Anxiety Disorders

Anxiety is a general term for several disorders that cause nervousness, fear, apprehension, and worrying.

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD) is a chronic disorder characterized by excessive, chronic,

unrealistic anxiety and worry about nonspecific life events, objects, and situations.

 The symptoms of anxiety should last for at least a period of 6 months for a diagnosis of generalized
anxiety disorder to be made.
 Prevalence of GAD is 2.5 to 8%.
 It is commonest psychiatric disorder in the general population.

Panic Disorder: is a type of anxiety characterized by brief or sudden attacks of intense terror and
apprehension that leads to shaking, confusion, dizziness, nausea, and difficulty breathing.

 Panic attacks tend to arise abruptly and peak after 10 minutes, but they then may last for hours.
 Panic disorders usually occur after frightening experiences or prolonged stress, but they can be
spontaneous as well.
 The life time prevalence of panic disorder is 1.5 – 2%.
 Panic disorder is seen 2-3 times more often in females

Symptoms of anxiety:
1. Physical symptoms:
a. Motoric Symptoms:Tremors, restlessness, muscle twitches, Fearful facial expression etc
b. Autonomic and Visceral symptoms: Palpitations, Tachycardia, Sweating, flushes, dyspnea, dry
mouth, frequency and hesitancy of micturation, dizziness, diarrhea etc
2. Psychic symptoms:
a. Cognitive symptoms: poor concentration, distractibility, hyperarousal
b. Perceptual symptoms: derealization, Depersonalization
c. Affective symptoms:unpleasant, fearfulness, inability to relax. Irritability, feeling of impending
doom
d. Other symptoms: Insomnia etc.

Etiology:
Psychodynamic theory: during disturbed psychological equilibrium, if primary and secondary defence
mechanisms fails to act or inadequately function, anxiety comes to the forefront.

Behavioral Theory: in anxiety unconditioned inherent response to the organism to painful or dangerous
stimuli becomes attached to relatively neutral stimuli by conditioning.

Biological Theory:

Genetic evidence: 15 – 20% of the first degree relatives of patients with anxiety disorder exhibit anxiety
disorders themselves.
Chemically induced anxiety state: infusion of sodium lactate, isoproterenol and caffeine, inhalation of 5% CO2
can produce panic episodes in predisposed individuals.

GABA and other neurotransmitters: Alteration in GABA levels may lead to production of clinical anxiety.
Norepinephrine, dopamine, opioid receptors and neuroendocrine dysfunction also leads to anxiety.\

Organic anxiety disorder: this disorder is characterized by the presence of anxiety which is secondary to the
various medical disorders. Ex – hyperthyroidism, coronary artery disease etc.

Treatment:
Psychotherapy: supportive psychotherapy is used either alone or combination with drug therapy.

Relaxation techniques: in mild to moderate anxiety, relaxation techniques are very useful. These techniques
include progressive relaxation technique, yoga, pranayama, meditation etc.

Drug treatment: Benzodiazepines (alprazolam) for mild and moderate anxiety

Antidepressants ( Imipramine and fluoxetine) for panic attacks.

Nursing diagnosis:
1. Panic anxiety related to real or perceived threats as evidenced by any physical symptoms
Objective:
Client will be able to recognize symptoms of onset of anxiety and to intervene before reaching panic
level.
Interventions:
 Stay with the client and offer reassurance of safety and security
 Maintain a calm, nonthreatening environment
 Use simple words and brief messages, spoken calmly and clearly, to explain hospital experiences.
 Keep immediate surroundings low in stimuli
 Administer anti anxiety drugs as ordered by physician.
 When level of anxiety has been reduced, explore possible reasons for occurrence.
 Teach signs and symptoms of anxiety and ways to interrupt its progression ( relaxation techniques,
deep breathing, meditation etc)

2. Powerlessness related to impaired cognition as evidence by verbal expression of no control over

life situation
Objective:
Client will be able to effectively problem solve ways to take control of life situation, thereby decreasing
feelings of powerlessness and anxiety.
Interventions:
 Allow client to take as much responsibility as possible for self care practices.
 Assist client to set realistic goals
 Help identify areas of life situation that client can control
 Help client identify areas of life situation that are not within his or her ability to control. Encourage
verbalization of feelings related to this inability.
 Phobic Disorders
Definition: Phobia is defined as an irrational fear of specific object, situation or activity often leading to
persistent avoidance of the feared object, situation or activity.

Common types of phobia:

1. Agoraphobia
2. Social phobia
3. Specific Phobia

Agoraphobia:
This is an example of irrational fear of situations. It is the commonest type of phobia seen in clinical practice.

 It is characterized by an irrational fear of being in places away from the familiar setting of home.
 It includes fear of open spaces, public places, crowded places and any other place from where there is no
easy escape to a safe place.
 It may occur with a full blown panic attack (agoraphobia with panic disorder) or only with symptoms like
dizziness or tachycardia ( agoraphobia without panic disorder).

Social phobia:
 This is an example of irrational fear of activities or social interaction
 It is characterized by an irrational fear of performing activities in the presence of other people or
interacting with others.
 Ex – Public speaking, public performance on stage, participating in groups, writing in public ( signing a
check), speaking to strangers ( for asking for directions), etc.

Specific or simple phobia:

It is characterized by an irrational fear of a specified object or situation.

Ex – Acrophobia ( fear of high places), zoophobia (fear of animals), xenophobia ( fear of strangers),
algophobia (fear of pain), claustrophobia (fear of closed palces) , aquaphobia (fear of water), nyctophobia (fear
of darkness), pyrophobia ( fear of fire) etc.

Incidence:
 More common among women
 Onset is late second decade or early third decade
 Onset is sudden without any apparent cause
 Course is usually chronic with gradually increasing restriction of daily activities.
Etiology:
Psychodynamic theory:

In phobia secondary defense mechanism displacement is activated and by this anxiety is transferred
from a really dangerous or frightening object to a neutral object. These two objects are connected by symbolic
associations.

Psychobiological theory: the traumatic experiences of childhood may affect the child’s developing brain in
such a manner that the child becomes susceptible to anxiety and fear in childhood.

Behavior theory: Phobia is explained as a conditioned reflex. Initially, the anxiety provoked by naturally
frightening or dangerous object occurs in contiguity with a second neutral object. If this happens often enough,
the neutral object becomes a conditioned stimuli for causing anxiety.

Treatment:
Psychotherapy: supportive psychotherapy

Behavior therapy: flooding, systematic desensitization, exposure and response prevention, relaxation
techniques.

Drugs: Benzodiazepines ( alprazolam)

Anti-depressants : SSRI (Paroxetine, imipramine etc)

Nursing diagnosis:
1. Fear related to a specific stimulus as evidenced by behavior directed toward avoidance of the
feared object or situation

Objective:
Client will be able to function in presence of phobic object or situation without experiencing panic
anxiety.

Interventions:
 Reassure client that he or she is safe.
 Explore clients’s perception of the threat to physical integrity or threat to self concept.
 Discuss reality of the situation with client to recognize aspects that can be changed and those that
cannot.
 Encourage client to explore underlying feelings that may e contributing to irrational fears and to
face them rather than suppress them.

2. Social isolation related to fears of being in a place from which one is unable to escape as
evidenced by staying alone or refusing to leave room or home.

Objective:
Client will voluntarily participate in group activities with peers.
Interventions:
 Convey an accepting attitude and unconditional positive regard.
 Attend group activities with client if it may be frightening for him or her.
 Discuss with client signs and symptoms of increasing anxiety and techniques to interrupt the
response. Ex – relaxation exercise
 Give recognition and positive reinforcement for voluntary interactions with others.
 Administer anti anxiety drugs as per doctors order.
Etiology of OCD
Psychoanalytical theory:

Psychoanalytical theorists propose that individuals with OCD have weak, underdeveloped egos. The
psychoanalytical concept views clients with OCD as having regressed to earlier developmental stages of the
infantile superego- the harsh, exacting, punitive characteristics of which now reappear as psychopathology.

Learning theory:

Learning theorists explain OCD as a conditioned response to a traumatic event. The traumatic event
produces anxiety and discomfort and the individual learns to prevent the anxiety and discomfort by avoiding
the situation with which they are associated. This type of learning is called passive avoidance. When passive
avoidance is not possible, the individual learns to engage in behaviors that provide relief from the anxiety and
discomfort associated with the traumatic situation. This type of learning is called active avoidance and this
describes the behavior pattern of the individual with OCD.

Biological Aspects: Neurobiological disturbances may play a role in the pathogenesis and maintenance of
OCD.

Biochemical : Neurotransmitter serotonin excess as influential in the etiology of OCD.

Treatment:
Psychotherapy: psychoanalytic psychotherapy and supportive psychotherapy.

Behavior Therapy: Behavior modification by following techniques

 Thought stopping
 response prevention
 systematic desensitization
 modeling

Drugs:

 Benzodiazepines : ex-alprazolam
 Antidepressants: SSRI, Ex-Clomipramine, Fluoxetine
 Antipsychotics: Occasionally used in low doses. Ex-haloperidol. Olanzapine etc

ECT: In the presence of Severe depression with OCD ECT may be needed. And also indicated when there is a
risk of suicide or poor response to other modes of treatment.

Nursing Diagnosis:
1. Ineffective coping related to underdeveloped ego as evidenced by ritualistic behavior or obsessive
thoughts

Objective:
Client will demonstrate ability to cope effectively without resorting to obsessive compulsive behaviors.
 Interventions:
 Work with client to determine types of situations that increase anxiety and result in ritualistic
behaviors.
 Encourage independence and give positive reinforcement for independent behaviors.
 Do not be judgmental
 Support clients efforts to explore the meaning and purpose of the behavior.
 Provide structured schedule of activities for client, including adequate time for completion of
rituals.
 Give positive reinforcement for non ritualistic behaviors.
 Help client learn ways of interrupting obsessive thoughts and ritualistic behavior with techniques
such as thought stopping, relaxation, exercise etc.

2. Ineffective role performance related to need to perform rituals as evidenced by inability to fulfill
usual patterns of responsibility.

Objective: Client will be able to resume role related responsibilities

Interventions:
 Determine clients previous role within the family and extent to which this role is altered by the
illness.
 Discuss clients perception of role expectations.
 Explore available options for changes or adjustments in role.
 Encourage family participation in the development of plans to effect positive change, and work to
resolve the cause to the anxiety from which the client seeks relief through use of ritualistic
behaviors.
 Give client lots of positive reinforcement for ability to resume role responsibilities by decreasing
need for ritualistic behaviors.