CARE STUDY

OF
MR. JAYASHANKAR
WITH
ANXIETY NEUROSIS
CLIENT PROFILE

NAME : Mr. Jayashankar

AGE : 31 Years

SEX : Male

QUALIFICATION : Uneducated.

DIAGNOSIS : Anxiety Neurosis

DATE OF CARE STARTED : 05/12/2010

DATE OF CARE ENDED : 11/12/2010

HOSPITAL : NIHMANS,Bangalore

INTRODUCTION

When I was posted in out patient department, I took Mr. Jayashankar for my case study. He
was a case of anxiety neurosis. I met the patient, first he did not respond to my questions but
slowly he answered to all my questions. He was tried and he is a well co-operative person.

IDENTIFICATION DATA

Name : Mr. Jayashankar

Age : 31 years
Sex : Male
Qualification : Uneducated
Occupation : Auto driver
Income : Rs. 1200 per month
Mother tongue : Tamil
Religion : Hindu
Nationality : Indian
Period of care plan : o0/12/2010 to 11/12/2010
Diagnosis : Anxiety Neurosis
Brought to the hospital by : Wife
Source of referral : Client is a case of anxiety neurosis and he had his first
admission in NIMHANS on 31/12/09 and now he is under
follow-up treatment.

RELIABILITY OF THE INFORMANT

Client had admission with his wife because of her request. He has good relationship with his
wife. She was uneducated and her observation was good. She has not much intelligent. At
present she is with her husband for the past 10 years. Mrs. Manju was very loving with her
husband. She gave reliable information of the client.

CHIEF COMPLAINTS DURING ADMISSION

 Anxiety
 Fear
 Hear some voice
 Increased psychomotor activity
 Sleep disturbance
 Loss of appetite
 Feels worried
 Not aware to urinate
 Want to die
 Palpitation, frightened and confused
 Experiencing fear and hopeless.

SYMPTOMS OBSERVED

 Anxiety temperament
 Fear
  Palpitation
 Confusion
 Twisting of ----- frequency.

PRECIPITATING FACTORS

There is presence of physical illness hypertension which was diagnosed back, no family
history of psychological illness. Patients social factors is affected because of his worries.

PAST MEDICAL AND SURGICAL HISTORY

Patient has the past medical history of hypertension before 10 years and has undergone
treatment. There is no relevant surgical history and no history of blood transfusion.

PAST PSYCHIATRIC HISTORY

There is no relevant past psychiatric history of the patient.

PRESENT PSYCHIATRIC HISTORY

Patient had two episodes of psychiatric illness since the year 1999. At present he is under
follow-up treatment and taking mediations regularly.

FAMILY HISTORY

Mr. Jayashankar belongs to a nuclear family. He has the habit of alcohol intake early. His
grand parents died due to ageing. Mr. Jayashankar’s monthly income is Rs. 1200 per month.
He is head of the family. Mr. Jayashankar had two episodes of psychiatric illness since the
year 1999. He has no properties and the house facilities are adequate and good. Mr.
Jayashankar had the attempts of committing suicide and expressed his ideas to his family
members because he was upset that he got married earlier. He has so wandering behavior.
Patient has good religious belief and he lacks social support. His wife and children was
loving to him. Client is a hypertensive person. He had suicidal ideas before 10 years because
of his dislike of early marriage at the age of 21 years. All are healthy in his family except
Mr. Jayashankar.

FAMILY TREE:-

PERSONAL HISTORY

PRE-BIRTH HISTORY OR PERINATAL HISTORY

Mr. Jayashankar was not born to blood related parents and his mother’s condition was good
during pregnancy. He was a full term baby and was breast fed adequately febrile, illness,
medications, drugs use but alcohol are rarely not trauma to abdomen and may physical or
psychiatric illness during pregnancy of the mother. He was a wanted child and his date of
birth is 10/2/1970 and was home delivered. APGAR score was normal and birth cry was
present soon after birth.

CHILD HOOD HISTORY

Mr. Jayashankar was brought up by his mother and was breast fed adequately. The age of
passing each important developmental milestone was normal and toilet training was also
normal. There was no occurrence of neurotic traits.

EDUCATIONAL HISTORY

Mr. Jayashankar was a follower and not a leader among his classmates. The age of his
begging formal education was normal but stopped from his schooling when he was in 1 st
standard. He does not have any school phobia. The reason for stopping from school is due to
poverty and he had no interest school.

ADOLESCENT HISTORY

Mr. Jayashankar adolescent history shows that he had normal secondary sexual characters
and his attitude towards opposite sex is also normal. He does not have any abnormal
behavior towards others.

OCCUPATIONAL HISTORY

Mr. Jayashankar started going for his job at the age of 20 years. He does not have any change
in his job. He is a auto driver. He does not have job satisfaction because he has no enough
earning. He lacks financial support.

PLAY HISTORY

Mr. Jayashankar played all the games and he was interested in playing cards. His attitude
towards peer group and his teachers and peer group was good and normal.

SEXUAL AND MARITAL HISTORY

Mr. Jayashankar was love married at the age of 21 years. At present he is living together with
his wife and his children. His sexual life was satisfactory but sometimes felt impotent. He
got examined for this and he was assured by the doctors, so he has confidence and how his
sexual life is normal.

PREMORBID PERSONALITY

Mr. Jayashankar has good interpersonal relationship with his family members and superiors.
He is extraverted character. His hobby is playing cards and he has the habit of alcohol intake
rarely and smoking.
He is a cheerful person and has many friends. His attitude to self and others are he
has self-confidence, thoughtful of others and has good achievements in life like earning
money and getting good name. He gets easily irritable and he is sensitive. He has good
decision making in facing problem and has good religious and moral beliefs.

MENTAL STATUS EXAMINATION

I GENERAL DESCRIPTION

 Mr. Jayashankar is a young man moderately body built man and looks comfortable.

 GROOMING AND HYGEINE

Mr. Jayashankar is clean and tidy. Nails are short and clean. He met his self care and
hygiene activity. His hair is short and healthy. There is perspiration in his face while
talking.
 FACIES: There is no non-verbal expression of mood.

 ATTITUDE TOWARDS THE EXAMINER

Mr. Jayashankar was attentive, co-operative, showed interest in answering to my
questions. He is irritated sometimes but has control over it.

 COMPREHENSION: Intact (fully)

 BEHAIVIOUR AND PSYCHOMOTOR ACTIVITY

 Gait : Unstable, often pulling his shirt.
Psychomotor activity : Increased.

CATATONIC SIGNS : Mannerism, roll shin eyes often upwards, twisting his arms
frequently.
Sterothypes : Absent.
Posturing : Absent.
Wax flexibility : Absent.
Negativism : Absent
Ambitendering : Absent
Ecopraxia : Absent
Conversion and dissociative signs : Absent

SOCIAL MANNER AND BEHAIVIOR

Mr. Jayashankar has appropriate social manner and eye contact is good.

RAPPORT
A good working and empathic relationship could be established with the patient.

HALLUCINATORY BEHAVIOR
Mr. Jayashankar had hallucination (auditory) behavior i.e., he says that he heard a male voice
in the right time irritating him that he is impotent and his life is completed.

II SPEECH
RATE AND QUANTITY OF SPEECH
Mr. Jayashankar’s speech was spontaneously, coherent and relevant. Rate of production of
speech normal.

VOLUME AND TONE OF SPEECH

Pitch normal. He does not have flight of ideas, circumstantially, tangentiality, association.

FLOW AND RHYTHM OF SPEECH

Normal
III MOOD AND AFFECT
A MOOD:
Nurse : How are you now?
Patient : Not good
B AFFECT
Inappropriate

IV THOUGHT
STREAM AND FORM OF THOUGHT
There is no loosening of association, circumstantiality, illogical thinking and verbigeration.

CONTENT OF THOUGHT
Delusion of grandeur was absent. He says that he has belief in Christ. Mr. Jayashankar has no
delusion, obsession and compulsion, phobia, poverty but had suicidal ideas.

V PERCEPTION
A HALLUCINATIONS:
Nurse : Do you have any voice in ears?
 AUDITORY
Patient : That he have a male voice in the right irritating him that
he is impotent and his life is completed.

Olfactory : Absent
Visual : Absent
Tactile : Absent
Gustatory : Absent

B ILLUSIONS AND MISINTERPRETATIONS : Absent

C DEPERSONALIZATION/DEREALIZATION
1. NURSE : What do you think of yourself?
Patient : I am fine and alright.
2. Nurse : Do you find any change in the external world?
Patient : No, I don’t find any change.

D SOMATIC PHENOMENOM: Absent.

IV COGNITION

A ALERTNESS AND LEVEL OF CONSCIOUSNESS: client is very conscious,

while asking questions. He is answering well and responding to all the questions. He is alert.

B ORIENTATION
Client is very conscious while asking questions. He is answering well and he is responding to
all questions. He is very alert.

Client has good orientation to time, place, and person.

 TIME : Oriented to time.
NURSE : What is the time now?
PATIENT : 9:45 am
 PLACE : Oriented to person.
NURSE : Who are we?
PATIENT : Training nurses.

C ATTENTION
Client’s attention is good.
1. Nurse : Can you repeat 5 digits forwards starting form 10?
Patient : 10, 11, 12, ----
2. Nurse : Can you repeat 3 digits backwards starting from 100?
Patient : 200, 99, 98,

D CONCENTRATION
Patient has good concentration.
Nurse : Can you substract serial----------- from 90?
Patient : 83, 76, 69-----
E MEMORY
Mr. Jayashankar has good recall to remote and immediate memory and abstract recall to
recent memory.

 Remote memory recall was good.

Nurse : Can you tell me your date of birth?
Patient : 10/2/1972

 Recent past memory is not good.

Nurse : When did you come for first admission?
Patient : I don’t know, I think before 1 month.

 RECENT
Nurse : What do you have in the morning?
Patient : Nothing (but client actually ate iddli)

 IMMEDIATE
Nurse : Can you tell numbers from 10 to backwards?
Patient : Repeated 10, 9, 8, 7, --------

F INTELLIGENCE

Mr. Jayashankar has the ability to think logically, act rationally and deal effectively with the
environment.

1. Nurse : Who is the chief minister of Tamil Nadu?

Patient : Karunanidhi
2. Nurse : Which is the capital of India?
Patient : New Delhi

G ABSTRACT THINKING
Abstract thinking is not good.
PROVERB TESTING
Nurse : Can you say a proverb which you know, and tell its meaning?
 Patient :
SIMILARITIES
Nurse : What is the similarity between chair and table?
Patient : Both has four legs.

DIFFERENCES
Nurse : What is the difference between ball and apple?
Patient : We use play with the ball and can eat the apple.

H INSIGHT : Present.
Nurse : What is your problem?
Patient : I have some problem with my mind

I JUDGMENT
PERSONAL JUDGMENT : Good
Nurse : If a snake comes close to you, what will you do?
Patient : I will run and don’t know what to do.
 SOCIAL JUDGEMENT : Good.
Nurse : If you find two patients fighting each other in the ward, what will you
do?
Patient : I will try to compromise them.

J RELIABILITY
All the information given by the patient was reliable to the case sheet.

SUMMARY
To summarize, assessment of mental status examination sums up totally his mental status is
good and he had abnormalities in memory, judgment, and hallucination (auditory).

Client has increased psychomotor activity and has disturbed mannerism, his mood is anxious
and fearful, and his talk is emotional and sometimes very quiet.
DIAGNOSIS
With the above findings by mental status examination and with the history client was
diagnosed as a case of “Anxiety Neurosis”.

PHYSICAL EXAMINATION

GENERAL APPEARANCE

Consciousness : Conscious
General condition : Fair
Body built : Thin
Nourishment : Under nourished
Activity : Has normal activity and works hard.

HEAD
Scalp : The hair is clean and there is no dandruff as hair loss.

EYES
Eyes contact is good. Conjunctiva and sclera are pink. Eye movements are normal. Pupils
react to light.

NOSE
There is no crust formation and no septal deviation.

EARS
Hearing acuity is normal and there is no waxy formation.

TEETH
Client’s teeth are slightly discolored and there is no dentures and dental carries and no tooth
fall.

MOUTH AND PHARYNX

There is no angular stomatitis and no infections or bleeding from the teeth.

NECK
No lymph nodes enlargement and no thyroid gland enlargement.

CHEST
Chest movements are normal. Breathing pattern is also normal.

ABDOMEN
The abdomen is normal and there is no abdominal distension. He has normal peristaltic
movements. There is no presence of fluid organs.

SPINAL CURVE
The spinal curve is normal. There is no kyphosis, lordosis or scoliosis.

EXTREMITIES
Extremities are normal, but has tremors in his arms. Range of motion is normal.

ANUS AND GENITALIA

There are no hemorrhoids and no enlargement of inguinal gland.

VITAL SIGNS : Normal

Temperature : 98.8 degree Fahrenheit.

Pulse : 82 beats per minute.
Respiration : 24 breaths per minute
Blood pressure: 120/90 mmHg.

CEREBRAL FUNCTION
Client has good communication with others. His pattern of emotional behavior is normal. He
also has good social interaction.

MENTAL STATUS
Patient’s appearance is good. His dress is clean and tidy. He has good personal hygiene. Mr.
Antony’s facial expression shows that he is very worried and sad.

INTELLECTUAL FUNCTION
Patient has good orientation to time, place and person and his recent memory is slightly
impaired. His immediate and remote memory is normal.

MOTOR ABILITY
Client easily understands and he performs the activity according to his desire with his normal
motor strength.

MUSCLE STRENGTH
Client has good muscle strength i.e., he is able to flex and extend the extremities against
resistance. He has tremors of his arms.

BALANCE AND CO-ORDINATION

Client’s hand is shivering while asked to extend the arms and counting the numbers. His
balance is normal and co-ordination has slightly abnormality.

CRANIAL NERVES FUNCTIONN CLINICAL

SYMPTOMS
I. Olfactory Sense of smell Normal
II. Optic Visual activity Normal
III. Occulomotor Regulation of eye, movements, Normal
eyelid.
IV. Trochlear Pupilary reaction Normal
V. Abducens Pupilary reaction Normal
VI. Trigeminal Facial sensation Normal
VII. Facial Facial muscle movement, Normal
facial expression, tear and
saliva secretion. Taste:
anterior 2/3rd of tongue.
VIII. Vestibulo cochlear Hearing and equilibrium Hear some male voices
like, saying that client is
impotent.
IX. Glosso pharyngeal Taste: Posterior third of Normal
tongue

CRANIAL NERVES FUNCTIONN CLINICAL

SYMPTOMS
X. Vagus Pharyngeal contraction, Normal
movements of vocal cords, soft
palate.
XI. Spinal accessory Movement of sternogledo Normal
mastoid and trapezes muscle
 XII. Hypoglossal Movement of tongue Normal

PROCESS RECORDING

CONVERSATION COMMENTS
Nurse: Good morning! Gait normal.
Patient: Good morning sister. Immediate memory intact.

Nurse: What is your name?

Patient: Mr. Jayashankar

Nurse: Did you have your breakfast?

Patient: No sister.

Nurse: What is the problem with you? Affect is inappropriate.

Patient: I am feared without reason and
feel anxious.

Nurse: Did you take treatment anywhere

other than this hospital?
Patient: No, I am taking treatment here
only.

CONVERSATION COMMENTS
Nurse: Do you take treatment regularly? Copies to treatment and shows interest in
Patient: yes, I will come every month to recovery.
get medicines and if I get excess
anxiousness I immediately approach the
doctor.

Nurse: Do you hear any voices or sounds Has auditory hallucination.

when you are alone?
Patient: Yes, I can hear a male voice
saying that I am impotent and my life is
over. Remote memory intact.

Nurse: When did you get married?

Patient: Ten years back.

Nurse: Can you tell the similarity

between chair and table?
Patient: Both have four legs. Abstract thinking is normal.

Nurse: Can you please tell the difference

between ball and apple?
Patient: We can eat the apple and play
with the ball.
Judgment is good.
Nurse: You are walking alone, on the
way you are seeing envelop with address,
what will you do?
Patient: I will post envelop.

CONVERSATION COMMENTS
Nurse: Tell me something about your
children?
Patient: I am having 4 children. 3 boys Patient is attached with his children and wife.
and 1 girl.
Nurse: Do you love your children and
wife?
Patient: yes, I love my wife and children.

Nurse: Does anyone in your family Accept his psychiatric problem.

affected with psychiatric illness?
Patients: No one, except me.
Nurse: What is your plan for future?
Patient: I want to earn more money and
spend for my wife and children. Concentration is good.

Nurse: Will you follow your plan?

Children: Yes! I am going sister.

Nurse: Where are you going?

Patient: I want to see the doctor, so I am
going.
Nurse: OK, Thank you.
INVESTIGATION

SL INVESTIGATIONS PATIENT’SVALUE NORMAL VALUE INFERENCE

NO
1. Blood 12.2 gms% 12-18gm% Normal
Hemoglobin
2. Total WBC count 6,600 cu mm 4,000 – 11,000 cu Normal
mm
3. Polymorph 59% 60-70% Normal
4. Lymphocyte 40% 20-30% Normal
5. Eosinophil 4% 1-4% Normal
6. Serum creatinine 0.8 mg/dL 0.7-1.4 mg /dL Normal

MEDICATION

Drug Name Pharmacologic Dos Rout Action Side effects Nurses

al name e e responsibilit
y
Tab Elavil 75- Oral Tricyclic Postural Administer
Amitriphyllin 300 Antidepresant hypotension, correctly in
e mg / It exist its tachycardia, sufficient
day antidepressant cardiac doses.
action by arrhythmias, Check BP.
blocking urinary
normal ---- retension,
take of nor- fatigue,
adrenaline and dizziness,
--------. It also confusion
has significant weight gain
anticholinergi and sexual
c activity. disturbances
.
Tab. Imipramine 75 Oral Tricyclic Sinus, Check vital
Imipramine mg antidepressant tachycardia, signs.
Inhibits --- postural Administer
adrenaline hypotension, correct
----- and to be urinary doses.
lesser extend retension,
 that of -------,liver
it reduces dysfunction,
RSM sleep weight gain,
and increases eosionphilia,
stage 4 sleep. tremors.
Tab BC BC 320 Oral Vit B and C Hyper See for side
mg complex vitaminosis, effects.
supplement. GI Explain
disturbances about ----
. Yellow color
colored change.
urine.
Tab. Diazepam 5 Oral Benzodiazepin Psychologic Check vital
Diazepam mg e ------------- al and signs.
Has typical physical Monitor
activity dependence vision and
spectrum of with value for
benzodiazepin withdrawal eye check
e encomparing syndrome, ups.
anxiolysis, visual
sleep disturbance,
modifying and mental
-------effects. change.
 CASE STUDY

INTRODUCTION
Anxiety is the commonest psychiatric symptom in clinical practice.

Anxiety is a normal phenomena which is characterized by a state of apprehension or uncare

arising out of anticipation of danger.

Normal anxiety becomes pathological when it causes significant subjective distress and for
impairment in functioning of individuals.

DEFINITION

Anxiety reaction is a neurotic state of chronic apprehension with recurrence of acute anxiety
symptoms.

TYPES

TRAIT ANXIETY
This is a habitual tendency to be anxious in general and is exemplified by I often feel
anxious.

STATE ANXIETY
This is the anxiety felt at the present moment exemplified by I feel anxious now. Persons
with trait anxiety often have episodes of state anxiety.

BOOK STUDY PATIENT’S

STUDY
ETIOLOGY
BIOLOGICAL FACTORS
 Heredity
 Constitution
 Endocrine disturbances, metabolic and biochemical
abnormalities.
There are not considered as significant causes in the illness.

ENVIRONMENTAL FACTORS
There are more important causes.

AGE
Childhood, adolescence, and involution periods are more susceptible.

SEX
Incidence equal in both sexes, it may be more in one sex than another at
different ages.

PERSONALITY
Persons with anxious, inadequate and obsessive personalities are more
susceptible.

FRUSTRATION IN SEXUAL AIM

PRECIPITATING FACTORS
 Physical, physiological or psychosocial stress of a moderate to
severe degree.
 Difficult family situation.
 Occupational and financial difficulties.
 Heavy responsibilities without adequate support.
 Prolonged or debilitating physical illness.
Example: Influenza.

BOOK STUDY PATIENT’S STUDY

THEORIES OF ANXIETY DISORDERS

PSYCHODYNAMIC THERAPY
According to this theory, anxiety is a signal that something is
disturbing the internal psychological equilibrium. This is called
as signal anxiety. This signal anxiety arouses the ego to take
defensive action which is usually in the form of repression, a
primary defense mechanism, like conversion, isolation, are
called i.e., to function adequately and the secondary defense
mechanisms are not activated. Hence, anxiety come to the
far front.

Develop mentally, physical anxiety is manifested as -------

symptomatology while develop mentally advanced anxiety is
signal anxiety.

Panic anxiety according to this theory is closely related to the

separation anxiety of childhood.

BEHAVIORAL THEORY
According to this theory, anxiety is viewed as an unconditioned
inherent response of the organism to painful or dangerous
stimuli. In anxiety and phobias, this becomes attached to
relatively neutral stimuli by conditioning.

Behavioral approach is more helpful in treatment rather than in

explaining the cause of anxiety.

COGNITIVE BEHAIVOR THEORY(CBT)

According to cognitive behavioral theory, in anxiety disorder,
there is evidence of selection information processing (with more
attention paid to threat related information), cognitive
distortions, negative automatic thoughts (NATs) and perception
of decreased control over internal and external stimuli.

BIOLOGICAL THEORY
i) GENETIC EVIDENCE
15-20% of the first degree relatives of patients with anxiety
disorder exhibits anxiety disorder

BOOK STUDY PATIENT’S STUDY

Themselves. The concordance rate in the monozygotic twin of
patients with panic disorders in as high as 80% (4 times more than
dizygotic twins).
ii) CHEMICALLY INDUCED ANXIETY STATES
Infusion of sodium lactate, isoproterenol and caffeine,
ingestion of yohimbine and inhalation of 5% CO2 can produce
panic episodes in predisposed individuals. Administration
l(oral) of HAOIs before lactate infusion protects the individual
form panic attach, thus providing a probable clue to the
biological model of anxiety.
I) GABA BENZODIAZEPINE RECEPTORS
This is one of the most recent advances in the search for
etiology of anxiety disorders. Benzodiazepine receptors are
disturbed widely in the central nervous system. Presently, two
types have been identified. The type I is GABA and chloride
independent, while type II is GABA and chloride dependent.

GABA is the most prevalent inhibitory neurotransmitter in the

central nervous system. It has been suggested that an
alteration in GABBA levels may lead to production of clinical
anxiety. The fact that the bencodiazepenin relieve anxiety and
inverse antagonists cause anxiety, lends heavy support to this
hypothesis.

II) OTHER NEUROTRANSMITTERS

Norepinephrine, 5-HT, dopamikne, opioid receptor and neuro
endrocrine dysfunction have also been implicated in the
causation of anxiety disorders.
III) NEUROANATOMICAL BASIS
Locus -----, ------- system and prefrontal cortex are some of
the areas implicated in the etiology of anxiety disorders.
Regional cuebral blood flow is increased in anxiety, though
vasoconstriction occur in severe anxiety.
IV) ORGANIC ANXIETY DISORDER
This disorder is characterized by the presence of anxiety
which is secondary to the various medical disorder. If anxiety
can occur secondary to medical disorders it is possible that
anxiety has a biological basis.

BOOK STUDY PATIENT’S

STUDY
PSYCHOPATHOLOGY
Early emotional conflicts in life interfere with the normal development
of personality and contribute to the development of anxious or
dythymic types of personality which under the influence of state of life
breakdown in attacks of anxiety state. The usual defense mechanism
which helps in the handling of anxiety become too inadequate resulting
in an anxiety state.

CLASSIFICATION
 Generalized anxiety disorder. Client belongs to
 Panic disorder. the classification of
generalize disorder.
GENERALISED ANXIETY DISORDER
It is characterized by a generalized persistent anxiety of at least six
month duration, and manifested by signs of motor tension, autonomic
hyper activity, intensive expectation and vigilance. It is the most
common neurotic disorder.

EPIDEMIOLOGY
 3-17 PER 1000 among men.
 1-38 per 1000 among women.

PANIC DISORDER
Panic disorder is defined as a sudden attack of intense discomfort, fear,
or tremor. Panic disorder is characterized by fear and subsequent
attempt to avoid of specific objects or situation, which the person
thinks are unreasonable.

ETIOLOGY OF GAD AND PANIC DISORDERS

GENETIC: Anxiety disorder is more frequent among relatives of
patients with their condition.
BIOCHEMICAL
Disturbance in nuro-transmitter especially nor-adrenaline , serotonin
and GABA may cause anxiety of disorder.

PSYCHOLOGICAL
As a result of intra psychic conflict, as a conditioned response a
---------- learning.

BOOK STUDY PATIENT’S STUDY

CLINICAL SYMPTOMS : PHYSICAL
SYMPTOMS IN GAD
1. CARDIOVASCULAR SYSTEM
  Tachycardia
 Chest pain
 Palpitations Client has the symptoms of palpitation,
 Dropped beats abdominal pain, hesitation to urination,
 Flushing tremors, sweating, aches and pain.
 Fainting
2. RESPIRATORY SYSTEM
 Sighing
 Choking
 Yawning
 Dyspnoea
3. ALIMENTARY SYSTEM
 Dry mouth’
 Dysphagia
 Dyspepsia
 Butterflies in stomach
 Nausea
 Abdominal pain
 Diarrhoea
4. GENITO-URINARY SYSTEM
 Frequency
 Hesitation
 Sexual dysfunction

BOOK STUDY PATIENT’S STUDY

5. NERVOUS SYSTEM
 Tension headaches
 Blurring of vision
 Tinnitus
 Sweating
 Tremor
 Dilated pupils
6. MUSCULO SKELETAL SYSTEM
 Aches and pain
 Teeth clinching
 Chronic terks.

PSYCHOLOGICA SYMPTOMS OF
ANXIETY Client has the symptoms f fearfulness,
1. CONGNITIVE SYMPTOMS irritability and worries.
Poor concentration.
Dis-hyperarousal
Vigilance or scanning.
2. PERCEPTUAL SYMPTOMS
 Derealization.
 Depersonalization.
AFFECTIVE SYMPTOMS
 Diffuse, unpleasant, vague sense of
apprehension.
 Fearfulness.
 Inability to relax.
 Feeling of imploding doom.
 Worries.

BOOK STUDY PATIENT’S STUDY

OTHER SYMPTOMS
 Insomnia (initial) Client has the symptoms of insomnia,
 Exaggerated startle response. reduction in efficiency and feeling fatigue and
 Vague somatic symptoms. tired.
 Reduction in efficiency,
 Feeling fatigued and tired.
COMMON SIGNS ARE
 Elevation of blood pressure
 Tachycardia
 Increased respiratory rate
 Sweating
 Hyper reflexia
PHYSICAL SYMPTOMS OF PANIC
DISORDER Client has the physical symptoms of sweating
 Increased heart rate. and trembling.
 Dizziness
 Sweating
 Trembling
 Dyspnoea
 GI disorder and others.

PSYCHOLOGICAL SYMPTOMS OF
PANIC DISORDER
  Intense anxiety.
 Fear of dying or losing control.
 Depersonalization.
 Derealization.
TYPES
Some authors separated anxiety in to two
types.

TRAIT ANXIETY
This is a habitual tendency to be anxious in
general.

BOOK STUDY PATIENT’S STUDY

STATE ANXIETY
This is the anxiety felt at the present moment.
PRESENT MOMENT
According to the duration of anxiety, it is divided into two.

ACUTE ANXIETY REACTIONS

It is also known as panic physiological symptoms are most mark. Client has acute
Patient may be bewildered, confused and agitated. anxiety reactions.

CHRONIC ANXIETY NEUROSIS

Psychological symptoms are more marked resulting in physical and
mental exhaustion (neuroasthenia)
LEVELS OF ANXIETY
Anxiety has four levels
 Mild +
 Moderate ++
 Severe +++
 Panic +++
Changes in attention and concentration during levels or forms of Client has mild level
anxiety. of anxiety.

MILD
 Increased alertness.
 Concentration poor.
 Appears confident.

MODERATE
 Misperception of stimuli.
 Concentration very poor.
 Paces up and down.
  May irritate others.

BOOK STUDY PATIENT’S STUDY

SEVERE
Decreased and distorted perception.

PANIC
Attention and concentration highly affected.

DIFFERENTIAL DIAGNOSIS
In acute attacks of anxiety should be differentiated from p------ In case of client history of
chromocytoma and chronic anxiety state should be emotional conflict and
differentiated from thyrotoxicosis. The personality type, history personality type show his
of emotional conflicts, absence of exapthalmous, abence cold anxiety disorder and hence
moist hands are more in favor of diagnosis of anxiety state. diagnosed.

TREATMENT
The treatment is usually multimodal.

PSYCHOTHERAPY
This is the principal treatment usually supportive psychotherapy
is used either alone, when anxiety is mild or in combination
with drug therapy. Deep analytical psychotherapy is needed of
chronic mal adjusted personalities since the modification of
basic psychic structure is important to set lasting benefit.

RELAXATION TECHNIQUES
In patient with mild to moderate anxiety relaxation techniques
are used. It is used by the patient himself as a routine exercise
everyday and also whenever anxiety provoking situation is at
hand.

The technique include.

 Progressive relaxation technique.
 Yoga.
 Pranayama.
 Self-hypnosis.
 Meditation (TM- transcendental meditation)
OTHER BEHAVIOR THERAPY
There include
  Cognitive behavioral therapy (BT) In case of client he gets drug
 Bio feedback. therapy such as tranquilizers.
 Hyper ventilation control.
DRUGS
Drugs used are
 Sedatives
 Hypnotics
 Tranquilizers (anxiolytics)
 Neuroleptics

TRANQUILLISERS
Example
- T.Meprobamate 200 mg t.d.s
- T. Chlordiazepoxide 5-10 mg t.d.s
- T.Alprzolam 0.25 to 1 mg t.d.s
- Buspirone 5-10 mg t.d.s given for symptomatic relief.

NEUROLEPTICS
Example:
T.Chloropromazine hydrochloride 25 mg t.d.s
T.Trifluoperazine 1 to 2 mg t.d.s
T.Haloperidol 0.25 mg t.d.

The tranquillizers and neuroleptics also by given

parenterally.
Beta blockers like propanalol. (Eg – ciplar) are useful in
the management of anticipatory anxiety.

SEMINARCOSIS THERAPY
It is useful for acute reactions. Patients is put to sleep for
16 to 20 hours per day with the help of drugs.

BOOK STUDY PATIENT’S STUDY

ABREACTIVE THERAPY
INDICATIONS
Definite psychological trauma feelings of guilt.
TREATMENT
Intravenous injections of sodium peritotal hypnosis.
Small doses (10 to 40 volts) of electric current passed bitemporally.

SOCIAL CASE WORK AND COUNSELLING In case of client

It is very useful in cases where the conflicts are extra psychic and the counselling was
environmental stress is responsible for the illness. The goal is to given.
modify the environment more specially the psychosocial situations so
as to reduce the unhealthy and abnormal interactions between the
patient and his family members, relatives, friends, colleagues etc.

PSYCHOPHSIOLOGICAL THERAPY (PPT)

A very distinct advantage of this therapy is that it involves active
participation and training in the part of the patient and avoids the use
of anxiolytic drugs which are known to be habit forming.
In case client
MODIFIED INSULIN TREATMENT prognosis is good in
It is useful in relieving anxiety and in improving the physical health both personality and
which will produce a sense of well-being. precipitating factors.

PROGNOSIS
This is determined by,

DURATION OF ILLNESS: Shorter duration carries better

prognosis.

PERSONALITY: Well adjusted personalities recover more easily

than the neurotic, maladjusted personalities.

PRECIPITATING FACTORS
Possibility of environmental manipulation to make it as stressful for
the person ensures quicker and long lasting remission of symptoms.

BOOK STUDY PATIENT’S STUDY

NURSING MANAGEMENT
 Provide calm and quiet environment. All the nursing management are carried out
 Speak slowly and calmly. with the patient correctly.
 Provide reassurance and comfort.
 Encourage to take rest.
 Don’t leave the patient alone.
  Limit intake of caffeinated drinks.
 Give relaxation technique.
 Encourage to come for follow-up care.
 Give counseling to him and also to the
family members.

NURSING DIAGNOSIS

1. Severe anxiety related to irrational thoughts and situations secondary to absence of

support system.
2. Exaggerated fear related to unknown stimuli.
3. Altered thought process reoccupation related to intense fear.
4. Self esteem disturbance related to intense fear.
5. Alteration in psychomotor activity, restlessness related to anxiety.
6. Altered perception auditory hallucination related to mental illness.
7. Sleep pattern disturbance related to emotional disturbances.
8. Impaired social interaction related to effects of behavior and action on forming and
maintaining relationship.
9. Altered spiritual distress, deviation, pain related to inability to deal with anxiety.
10. Knowledge deficit regarding psychiatric illness and treatment.
PSYCHO EDUCATION
HEALTH EDUCATION GIVEN ABOUT :

 PERSONAL HYGEINE

1) Instructed the patient to take bath daily, to brush daily, to wash hands before and
after defecation and before eating.
2) Instructed to cut short the nails once in a week, to comb hair properly and to wear
the cloths after washing and drying in sunlight.

FAMILY THERAPY
Encouraged the client and the family members to cope with the patient’s disease condition
and take special care of him without any avoidance of him.

Notified the patient carefully and encouraged him to do his works correctly.

BEHAVIOR THERAPY

Encourage the client to change his behavior by improving his activities of daily living,
maintaining his personal care and to make him to be socialized with others.

INDIVIDUAL PSYCHO THERAPY

Encouraged supportiveness for disease condition and to be confidence in his life.

GROUP PSYCHOTHERAPY
Group psychotherapy was given by forming a group in the hospital ad detailing the disease
condition and the methods of treatment.

FOLLOW UP CARE
Instructed the patient to take medications regularly.

Avoid discontinuing the drugs once he felts better without doctor’s order and to come for a
regular check up.

CONCLUSION
Client showed improvement after his starting of treatment. H showed interest and coped with
the treatment. His symptoms were reduced which was severe during admission. At present
this under follow-up treatment.

BIBLIOGRAPHY
1. Ahuja neeraj. A short text book of psychiatry. 5 th Edition. New delhi: Jay Pee; 2002;
91-95.
2. Nambi S. Psychiatry for Nurses. 1st Edition. 6th Edition. New delhi; Jay Pee
Company; 1998; 46-52.
3. Kapoor bimla.Text book of psychiatric nursing. 1st Edition. Delhi; 1994 (II).
4. Lynda juall carpentio. Handbook of nursing diagnosis. 7th Edition. New York;
Lipincott; 1997.
5. Stuart G W. Principles and practice of psychiatric nursing. 7 th Edition. Harcourt;
Mosby.2001.

6. CIMS – Current Index of Medical specialities.