CLIENTS WITH

ANXIETY DISORDERS
Reported by:
Diane Michelle C. Lee
Anxiety
A normal reaction to stress
A protective response and an innate form of
communication that the body uses to mobilize its
coping resources to maintain homeostasis
 Anxiety and Fear
Anxiety can be described as a sense of uneasiness,
nervousness, worry, fear, or dread of what’s about to
happen or what might happen.
Fear is the emotion we feel in the presence of threat, a
known, external source of danger.
Physiological manifestations are similar
Physical symptoms of anxiety:
•Palpitations
•Sweating
•Trembling or shaking
•Difficulty swallowing
•Chest discomfort
•Dizziness
•Hot or cold flashes
•Stomach pain
 Excessi
Anxiet ve and Disord
y irratio er
nal
Anxiety Disorders
Maladaptive responses or failure to mobilize
homeostatic processes that can globally affect one’s
level of functioning
Mental health conditions that involve excessive
amounts of anxiety, fear, nervousness, worry, or dread
One of the most common psychiatric conditions (APA,
2000)
Affect people of all ages
Sigmund Freud
First introduced the concept of anxiety to
psychological theory (the early 1900’s)
Anxiety is a danger signal a person exhibits
in response to the perception of physical
pain or danger
Anxiety is the central component of mental
disease
 Levels of Anxiety
Normal Periodic warnings of a threat – such as uneasiness or
apprehension – that prompt the client to take necessary
steps to prevent a threat or lessen its consequences
Euphoria Exaggerated feeling of well-being that is not directly
proportionate to a specific circumstance or situation
Mild Anxiety Increased alertness to inner feelings or the environment
Increased ability to learn, experiences a motivational
force, may become competitive, and has the opportunity
to be individualistic
Moderate Anxiety Narrowing of the ability to concentrate, with the ability
to focus on only one specific thing at a time
Severe Anxiety The ability to perceive is further reduced, and focus is on
small or scattered details
Inappropriate verbalization, or the inability to
communicate clearly
Lack of determination or the ability to perform
Panic State Complete disruption of the ability to perceive
Disintegration of the personality
The Different Anxiety
Disorders
(DSM-IV-TR )
Panic Disorder
with or without Agoraphobia
“panikos” = fear
PANIC DISORDER
 Characterized by unexpected and repeated episodes of
intense fear accompanied by physical symptoms that
may include chest pain, heart palpitations, and
shortness of breath, dizziness, or abdominal distress
 Normally, attacks peak within 10 minutes (APA, 2000)
 1 out of 75 people in the US and worldwide experience
panic attacks during their lifetime
 Late teens or early twenties
 Women 2x > Men
Panic attack
Out of the blue
Suddenly experiences frightening and uncomfortable
symptoms that may include terror, a sense of unreality,
or a fear of losing control
Phobias
Most common form of mental disorders among
women and second among men, affecting 8% of adult
Americans (Sadock & Sadock, 2003)
Irrational fear of an object, activity, or situation that is
out of proportion to the stimulus and results in
avoidance of the identified object, activity or situation
Agoraphobia
Fear of public places
Most common phobic disorder; 60% of phobias
May arise from the fear of having a panic attack in a setting
from which there is no perceived easy means of escape
As a result, sufferers avoid public and/or unfamiliar places,
especially large, open spaces such as shopping
malls or airports where there are few places to hide
In severe cases, the sufferer may become confined to his or
her home
Develops as a complication of panic attacks
Onset is usually between ages 20 and 40 years
Women > Men
Social Phobia/Social Anxiety Disorder
Characterized by overwhelming anxiety and excessive
self-consciousness in everyday social situations
Can be limited to only one type of situation — such as
a fear of speaking in formal or informal situations, or
eating or drinking in front of others — or, in its most
severe form, may be so broad that a person
experiences symptoms almost anytime they are around
other people
Social Phobia/Social Anxiety Disorder
Persistent, intense, and chronic fear of being watched
and judged by others and being embarrassed or
humiliated by their own actions
 Blushing
 Profuse sweating
 Nausea
 Difficulty talking
Specific phobias

Acrophobia Ophidiophobia Algophobia Nyctophobia Claustrophobia

Entomophobia Iatrophobia Pyrophobia Astrophobia Thanatophobia

Generalized Anxiety Disorder
Characterized by chronic anxiety, exaggerated worry
and tension, even when there is little or nothing to
provoke it
Commonly seen in the primary care setting and is
associated with disability, medically unexplained
symptoms and worry occurring most of the day than
not in a 6 month period
Obsessive-Complusive Disorder
Characterized by recurrent, unwanted thoughts
(obsessions) and/or repetitive behaviors
(compulsions)
Repetitive behaviors such as hand washing, counting,
checking, or cleaning are often performed with the
hope of preventing obsessive thoughts or making
them go away
Performing these so-called "rituals," however, provides
only temporary relief, and not performing them
markedly increases anxiety
On average, people with OCD see three to four doctors
and spend several years seeking treatment before they
receive a correct diagnosis
Studies find that it takes an average of 17 years from
the time OCD begins for people to obtain appropriate
treatment
OCD tends to be under-diagnosed and undertreated
for a number of reasons
 People with OCD are secretive about their symptoms or
lack insight about their illness
 Many healthcare providers are not familiar with the
symptoms or are not trained in providing the
appropriate treatments
Post Traumatic Stress Disorder
Develop after exposure to a terrifying event or ordeal in
which grave physical harm occurred or was threatened
Persistent frightening thoughts and memories of their
ordeal and feel emotionally numb, especially with
people they were once close to
The diagnosis of acute onset refers to symptoms that
last fewer than 3 months. If symptoms persist beyond 3
months, the diagnosis of chronic onset is used. Delayed
onset is used to describe the onset of symptoms that
occur at least 6 months after exposure to the initial
stressful situation or trauma.
Symptoms include isolation secondary to self-
perceived or actual feelings of rejection by peers;
unpredictable outbursts of rage; exaggerated startle
response; avoidance of feelings; survival guilt, sleep
disturbances and nightmares; recurrent and intrusive
distressing recollections.
Acute Stress Disorder
differentiated from PTSD in that symptoms occur
during or immediately after the trauma, last for at least
2 days, and either they resolve within 4 weeks after the
conclusion of the event or the diagnosis is changed to
PTSD
Atypical Anxiety Disorder
catch-all category for clients who exhibit signs of an
anxiety disorder, but do not meet criteria for any of the
previously described conditions listed in this
classification.
Epidemiology of Anxiety Disorders
Most common form of psychiatric disorder in the US
They affect up to 40 million adults or about 18% of the
population aged 18 and older (Kessler, Chiu et al, 2005)
Nearly ¾ of those with an anxiety disorder will have
their first episode by the age 21.5. (Kessler, Berglund et
al 2005)
People with anxiety disorder frequently seek health
care services for relief of physical symptoms, at a cost
of approximately $22 billion per year
Women are affected more frequently than men
 One Year Prevalence of Anxiety Disorder
Disorder Prevalence in Age of onset Gender
adults in any given predilection
year (%)
Median age of Twice more
Panic Disorder 2.7 onset 24 years frequent in women
Median age of Twice more
GAD 3.1 onset 31 years frequent in women
Median age of Twice more
Phobias (specific) 8.5 onset 7 years frequent in women
Social anxiety Median age of Equal
disorder 6.8 onset 13 years
Median age of Equal
OCD 1.0 onset 19 years
Median age of Women more
PTSD 3.5 onset 19 years likely affected
(Rape is a major
trigger)

Data from Kessler, Chiu et al 2005

Cultural Considerations
Reliable data on the incidence of anxiety disorders are
sparse, but socio-cultural variation in symptoms of
anxiety disorders has been noted
It is important to consider the cultural context,
cultural norms and environmental setting when
evaluating clinical symptoms exhibited
In some cultures, individuals express anxiety through
somatic symptoms, whereas other cultures, cognitive
symptoms predominate. Panic attacks in Latin
Americans and Northern Europeans often involve
sensations of choking, smothering, numbness, or
tingling, as well as fear of dying
In some cultures, panic attacks may involve intense
fear of witchcraft or magic
Social phobias in Japanese and Korean cultures may
relate to beliefs that the individual’s blushing, eye
contact, or body odor is offensive to others (APA,
2000)
Some immigrants may be reluctant to discuss
experiences of torture or trauma due to fear of reprisal
as they seek political asylum.
Ataque de Nervios or “Attack of the Nerves”
- is a disorder found among Hispanic populations
in response to stressful events like death, acute family
discord or witnessing an accident which causes sudden
trembling, faintness, palpitations, out of control
shouting, heat that moves from chest to head and
seizure-like activities.
Anxiety Across the Life
Span
Childhood and Adolescent
Anxiety is a normal part of childhood, and every child
goes through phases
A phase is temporary and usually harmless
But children who suffer from an anxiety disorder
experience fear, nervousness, and shyness, and they
start to avoid places and activities
It affects one in eight children.
Research shows that untreated children are at higher
risk to perform poorly in school, miss out on
important social experiences, and engage in substance
abuse
Generalized Anxiety Disorder
A child with GAD worry excessively about a variety of
things such as grades, family issues, relationships with
peers, and performance in sports
These children tend to be very hard on themselves and
strive for perfection.
They also seek constant approval or reassurance from
others
The essential features of overanxious disorder are
unwarranted distress over the future, somatic or
hyperarousal complaints, and inability to relax or
settle down, all occurring for at least a 6-month period
(APA, 2000)
Treatment:
 Individual psychotherapy
 Psychoeducation
 Family therapy
 Cognitive-behavioral interventions that emphasize
identification and recognition of anxiety and
clarification of anxiety-provoking cognitions
Obsessive-Compuslive Disorder
Most children with OCD are diagnosed around age 10,
although the disorder can strike children as young as
two or three
1/3 to ½ of adults with OCD report a childhood or
adolescent onset
Boys are more likely to develop OCD before puberty,
while girls tend to develop it during adolescence
Treatment: cognitive therapy, psychopharmacology,
anxiety management training, desensitization,
psychoeducation and family therapy
OCD can make daily life very difficult and stressful for
children
Children worry that they are "crazy" because they are
aware their thinking is different than their friends and
family
A child's self-esteem can be negatively affected
because the OCD has led to embarrassment or has
made the child feel "bizarre" or "out of control".
Children with OCD have episodes in which they are
extremely angry with their parent
Post-Traumatic Stress Disorder
The more personal the trauma, evidence suggests, the more
likely long-term psychological problems are to arise from it
Five million children are exposed to a traumatic event in
the United States every year, amounting to 1.8 million new
cases of post-traumatic stress disorder (PTSD). Some 36%
of children who experience traumatic events develop PTSD,
compared with 24% of adults.
The younger a child is at the time of the trauma, the more
likely he or she is to develop PTSD. Thirty-nine percent of
preschoolers develop PTSD in response to trauma, while
33% of middle school children and 27% of teens do.
By age 18 years, 1 in 4 children has experienced a
personal or community act of violence
The experience of childhood trauma appears to evolve
over time and has the potential to produce variable
and enduring effects that generate the array of
adulthood psychiatric problems
Children are more likely to have difficulty coping with
physical and emotional trauma than adults because of
their inadequate coping skills
Major manifestations of PTSD in the child or adolescent
include (Copeland et al, 2007; Turner, Finkelhor, &
Ormrod, 2006) rejection of closeness, sense of a loss of
vigor and magic of youth, cognitive impairment or
forgetfulness, nightmares, dependency behaviors, intrusive
re-experiencing of the event, regression to previous
developmental stage, questions about self-worth, and
personality development arrest in profound cases
The treatment of childhood PTSD is multimodal and
includes cognitive-behavioral approaches, individual and
family therapy, psychoeducation, and pharmacologic
interventions.
Separation Anxiety Disorder
Many children experience separation anxiety between 18
months and three years old, when it is normal to feel some
anxiety when a parent leaves the room or goes out of sight.
Usually children can be distracted from these feelings.
This disorder is most common in kids ages seven to nine
and affects 4% of children. It affects girls more than boys.
These children experience panic or excessive worrying
about losing their primary caregiver. They are reluctant to
go to school or depart from their caregiver because of fear
of separation. These symptoms exist for at least 4 weeks
and produce significant or subjective distress (APA, 2000)
The child’s history often reveals significant separations
in his life (i.e. hospitalizations)
These children are often reluctant or refuse to go to
sleep, fear the dark, and experience nightmares.
Mainstay treatment for separation anxiety disorder is
cognitive behavioral therapy, family and individual
therapy, and psychoeducation.
Social Anxiety
Social phobia in children and adolescents involves distress in
a broad range of interpersonal encounters such as formal
speaking, eating in front of others, using public restrooms,
and speaking to authority figures (Hirshfeld-Becker et al 2007)
Avoidant behaviors in children and adolescents are manifested
as persistent or extremely constricted social interaction with
unfamiliar people to the point of intense social impairment of
interaction with peers
These observations may occur as early as 2 ½ years of age and
endure for at least 6 months for diagnosis. If this disorder
continues into adulthood, it is linked with avoidant
personality disorder (APA 2000).
Factors that increase the risk of social phobia in
children and adolescents include modeling of shy,
aloof behaviors by the primary caregiver, child abuse,
and early traumatic childhood losses.
Treatment consists of cognitive-behavioral
interventions that involve gradual exposure, cognitive
reconstructuring, coping skills, assertiveness training
for shyness, and anxiety self-monitoring.
 Selective Mutism
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 Adulthood
Anxiety disorders in adults, like child and adolescent anxiety
disorders evolve over a continuum
 dulthood
Older A
Research, on both the course and treatment of anxiety
in older adults, lags behind that of other mental
conditions, such as depression and Alzheimer's.
Until recently, anxiety disorders were believed to
decline with age. But now experts are beginning to
recognize that aging and anxiety are not mutually
exclusive: anxiety is as common in the old as in the
young, although how and when it appears is distinctly
different in older adults.
Anxiety disorders in the elderly population are real
and treatable, just as they are in younger people.
 Another commonality between old and young is the
high incidence of depression with anxiety.
Depression and anxiety go together in the elderly, as they
do in the young, with almost half of those with major
depression also meeting the criteria for anxiety and about
one-quarter of those with anxiety meeting criteria for
major depression.
As with younger persons, being a woman and having less
formal education are risk factors for anxiety in older
adults.
Most older adults with an anxiety disorder had one when
they were younger.
What "brings out" the anxiety are the stresses and
vulnerabilities unique to the aging process: chronic
physical problems, cognitive impairment and significant
emotional losses.
Although anxiety disorders in older adults are likely to
evolve over time, distinguishing medical conditions
that mimic anxiety disorders is a priority in this age
group.
These clients are especially susceptible to delirium,
which may arise from systemic infections; drug
toxicity; polypharmacy; substance intoxication and
withdrawal; endocrine disorder; and fluid and
electrolyte imbalance.
Therefore, before treating anxiety disorders in the
older adult, differential diagnoses must be made to
rule out various medical and psychiatric illnesses.
 Treatment in the
Community Setting
The client with an anxiety disorder is more likely to
receive care in the home or community setting than in
an inpatient psychiatric unit.
Shifting mental health care from hospital to
community and home care may produce intense
family tension and overtax their coping skills, thus
increasing the risk of treatment failure.
The nurse must continuously assess the family’s ability
to cope with the illness, the client’s response to
treatment, mental and physical status, and potential
for violence towards self and others.
Panic Disorders
nurses should have information sheets or pamphlets
available concerning the disorder and any medications
prescribed
A referral for family therapy may be indicated
Families experience the symptoms, treatments, clinical
setbacks, and recovery from chronic mental illnesses as
a unit
Nurses are more directly involved in treatment,
conducting psychoeducation groups on relaxation and
breathing techniques, symptom management, and
anger management.
Obsessive-Compulsive Disorder
The family will need to be educated about the etiology
of the disorder. Understanding the biologic basis of
the disorder should decrease some of the stigma and
embarrassment they may feel about the bizarre nature
of the patient’s obsessions and compulsions.
Be sure to include the patient’s caregiver, if
appropriate, in health teaching and address the
following topic areas in the teaching plan: medications;
skin care measures; ritualistic behaviors and alternative
activities; though stopping; relaxation techniques;
cognitive restructuring; and community resources