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Course: Mental Health Nursing�Topic: Anxiety Related Disorders Part - I

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Module Goals

Learners will be able to:

Describe the types of anxiety disorder.
List the diagnostic criteria for anxiety disorders.
Describe the clinical manifestations of anxiety disorders.
Describe the nursing implications for anxiety disorders.

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Anxiety Related Disorders

Anxiety disorders are the collection of symptoms that involve more than temporary worry or fear.
Anxiety disorder differs from occasional feelings of nervousness or anxiousness, and involves excessive fear or anxiety.
Impedes daily life and function as the anxiety does not go away and may get worse over time.
The symptoms may interfere with daily activities such as job performance, school work, and relationships.

National Institute of Mental Health, 2018

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General Types of Anxiety Related Disorders

Generalized Anxiety Disorders
Panic Disorder
Phobias, Specific Phobias
Agoraphobias
Social Anxiety Disorder
Separation Anxiety Disorder
Post Traumatic Stress Disorder

National Institute of Mental Health, 2018

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General Anxiety Disorders

People with generalized anxiety disorder (GAD) display excessive anxiety or worry, most days for at least 6 months, about a number of things such as personal health, work, social interactions, and everyday routine life circumstances.

The fear and anxiety can cause significant problems in areas of their life, such as social interactions, school, and work.

National Institute of Mental Health, 2018

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Generalized Anxiety Disorder (GAD): Diagnostic Criterias

The anxiety and worry are associated with three (or more) specific symptoms.
However, for children only one symptom is enough to diagnose GAD.
The disturbance is not attributable to the physiological effects of a substance use or another medical condition (e.g., hyperthyroidism).
The disturbance is not better explained by another mental disorder.

American Psychiatric Association, 2013

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The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

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General Anxiety Disorders: Symptoms

National Institute of Mental Health, 2018

Generalized anxiety disorder symptoms include:

Feeling restless, wound-up, or on-edge
Easily fatigued.
Difficulty concentrating; mind going blank.
Being irritable
Muscle tension
Difficulty controlling feelings of worry
Sleep problems, restlessness, or unsatisfying sleep.

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General Anxiety Disorders: Treatment

Psychopharmacology: Serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).
Rational-Emotive Therapy: Identifies negative irrational feelings and teaches the client to replace them with the positive and productive thoughts.
Cognitive Behavioral Therapy: identify and restructure maladaptive thoughts.
Biofeedback: Provides a visual representation of client’s physiological arousal.

Bridley & Daffin, 2018

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Treatment

Psychopharmacology: Hypnotic drugs like: Benzodiazepines are considered to be effective drugs in treating anxiety or related disorders because of their less addictive properties, yet equally effective ability to calm individuals at low dosages. There have been research lately about the serious side effects of benzodiazepines which reveals the chances of physical dependence remains higher. Due to these negative effects, selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are generally considered to be first-line medication options for those with GAD. However, none of these medications continue to provide any benefit once they are stopped; therefore, other more effective treatment options such as CBT, relaxation training, and biofeedback are often encouraged before the use of pharmacological interventions.

Rational-Emotive Therapy : It is a form of cognitive behavioural therapy which identifies irrational, self-defeating assumptions, challenge the rationality of those assumptions, and teach how to replace them with new more productive thoughts and feelings. It is proposed that through identifying and replacing these assumptions that one will experience relief of GAD symptoms.

Cognitive Behavioral Therapy (CBT) : One of the most effective treatment options for a variety of anxiety disorders. CBT is a combination of cognitive and behavioral strategies aimed to identify and restructure maladaptive thoughts and provides opportunities to utilize these more effective thought patterns through exposure based experiences. Through repetition, the individual will be able to identify and replace anxious thoughts outside of therapy sessions which ultimately reduces their overall anxiety levels.

Biofeedback: Provides a visual representation of a client's physiological arousal. A computer is connected to the clients and it provides continuous information on their physiological states. There are several ways a client can be connected to the computer like Electroencephalography (EEG), electromyography (EMG). EMG measures the amount of muscle activity currently experienced by the individual. An electrode is placed on an individual's skin just above a major muscle group- commonly the forearm or the forehead. EEG measures the neurofeedback or brain activity; heart rate variability (HRV) which measures autonomic activity such as heart rate or blood pressure; and galvanic skin response (GSR) which measures sweat. Once the client is connected to the biofeedback machine, the clinician is able to walk the client through a series of relaxation scripts or techniques as the computer simultaneously measures the changes in muscle tension. The theory behind biofeedback is that in providing a client with a visual representation of changes in their physiological state, they become more skilled at voluntarily reducing their physiological arousal, and thus, their overall sense of anxiety or stress.

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Nursing Management of Client with GAD

Assess for anxiety by asking if client is feeling nervousness, fear, panic, having ‘butterflies’, or feeling tense.
Assess autonomic nervous system: Heart rate, breathing, sweating, dry mouth, the presence of tremors or twitching.
Use an anxiety tool to determine severity of symptoms

Be supportive
Acknowledge client’s feelings
Communicate and educate
Familiarize client to surroundings

Munir et al, 2021

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Nursing Management of Client with GAD

Interact in a calm manner
Converse in simple language
Reinforce client's feelings-it is okay to feel nervous
Listen to what the client is saying
Provide a quiet room for the client
Avoid anxiety triggers like caffeine
Teach deep breathing exercises to relieve stress
Educatt about anti-anxiety medications

Munir et al, 2021

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Case Study

Which of the following is a first-line treatment In generalized anxiety disorder (GAD)?

Benzodiazepines
Selective Serotonin Reuptake Inhibitors (SSRIs)
Hydroxyzine
Mirtazapine

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Panic Disorder

Panic attack is defined as sudden or abrupt surge of intense fear that comes on quickly and reaches its peak within minutes.
The attacks are recurrent.
Impending doom along with at least 4 physical or cognitive symptoms.
Attacks may occur unexpectedly or brought on by a trigger, such as a feared object or situation.

Bridley & Daffin, 2018

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Panic Disorder: Symptoms

Heart palpitations, pounding heartbeat
Sweating
Trembling or shaking
Numbness or tingling sensation
Shortness of breath, smothering, or choking
Feeling of impending doom
Feeling of being out of control
Fear of dying

National Institute of Mental Health, 2018

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Panic Disorder: Diagnostic Criteria

Four or more symptoms occur during an attack.
Constant worry (for 1 month or more) about additional panic attacks.
The disturbance is not attributable to the physiological effects of a substance or another medical condition.
The disturbance is not better explained by another mental disorder.

American Psychiatric Association, 2013

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During the time of attack, four or more symptoms should occur
Constant concern or worry about additional panic attacks or their consequences and maladaptive change in behaviour (neglecting exercises) followed by 1 month or more
The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder). Diagnostic Features Panic disorder refers to recurrent unexpected panic attacks (Criterion A). A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes.

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Panic Disorder: Treatment

Cognitive Behaviour Therapy

Given in the following order:

Psychoeducation
Self Monitoring
Relaxation Techniques Trainings
Cognitive Restructuring
Exposure

Psychopharmacology: Drugs are given only if the client does not respond to CBT therapy alone.

Bridley & Daffin, 2018

Contact info: info@nursesinternational.org

Treatment

Cognitive Behavioral Therapy (CBT) : The most effective treatment option for individuals with panic disorder as the focus is on correcting misinterpretations of bodily sensations. This therapy consists of various following steps:

Psychoeducation: Treatment begins by educating the client on the nature of panic disorder, the underlying causes of panic disorder, as well as the mechanisms that maintain the disorder such as the physical, cognitive, and behavioral response systems. It corrects the myths or misconceptions about the disorder.
Self-monitoring: It is about self awareness: the awareness of the symptoms, relationship between physical arousal and behavioral responses of self observation. In this process an individual is taught to identify the physiological cues leading panic attack. The client is then encouraged to identify and document/record the thoughts and behaviors associated with these physiological symptoms. When this awareness is brought in the client, it has proven that a client will learn to manage the panic symptoms.
Relaxation Training: In this process, a client is taught about the relaxation technique to apply during the onset of panic attacks. Deep breathing exercises, muscle relaxation exercises (client will learn to tense and relax various large muscle throughout the body starting from feet and gradually work their way up through the entire body holding the tension roughly for 10 seconds and relaxing). Note; Breathing exercise (which once was included in relaxation techniques. While breathing training was once included as the relaxation training technique of choice for panic disorder, due to the high report of hyperventilation during panic attacks more recent research has failed to support this technique as effective in the use of panic disorder. Findings suggest that breathing retraining is more commonly misused as a means for avoiding physical symptoms as opposed to an effective physiological response to stress
Cognitive restructuring: This therapy helps to develop an ability to recognize cognitive errors and place them with alternate, more appropriate thoughts. It also identifies the role of thoughts in generating and maintaining emotions. The clinician encourages the individual to view these thoughts as “hypotheses” as opposed to facts, which allows the thoughts to be questioned and challenged. Then the recorded part is discussed and the clinician will be able to help the individual restructure the maladaptive thought processes to more positive thought processes which in return, helps to reduce fear and anxiety.
Exposure: In this session, the client is encouraged to engage in a variety of exposure techniques such as in vivo exposure and interoceptive exposure, while also incorporating the cognitive restructuring and relaxation techniques previously learned in efforts to reduce and eliminate ongoing distress.

Pharmacological Interventions: There has been debates about the use of medication i.e. anti anxiety medications to treat panic disorders. Some large clinical trials show that there are no advantage during or immediately after treatment of combining CBT and medication. Additionally, when medications were discontinued post-treatment, the CBT+ medication groups fared worse than the CBT treatment alone groups, thus supporting the theory that immersion in interoceptive exposure is limited by the use of medication. Therefore, it is suggested that medications are reserved for those who do not respond to CBT therapy alone.

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Nursing Management of Client with Panic Disorder

Be supportive, calm and non-threatening
Present with non-judgemental attitude
Ensure client’s safety
Listen actively, validate the client's feelings
Be clear and concise with words
Provide a calm and suitable (non-stimulating) environment
Educate about and administer medications as prescribed
Recognize triggering factors
Encourage client to verbalize feelings
Encourage relaxation techniques

Munir et al, 2021

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Case Study

A teenage girl who has hyperthyroidism walks into the clinic and says “I had a panic attack yesterday. I have been researching my symptoms in google and I am sure that I have panic disorder.”

On assessment she verbalizes her symptoms were tremors, sweating, pounding heart, anxiety, worries and she remains irritable most of the time and does not like to do exercises.

The nurse recognizes that the symptom are not associated with panic disorder.

Why?

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Post Traumatic Stress Disorder (PTSD)

An anxiety disorder caused by very stressful, frightening or distressing events such as:

Serious road accidents, wars
Violent personal assaults, such as sexual assault,robbery
Serious health problems
Trauma like childbirth experiences

Can develop immediately after someone experiences a disturbing event, or it can occur weeks, months or even years later.

National Health Service, 2018a

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PTSD: Diagnostic Criteria

To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:

At least one re-experiencing symptom
At least one avoidance symptom
At least two arousal and reactivity symptoms
At least two cognition and mood symptoms

National Institute of Mental Health, 2019

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PTSD: Symptoms

Re-experiencing: Flashbacks, nightmares, repetitive/distressing images.

Physical symptoms: Like pain, sweating, feeling sick or trembling.�
Avoidance and emotional numbing: Avoiding certain people or places that reminds of the trauma, or avoiding talking to anyone about the experience.

(National Health Service, 2018b)

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PTSD: Symptoms

Hyperarousal (feeling 'on edge'): irritability, angry outbursts, sleeping problems, difficulty concentrating.
Other Problems:

Other mental health problems: depression, anxiety or phobias
Self-harming or destructive behaviour, such as drug misuse or alcohol misuse.
Other physical symptoms: Headaches, dizziness, chest pains and stomach aches.

National Health Service, 2018b

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PTSD in Children

PTSD may affect children as well as adults.
Children with PTSD may have similar symptoms as adults.
Examples include: Trouble sleeping and upsetting nightmares, loss of interest in activities they used to enjoy, headaches and stomach aches.

National Health Service, 2018b

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PTSD in Children

Other symptoms include:

Difficult behaviour
Avoiding things related to the traumatic event.
Re-enacting the traumatic event again and again through their play.
Wetting the bed after having learned to use the toilet.
Forgetting how to, or being unable to talk.
Acting out the scary event during playtime
Being unusually clingy with a parent or other adult.

National Health Service, 2018b

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PTSD: Treatment

A detailed assessment of symptoms to tailor the treatment.
Active monitoring: watchful waiting – symptoms have to be monitored to determine if they improve or get worse without treatment.

Psychotherapies:

Cognitive behavioural therapy (CBT)
Eye movement desensitisation and reprocessing (EMDR)
Support and advice

Psychopharmacology: Antidepressants: paroxetine or mirtazapine.

National Health Service, 2018c

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Active monitoring

If mild symptoms of PTSD is present, or if the symptoms persist for less than 4 weeks, an approach called active monitoring may be recommended. Active monitoring involves carefully monitoring the symptoms to see whether they improve or get worse. It's sometimes recommended because 2 in every 3 people who develop problems after a traumatic experience get better within a few weeks without treatment. If active monitoring is recommended, one should have a follow-up appointment within 1 month.

Psychological therapies : If one has PTSD that requires treatment, psychological therapies are usually recommended first. A combination of a psychological therapy and medicine may be recommended if one have severe or persistent PTSD. There are 3 main types of psychological therapies used to treat people with PTSD.
Cognitive behavioural therapy (CBT)
Eye movement desensitisation and reprocessing (EMDR) :A psychological treatment that is involved recalling the traumatic incident in detail while making eye movements, usually by following the movement of the therapist's finger/tapping finger or playing a tone. It's not clear exactly how EMDR works, but it may help change the negative way one think about a traumatic experience.
Support and advice: There are a number of charities that provide peer support and advice for PTSD. For example:
Combat Stress – a military charity specialising in helping ex-servicemen and women
Rape Crisis – a UK charity providing a range of services for women and girls who have experienced abuse, domestic violence and sexual assault
Victim Support – providing support and information to victims or witnesses of crime
CRUSE – a UK charity providing support and information for people who have experienced bereavement
Medicine: Antidepressants, such as paroxetine, sertraline, mirtazapine, amitriptyline or phenelzine, are sometimes used to treat PTSD in adults. Of these medicines, only paroxetine and sertraline are licensed specifically for the treatment of PTSD. But mirtazapine, amitriptyline and phenelzine have also been found to be effective and may be recommended as well.

These medicines will only be used if:

one chooses not to have trauma-focused psychological treatment
psychological treatment would not be effective because there's an ongoing threat of further trauma (such as domestic violence)
one has gained little or no benefit from a course of trauma-focused psychological treatment
one has an underlying medical condition, such as severe depression, that significantly affects one’s ability to benefit from psychological treatment

But they're not usually prescribed for people younger than 18 unless recommended by a specialist. If medicine for PTSD is effective, it'll usually be continued for a minimum of 12 months before being gradually withdrawn over the course of 4 weeks or longer. If a medicine is not effective at reducing the symptoms, dosage may be increased.

Children and young people

Trauma-focused CBT is usually recommended for children and young people with PTSD. This normally involves a course of 6 to 12 sessions that have been adapted to suit the child's age, circumstances and level of development. Where appropriate, treatment includes consulting with and involving the child's family. Children who do not respond to trauma-focused CBT may be offered EMDR.

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Complex PTSD

Diagnosed in people who repeatedly experience traumatic situations, such as severe neglect, abuse or violence.
Complex PTSD may cause similar symptoms as PTSD and may not develop until years after the event.
It's often more severe if the trauma was experienced early in life, trauma was caused by close person, trauma was experienced for a very long time, victim was alone during the trauma, and the perpetrator is still in contact with the person.

National Health Service, 2018d

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Complex PTSD - Post-traumatic stress disorder: Complex PTSD may be diagnosed in adults or children who have repeatedly experienced traumatic events, such as violence, neglect or abuse.

Complex PTSD is more severe if:

The traumatic events happened early in life
The trauma was caused by a parent or carer
The person experienced the trauma for a long time
The person was alone during the trauma
There's still contact with the person responsible for the trauma

As it may take years for the symptoms of complex PTSD to be recognised, a child's development, including their behaviour and self-confidence, can be altered as they get older. Whereas, adults with complex PTSD may lose their trust in people and feel separated from others.

Symptoms of complex PTSD

Involves all the symptoms of PTSD, but may include:

Feelings of shame or guilt
Difficulty controlling emotions
Periods of losing attention and concentration (dissociation)
Physical symptoms, such as headaches, dizziness, chest pains and stomach aches
Cutting oneself off from friends and family
Relationship difficulties
Destructive or risky behaviour, such as self-harm, alcohol misuse or drug abuse
Suicidal thoughts

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Symptoms of Complex PTSD

Involves all the symptoms of PTSD, but may include:

Feelings of shame or guilt
Difficulty controlling emotions
Periods of losing attention and concentration (dissociation)
Physical symptoms, such as headaches, dizziness, chest pains and stomach aches
Cutting off from friends and family
Relationship difficulties
Destructive or risky behaviour, such as self-harm, alcohol misuse or drug abuse
Suicidal thoughts

National Health Service, 2018d

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Case Study

While interacting with a client who recently has been diagnosed with post-traumatic stress disorder, which of the following actions would be the most efficient interventions?

Teach client to use distraction techniques to cope with memories of trauma
Encourage the client to verbalize thoughts and feelings about the trauma.
Encourage the client to accept the past and change the perspective of life.
Try not to talk about the trauma client is experiencing as it might provoke memories and cause the client to feel worse

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References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Publishing.

Bridley, A., Daffin, L.W. (Eds.). (2018). Essentials of Abnormal Psychology. By Washington State University, licensed under CC BY 4.0. https://opentext.wsu.edu/abnormalpsychology/chapter/module-7-anxiety-disorders/

Munir S, Takov V, Coletti VA. Generalized Anxiety Disorder (Nursing) [Updated 2021 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568696/

National Institute of Mental Health. (2018). Anxiety Disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders

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References:

National Institute of Mental Health. (2019). Post Traumatic Stress Disorder. https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd

National Health Service (2018a). Overview: Post-Traumatic Stress Disorder. https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/overview/

National Health Service (2018b). Symptoms: Post-Traumatic Stress Disorder. https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/symptoms/

National Health Service (2018c). Treatment: Post-Traumatic Stress Disorder. https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/treatment/

National Health Service (2018d). Mental Health: Complex PTSD: Post-Traumatic Stress Disorder. https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/complex/

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