Anxiety Disorders (Anxiety and Phobic Neuroses)

1. Definition: emotional illnesses characterized by fear and autonomic nervous system symptoms (palpitations, tachycardia, dizziness, tremor); related to intrapsychic conflict and psychogenic origin where instinctual impulse (related to sexuality, aggression, or dependence) may be in conflict with the ego, superego, or sociocultural environment; related to sudden object loss.
   An anxiety disorder is a mild to moderately severe functional disorder of personality in which repressed inner conflicts between drives and fears are manifested in behavior patterns, including generalized anxiety and phobic, obsessive-compulsive disorders. (Other related disorders are dissociative, conversion, and hypochondriasis.)


2. General concepts and principles related to anxiety disorders:
   1. Behavior may be an attempt to “bind” anxiety: to fix it in some particular area (hypochondriasis) or to displace it from the rest of personality (phobic, conversion, and dissociative disorders - amnesia, fugue, multiple personalities; obsessive-compulsive disorders).
   2. Purpose of symptoms:
      1. To intensify repression as a defense.
      2. To exhibit some repressed content in symbolic form.
      
      
3. General assessment of anxiety disorders:
   1. Uses behavior to avoid tense situations.
   2. Frightened, suggestible.
   3. Prone to minor physical complaints (e.g., fatigue, headaches, and indigestion) and reluctance to admit recovery from physical illnesses.
   4. Attitude of martyrdom.
   5. Often feels helpless, insecure, inferior, inadequate.
   6. Uses repression, displacement, and symbolism as key coping mechanisms.

1. Generalized anxiety disorder:
   1. Assessment:
      1. Persistent, diffuse, free-floating, painful anxiety for at least 1 month.
      2. Motor tension, autonomic hyperactivity.
      3. Hyper attentiveness expressed through vigilance and scanning.
   2. Analysis/nursing diagnosis:
      1. Anxiety/powerlessness: excessive worry related to real or perceived threat to security, unmet needs.
      2. Altered attention related to overwhelming anxiety.
      3. Fear related to sudden object loss.
      4. Guilt related to inability to meet role expectations.
      5. Risk for alteration in self-concept related to feelings of inadequacy.
      6. Altered role performance related to inadequate support system.
      7. Impaired social interaction related to use of avoidance in tense situations.
      8. Distractibility related to pervasive anxiety.
      9. Hopelessness related to feelings of inadequacy.
      10. Sleep pattern disturbance.
   3. Nursing care plan/implementation:
      1. Fulfill needs as promptly as possible.
      2. Listen attentively.
      3. Stay with client.
      4. Avoid decision making and competitive situations.
      5. Promote rest; decrease environmental stimuli.
      6. Health teaching: teach steps of anxiety reduction.
   4. Evaluation/outcome criteria: symptoms are diminished.
   
   
2. Panic disorder:
   1. Assessment:
      1. Three acute, terrifying panic attacks within 3 week period, unrelated to marked physical exertion, life-threatening situation, presence of organic illness, or exposure to specific phobic stimulus.
      2. Discrete periods of apprehension, fearfulness (lasting from few moments to an hour).
      3. Mimics cardiac disease: dyspnea, chest pain, smothering or choking sensations, palpitations, tachycardia, dizziness, fainting, sweating.
      4. Feelings of unreality, paresthesias.
      5. Hot, cold flashes and dilated pupils.
      6. Trembling, sense of impending death, fear of becoming insane.
   2. Analysis/nursing diagnosis:
      1. Ineffective individual coping related to undeveloped interpersonal processes.
      2. Altered comfort pattern: distress, anxiety, fear related to threat to security.
      3. Decisional conflict related to apprehension.
      4. Altered thought processes related to impaired concentration.
   3. Nursing care plan/implementation:
      1. Reduce immediate anxiety to more moderate and manageable levels.
         1. Stay physically close to reduce feelings of alienation and terror.
         2. Communication approach: calm, serene manner; short, simple sentences; firm voice to convey that nurse will provide external controls.
         3. Physical environment: remove to smaller room to minimize stimuli.
      2. Provide motor outlet for diffuse energy generated at high anxiety levels, e.g., moving furniture, scrubbing floors.
      3. Administer antianxiety medications as ordered.
      4. Health teaching: recommend more effective methods of coping.
   4. Evaluation/outcome criteria: can endure anxiety while searching out its causes.
   
   
3. Obsessive-compulsive disorder:
   1. Assessment - chief characteristic: fear that client can harm someone or something.
      1. Obsessions - recurrent, persistent, involuntary, senseless thoughts, images, ideas, or desires that may be trivial or morbid, e.g., fear of germs, doubts as to performance of an act, thoughts of hurting family member, death, suicide.
      2. Compulsions - uncontrollable, persistent urge to perform repetitive, stereotyped behaviors that provide relief from unbearable anxiety, e.g., hand washing, counting, touching, checking and rechecking doors to see if locked, elaborate dressing and undressing rituals.
   2. Analysis/nursing diagnosis:
      1. Ineffective individual coping related to:
         1. Intellectualization and avoidance of awareness of feelings.
         2. Limited ability to express emotions (may be disguised or delayed).
         3. Exaggerated feelings of dependence and helplessness.
         4. High need to control self, others, and environment.
         5. Rigidity in thinking and behavior.
         6. Poor ability to tolerate anxiety and depression.
      2. Social isolation related to:
         1. Resentment.
         2. Self-doubt.
         3. Exclusion of pleasure.
   3. Nursing care plan/implementation:
      1. Accept rituals permissively (e.g., excessive hand washing); stopping ritual will increase anxiety.
      2. Avoid criticism or “punishment,” making demands, or showing impatience with client.
      3. Allow extra time for slowness and client’s need for precision.
      4. Protect from rejection by others.
      5. Protect from self-inflicted harmful acts.
      6. Engage in nursing therapy after the ritual is over, when client is most comfortable.
      7. Redirect client’s actions into substitute outlets.
      8. Health teaching: teach how to prevent health problems related to rituals, e.g., use rubber gloves, hand lotion.
   4. Evaluation/outcome criteria: avoids situations that increase tension and thus reduces need for ritualistic behavior as outlet for tension.
   
   
4. Phobic disorders - intense, irrational, persistent fear in response to external object, activity, or situation; e.g., agoraphobia - fear of being alone or in public places; claustrophobia - fear of closed places; acrophobia - fear of heights; simple phobias such as mysophobia - fear of germs. Social phobias: fear of situations that may be humiliating or embarrassing. Dynamics: displacement of anxiety from original source onto avoidable, symbolic, external, and specific object (or activity or situation); i.e., phobias help person control intensity of anxiety by providing specific object to attach it to, which he or she can then avoid.
   1. Assessment: same as for anxiety symptoms; fear that someone or something will harm them.
   2. Analysis/nursing diagnosis: social isolation; avoidance; irrational fear out of proportion to actual danger; defensive coping with high need to control self, others, environment.
   3. Nursing care plan/implementation: promote psychological and physical calm:
      1. Use systematic desensitization: never force contact with feared object or situation.
      2. Health teaching: progressive relaxation, meditation, biofeedback training, or other behavioral conditioning techniques.
   4. Evaluation/outcome criteria: phobia is eliminated (i.e., able to come into contact with feared object with lessened degree of anxiety).
   
   
5. Acute stress disorder and posttraumatic stress disorder:
   1. Assessment:
      1. Acute stress disorder: symptoms occur within 1 mo of extreme stressor.
      2. Posttraumatic stress disorder (PTSD): symptoms occur after 1 mo.
      3. Precipitant: severe traumatic event (natural or man-made disaster) that is not an ordinary occurrence, e.g., rape, fire, flood, earthquake, tornado, bombing, torture, kidnapping.
      4. Self-report of reexperiencing incident; intrusive memories.
      5. Numb, unresponsive, detached, estranged reaction to external world (unable to feel tenderness, intimacy).
      6. Change in sleep pattern (insomnia, recurrent dreams, nightmares), memory loss, hyper alertness (startle response).
      7. Guilt rumination about survival.
      8. Avoids activities reminiscent of trauma; phobic responses.
      9. Difficulty with task completion and concentration.
      10. Depression.
      11. Increased irritability may result in unpredictable, explosive outbursts.
      12. Impulsive behavior, sudden lifestyle changes.
   2. Analysis/nursing diagnosis:
      1. Posttrauma response related to overwhelming traumatic event.
      2. Anxiety (severe to panic)/fear related to memory of environmental stressor, threat to self concept, negative self-talk.
      3. Risk for violence directed at self/others related to a startle reaction, use of drugs to produce a psychic numbing.
      4. Sleep pattern disturbance related to fear and rumination.
      5. Decisional conflict (impaired decision making) related to perceived threat to personal values and beliefs.
      6. Guilt related to lack of social support system.
      7. Altered feeling-states: emotional lability related to diminished sense of control over self and environment.
   3. Nursing care plan/implementation:
      1. Crisis counseling (listen with concern and sympathy).
         1. Ease way for client to talk out the experience and express fear.
         2. Help client to become aware and accepting of what happened.
      2. Health teaching: suggest how to resume concrete activity and reconstruct life with available social, physical, and emotional resources. Help make contact with friends, relatives, and other resources.
   4. Evaluation/outcome criteria: can cry and express anger, loss, frustration, and despair; begins process of social and physical reconstruction.
   5. Critical Pathway for Posttrauma Client.