown. #### Epidemiology Anxiety disorders are the most common mental health conditions in the United States affecting approximately 40 million Americans. They happen to nearly 30% of adults at some point. Anxiety disorders most often begin in childhood, adolescence, or early adulthood. Anxiety disorders frequently occur with physical and medical disorders, depressive disorders, eating disorders, or substance abuse and lead to morbidity, frequent use of health care facilities and functional impairment. ### Causes of Anxiety Disorders Biological Theories \(a) Genetics \(b) Neuroanatomical \(c) Neurobiological Psychological Theories Psychosocial Factors Medical Factors ### Causes of Anxiety Disorders Biological Theories Genetics - First degree relatives (your parent, sibling, or child) - Monozygotic twins (1 egg splits into 2 after fertilization) - Family history Neuroanatomical Increased sympathetic nervous system (SNS) activity SNS adaptivity to repeated stimuli and responds excessively to moderate stimuli Neurobiological The amygdala alerts the brain to the presence of danger and brings about fear or anxiety to preserve the system. Memories with emotional significance are stored in the amygdala and have been implicated in phobic responses such as fear of snakes or heights. ### Causes of Anxiety Disorders Psychological Theories #### Psychoanalytic Theory According to the Freud\'s psychoanalytic theory anxiety is the result of inability of the ego defense mechanism to resolve the conflict between id and superego. Repression helps in dealing with the anxiety producing situations without symptom formation. If repression is unsuccessful as a defense mechanism other defense mechanisms (conversion, displacement, regression) are used. These defense mechanisms may cause symptoms that produce a picture of neurotic disorder. #### Cognitive Behaviour Theory According to this theory anxiety is the result of faulty cognitions of an individual. Response to any anxiety producing situation depends on the cognitive appraisal of the situation by the individual. Clients suffering from anxiety disorders tend to overestimate the degree of danger in a given situation and underestimate their capacity, to cope with that situation. #### Behaviour Theory This theory explains that anxiety is a conditioned or learned response to a specific environmental stimulus. Example: Someone with no food allergies gets sick after eating contaminated food at a restaurant. Through generalization they distrust all food prepared by others. ### Behaviour Theory Individuals may also learn to have an internal response of anxiety, imitating the anxiety response of their parents or significant others (social learning) ### Social-Cultural Theory The stressful stimuli of society and one\'s culture pose a psychological threat resulting in the development of maladaptive behavior and the onset of an anxiety disorder. ### Causes of Anxiety Disorders #### Psychosocial Factors - Disturbed mother child relationship - Object loss theory - Stressful life events - Certain temperament or personality traits - Childhood maltreatment (abuse or neglect) - Overprotective parents - Family environment #### Medical Factors Anxiety may be linked to an underlying health issue. In some a medical illness. cases, anxiety signs and symptoms are the first indicators of include: Examples of medical problems that can be linked to anxiety - Heart disease - Diabetes - Thyroid problems, such as hyperthyroidism Causes of Anxiety Disorders Medical Factors - Respiratory disorders, such as chronic obstructive pulmonary disease (COPD) and asthma - Drug misuse or withdrawal - Withdrawal from alcohol, anti-anxiety medications (benzodiazepines) or other medications - Chronic pain or irritable bowel syndrome - Rare tumors that produce certain fight-or-flight hormones - Sometimes anxiety can be a side effect of certain medications Complications of Anxiety Disorders These can be worsened by anxiety disorders: - Trouble sleeping (insomnia) - Digestive or bowel problems - Headaches and chronic pain - Problems functioning at school or work - Depression or other mental health disorders - Social isolation - Substance misuse - Poor quality of life - Suicide ### Classifications of Anxiety Disorders - Separation Anxiety Disorder - Selective Mutism - Specific Phobias - Social Anxiety Disorder - Panic Disorder - Agoraphobia Classifications of Anxiety Disorders Generalized Anxiety Disorder Substance or Medication Induced Anxiety disorder Anxiety disorder due to another medical condition Other specified anxiety disorder Unspecified Anxiety Disorder Diagnosis Check with a primary care provider to find out if your anxiety could be related to your physical health. The Doctor can check for signs of an underlying medical condition that may need treatment. If the anxiety is severe see a mental health specialist for treatment and psychotherapy. The mental health provider may: Conduct a psychological evaluation. This involves discussing your thoughts, feelings, and behavior to help pinpoint a diagnosis and check for related complications. Compare your symptoms to the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Clinical Symptoms & Diagnostic Characteristics The clinical symptoms of anxiety are numerous and are classified as physiologic, psychologic, and emotional, behavioral, and intellectual or cognitive. The clinical symptoms may vary according to the level of anxiety exhibited by the client. Anxiety occurs on a continuum CONTINUUM OF ANXIETY RESPONSES ============================== Adaptive responses: anticipation to, mild, to moderate, to (maladaptive responses) severe and then panic. Maladaptive responses: panic, to severe, to moderate, (Adaptive response) to mild and then anticipation Clinical Symptoms & Diagnostic Characteristics ============================================== Normal ------ Client experience periodic warnings of threat such as uneasiness or apprehension that, prompt the client to take necessary steps to prevent a threat or lessen its consequences. Euphoria- --------- the client experiences an exaggerated feeling of wellbeing that is not directly proportional to a specific circumstance or, situation Clinical Symptoms & Diagnostic Characteristics Mild Anxiety ------------ Increase alertness to inner feelings or the environment. There is an increase ability to learn, experiences a motivational force, may become competitive. Feeling of restlessness and the inability to relax. Moderate Anxiety ---------------- inability to concentrate, only able to concentrate on one specific thing at a time. Pacing voice tremors, increase rate of speech, verbalization of expected danger Severe Anxiety -------------- Inability to perceive, reduced focus or is small or scattered. Inappropriate verbalization or inability to communicate clearly, occurs due to decreased intellectual thought process. Lack of determination or the inability to perform occurs as the person experiences feelings of purposelessness. The person experiences a sense of impending doom Panic State ----------- a complete disruption of the ability to perceive occurs. Disintegration of the personality occurs, the individual becomes immobilized, experiences difficulty communicating, inability to focus on reality and is unable to function normally. Physiologic, emotional, and intellectual changes occur as the individual experiences a loss of control Physiologic Symptoms ==================== - Dyspnea and hyperventilation - Anorexia, nausea, and vomiting - Frequency of urination - Headache - Diaphoresis - Blurred vision - Elevated pulse, blood pressure and respiration - Vertigo or light-headedness - Insomnia or sleep disturbance - Weakness or muscle tension - Tightness in the chest - Sweaty palms - Dilated pupils Psychological or Emotional Symptoms - Withdrawal - Depression - Hypercriticism - Lack of interest or apathy - Anger - Crying - Irritability - Feelings of worthlessness, apprehension, or helplessness Behavioral Symptoms - Pacing - Inability to sit still - Ritualistic behaviors (washing hands) - Fingering hair continuously or other nervous habits - Hypervigilance Intellectual or Cognitive Symptoms - Decreased interest - Inability to concentrate - Rumination. *Rumination is a deep or considered thought about something* - Forgetfulness - Non-responsiveness to external stimuli - Preoccupation - Decreased productivity - Orientation to the past rather than to present or future Clinical Features of Common Anxiety Disorders ============================================= Separation Anxiety Disorder --------------------------- Characterized by developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached. The fear, anxiety or avoidance is persistent lasting 6 or more months in adults It causes clinically significant distress and impairment in social, academic, occupational, and other important areas of functioning Selective Mutism ---------------- Consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations Duration is a least 1 month The failure to speak is not due to lack of knowledge, or comfort with the spoken language This is a rare disorder and mostly occur in children **Specific phobias.** --------------------- Most common of the mental disorders among women and second among men. A phobia is described as an irrational fear of an object, activity or situation that is out of proportion to the stimulus and results in avoidance of the identified object, activity, or situation. Avoidance of the subject of the object or situation allows a person to remain free of anxiety. ### Common Phobias Clinical Name with Feared Object or Situation - Acrophobia; Heights - Astraphobia; Electrical storms - Claustrophobia; Closed spaces - Glossophobia; Public speaking - Hematophobia; Blood - Hydrophobia; Water - Monophobia; Being alone - Mysophobia; Germs or dirt - Nyctophobia; Darkness - Pyrophobia; fire - Xenophobia; Strangers - Zoophobia; Animals Clinical Features of Common Anxiety Disorders Agoraphobia ----------- The most common phobic disorder Fear of being alone in public places from which the person think escape would be difficult or help would be unavailable Affects mostly women and manifest between the age of 18-35 years Onset of symptom maybe sudden or gradual Social Phobia ------------- Referred to as social anxiety disorder Desire to avoid situations in which others my criticize a person Social phobias begin early, interferes with development, predisposes an individual to depression and substance abuse. Examples of social phobia include fear of public speaking, eating, or drinking in public, using restrooms, or using public transportation Generalized Anxiety Disorder ---------------------------- Characterized by unrealistic or excessive anxiety or worry occurring more days than not, in a six-month period. The concern is about several events such as job or school performance The individual is unable to control the worry They experience 3 of the following six symptoms: restlessness, fatigue, impaired concentration, irritability, muscle tension, and sleep disturbance. Clinical Features of Common Anxiety Disorders Panic Disorder -------------- Characterized by recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that peaks within minutes during which time 4 or more of 13 physical and cognitive symptoms occur. ### Unexpected attack, Occurs without warning and for no discernible reason \"out of the blue\". When an individual is doing their normal everyday activity. ### Situational Panic Attack, ### Occurs in response to specific environmental stimuli or events that are anxiety producing (riding in an elevator or flying on an airplane). ### Situationally predisposing panic attack - Refers to an attack with the likelihood or potential to reoccur when an individual\'s anxiety level increases - If the client is able to utilize anxiety - reducing coping skills, the likelihood of a panic attack reoccurring decreases. - Panic attack usually last from 1 minute to an hour the intensity my fluctuate considerably in the same person Substance or Medication-Induced Anxiety Disorder ------------------------------------------------ Panic attacks or anxiety is predominant in the clinical picture. This is evident from the history, physical examination, or laboratory findings or after exposure to a medication The predominant features are symptoms of panic or anxiety which develop after exposure to a drug, medication, or toxin Once the treatment is discontinued the panic or anxiety symptom will usually improve or remit within days to weeks The diagnosis should not be given if the onset of the panic or anxiety symptoms persist for a substantial time that is, longer than a month Anxiety Disorder Due to Another Medical Condition ------------------------------------------------- The essential feature that is judged to be best explained as a physiological effect of another medical condition. Symptoms can include prominent anxiety symptoms or panic attacks It must be established that anxiety symptoms can be etiologically related to the medical condition, through the physiological mechanism before making a judgement Other specified anxiety disorder -------------------------------- This category applies to presentation in which, symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, predominate but, do not meet the full criteria for any of the disorders, in the anxiety disorders diagnostic class. And do not meet criteria for adjustment disorder with anxiety or adjustment disorder with mixed anxiety or depressed mood. The other specified anxiety disorder category is used in situations where the clinician chooses to communicate the specific reason, that the presentation does not meet the criteria for any specific anxiety disorder. Examples: wind attacks (Vietnamese culture) attack of nerves (Latin American culture) Clinical Features of Common Anxiety Disorders Unspecified Anxiety Disorder ---------------------------- This category applies to presentation in which symptoms characteristic of an anxiety disorder, that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, predominate but do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class. And do not meet criteria for adjustment disorder with anxiety or adjustment disorder with mixed anxiety or depressed mood. The unspecified anxiety disorder category, is used in situations where the clinician chooses not to specify the reason that the criteria are not met, for a specific anxiety disorder and includes presentations in which there is insufficient information, to make a more specific diagnosis. Example: emergency room settings Medical Management ================== symptoms of anxiety Psychotropic drugs are used to treat moderate to severe A multidimensional pharmacologic treatment approach may be necessary when medical or psychiatric disorders exist Common drugs used to treat the symptoms of anxiety include benzodiazepines, antidepressants, anxiolytics, beta blockers and neuroleptics in some cases. Medical Management Benzodiazepines are no longer recommended as the first line of treatment. Due to high level of dependence Antidepressants such as selective serotonin reuptake inhibitor (SSRI) such as paroxetine or paxil and serotonin - norepinephrine reuptake inhibitor (SNRI) Venlafaxine (Effexor) are the agents of choice. Beta blockers are effective in treating social phobias Neuroleptics are prescribed when clinical symptoms cause extreme functional impairment or reach paranoid or delusional levels. Neuroleptics are used when the client cannot tolerate benzodiazepines or selective serotonin reuptake inhibitors. Benzodiazepines --------------- - Alprazolam (Xanax) 0.5-8mg - Clonazepam (Klonopin) 0.5-20 mg - Diazepam (Valium) 2-40 mg - Lorazepam (Ativan) 1.0-10 mg Medical Management 1. **Selective Serotonin Reuptake Inhibitors (SSRIs)**: - **Citalopram (Celexa)**: 10-50 mg - **Fluoxetine (Prozac)**: 20-50 mg - **Fluvoxamine (Luvox)**: 50-300 mg 2. **Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)**: - **Venlafaxine (Effexor)**: 75-375 mg 3. **Atypical Agents**: - **Buspirone (Buspar)**: 15-60 mg Medical Management Beta blockers ------------- Atenolol, 50-200mg Propranolol, 40-120 mg Antihistamines -------------- Diphenhydramine (Benadryl) 20-300mg Other Management ================ - Interactive Therapy- beneficial to client suffering from Generalized Anxiety Disorder. - The client is provided with informational literature, - is taught relaxation technique, encouraged to participate in diversional activities and hobbies to express their feelings - Cognitive Behaviour therapy (CBT) is used to treat social phobia and panic disorder - CBT involves teaching the client to recognize and change certain negative or faulty conditions - Uses behavioral techniques to desensitize fears or anxiety - Visual imagery - Change of pace or scenery - Exercise or massage - Systematic desensitization - Relaxation exercise - Therapeutic touch - Hypnosis Nursing Management ================== Assessment ---------- - Identify the client\'s level of anxiety - Determine whether a threat of self-harm exists - Obtain a through history (physiologic, emotional, behaviour, cognitive functioning - Keep in mind that the chief complaint may not be anxiety - Use a screening tool or assessment scale (Hamilton anxiety rating scale, Liebowitz Social Anxiety Scale) General Appearance ------------------ - The client may be in severe distress or immobilized - Engaged in purposeless, disorganized, or aggressive activity - Feeling of dread or terror - Express fear of losing control - Ask about stressors - Assess cognitive ability Nursing Management Mood Affect and Feelings ------------------------ - Ask client how they are feeling? - Ask whether similar symptoms have occurred in the past - Obtain information from family or friends - Nervous habits (nail biting, finger picking) - Ask about self-medication - Pacing - Behaviour - Hypervigilance - Sleep disturbance - Avoidance behaviour - Occupational functioning - Social or functional relationships Nursing Diagnoses ----------------- - Anxiety related to impending divorce or life changing event - Impaired Verbal communication - Ineffective coping - Powerlessness - Disturbed Sleep pattern - Impaired Social interaction Planning -------- - Accept that the experience of anxiety is natural and inevitable - Understand that the client\'s level of anxiety may fluctuate - Understand that shame is a self-impose response to anxiety - The ability to learn self-help techniques reduce anxiety - Develop problem solving and coping skills Implementation -------------- - Maintain a calm non-judgmental attitude - Convey acceptance - Communicate in short simple sentences - Reduce environmental stimuli - Assist client to meet basic needs - Encourage verbalization - Channel the client behaviour in physical activities which provide an outlet for tension or frustration - Promote sleep Evaluation ---------- - Evaluation focuses on the client\'s ability to an understanding of anxiety - Develop and effectively use coping skills to promote behaviour change - Have an appreciation of how to manage self Summary ------- - Anxiety is an emotional response to an unknown object or situation, whereas fear is a response to a known or recognized danger - The etiology of anxiety is addressed by various theories, genetic, biologic, psychoanalytic, cognitive behaviour and socio-cultural - Clinical symptoms are classified as physiological, psychological, or emotional, behavioral, and intellectual or cognitive. - Nursing Management include providing a safe environment for the client - Accept the client - Channel behaviour in an acceptable manner - Verbalize feelings while meeting basic needs - The nurse ensures various modalities of treatment are utilized example, medication management, interactive therapies, cognitive behaviour therapy, and client education