Understanding common

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Understanding common

KATHRYN MURPHY, NP, MSN, DNS

Nursing Faculty • Hawaii Community College • Hilo, Hawaii

DEMANDING JOBresponsibilities, family obligations, and

challenging relationships can add stress to our lives and make anyone feel anxious. Stress and anxiety are a nor-mal part of living. Some stress, in fact, can be a good thing because it makes us more alert and helps us make better decisions.

In most instances, stress and anxiety do their job, and then they disappear when the stressor goes away. At least that’s what’s supposed to happen. But for millions of peo-ple, it doesn’t: The loss of a stressor doesn’t mean the loss of the anxiety. Anxiety becomes a constant companion and disrupts the person’s daily functions, such as job perfor-mance and relationships.

That’s when anxiety ceases to be normal and instead becomes a disorder. Because anxiety disorders are so common in the United States, it’s important for you to

disorders

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Understanding common

Anxious moments:

The most frequently

occurring of all psychiatric disorders, anxiety

disorders affect 23 million Americans, or 1 in 4. These disorders can seriously hamper a person’s health and lifestyle. Find out what you can do to help them cope with their disorder and get the pharmacologic and psychotherapeutic care they need.

A M Y G U IP

know the different types of anxiety disorders, their signs and symptoms, and their treatment options (see The stats on anxiety). That’ll help you bet-ter help your patients.

Let’s start with what causes an anxiety disorder.

A combination of factors

Different anxiety disorders may ex-hibit different etiologies. However, experts agree that a combination of factors contributes to the develop-ment of an anxiety disorder. These factors include external events (stres-sors like divorce or job loss), genet-ics, and biochemical alterations.

Geneticsplay a strong role in anxi-ety disorders. A person may have a genetic predisposition that makes him more sensitive to stress; he experi-ences more anxiety that leads to an anxiety disorder. Similar to diabetes, having close relatives with a history of an anxiety disorder puts a person at increased risk for an anxiety disorder. If one identical twin suffers from an anxiety disorder, for example, the sec-ond twin is likely to be diagnosed with one too.

Biochemical alterationshappen when there’s an imbalance of neuro-transmitters, the chemical vehicles that help pave the way for smooth transmission of nerve impulses. Neurons produce neurotransmitters and store them in the synaptic vesi-cles until they’re needed. Any re-leased neurotransmitter that isn’t used for impulse transmission is sent back to storage through a “reuptake” mechanism.

Serotonin and gamma-aminobu-tyric acid (GABA) are two neuro-transmitters that play a role in anxi-ety. Low levels of serotonin increase anxious feelings. GABA modulates the release of norepinephrine (NE), decreasing neuron excitability and easing anxious feelings. Without suf-ficient GABA, activity in the neurons

rises, leading to anxiety. See Benzodi-azepines aid in the function of GABA.

Another biochemical-related fac-tor for anxiety may be excessive release of NE. This is caused by hyperactivity of the autonomic ner-vous system and arousal of the limbic system, which prepare the person for increased mental and physical demands. Normally, activation of the autonomic nervous system kicks the release of NE into high gear. NE floods the neuron synapse, leading to increased heart rate, blood pressure, respirations, and alertness to help the person cope with the perceived stres-sor (fight-or-flight response). But when this system is overactive, these physiologic responses go overboard and an anxiety disorder results. Over time the level of NE will decrease, which also will contribute to anxiety and depression.

Before we move on, let’s stop and test your knowledge of anxiety disor-ders so far.

Self-Test

1. True or false:An increase in GABA decreases anxiety.

2. True or false:An increase in the norepinephrine level leads to a decrease in the heart rate and blood pressure.

A spectrum of disorders

The physical symptoms of anxiety disorders—increased heart rate, blood pressure, and respirations; di-aphoresis; and restlessness—can be pretty distressing. It’s not surprising,

then, that anxiety is one of the most common reasons people seek med-ical attention. The person may com-plain of dizziness or cognitive prob-lems like forgetfulness, a short attention span, or difficulty concen-trating. He might report other signs and symptoms, such as appetite changes, irritability, decreased libido, or urinary frequency or urgency. Age and cultural factors can also af-fect how an anxiety disorder mani-fests (see Age, culture, and anxiety).

Not all anxiety disorders are creat-ed alike, though. They may have some characteristics in common, such as emotional distress that inter-feres with everyday life, but they also have unique signs and symptoms and may require unique treatment approaches that won’t work for another type of anxiety disorder. And, not everyone who has a certain type of anxiety disorder will react the same; in some people, the disorder will be milder than in others.

So given the prevalence of anxiety disorders and their variety, it’s important for you to understand the ins and outs of the different types of disorders. Let’s take a closer look at five of them: panic disorder, general-ized anxiety disorder, phobic disor-der, obsessive-compulsive disordisor-der, and posttraumatic stress disorder.

Panic disorder

More than 15% of the adult popu-lation experiences panic attacks at some time in their lives, yet only 3.5% meet the American Psycho-logical Association’s criteria for

The stats on anxiety

•One in four people in the United States exhibits symptoms of an anxiety disorder sometime in life.

•Women are twice as likely as men to suffer from an anxiety disorder.

•Anxiety disorders are the most prevalent mental illness in older adults and children.

•Almost 9% of children suffer some disruption in daily functioning from anxiety disorders, and more than 17% of children exhibit mild symptoms of anxiety.

panic disorder, as indicated in the

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR).

To understand the difference between a panic attack and a full-blown panic disorder, consider this example. A woman with a fear of fly-ing is scheduled to take a business trip. Shortly after takeoff, she begins to experience the physiologic symp-toms of a panic attack: shortness of breath, racing heart, diaphoresis, chest pain with palpitations, and feel-ings of doom. Once she’s off the plane and on firm ground, the

symp-toms go away. She doesn’t have these symptoms in any other situation.

So that’s a panic attack. Now, sup-pose the same woman is sitting in her living room and watching one of her favorite television programs. She suddenly begins to experience the physiologic symptoms she generally experiences only when she’s flying. That same day, while she’s watering her houseplants, it happens again. About a month later, she’s walking down the hall at her office and—you guessed it—she has another panic attack. And now she’s really worried because she doesn’t know why this is

happening, when it’ll happen again, and what she can do to avoid the attacks.

That’s a panic disorder. There’s no rhyme or reason to the panic attacks: They occur in everyday situ-ations that normally wouldn’t cause someone to panic, and they occur unpredictably, from several times a day to once every couple of months. They’re characterized by at least four of the physiologic symptoms I described at the beginning of this discussion of panic disorder. The severity of these symptoms can range from mild, with little effect on a per-son’s daily life, to paralyzing panic that stops a person from experienc-ing a normal life.

Panic disorder can also be accom-panied by agoraphobia, a fear of being trapped in situations or places where escape is difficult or impossi-ble, causing panic. Agoraphobia can progress to the point that the person becomes isolated and incapable of leaving the safety of her home.

Generalized anxiety disorder

Think of the person affected by generalized anxiety disorder (GAD) as a “constant worrier.” We all worry from time to time, of course. So when does normal worrying cross the line to GAD? It all comes down to the duration of the anxiety and how much the anxiety affects the person’s life. A person with GAD has a pervasive anxiety that occurs more days than not for at least 6 months and that interferes with his daily life and creates signifi-cant distress. Even minor daily events can push the anxiety button. The most frequently occurring symptoms of GAD are nervousness, restlessness, tachycardia, shortness of breath, insomnia, and agitation.

GAD usually starts in the second decade of life, is chronic, and is often accompanied by depression.

Al-Age, culture, and anxiety

A patient’s age and cultural background can affect your evaluation of his level of anxi-ety. Evaluation of anxiety disorders in children, for example, is often difficult because many other psychiatric disorders share similar symptoms. Restlessness, difficulty con-centrating, and increased aggression are some of the symptoms present in anxiety dis-orders, but they could also indicate depression or attention-deficit disorder.

Anxiety disorders manifest differently in various cultural groups. For example, African-Americans are more likely to suffer from phobias than whites. Different cul-tures respond to anxiety according to cultural beliefs, customs, and health prac-tices. For example, what a person in New York considers to be normal anxiety dif-fers from what a person in South Africa thinks.

Calming effect Neuron

GABA receptor Benzodiazepines

though the exact etiology of GAD is unknown, it’s associated with biolog-ic factors, low self-esteem, and gen-der (it’s more common in women than in men).

Phobic disorder

Phobic disorders can occur as spe-cific phobias or as a general social phobia.

Specific phobiasare characterized by a persistent and excessive fear in the presence of a particular situation, event, or object. The avoidance, anx-ious anticipation, or distress caused by this phobia interferes significantly with the person’s normal routine, job or school, and social interactions. Often the person feels distress about having the phobia.

Social phobiais the persistent fear and avoidance of situations that

expose the person to potential embarrassment, such as public speaking or eating in a restaurant. The person with this phobia has an intense and persistent feeling of being closely scrutinized and judged in a negative way. More than 10% of the population suffers from this dis-order, and it occurs equally in men and women. A person with social phobia may pick life situations or jobs where his disorder will have a minimal effect on his daily activities.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) usually begins in adolescence or early adulthood and becomes chronic. Obsessionsare intrusive, re-current thoughts, impulses, or im-ages that cause distress. Common obsessive themes include fear of

contamination or a need for order.

Compulsionsare recurrent, persistent behaviors that are done in response to the obsession, such as repeated hand washing.

Many of us have some obsessive-compulsive tendencies. But when obsessions and compulsions interfere with daily functioning or cause great distress, a person is diagnosed with OCD.

Posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is described by the DSM-IV-TRas the development of spe-cific symptoms after exposure to an extreme traumatic event that in-volved a personal threat to that per-son or others around him or her.

When we think of PTSD, we often think of the soldier returning

Medications to manage anxiety

Class Benzodiazepines None SSRIs SSNRIs TCAs Beta-blockers Examples Diazepam (Valium), lorazepam (Ativan), chlordiazepoxide (Librium), alprazolam (Xanax) Buspirone (BuSpar) Fluoxetine (Prozac), ser-traline (Zoloft), paroxe-tine (Paxil), fluvoxamine (Luvox) Venlafaxine (Effexor), duloxetine (Cymbalta) Clomipramine (Anafranil), desipramine (Norpramin), imipramine (Tofranil) Propranolol (Inderal), atenolol (Tenormin) Actions

Increase GABA, which is an inhibitory neurotransmitter Not completely understood; may act directly on recep-tors in the limbic system, a part of the brain that deals with emotions

Block the reuptake of sero-tonin, resulting in an increase in available sero-tonin

Block the reuptake of sero-tonin and norepinephrine, resulting in increased levels of serotonin and norepinephrine Inhibit reuptake of norepi-nephrine and serotonin by different mechanisms Block the beta-adrenergic receptors in the sympathetic nervous system, causing a relaxation response

When used

Transient anxiety, acute panic attack Anxiety

All types of anxi-ety disorders, including panic disorders, OCD, PTSD Depression, anxiety disorders Panic disorder, phobic disorder, OCD, PTSD Panic disorder, GAD

Possible adverse effects

Sedation, drowsiness, slowed cog-nition, abuse or dependency, with-drawal symptoms

Nausea, headache, lightheaded-ness; does not seem to produce tol-erance or dependence like benzodi-azepines

Sexual dysfunction, gastrointestinal upset, mild sedation, restlessness (often decrease after 2 to 4 weeks on the medication); discontinuation syndrome; serotonin syndrome Sexual dysfunction, gastrointestinal upset, mild sedation, restlessness (often decrease after 2 to 4 weeks on the medication); discontinuation syndrome; serotonin syndrome Anticholinergic effects such as dry mouth, dry eyes, constipation, weight gain, and sedation; cardiac arrhythmias

from war. The soldier had been exposed to graphic images of people being killed in horrific ways, and when he returns home, he may con-tinue to experience these images through “flashbacks.” Flashbacks may keep the soldier from healthy relationships or productive jobs, and he may experience insomnia or nightmares, emotional numbing, heightened alertness, or increased anxiety.

War isn’t the only trauma that can trigger PTSD. Others include rape, sexual abuse, an airplane crash, or a fire. The survivors of the trauma often express guilt and persistently question their own survival.

PTSD can also occur in children who have experienced a significant trauma, such as incest or seeing a family member murdered.

Let’s stop again and try a few more questions about anxiety disorders.

Self-Test

3. A woman gets on an elevator and begins sweating, having shortness of breath and palpita-tions, and experiences a feeling of doom. These are characteristic of

a. OCD. b. panic attack. c. GAD.

4. A man who constantly washes his hands for fear of becoming dirty is experiencing

a. panic disorder. b. social phobia. c. OCD.

The value of medications

Pharmacologic therapy is an ef-fective method of treating the symptoms of a variety of anxiety disorders. Benzodiazepines, anti-depressants, and beta-blockers are commonly used (see Medications to manage anxiety).

Benzodiazepinesare used to treat transient anxiety symptoms com-monly seen in panic disorder, GAD, and social phobia. They’re especially useful in managing the acute symptoms of panic attacks or acute anxiety. If a woman experi-ences panic attacks when she goes shopping at a mall, for example, she can take diazepam ahead of time to ease her symptoms.

Benzodiazepines have a range of duration, from short- to long-acting. These drugs work by increasing the neurotransmitter GABA. When a benzodiazepine is prescribed for one of your patients, warn him about possible slowed cognition. Tell him not to drink alcohol (alcohol will intensify the central nervous effects), operate heavy machinery, or drive while on benzodiazepines. It’s important to discontinue these med-ications slowly to avoid withdrawal symptoms.

Buspironeisn’t structurally related to the benzodiazepines, but it exerts a similar effect to help reduce anxi-ety. It’s particularly useful in patients with a history of substance abuse or sleep apnea. Buspirone needs 1 to 2 weeks to take effect, and daily dosing is necessary to ensure a therapeutic response.

Selective serotonin reuptake in-hibitors (SSRIs) are often used to treat anxiety because of their effec-tiveness and low adverse effect pro-file. They exert their activity by decreasing the reuptake of serotonin by the presynaptic neuron, resulting in more serotonin being available in the synaptic cleft.

SSRIs are effective in treating all types of anxiety disorders. They may be helpful in the patient with fre-quent panic attacks, and, at high doses, they’re effective in treating the symptoms of OCD or PTSD.

The adverse effects of SSRIs often decrease after 2 to 4 weeks on the

High-affinity GABA receptor

Benzodiazepines facilitate GABA receptor binding

GABA modulin GABA GABA GABA High-affinity GABA receptor GABA GABA GABA benzodiazepine

medication. Switching from one SSRI to another can alleviate persis-tent adverse effects.

SSRIs can interact with other drugs such as warfarin (Coumadin), cardiac medications, and diabetic medications. This can cause one medication level to be too high while the other medication level may be too low. In other words, patients tak-ing warfarin and an SSRI may need to be closely monitored. The war-farin dose may have to be increased or decreased in response to this drug-drug interaction.

You also need to be aware of the potential for discontinuation syn-drome or serotonin synsyn-drome. Gradually discontinuing an SSRI will help to prevent discontinuation syndrome, which causes symptoms like dizziness, headache, diarrhea, insomnia, irritability, nausea, and depression.

Serotonin syndromeis a potentially life-threatening drug interaction that can occur when another medication that increases the serotonin level is given to a patient already taking an SSRI. Signs and symptoms of this syn-drome are high temperature (hyper-thermia), restlessness, tachycardia, labile blood pressure, changes in men-tal status, diaphoresis, and tremors. You need to recognize this syndrome early because it progresses rapidly to seizures, respiratory failure, and coma.

If you suspect a patient is experi-encing serotonin syndrome, immedi-ately discontinue all medications, notify the health care provider, and treat the patient’s symptoms. The health care provider may order med-ications to block the effects of the SSRIs, treat hyperthermia, and man-age seizures.

Selective serotonin norepineph-rine reuptake inhibitors(SSNRIs) work similarly to SSRIs by blocking the reuptake of serotonin and norep-inephrine. This increases the amount

of these neurotransmitters available at the synapse. The adverse effects are similar to those of SSRIs.

Tricyclic antidepressants(TCAs) are effective in treating panic disor-der, PTSD, and phobic disorder. Clomipramine is one of the most effective drugs in relieving symptoms of OCD.

TCAs are older than SSRIs and less expensive, but they have more unpleasant adverse effects. To help lessen discomfort from the anti-cholinergic effects of TCAs, teach your patient to drink plenty of fluids and to increase fruit and fiber con-sumption to prevent constipation. You also need to know that TCAs can cause fatal cardiac dysrhythmias, especially when taken as an overdose by a patient attempting suicide.

Beta-blockerssuch as propranolol are used to treat panic disorder and GAD, as well as PTSD and social anxiety disorder in some cases, although the U.S. Food and Drug Administration has not approved them for those indications. They’re also prescribed to manage hyperten-sion. Because of the possibility of orthostatic hypotension, teach a patient taking these drugs to rise slowly when moving from a sitting to standing position.

Time to take another break and find out how much you’ve learned about anxiety disorders.

Self-Test

5. Benzodiazepines increase the level of

a. GABA.

b. norepinephrine. c. serotonin.

6. Clomipramine, desipramine, and imipramine are examples of

a. SSRIs. b. TCAs. c. beta-blockers.

That’s the last of the questions. You can find out how you did by checking the answers at the end of the article.

Next, let’s look at the role of psy-chotherapy in treating anxiety disor-ders.

Talking the talk

In psychotherapy, or “talk” therapy, a person with an anxiety disorder meets with a professional to talk about issues and feelings. This is vital in the treatment of anxiety disorders. For patients with mild anxiety, psy-chotherapy may be sufficient, but most people do better with a combi-nation of psychotherapy and phar-macologic therapy. Psychodynamic approaches used to treat anxiety dis-orders include cognitive-behavioral therapy, psychodynamic therapy, and group therapy.

Cognitive-behavioral therapyis both clinically effective and cost effec-tive in treating anxiety disorders. Its goal is to change the “automatic thoughts” that occur spontaneously and contribute to dysfunctional think-ing. In this type of therapy, psycho-logical pain is thought to be caused not by what happens to a person, but what the person thinks it means.

A person with an anxiety disorder may have faulty cognitive processes that interpret each event as a cata-strophe. For example, someone expe-riences car trouble on a snowy road. A person with an anxiety disorder starts to think of all the negative things that can occur as a result of the car trouble, such as getting mugged or freezing to death. These thoughts increase anxious feelings. A person who doesn’t have an anxiety disorder views the stressor of car trouble real-istically and plans how to get help. The two different conclusions are influenced by each person’s “auto-matic” thoughts and result in differ-ent emotional responses.

The cognitive-behavioral therapist uses cognitive restructuring to help the person change his or her auto-matic thoughts and, thus, the emo-tional response. The therapist points out the errors of thinking and logic that underlie the anxiety disorder and then uses behavioral therapy to change these dysfunctional cognitive patterns.

Cognitive-behavioral therapists believe that anxiety is a learned response to stressors. If a child grows up with a father with GAD, for example, that child will learn to overreact to stressors. Cognitive-behavioral therapists will help the person unlearn these maladaptive responses to stressors.

One tool cognitive-behavioral therapists use is exposure or desen-sitization therapy. This form of cognitive-behavioral therapy uses relaxation techniques to help a per-son systematically tolerate small increments of exposure to anxiety-producing situations. For example, let’s return to the woman we dis-cussed earlier who was afraid to fly. The therapist would first teach her relaxation techniques such as deep breathing and progressive muscle stretching. Next, the therapist would ask the woman to talk about flying on an airplane. After that, the woman might be asked to watch pos-itive movies about flying. Trips to

the airport, getting on a plane, and finally flying a short distance may be the next steps. The woman would use her relaxation techniques to help her cope with each situation.

Psychodynamic therapylinks anxi-ety to trauma or conflicts that hap-pened in childhood. For example, a man with PTSD who was abused as a child doesn’t feel good about him-self as an adult. The therapist helps the man make the link between the past abuse and the current feeling.

Exploring how the anxiety disor-der affects different parts of a per-son’s life is also important in this type of therapy.

Group therapyprovides the opportunity for a person with an anxiety disorder to meet with others who are experiencing the same prob-lem. Being able to share feelings with others—and knowing that others have similar feelings—helps the per-son heal. Group members may have suggestions for how to cope with everyday events or relationships.

When a patient is being treated for an anxiety disorder, whether with psychotherapy or pharmacologic therapy, it’s important for you to provide emotional support. See

Nursing care points for ideas on how you can help.

Mind-body connection

As nurses, we understand the connec-tion between the mind and the body, and that puts us in an ideal position to help patients who have anxiety dis-orders. Through our holistic ap-proach to care, we can work effec-tively to ease patients’ anxiety and help them live rewarding lives. LPN

Selected references

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), 4th edition, text revision. Washington, DC, American Psychiatric Association, 2000. Antai-Otong D. Anxiety disorders: Helping your

patient conquer her fears. Nursing2003.

33(12):36-41, December 2003.

Kaiman C. PTSD in the aging World War II

combat veteran. AJN, American Journal of Nursing.

103(11):32-40. November 2003.

McIntosh A, et al. Clinical guidelines for the management of anxiety. Management of anxiety panic disorder, with or without agoraphobia, and generalised anxiety disorder in adults in primary, secondary and community care. December 2004. http://www.guidelines.gov/summary/summary. aspx?doc_id=6248&nbr=004008&string=anxiety. Accessed December 1, 2006.

Murphy K. Anxiety: When is it too much?

Nurs-ing made Incredibly Easy!3(5):22-23, 25-31, 33,

September/October 2005.

National Institute of Mental Health. Anxiety disorders. http://www.nimh.nih.gov/health information/anxietymenu.cfm. Accessed Decem-ber 1, 2006.

Tefera L, et al. Anxiety. http://www.emedicine. com/EMERG/topic35.htm. Accessed December 1, 2006.

Self-Test Answers

On the Web

Anxiety Disorders Association of America:http://www.adaa.org

Anxiety Network: http://www.anxietynetwork.com National Center for PTSD: http://www.ncptsd.va.gov

Obsessive-Compulsive Foundation: http://www.ocfoundation.org PsychCentral: http://psychcentral.com

PTSD Alliance:http://www.ptsdalliance.org

1-true, 2-false, 3-b, 4-c, 5-a, 6-b

Nursing care points

•Explain the condition to the patient and family. Remind them that the patient doesn’t have control over his symptoms. Part of the treatment for an anxiety disorder will be to learn how to control the anxiety.

•Help the patient identify early signs of anxiety so he can take appropriate actions, such as breathing exercises.

•Teach the patient about medications, including how they work and their adverse effects.

•Help the patient manage any rituals associated with OCD. For example, he may need to establish a set time limit to perform the ritual until therapy or medication can help him eliminate the need for the ritual.

•Teach the patient to avoid any substance that increases anxiety, such as caffeine, nicotine, and alcohol.