Anxiety disorders


Mr. Malik Manasrah
 Introduction

Anxiety is unavoidable in life and can serve many positive
functions such as motivating the person to take action to
solve a problem or to resolve a crisis. It is considered
normal when it is appropriate to the situation and
dissipates when the situation has been resolved
 Lifetime Prevalence of Mental Illnesses
Risk of any disorder 46.4 %
2 or more disorders 27.7 %
50%
3 or more disorders 17.3 %

40%

30% 28.8%
24.8%
20.8%
20% 14.6%
10%

0%
Substance Mood D/O Impulse Anxiety D/O
Use D/O Control D/O
Kessler, Ronald C, et al. Arch Gen Psychiatry 2005;62:593-602.
Anxiety and fear

 Anxiety and fear are indistinguishable except of the
cause.
 A simple explanation for the difference between anxiety
and fear is that anxiety has an unknown or unrecognized
source, where as fear is a reaction to a specific threat.
 Another important distinction between anxiety and fear is
that anxiety affects us at a deeper level than does fear.
 Anxiety invades the central core of the personality. It
erodes the individual feelings of self -esteem and personal
worth.
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 Anxiety vs. Fear

Anxiety Fear

Threat
Threat

Response to a threat that is Response to a known,

unknown, internal, vague or external, definite threat
conflictual
 Symptoms of anxiety are both
somatic and psychological
Type of symptom Manifestation
Somatic Trembling, twitching, shakiness; muscle tension,
aches or soreness; restlessness; easily fatigued
(Motor tension)
Somatic Shortness of breath or smothering sensations;
hyperventilation; palpitations or tachycardia; chest
(Autonomic pain; sweating or cold clammy hands; dry mouth;
hyperactivity) dizziness; headache; nausea; diarrhoea; flushes;
chills; frequent urination; dysphagia

Psychological Feeling keyed up or on edge; exaggerated startle

response; fear; difficulty concentrating; disordered
(Autonomic sleep; irritability
vigilance and David Baldwin 6
scanning)
 Normal anxiety is a healthy life force that is necessary for
survival.
 It provides the energy needed to carry out the tasks involved
in living and striving toward goals.
 Anxiety motivates people to make change and survive.
 It prompts constructive behaviors, such as studying for an
examination, being on time or a job interview, preparing or a
presentation, and working toward a promotion.
 Anxiety becomes a disorder when it become out of
proportion or when it significantly interferes with life.
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 
 Normal Vs. Pathologic Anxiety
Normal anxiety is adaptive. It is an inborn response to threat or to the
absence of people or objects that signify safety can result in cognitive
(worry) and somatic (racing heart, sweating, shaking, freezing, etc.)
symptoms.
Pathologic anxiety is anxiety that is excessive, impairs function.
 
When does anxiety become a disorder?
1) Greater intensity and/or duration than expected given the
circumstances
2) Leads to impairment or disability
3) Daily activities are disrupted by avoidance of certain situations or
objects to decrease anxiety
4) Includes clinically significant unexplained physical symptoms,
obsessions, compulsions, or intrusive recollections of trauma
 Etiologies of anxiety Disorders

❑ Neurobiological causes
 Caudate nucleus has been implicated in OCD
 fMRI studies have found increased activity in the amygdala in PTSD
 Abnormalities in parahippocampal gyrus in Panic Disorder
❑ Neurochemical:
 Major neurotransmitters involved are : NA, 5HT, and GABA
 * Slide courtesy of Dr. Elliott Lee

Neurobiology of anxiety
Limbic cortex

Nucleus
accumbens

Orbitofrontal Periaqueductal
cortex Gray matter

Amygdala
Locus
coeruleus
Brain Stem
Hippocampus Ventral
Tegmental Area
 4. More considered
response based on
1. Thalamus cortical processing
receives stimulus
and sends to both
amygdala and
cortex

Sensory Input 2. Amygdala

registers
danger

3. Amygdala
triggers fast
response

• Parts of the brain involved in fear response = thalamus, amygdala,

hypothalamus, which then instruct the endocrine glands and autonomic nerv.sys.
• Evolved fear module (pink) versus considered response (green) = “fight or flight”
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versus “feel the fear and do it anyway (or do it differently)”!
 
❑ Genetics
 There is significant familial aggregation for PD, GAD, OCD and phobias
 Twin studies found heritability of 0.43 for panic disorder and 0.32 for
GAD.
❑ Psychological
 Patients try to alleviate the unpleasant feeling of anxiety by:
1) Avoiding the trigger
2) Developing a safety behaviour (i.e. having someone else accompany
them)
3) Using a substance or medication
 
 Medical conditions & Substance abuse
❑ Endocrine conditions : Thyroid Diseases, Cushing, Addison,
Pheochromcytoma
❑ Cardiopulmonary: MI, Heart Failure, HTN, Asthma , COPD
❑ Neurological: Epilepsy, CVAs, Encephalitis, MS
❑ Others: Anemia, IBS.
❑ Drugs: Substances use, some drugs
 Levels of Anxiety

 Levels o anxiety range from mild, to moderate, to severe, and panic.
Peplau’s (1968)

❑Mild
❑Moderate
❑Severe
❑Panic
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 Behavioral & Physiologic changes
in Mild Anxiety

Perceptual field widens Restlessness

Î awareness & motivation “butterflies in stomach”
Î problem solving & learning Î sleep disturbance
Irritable More sensitive to noise

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 Behavioral & Physiologic changes
Moderate Anxiety
Immediate task oriented ❑ V/S normal –increased
Attentive to immediate task ❑ Frequent urination
Difficulty ❑ Dry mouth/muscle tension
w/concentration,but can be ❑ Î rate of speech
redirected ❑ diaphoretic

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 Behavioral & Physiologic changes
in Severe Anxiety
 Narrowed perceptual field-one Headache/nausea
detail &vomiting
 Difficulty completing task or
Vertigo
solving problems
 Cannot learn effectively Pale
 Feelings of dread/doom Tachycardia
 Crying C/o chest pain
 Ritualistic behaviors ie. Rocking Rigid stance
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 Behavioral & Physiologic changes
in Panic level anxiety
 Unable to process environmental Can run away from scene or
stimuli
 Distorted perceptions Can be immobilized & mute
 Can only focus on self Dilated pupils
 Risk for self harm Î B/P, P, R
 Unable to communicate
Flight, fight or freeze reaction
 Irrational thoughts/behaviors
 Possible delusions/hallucinations

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 Anxiety disorders…

 Highly treatable yet also resistant to extinction
 Often begins early in life
 Reported more by women than men
 Reported more in Western countries
 Often comorbid both with other anxiety diagnoses and with other
disorder groups (e.g. Mood disorders, psychoses)

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 Anxiety Disorders in DSM-V

 Panic Disorder with and without agoraphobia
 Agoraphobia without history of Panic Disorder
 Social Phobia
 Specific Phobia
 Obsessive Compulsive Disorder
 Generalized Anxiety Disorder
 Post Traumatic Stress Disorder
 Acute Stress Disorder
 Anxiety Disorder due to a General Medical Condition
 Substance-Induced Anxiety Disorder
 Anxiety Disorder NOS
 Panic attack

 Sudden onset of intense fear
 Often occurs with no trigger
 Sometimes triggered by stressful event
 Last for minutes to an hour
 Median age is 24 years old
 More common in women
❑ Risk factors
 Genetic
 History of physical abuse
 Life stress
 
❑ Diagnosis: four or more of the following
 Palpation, racing heart
 Sweating
 Trembling or shaking
 Chest pain or discomfort
 Sensation of shortness of breath
 Feeling of chocking
 Nausea and abdominal pain
 Chills or heat sensation
 Numbness and tingling sensation
 Fear of losing control
 Fear of dying
 Derealization
 Depersonalization
 
❑ Derealization:
 Items in room look foggy ‫ ضبابي‬, unreal
 Feel like in foreign place despite being at home
 Often intensely scary

❑ Depersonalization
 Out of body experience
 Detached looking to self from above
 Panic Disorder

❑ Recurrent unexpected panic attacks and for a one month period or
more of:
 No obvious trigger
 No post traumatic
 Not response to phobia
 Persistent worry about having additional attacks
 Worry about the implications of the attacks
 Significant change in behavior because of the attacks
 
❑ Treatment
❑ Pharmacotherapy:
 1st line SSRI or SNRI
 2nd line Benzodiazepines
 Only recommended for short term use due to side effects (cognitive
impairment, ataxia, sedation) and dependence and withdrawal
 Avoid in substance abuse and the elderly

** Often clinically, a small dose of long acting benzodiazepine is started

along with SSRI/SNRI to provide more immediate relief from
distressing symptoms
i.e. 0.5 mg clonazepam BID for 2-3 weeks, then tapered until it is stopped
 
❑ Psychological treatment:
 CBT most consistently efficacious psychotherapy for Panic Disorder, according to the literature
 Also incorporates interoceptive exposure (exposure to feared symptoms → therapist may ask
patient to hyperventilate or spin to make themselves dizzy)
 Exposure to avoided situations is important
 CBT for Panic Disorder includes same CBT concepts of
❑ Psychoeducation
❑ Cognitive approaches
❑ Relaxation
❑ Problem solving
 Specific phobias

 Fear of specific object or situation
 Lead to avoidance behavior
 Persist more than 6 months
 Common: flying, dental procedure, blood draw
❑ Social anxiety disorder
❑ Specific phobia of social settings
❑ Fear of being humiliated or judged
 
❑ Treatment
 Cognitive behavioral therapy
 Systematic desensitization
 Imaging exposure to fear stimulus
 Relaxation
 Exposure therapy
 Confrontation of feared stimulus in safe/ controlled manner
 Fear reduce overtime
 Medications
 Benzodiazepines
 Beta blockers
 SSRIs
Agoraphobia

 Agoraphobia

 Afraid of inability to scape.
 Marked fear or anxiety for more than 6 months about two or more of the following 5
situations:
 Using public transportation
 Being in open spaces
 Being in enclosed spaces
 Standing in line or being in a crowd
 Fear of leaving safe place (home) alone
 Fear of needing of flee ‫ هروب‬with no help available

 Example: fear of empty bus

 Often co occur with panic disorder
 Often patient fear panic attack in public settings
 Generalized anxiety disorder

 Chronic persistent anxiety about many different activities or events
 Not due to a substance, medical condition or other mental disorder
 More common in women
 Last of more than 6 months
 Diagnosed by three or more of the following
 Restlessness
 Fatigue
 Difficulty in concertation
 Muscle tension
 Sleep disturbance
 
❑ Treatment
❑ Pharmacotherapy:
 1st line SSRI or SNRI
 2nd line Benzodiazepines
 Only recommended for short term use due to side effects (cognitive
impairment, ataxia, sedation) and dependence and withdrawal
 Avoid in substance abuse and the elderly
 3rd line Adjunctive olanzapine or risperidone Mirtazapine
 
 An optimal trial involves 9-12 months
 If there is not an adequate response, switch to another 1st line agent
 Reasonable to try another 1st line agent with a different mechanism of
action
 Treatment resistant patients should be assessed for comorbid medical
and psychiatric conditions
 
❑ Psychological treatment:
 CBT as effective as medication (also 1st line)
 CBT involves:
 Psychoeducation
 Cognitive interventions (addressing cognitive distortions, unrealistic beliefs)
 Exposure
 Relaxation strategies
 Problem Solving
 Assertiveness training
 Relapse Prevention
 Obsessive compulsive disorder

❑ Obsessions
 Recurrent persistent thoughts, urge or image
 Instructive and unwanted
 Patient attempt to ignore or suppress and it can lead to distress
❑ Compulsions
 Repetitive behavior or mental act
 Done to relive obsessions, hand washing, checking stove, counting,
repeating
37
 
 In 50-70% of patients, onset of symptoms is following a stressful event
(i.e. pregnancy, death)
 Course is usually long, can be constant or fluctuating
 20-30 % have significant improvement
 40-50% have moderate improvement
 20-30% have no improvement or worsening
 20-30% have tics, 6-7% Tourette’s

 Possible link between a subset of OCD and tics

 
The obsessions or compulsions cause marked distress, take
> 1 hour/day or cause clinically significant distress or
impairment in function
 
 Most common obsessions include:
 Contamination (#1)
 Doubt/safety (idea that stove was left on, door unlocked etc.) (#2)
 Sexual and aggressive impulses (#3)
 Symmetry and exactness (#4)
 Somatic and religious preoccupations

 Most common compulsions include:

 Checking
 Washing
 Repeating
 Ordering
 Counting
 Hoarding ‫ادخار‬

 
❑ Treatment
❑ Pharmacotherapy:
 1st line SSRI or SNRI
 2nd line : Clomipramine (2nd line due to side effects – cardiotoxicity,
anticholinergic, drug interactions and lethality in overdose)
 Dosages of meds e.g. SSRIs may need to be higher than in mood
disorders
 Response may take 6 wks or longer (Guidelines state adequate trial 6-8
weeks)
 
❑ Psychological
❑ Exposure with Response Prevention (ERP) – form of behavioral therapy
❑ CBT which combines Exposure and Response Prevention with cognitive
interventions
 
❑ OCD Co occur with
 Schizophrenia
 Bipolar disorder
 Eating disorders
 Tourette syndrome
 Post traumatic stress disorder

 Follow traumatic event: rape, war, physical assault
 Re-experiencing of trauma through flashbacks, recollections, nightmares.
 Avoidance of reminders
 Hypervigilance ‫ حذر‬: anxious, alert, scanning
 Sleep disturbance
 Lead to social dysfunction
 
❑ Diagnosis
 Exposure to traumatic event
 Trauma is persistently and re experiences: thoughts, nightmares, flashbacks
 Avoidance to trauma related stimuli
 Trauma related arousal and reactivity
 Symptoms last more than one months
❑ Treatment
 CBT
 SSRIs and SNRIs
 Prazosin: alpha one blocker, reduce nightmares and improve sleep
 Avoid benzodiazepines and opioids because risk of addiction
 Acute stress syndrome

 Exposure to threatened death, injury, sexual insult
 Recurrent instructive memories
 Recurrent distressing dreams
 Last less than one month
 Dissociative symptoms
 Altered sense of reality
 In daze time is slow
 Dissociative amensia (cannot remember aspects of trauma)

 Treatment: CBT only

 Adjustments disorders

 Behavioral or emotional symptoms
 Develop within one month after stressful life event
 Distress in excess of expected
 Impairment of daily function
 Usually resolved within 6 months
 Treatment: psychotherapy
Body dysmorphic disorder

 Occurs in physically normal patients
 Preoccupation of physical appearance
 Focused on non existing or minor
defects
 Patient thick they looks abnormal, ugly,
deformed
 Lead to repetitive behavior
 Checking mirror
 Combing hair
 Treatment: CBT+SSRIs
 Somatic Symptom and Related Disorders

 Somatic Symptom Disorder (SSD)
 Somatic refers to the body. The new term somatic symptom disorders (SSD) replaces the old term
somatoform disorders in DSM-5.
 SSD is characterized by somatic symptoms that are either very distressing
or result in significant disruption of functioning, as well as excessive and
disproportionate thoughts, feelings, and behaviors regarding those
symptoms. To be diagnosed with SSD, the individual must be persistently
symptomatic (typically at least for 6 months). It is a category of disorders
in DSM-5 as well as a specific diagnosis. In the past the term somatoform
disorders was more associated with physical symptoms with no organic
cause.
 Conversion Disorder

 Conversion reaction, as defined in the defense mechanisms, is converting anxiety into
a physical symptom. Conversion disorder is the illness that emerges from overuse of
this mechanism. In conversion disorder, there is a loss or decrease in physical
functioning that cannot be explained by any known medical disorder or
pathophysiological mechanism. Paralysis and blindness are two of the more common
examples of this disorder. It is common for the dysfunction to somehow be deeply
connected to denial and to a prior negatively perceived experience (e.g., someone who
loses the sense of vision after watching a pornographic movie). Age of onset is usually
adolescence and young adulthood, but it can occur later in life as well. Conversion
disorder is also referred to as Functional Neurological Symptom Disorder. The
rationale is that persons diagnosed with Functional Neurological Symptom Disorder
will likely be seen by a neurologist.
 Hypochondriasis

 Hypochondria is a type of anxiety disorder. It is also known as health anxiety, or
illness anxiety disorder, or hypochondriasis. It is normal for people to worry
about their health now and again. But people who experience hypochondria get
very worried that they are seriously ill, or are about to become seriously ill.
 Nursing intervention for patient with
Anxiety disorders
Nursing Assessment:
Assessment of

general appearance and motor
behavior
Assessment of mood and affect may reveal that the
client is anxious, worried, tense, depressed, serious,
or sad.
Assessment of thought processes and content the
client is overwhelmed, thoughts are disorganized, and
the client loses the ability to think rationally.
Assessment of self-concept
Nursing diagnoses can include the following:

 Anxiety
 Ineffective Coping

 Fatigue
 Situational Low Self Esteem
 Impaired Skin Integrity (if scrubbing or washing rituals in OCD)
 outcome IDENTIFICATION

 The client will complete daily routine activities within a realistic
time frame (for client with OCD)
 The client will demonstrate effective use of relaxation
techniques.
 The client will discuss his feelings with another person.
 The client will demonstrate effective use of behavior therapy
techniques.
 Nursing Intervention
Using therapeutic communication:

Offering support and encouragement to the client is
important to help him or her manage anxiety responses.
 Validate the overwhelming feelings the client experiences
while indicating the belief that the client can make needed
changes and regain a sense of control.
Encourages the client to talk about the feelings and to
describe them in as much detail as the client can tolerate.
Teaching relaxation and behavioral techniques:


The nurse teach the client about relaxation techniques such as
deep breathing, progressive muscle relaxation, and guided
imagery. This intervention should take place when the client’s
anxiety is low so he or she can learn more effectively. Initially,
the nurse can demonstrate and practice the techniques with the
client.
 Providing client and family education


It is important for both the client and family to learn about
anxiety disorders.
Helping the client and family to talk openly about, anxiety.
Family members also can better give the client needed
emotional support when they are fully informed.
Best wishes

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 

Best wishes