Maladaptive Patterns of Behavior A. Anxiety
Maladaptive Patterns of Behavior A. Anxiety
Maladaptive Patterns of Behavior A. Anxiety
A. ANXIETY
I. ANXIETY RESPONSE
Anxiety at a certain level may serve as a normal response to alert the person experiencing
it to protect the self against anything which may threaten the person’s mental security motivating
defensive behaviors which are consciously or unconsciously aimed to reduce or alleviate anxiety’s
associated discomfort
Normal anxiety is a healthy reaction necessary for survival. Anxiety provides the energy
needed to carry out the tasks involved in living and striving toward goals. Anxiety motivates people
to make and survive change. It prompts constructive behaviors, such as studying for an
examination, being on time for a job interview, preparing for a presentation, and working toward
a promotion.
A. Biological Factors
1. Genetic
• Numerous studies substantiate that anxiety disorders tend to cluster in
families.
• Genetic variants have been identified that are associated with increased
risk for anxiety and obsessive-compulsive disorders. Twin studies
demonstrate the existence of a genetic component to both panic disorder
and OCD.
• First-degree biological relatives of those with OCD or phobias have a
higher frequency of these disorders than exists in the general population.
2. 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 brain and have been implicated in phobic
responses such as fear of snakes, heights, or open spaces.
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• The Limbic System - anatomic pathways provide the transmission
structure for the electrical impulses that occur when anxiety-related
responses are sent or received.
• Neurotransmitters – a chemical released by Neurons that convey
electrical messages. The neurochemicals that regulate anxiety include
epinephrine, norepinephrine, dopamine, serotonin, and gamma-
aminobutyric acid (GABA). GABA, an inhibitory neurotransmitter that
puts a brake on excitatory neurotransmitters, is commonly the focus of
pharmacological therapy for anxiety symptoms. GABA slows neuron
activity, which plays a role in lowering anxiety. It is believed that people
with too little GABA may suffer from anxiety disorders.
B. Psychological Factors
1. Psychodynamic theories suggest that unconscious childhood conflicts are the
basis for future symptom development. Sigmund Freud posited that anxiety results
when threatening repressed ideas or emotions are close to breaking through from
the unconscious mind into the aware and conscious mind. Freud also suggested
that ego-defense mechanisms are used to keep anxiety at manageable levels. The
use of defense mechanisms may result in overuse of behavior that is not wholly
adaptive because of its rigidity and repetitive nature. Harry Stack Sullivan believed
that anxiety is linked to the emotional distress caused when early needs go unmet
or disapproval is experienced (interpersonal theory). He also suggested that
anxiety is “contagious,” being transmitted to the infant from the mother or
caregiver. Thus the anxiety felt early in life becomes the prototype for anxiety
responses when unpleasant events occur later in life.
2. Behavioral theories suggest that anxiety is a learned response to specific
environmental stimuli (classical conditioning). An example of classical conditioning
is a boy who is anxious in the presence of his abusive mother. He then generalizes
this anxiety as a response to all women. Conditioning can be reversed through the
influence of safe and loving female friends and significant others. The social
learning model suggests that anxiety is learned through the modeling of parents or
peers. For example, a mother who is fearful of thunder and lightning and hides in
closets during storms may transmit her anxiety to her children. These children
continue to imitate this fearful behavior into adult life. Such individuals can unlearn
this behavior by observing others who react normally to a storm by lighting candles
and telling stories.
3. Cognitive theorists believe that anxiety disorders are caused by distortions in an
individual’s thoughts and perceptions. Because individuals with such distortions
exaggerate any mistake and believe that they will have catastrophic results, they
experience acute anxiety. People who tend to perceive events and situations as
being potentially dangerous may be overly responsive and become anxious or
even experience panic attacks.
PRECIPITATING STRESSORS
A. Stressor
An internal stimulus (chemical or biological agent) or external stimulus (environmental
condition, or an event) seen as causing tension to an organism.
Motivates people to continue participating in and enjoying activities and events that require
effort, but ultimately promote their physical and emotional well-being
C. Crisis
A state of acute emotional upset that includes a temporary inability to cope by means of
one's usual problem-solving methods
Typically lasts for 4-6 weeks, no more than 6-8 weeks because a person cannot remain
for too long in a state of acute emotional upset
Stages of Crisis:
a. Precrisis -
The person is exposed to stressors
There may be warning signs of stress or none at all
The person is in equilibrium
b. Impact - the person experience the stressor
• High level of stress, confusion, anxiety
• Inability to reason logically
• Inability to apply problem-solving behavior
• Inability to function socially, helplessness
• Chaos, Possible panic
c. Crisis - Use coping skills to deal with the stressor
• Denial of problem
• Rationalization about cause of the situation
• Projection of feelings of inadequacy onto others
• (may last a brief or prolonged period of time)
d. Resolution - When coping is effective: integration occurs
• The person perceives the crisis situation in a positive way
• Successful problem-solving occurs
• Anxiety lessens, Self-esteem rises
• Social role is resumed
• When coping attempts fail: disequilibrium occurs
• Tension and anxiety resurface as reality is faced
• Feelings of depression, self-hate, and low self-esteem may occur
e. Postcrisis
• May be at a higher level of adaptation and maturity due to acquisition of
new positive coping skills
• May function at a restricted level in one or all spheres of the personality
due to denial, repression, or ineffective mastery of coping
Types of Crisis:
a. Maturation crisis (Developmental crisis)
The crisis origin is embedded in a person's struggles with transition from one
life stage (or role) to another
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It can be anticipated but not necessarily prepared for (ex. Graduation,
Retirement)
b. Situational crisis
The crisis origin is a sudden, random, shocking, and often catastrophic event
that can't be anticipated or controlled that largely affects a person's identity and
roles (ex. Death of husband, Loss of Job)
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Characteristics of Crisis:
a. Self-limiting (4 to 6 weeks)
b. Crisis resolved in any of three ways
a. Returns to pre-crisis level of functioning
b. Begins to function at a higher level of functioning
c. Regresses at a lower level of functioning
Crisis Intervention:
a. An active but temporary entry into the life situation of an individual, a family, or
a group during a period of stress (Mitchell &Resnik, 1981).
b. It is an attempt to resolve an immediate crisis when a person’s life goals are
obstructed and usual problem-solving methods fail.
c. The client is called on to be active in all steps of the crisis intervention process,
including clarifying the problem, verbalizing feelings, identifying goals and
options for reaching goals, and deciding on a plan.
d. TYPES OF CRISIS INTERVENTION:
1. Directive intervention - To take temporary control and responsibility for the
situation
2. Supportive intervention - Collaborative and non-directive
e. GOALS OF CRISIS INTERVENTION
1. To decrease emotional stress and protect the client from additional stress
2. To assist the client in organizing and mobilizing resources or support
systems to meet unique needs and reach a solution for the particular
situation or circumstance that precipitated the crisis.
3. Enable the individual to understand the relationship of past life experiences
to current stress;
4. Reduce the risk of chronic maladaptation;
5. Promote adaptive family dynamics
6. To return the client to a pre-crisis or higher level of functioning
FEAR ANXIETY
Involves intellectual appraisal of a An emotional response to threat
threatening stimulus
Use of Ego Defense Coping Disequilibrium in Ego Defense Coping
Mechanism Mechanism
A result of a physical or A result of unresolved FEAR
psychological exposure to a
threatening
Anxiety occurs once selfhood, self-esteem, identity existence or security is threatened. It may be
connected with the fear of punishment, disapproval, rejection, withdrawal of love, disruption of a
relationship, isolation or loss of body functioning.
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CONTINUUM OF ANXIETY RESPONSE
4. Panic –
Highest level of anxiety leading to irrational behavior. Disorganization of one’s
behavior characterized by dread, terror and awe. The person is unable to do things
even with direction
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*A CLOSER LOOK ON SPHERE OF AWARENESS / PERCEPTUAL FIELD OF A PERSON
EXPERIENCING ANXIETY
STUDY
PLANTING
KEEPING SELF HEALTHY
DISTRACTED
STUDY
EAT A BIT
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3. Severe Anxiety – abnormal, free floating
CANNOT FOCUS
ON STUDIES
4. PANIC –
LOCKDOWN DUE
TO
PANDEMIC
INSOMNIAC AVOIDANT
SELF ISOLATION
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V. MANIFESTATIONS AND DISCOMFORTS OF ANXIETY
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Physiological Response-
Severe headache
Nausea, vomiting
Diarrhea
Trembling
Rigid stance
Vertigo
Pale
Tachycardia
Chest pain
D. Panic Level
Cognitive Response-
Flashbacks/Nightmares
Distorted perceptions
Loss of rational thoughts
Doesn’t recognize danger
Can’t communicate verbally
Possible hallucination and
Delusion
Affective /Behavioral Response
May be suicidal
Physiological Response-
May bolt and run or
Totally mute & immobile
Dilate pupils
Increased VS
Flight, Fight, or Freeze
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A. Panic Disorder with or without phobia– pathological fear of an object, place and people
that is symbolical in nature. Most common among patients with this anxiety disorder has
agoraphobia.
Other Examples:
a. Ablutophobia – fear of washing and bathing
b. Claustrophobia – enclosed place
c. Erythrophobia – red
d. Gynephobia – Women
e. Androphobia - men
f. Xenophobia – strangers
g. Alektorophobia – chicken / poultry
h. Photophobia – light
i. Arachnophobia - spider
j. Cacophobia – ugly
k. Haptephobia – touch
l. Ombrophobia – rain
m. Pyrophobia – fire
n. Thanatophobia – death
o. Tokophobia - pregnancy
C. Posttraumatic Stress Disorder – The person has been exposed to a traumatic event in
which both of the following were present:
• The person has experienced, witnessed or been confronted with an event that involved
actual or threatened death or serious injury
• The person’s response involved intense fear, helplessness or horror. The traumatic
event is reexperienced in mind.
• Other Criteria:
o Persistent Avoidance of Stimuli Associated with the Trauma & Numbing of
General Responsiveness
o Persistent Symptoms of Increased Arousal
o Duration of Disturbance is more than one month
o Disturbance causes distress and dysfunction
Obsessions are defined as thoughts, impulses, or images that persist and recur so that
they cannot be dismissed from the mind even though the individual attempts to do so.
Obsessions often seem senseless to the individual who experiences them (ego-dystonic),
and their presence causes severe anxiety.
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must be repeated again and again. Although obsessions and compulsions can exist
independently of each other, they most often occur together.
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o Adults, with Separation Anxiety Disorder commonly coexists with other
maladaptive patterns of behaviors too such as: depressive disorders, bipolar
disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive
disorder, and personality disorders.
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Sample:
Signs and Symptoms Nursing Diagnosis Outcomes
Separation from significant other, concern Anxiety (moderate, Monitors intensity of anxiety, uses
that a panic attack will occur, exposure to severe, panic) relaxation techniques, decreases
phobic object or situation, presence of environmental stimuli as needed,
obsessive thoughts, fear of panic attacks, controls anxiety response, maintains
preoccupation with perceived physical flaws, role performance
apprehension about losing prized
possessions, pulling hair or picking skin
Unable to attend social functions or take Ineffective coping Identifies ineffective coping patterns,
employment, anxiety interferes with the ability asks for assistance, seeks information
to work, avoidance behaviors (phobia, about illness and treatment, identifies
agoraphobia), inordinate time taken for multiple coping strategies, modifies
obsession and compulsions lifestyle as needed
Exaggerated negative perception of physical Chronic low self-esteem Verbalizes self-acceptance,
appearance, ashamed of the appearance of communicates openly, increases
the house due to hoarding activity, believes confidence, describes a positive sense
that others are disgusted with his of self-worth
appearance, embarrassment about the hair or
skin condition
Skin excoriation related to rituals of excessive Self-mutilation Identifies feelings that lead to impulsive
washing, excessive picking at the skin, or actions, practices self-restraint of
pulling hair out compulsive behavior
From Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). Nursing diagnoses—Definitions and classification 2015-2017. Oxford, UK: Wiley
Blackwell. Copyright © 2014, 1994-2012 by NANDA International. Used by arrangement with John Wiley & Sons Limited; Moorhead, S.,
Johnson, M., Maas, M. L., & Swanson, E. (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby.
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Patterns of Behavior. Refrain from reproducing this material without the consent of the preparer and the PLM-CN
Sample Interventions with Rationale
INTERVENTION RATIONALE
Help the patient identify anxiety. “Are you comfortable It is important to validate observations with the patient,
right now?” name the anxiety, and start to work with the patient to
lower anxiety
Anticipate anxiety-provoking situations. Escalation of anxiety to a more disorganizing level is
prevented.
Use nonverbal language to demonstrate interest (e.g., your head). Verbal and nonverbal messages should be
lean forward, maintain eye contact, nod your head). consistent. The presence of an interested person
provides a stabilizing focus.
Encourage the patient to talk about his or her feelings When concerns are stated aloud, problems can be
and concerns discussed and feelings of isolation decreased.
Avoid closing off avenues of communication that are When staff anxiety increases, changing the topic or
important for the patient. Focus on the patient’s concerns offering advice is common but leaves the person
isolated.
Ask questions to clarify what is being said. “I’m not sure Increased anxiety results in scattering of thoughts.
what you mean. Give me an example.” Clarifying helps the patient identify thoughts and
feelings.
Help the patient identify thoughts or feelings before the The patient is assisted in identifying thoughts and
onset of anxiety. “What were you thinking right before feelings, and problem solving is facilitated.
you started to feel anxious?”
Encourage problem solving with the patient.∗ Encouraging patients to explore alternatives increases
sense of control and decreases anxiety.
Assist in developing alternative solutions to a problem The patient is encouraged to try out alternative behaviors
through role play or modeling behaviors and solutions.
Explore behaviors that have worked to relieve anxiety in The patient is encouraged to mobilize successful coping
the past. mechanisms and strengths
Provide outlets for working off excess energy (e.g., Physical activity can provide relief of built-up tension,
walking, playing ping-pong, dancing, exercising). increase muscle tone, and increase endorphin levels.
∗Patients experiencing mild to moderate anxiety levels can problem solve .
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PHARMACOTHERAPY: ANXIOLYTICS
A. DRUG CLASSIFICATION AND LIST:
• FDA Approved Drugs for Anxiety Disorders: Food and Drug Administration. (2016). FDA label repository.
Retrieved from labels.fda.gov; Burchum, J., & Rosenthal, L. (2016). Lehne’s pharmacology for nursing care (9th
ed.). St Louis, MO: Elsevier.
Patients cannot eat foods containing tyramine and must be given specific
dietary instructions. The risk of hypertensive crisis also makes the use of
MAOIs contraindicated in patients with comorbid substance use disorders
B. SIDE EFFECTS
1. Suicidal tendencies
2. Depression, hallucination, confusion, agitation, bizarre behavior, amnesia
3. Drowsiness, lethargy and headache
4. Tremors, EPS
5. Rash and itching
6. Sensitivity to light
VIII. EVALUATION
Identified outcomes serve as the basis for evaluation. In general, evaluation of outcomes for
patients with anxiety disorder deals with questions such as the following:
• Is the patient experiencing a reduced level of anxiety?
• Does the patient recognize symptoms as anxiety related?
• Does the patient continue to display signs and symptoms such as obsessions,
compulsions, phobias, worrying, or other symptoms of anxiety disorders?
• If still present, are they more or less frequent? More or less intense?
• Is the patient able to use new behaviors to manage anxiety?
• Does the patient adequately perform self-care activities?
• Can the patient maintain satisfying interpersonal relations?
• Is the patient able to assume usual roles?
References:
• Margaret Jordan Halter, Varcaroli’s Foundations of Psychiatric-Mental Health Nursing, 8th
edition, 2018
• Shiela L. Videbeck, Psychiatric Mental Health Nursing 6th edition 2011.
• Stuart and Sundeen, Principles and Practice of Psychiatric Nursing.
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CRITICAL THINKING EXERCISES:
1. Which goal should be addressed initially when providing care for 40-year-old Jose who is
diagnosed with posttraumatic stress disorder (PTSD)?
a. Jose will be able to identify feelings through the use of behavioral therapy.
b. Jose will have access to protective resources available through social services.
c. Jose will demonstrate the effective use of relaxation techniques to restore a sense of
control over disturbing thoughts.
d. Jose will demonstrate an understanding of the personal human response to traumatic
events.
2. The nurse is providing care for a patient demonstrating behaviors associated with moderate levels
of anxiety. What question should the nurse ask initially when attempting to help the patient
deescalate their anxiety?
a. “Do you know what will help you manage your anxiety?”
b. “Do you need help to manage your anxiety?”
c. “Can you identify what was happening when your anxiety began to increase?”
d. “Are you feeling anxious right now?”
3. To maximize the therapeutic effect, which lifestyle practice should the nurse discourage for a
patient who has been recently prescribed an antianxiety medication?
a. Eating high protein foods.
b. Using acetaminophen without first discussing it with a healthcare provider
c. Taking medications after eating dinner or while having a bedtime snack
d. Buying a large coffee with sugar and extra cream each morning on the way to work
4. In a parent teacher conference, the school nurse meets with the parents of a profoundly shy 8-
year-old girl. The parents hold hands, speak softly, respond briefly, and have poor eye contact.
The nurse recognizes that the child is most likely exposed to parental modeling and:
a. The inherited shyness trait
b. A lack of affection in the home
c. Severe punishment by the parents
d. Is afraid to say something foolish
5. Isabel is a straight-A student, yet she suffers from severe test anxiety and seeks medical attention.
The nurse interviews Isabel and develops a plan of care. The nurse recognizes effective teaching
about mild anxiety when Isabel states:
a. “I would like to try a benzodiazepine for my anxiety.”
b. “If I study harder, my anxiety level will go down.”
c. “Mild anxiety is okay because it helps me to focus.”
d. “I have fear that I will fail at college.”
6. A homebound patient diagnosed with agoraphobia has been receiving therapy in the home. The
nurse evaluates patient teaching is effective when the patient states:
a. “I may never leave the house again.”
b. “Having groceries delivered is very convenient.”
c. “My risk for agoraphobia is increased by my family history.”
d. “I will go out again, someday, just not today.”
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7. On admission, which assessment finding is true on patient who is suffering from Generalized
Anxiety Disorder?
a. Patient states that he is always worried about his work
b. Patient had unexplainable fear of people in his work place
c. Patient experience nightmares and flashbacks
d. Patient has recurrent thoughts of ending his life
8. Marina periodically has acute panic attacks. These attacks are unpredictable and have no apparent
association with a specific object or situation. During an acute panic attack, Marina may
experience:
a. Heightened concentration
b. Decreased perceptual field
c. Decreased cardiac rate
d. Decreased respiratory rate
9. The nurse describes a client as anxious. Which of the following statement about anxiety is true?
a. Anxiety is usually pathological
b. Anxiety is directly observable
c. Anxiety is usually harmful
d. Anxiety is a response to a threat
10. Crisis does not last indefinitely but usually exists for:
a. 2 weeks
b. 4-6 weeks
c. 6 months
d. One year
Critical Thinking Part 1: Answer the questions by selecting the right answer from the choices
After answering each question, compare your answer on the correct answers provided below this page.
Critical thinking part 2: Analyze what rationale supports the right answer
(1c, 2c, 3d, 4a,5c,6c,7a,8b,9d,10b)
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