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NUR2225 > W4: anxiety disorders > Flashcards

W4: anxiety disorders Flashcards

1
Q

What are anxiety disorders?

A

= Disorders that share features of excessive fear and anxiety and related behavioural disturbances
- Fear: the emotional response to real or perceived imminent threat
- Anxiety: the anticipation of future threat
- Behavioural disturbances: Sometimes the level of fear or anxiety is reduced by pervasive avoidance behaviours

Various types of anxiety disorders e.g. separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, general anxiety disorder, panic disorder (and panic attack)
- Can exist in isolation, but more commonly occur with other e.g. depressive disorders
- Disorders are differentiated by types of situations that are feared or avoided and the content of the associated thoughts or beliefs
- They differ from transient fear or anxiety, often stress-induced, by being persistent (e.g. typically lasting 6 months or more)
- There are many effective treatments available. The sooner the person gets help, the more likely they are to get better.

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2
Q

What is anxiety?

A

= intense worry, apprehension and uneasy about a situation.
= the anticipation of future threat
- becoming anxious is normal
- moderate anxiety can make us alert and perform well e..g before a sporting event
- in the interplay between behaviour, feelings (physical/emotional) and thoughts

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3
Q

Can you give an example of the interplay of three factors of anxiety?

A

Situation: being invited to a party
- Thoughts: “I will embarrass myself” “no one will like me”
-> causes
- Feelings: tightness in chest, increased HR, worried.
-> causes
- Behaviour: leaves party after 25mins
-> causes (more likely to have thoughts like the above on another occasion)

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4
Q

What are some cognitive responses to anxiety?

A
  • Impaired attention
  • Poor concentration
  • Forgetfulness
  • Errors in judgement
  • Preoccupation
  • Blocking of thoughts
  • Decreased perceptual field
  • Frightening visual images
  • Reduced creativity
  • Diminished productivity
  • Confusion
  • Hypervigilance
  • Self consciousness
  • Loss of objectivity
  • Fear of losing control
  • Fear of injury or death
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5
Q

What are some cognitive distortions or unhelpful thinking styles that proceeded anxiety and that increases?

A
  • Mental filter
  • Jumping to conclusions (aka predictive thinking)
  • Personalisation
  • Catastrophising= blow things out of proportion
  • Black and white thinking= only seeing one extreme or the other.
  • Shoulding and musting
  • Overgeneralisation
  • Labelling
  • Emotional reasoning
  • Magnification and minimisation
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6
Q

What are some Psychological/Affective Responses to
Anxiety?

A
  • Edgy
  • Impatient
  • Uneasy
  • Tense
  • Nervous
  • Fearful
  • Scared
  • Fright
  • Alarm
  • Terror
  • Jittery
  • Jumpy
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7
Q

What are some acute and long term physical responses to Anxiety?

A
  • Increased blood pressure
  • Palpitations
  • Faint
  • Rapid shallow breathing
  • Shortness of breath
  • Choking sensation
  • Gasping for air
  • Flushed skin
  • Pale face
  • Increased perspiration
  • Loss of appetite
  • Abdominal discomfort/ pain
  • Diarrhoea
  • Nausea
  • Vomiting
  • Dilated pupils
  • Increased urine output

Long term physical effects of anxiety include;
- compromised immune system
- diminished stores of neurotransmitters
- the impact of chronic elevations of cortisol can lead to death of neurons

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8
Q

What are some behavioural responses to anxiety?

A

Escape or avoid the situation by either leaving/avoiding or substance use

Initiate safety behaviours
e.g. stay quiet, compulsory hand washing, take bottle of water everywhere to alleviate dry mouth from anxiety

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9
Q

What are some symptoms associated with mild anxiety?

A
  • Slightly elevated HR and BP
  • Feels irritable
  • Perceptual field widened
  • Sharpened senses
  • Mild gastric symptoms – ‘butterflies in the stomach’
  • Ability to learn is increased
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10
Q

What are some symptoms associated with moderate anxiety?

A
  • Diaphoresis
  • Muscular tension
  • ‘Pounding’ pulse
  • Selectively attentive
  • Narrowing of perceptual field
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11
Q

What are some symptoms associated with severe anxiety?

A
  • Severe headache
  • Tachycardia
  • Vertigo, chest pain
  • Nausea, vomiting, diarrhoea
  • Extremely narrowed perceptual field to immediate task
  • Unable to complete task/problem solve
  • Feels dread, horror
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12
Q

What are some symptoms associated with panic anxiety?

A
  • Dilated pupils
  • Hypertension, tachycardia
  • Perceptual field limited to self
  • May bolt and run or freeze and be mute (fight/flight)
  • Unable to process external stimuli
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13
Q

What are some disorders that feature anxiety that the DMS 5 doesn’t recognise?

A
  • Obsessive-compulsive disorder
  • Post-traumatic stress disorder

They represent with anxiety

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14
Q

What is the diagnostic criteria for generalised anxiety disorder?

A

Excessive anxiety and worry, occurring more days than not for a period of 6 months or more, about a number of events/activities; the person finds it difficult to control the worry;
Three or more of the following symptoms (with some present more days than not for 6 months)
1. Restlessness
2. Fatigue
3. Difficulty concentrating/mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance

The above create significant distress, impairment in functioning (social/occupational/other)= necessary for diagnosis

Not attributable to physiological effects of substances, another medical condition or cannot be explained
by another mental disorder

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15
Q

What is the diagnostic criteria for panic disorder?

A

= Form of anxiety disorder where a person experiences repeated and unexpected panic attacks (not due to physiological effects of a substance or medical condition)

  • A panic attack is a sudden, intense surge of fear or impending doom, often not related to any external
    threat (McAllister & Cross, 2018)

Symptoms include:
- Palpitations, pounding heart or increased HR
- Sweating
- Trembling/shaking
- Feelings of SOB
- Chills/hot flushes
- Chest pain/discomfort
- GI upset
- Dizziness
- Fear of losing control
- Fear of dying

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16
Q

What are some immediate nursing management for a panic attack?

A

Stay with the person and provide reassurance
- Being left alone may increase anxiety

Maintain a calm manner
- Prevents transmission of anxiety from nurse to person

Use short, simple sentences
- Perceptual field disturbance causes difficulty to focus

Use a firm, authoritative voice
- Coveys ability to control situation when the person cannot

Take the person to a quiet, safe environment
- Prevents further disruption of perceptual field

Administer anti-anxiety medication if prescribed

Encourage controlled breathing

e.g. Hello, my name is Ellen, I am the nurse, I am here to stay with you.

17
Q

What are some post/ongoing nursing management for a panic attack?

A

Education
- Identify as panic attack

Teach person to use techniques that assist in reducing anxiety (deep breathing, cognitive restructuring)

Explore how to decrease possible
stressors/situations and early identification of triggers

If no history of panic attacks/prior symptoms, refer to GP

18
Q

When carrying out assessments on someone with anxiety what may you see in various assessments?

A

MSE – fidgeting, worried, tense, depersonalisation, derealisation

Risk Ax – impaired decision making, heightened impulsivity

Level of anxiety – mild/moderate/severe (impact on functioning)

Physical Ax – exclude anything else/organic factors that may contribute to presentation

Drug & Alcohol Ax – amount, frequency, last use, interaction between substances

Suicide risk

Support – social, professional, carer, family

Specific ax tools once diagnosis is suspected will aid in quantifying the level of impairment
- Hamilton Rating Scale for Anxiety
- Yale-Brown Obsessive- Compulsive Scale

19
Q

What are some good questions to ask when assessing someone anxiety?

A
  • What are your symptoms and fears?
  • What do they stop you from doing?
  • How long have you had symptoms like this?
  • What do you normally do when you experience symptoms like this?
20
Q

What actions can we do to intervene and support acute anxiety?

A
  • Reduce the immediate demands on the client, where possible move the client to a quieter environment
  • Respond to immediate needs
  • Give the client regular feedback and ownership of successes
  • Assist the client to identify adaptive coping mechanisms that were previously trialled and successful
  • Utilise diversion activities/ Promote relaxation techniques – guided visualisation/mindfulness
  • Evaluate and assess the need for medications
  • Assist the client to explore and mutually identify any events / factors that may have precipitated their distress (if appropriate)
21
Q

What actions can we do to intervene and support ongoing anxiety?

A

Educate
- How the anxious brain works (interplay between thought, behaviours and feelings)
- The cycle of anxiety
- Relaxation techniques
- Attention training
- Problem solving

Thought diary to identify triggers/ cognitive distortions (self-monitoring)

Challenge/reframe unhelpful thoughts

Life-style interventions (sleep, stress, caffeine, smoking, socialising, exercise)

22
Q

What is the psychological approaches to treating anxiety that is CBT?

A

CBT= proven to be as effective ad medication
= works by identify how a person thoughts and behaviours interact to create anxiety
- CBT challenges negative thought patterns to interrupt the cycle of feelings and behaviours.
- can be formal and information in everyday nursinging
Goal: identify and correct negative thoughts people have,
- re-frame thoughts is an approach to achieve this

  • this is a long term and on gong approach
    - can be months or years
    - once of may not be effective
    - long term, formal CBT can be more helpful
23
Q

What are some approaches to anxiety treatment?

A
  • a combination of both pharmacological an psychological works best
24
Q

What is the pharmacological approach to treating anxiety?

A
  • Medications from several classifications can be used to treat anxiety disorders
  • medications should not be used as the sole method of treatment when adaptive coping skills can be mastered through CBT and other psychological process

Given the role of reduced GABA & serotonin in clients with an anxiety disorders, adjunctive medications used in combination with psychological approaches includes use of
- SSRI
- antidepressants
- short term use of Benzodiazepines

25
Q

discuss the use of antidepressants in anxiety treatment

A
  • Antidepressant medication (typically SSRI category) are preferred medication in anxiety treatment
    = works by changing the level of the neurotransmitter, serotonin in the brain.
  • Serotonin is thought to have an important effect on mood and anxiety. Low seretonin= low levels of mood and anxiety
    SSIR= increase uptake of serotonin in the brain and thus increase mood.

Benifits
- They are well tolerated by most people
- Not addictive

Side effects include;
- feeling agitated
- anxious
- feeling or being sick
- diarrhoea
- headache
- problems sleeping
- drowsiness
- sexual problems (most will diminish).

Most people start to feel better within 2-4 weeks

SSRI’s commonly prescribed for anxiety include sertraline, citalopram, fluoxetine, fluvoxamine,paroxetine

26
Q

Discuss the use of benzodiazepines in anxiety treatment

A

= Benzodiazepines suppress the CNS and enhance the effects of GABA.
- GABA is a inhibitory neurotransmitter making the neurons less responsive to excitatory neurotransmitters of norepinephrine, serotonin, and dopamine therefore reduce symptoms of anxiety.

  • also known as anxiolytics - anti anxiety medications.

Benifits
- rapid onset of action

Risks
- risk of dependence, sedation and tolerance.
- NOT first line of treatment.

Symptoms of anxiety;
- increased heart rate
- fearfulness
- sense of dread
- relaxing muscles
- severe agitation

27
Q

Summarie some examples of the physical, psychological/affective and behaviours responses to anxiety

A

Physical responses:
palpitations, tachycardia, dry mouth, chest pain, sweating, shortness of breath, GI upset, hot flashes, insomnia, trembling.

Psychological or affective responses:
feeling on edge, extreme or irrational fear, hypervigilance, tense, nervous, scared, fearful, impaired concentration.

Behavioural responses:
isolation, avoidance, aggression, increasing consumption of substances.

28
Q

What are some biological, psychological and social factors that contribute to anxiety disorder?

A

Biological:
- Drugs; nicotine, caffeine, prescription drugs, amphetamines, marijuana, and cocaine
- Drug withdrawal
- Inadequate nutrition
- Endocrine (thyroid or adrenal)
- Chronic illness
- Menopause
- Cardiac
- Eating disorders
- Other mental illnesses

Psychological:
- Coping strategies
- Personality traits
- Self-talk or thinking processes

Social:
- Life events, e.g. divorce or financial difficulties, changing jobs or schools, natural disaster, school exams
- Bullying/ Punishment
- Childhood experiences and associations, e.g. role modelling, unsafe early childhood, parenting (rewards and punishment)

29
Q

What are some physiological changes triggered by unhelpful thinking?

A

Ilicits a fight, flight or fright/freeze

  • Increase heart rate/ strength of beat
  • Redistribution of blood from areas that are not vital to those that are (ever notice your hands going cold when you’re nervous?)
  • Increase in rate and depth of breathing
  • Increased sweating
  • Pupils dilating
  • Decreased activity of the digestive system
  • Muscle tension.
30
Q

What are some overall aims of an assessment when assessing for anxiety?

A
  • To establish a good therapeutic relationship
  • To consider differential diagnoses and establish a primary diagnosis (only psychiatrists and psychologists can give official diagnoses. As nurses we can still make a provisional diagnosis)
  • To identify comorbid disorders and risks that may affect treatment and outcome
  • To assist treatment planning
  • To assess psychosocial and lifestyle factors that could predispose and perpetuate the anxiety disorder
  • To assess the capacity of the individual to benefit from self-help material independent of the nurse.
31
Q

What are some things to assess for when assessing for anxiety?

A

The nature, severity and duration of symptoms
- Nature (ask the client to talk about where in their body they experience the anxiety. What does it feel like?)
- Severity (Get the client to rate this from 0 no anxiety to 10 worst anxiety they have ever experienced)
- Duration (How long does the anxiety remain? minutes, hours, half a day, whole day, weeks, months)

  • The underlying cognitions
  • Behavioural and cognitive responses to anxiety (e.g. avoidance, worry, reassurance-seeking, safety behaviours)
  • Precipitants for anxiety
  • The degree of distress and functional impairment
  • The presence of any comorbid mood disorders or anxiety disorders, substance use disorders, personality disorders or medical conditions
  • The presence of suicidal ideation
  • Experience with previous treatment for the disorder, including therapeutic response and adverse effects
  • Personal and family history of mental disorders
  • Social life and circumstances (e.g. quality of interpersonal relationships, social media presence, living conditions, employment, immigration status)
  • Factors that could be maintaining the disorder or preventing the individual from recovering
32
Q

What might your MSE findings be on someone with

A

General appearance and behaviour
- psychomotor agitation (they be may restless) or have difficulty sitting still
- sweats, shaking or have muscle tension
- GI upset or complain of feeling sick
- hyperventilation

Speech
- increased rate
- hesitant or shaky

Mood
- low
- related in insomnia, loack of sleep or Gi upset/distrubances

Thought content
- constant worry of issues and events
- worry out of proportion
- catastrophising
- engaging in unhelpful thinking patterns and negative self talk

Cognition
- difficulty concentrating
- easily distracted
- difficult making decisions
- memory impairment e.g. forgetting daily commitments that they wouldn’t usually forget

Insight
- understand their fear/anxiety is unwarranted but have limited ability or are unable to control it and feel overwhelmed

33
Q

What are some keys to supporting an anxious person?/

A
  • Convey calmness and confidence, assist in containing their anxiety
  • Reduce the immediate demands on the person, where possible move the person to a quieter environment
  • Respond to their immediate needs
  • Avoid medical terminology and jargon that will impede the therapeutic relationship
  • Utilise diversion activities when the person displays signs of escalating anxiety levels
  • Give the person regular feedback and ownership of successes
  • Assist the person to explore and mutually identify any events / factors that may have precipitated their distress
  • Assist the person to identify adaptive coping mechanisms that were previously trialled and successful
34
Q

What are some nursing considerations to enhance therapeutic relationships?

A
  • Establish therapeutic rapport
  • Remain person centred and responsive to the person’s immediate needs using active listening skills, being supportive and providing reassurance
  • Encourage the person to discuss their feelings and share their thoughts and associated experiences – acknowledge, validate, clarify and empathise
  • Covey a shared understanding of the person’s situation and accept the person’s feelings
  • Be mindful that people with anxiety disorders will be sensitive to any indication that they are being judged and will fear perceived rejection
  • Be mindful of our own anxieties – this can further exacerbate the client’s anxiety
35
Q

What are the aims of nursing interventions when dealing with anxiety?

A
  • break the cycle of anxiety by distracting them away from worry.
  • decrease body physiological response
36
Q

What are some nursing interventions we can implement to support someone with anxiety?

A

Physical exercise
- implement/encourage physical exercise e.g. running, pelvic floor as more decent option

Mental exercises
- e.g. count backwards by 7s

Sensory modulation:
Using targeted sensory input can lead to reduced anxiety and produces calmer states in people with mental illness. There are various ways that you could do this in a ward setting for example vestibular input through a rocking chair, deep pressure touch through encouraging the client to engage in self-massage or use of weighted blankets, auditory input through use of the application of aromas through scented hand-creams. Look for the sensory room or sensory box when you are on placement.

Mindful
- focusing on the present moment and becoming less focused on unhelpful things
- lead a mediation

breathing exercises
- increase rate and depth of breathing to overcome physiological changes caused by anxiety
- something mindful breathing

37
Q

How can we help someone reframe thoughts?

A

Some questions to guide this process are:

  1. What is the evidence?
    What evidence do you have to support the thoughts?
    What evidence do you have against them?
  2. What alternative views are there?
    How would someone else view this situation?
    What evidence do you have to back these alternatives?
  3. What is the worst that could happen?
    Could you live through it?
    What is the best that could happen?
    What is the most realistic outcome?
  4. What is the effect of thinking the way you do?
    Does it help you, or hinder you from getting what you want?
    How?
    What would be the effect of looking at things less negatively?
    What would you tell a friend if they were in the same situation?
    Am I blaming myself for something that is not my fault?
    Am I taking something personally which has little or nothing to do with me?
    Am I expecting myself to be perfect?
    Am I using a double standard- how would I view someone else in my situation?
    Am I overestimating the changes of disaster?
    Am I exaggerating the importance of events?
    Am I fretting about the way things ought to be instead of accepting and dealing with them as they come?
    Am I assuming I can do nothing to change my situation?
    Am I predicting the future instead of experimenting with it?
  5. What action can I take?
    What can I do to change my situation?
    Am I overlooking solutions to problems on the assumption they won’t work?
    What can I do to test out the validity of my rational answers?
38
Q

Why is education so important for anxiety?

A
  • People who are experiencing anxiety may report feel like they are ‘out of control.’
  • Education on anxiety and strategies to decrease unpleasant symptoms will give the client hope and a sense of control over their life.
  • Education is an important strategy when working within a recovery-orientated framework as it helps to build a culture of hope, it promotes autonomy and self-determination, and it fosters collaboration and meaningful engagement.
39
Q

What are some things you can education a client with anxiety about?

A
  • What anxiety is, including the body’s physiological response
  • The relationship between increased stress and anxiety
  • Lifestyle interventions (sleep hygiene, decreasing caffeine, decreasing drug and alcohol use, getting adequate exercise).

A helpful strategy here is to teach your client to reflect on the acronym PLEASE. Have I….
- Treated PhysicaL illness?
- Balanced Eating?
- Avoided mood-Altering substances?
- Balanced Sleep?
- Exercised? (Linehan, 2015, p249)
- The relationship between unhelpful thinking styles and anxiety and how to challenge these thoughts
- How relaxation and distraction can help with anxiety
How to identify triggers for escalating anxiety

NUR2225 (9 decks)

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