Definition of Anxiety

Anxiety disorder refers to a group of conditions in which the affected person experiences persistent anxiety that he or she cannot dismiss and that interferes with his or her daily activities.

Historical Aspect
Anxiety was not clearly defined or isolated as a separate entity by psychiatrists or psychologists until the 19th and 20th centuries. Anxiety was first recognized as a medical diagnostic entity in the late 1800s Anxiety was once identified solely by its physiological symptoms, focusing largely on the cardiovascular system

Historical Aspect
A myriad of diagnostic terms were used in attempts to identify these symptoms. For example, cardiac neurosis, DaCostas syndrome, irritable heart, nervous tachycardia, neurocirculatory asthenia, soldiers heart, vasomotor neurosis, and vasoregulatory asthenia In 1871, Jacob DaCosta described a chronic cardiac syndrome with no apparent organic cause

Historical Aspect
In the early 1900s, Sigmund Freud recognized anxiety as a central component of mental diseases, and coined term "anxiety neurosis"

Epidemiological Statistics
Common of all psychiatric illnesses more common in women than in men, in a ratio of at least 2 to 1 Prevalence rates for anxiety disorders within the general population is - 4 to 6 percent for GAD and panic disorder, 2 to 3% for OCD, 8% for PTSD, 13 % for social anxiety disorder, and 22% for phobias

Epidemiological Statistics
Prevalence of anxiety disorders in children 2 percent to 43 percent More prevalent among girls children in minority groups and children from low socioeconomic environments may be at greater risk

How much is too much

Anxiety can be considered abnormal or pathological if: It is out of proportion to the situation that is creating it. The anxiety interferes with social, occupational, or other important areas of functioning.

Causes of anxiety disorders

Traumatic experience Anxiety is a signal to the ego to take defensive action against the 'pressure' from within (Psychoanalytic theory) Stimulation of autonomic nervous system and central nervous system Genetic component

Causes of anxiety disorders

Socio-cultural factors Psychological factors Behavioral Factor : Unconditional inherent response of the organism to painful stimuli Cognitive Factor Medications and substances which can induce anxiety

Causes of anxiety disorders

Biological Theories Nor epinephrine (NE) Human studies have found that , in patients with panic disorders, adrenergic agonists (eg.Isoproterenol) and 2 adrenergic antagonists can produce frequent and severe panic attacks.

Classification of anxiety disorders

ICD-10 CLASSIFICATION F40-F48 Neurotic, stress-related and somatoform disorders F40 Phobic anxiety disorders F41 Other anxiety disorders - F41.0 Panic disorder [episodic paroxysmal anxiety] - F41.1 Generalized anxiety disorder

Classification of anxiety disorders

- F41.2 Mixed anxiety and depressive disorder - F41.3 Other mixed anxiety disorders - F41.8 Other specified anxiety disorders - F41.9 Anxiety disorder, unspecified F42 Obsessive - compulsive disorder F43 Reaction to severe stress, and adjustment disorders F44 Dissociative [conversion] disorders

Classification of anxiety disorders

F45 Somatoform disorders F48 Other neurotic disorders

Classification of anxiety disorders

DSM IV CLASSIFICATION Anxiety Disorders 300.01 Panic disorder without Agoraphobia 300.21 Panic disorder with Agoraphobia 300.22 Agoraphobia without history of Panic disorder. 300.29 Specific Phobia Specify type

Classification of anxiety disorders

300.23 Social Phobia Specify if : Generalized 300.3 Obsessive-compulsive disorder Specify if : with poor insight 309.81 Post Traumatic stress disorder Specify if : acute / chronic Specify if : with delayed onset

Classification of anxiety disorders

308.3 Acute stress disorder 300.02 Generalized Anxiety Disorder 293.84 Anxiety disorder due to......... [indicate the general medical condition] Specify if : with generalized anxiety / with panic attacks /with obsessive compulsive symptoms ----- Substance induced anxiety disorder 300.00 Anxiety Disorder NOS

Types of Anxiety Disorders

Panic Disorder Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder Phobias Generalized Anxiety Disorder Acute stress disorder

GENERALIZED ANXIETY DISORDER

Generalized Anxiety Disorder

Excessive and pervasive worry,accompanied by a variety of somatic symptoms that causes significant impairment in social or occupational functioning or marked distress in the patient. ------ DSM- IV

Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) is characterized by excessive anxiety or worrying about numerous things that lasts for 6 months or longer ---- (APA 2000)

Epidemiology

The lifetime prevalence of GAD is 4.1 to 6.6 percent Incidence Rate of Generalized anxiety disorder: approx 1 in 35 or 2.80% or 7.6 million people in USA The usual age of onset is variable from childhood to late adulthood, with the median age of onset being approximately 31

Onset and Course

Patients with GAD often present with a lifelong history of generalized anxiety. In the National Comorbidity Survey (NCS), the lowest prevalence of GAD occurred in the 15- to 24-year age group

Comorbidity
In the NCS, 82% of persons with GAD reported that their problem was associated with significant impairment, as indexed by past treatment-seeking behavior or substantial lifestyle interference. Research has routinely shown that GAD rarely presents in isolation.

Comorbidity
Community surveys indicate that 90% of persons with GAD have a history of some other mental disorder at some point in their lives Studies of clinical samples have found that over 75% of patients with a current principal diagnosis of GAD have other co-occurring anxiety or mood disorders. Epidemiological data from the NCS suggest

Comorbidity
In studies of patient samples, panic disorder, mood disorders (major depression, dysthymia), social phobia, and specific (formerly simple) phobia are typically found to be the most common additional diagnoses. Some studies indicate that GAD is the most common comorbid diagnosis in patients seeking treatment for another anxiety or mood disorder.

Comorbidity
Relative to other anxiety and mood disorders, GAD may be the most commonly occurring disorder in persons presenting for treatment of physical conditions associated with stress (e.g., irritable bowel syndrome, chronic headaches).

Predisposing factors for GAD

a) Psychodynamic theory b) Cognitive Theory c) Biological Aspects Genetics Neuroanatomical Biochemical

Predisposing factors for GAD

Brain chemistry - GABA-benzodiazepines - Serotonin - Neuropeptides

Predisposing factors for GAD

Medical Conditions and Drugs That May Cause Anxiety Endocrine Disorders - Addisons disease - Cushings syndrome - Hyperparathyroidism - Hyperthyroidism - Hypothyroidism - Carcinoid

Cardiovascular and Circulatory Disorders - Anemia - Congestive heart failure - Coronary insufficiency - Dysrhythmia - Hypovolemia - Myocardial infarction

Drug Intoxication - Anticonvulsants - Antidepressants - Antihistamines - Antihypertensive agents - Antiinflammatory agents - Antiparkinsonian agents - Caffeine - Digitalis

Substance Use Related - Cocaine - Hallucinogens - Amphetamines Withdrawal Syndromes - Alcohol - Narcotics - Sedative - hypnotics

Gastrointestinal Disorders Peptic ulcer disease Infectious Diseases Miscellaneous viral and bacterial infections

Respiratory Disorders - Asthma - Chronic obstructive - pulmonary disease - Pulmonary embolism - Pulmonary edema

Immunological, Collagen and Vascular Disorders - Systemic lupus erythematosus - Temporal arteritis Metabolic Conditions - Acidosis - Acute intermittent porphyria - Electrolyte abnormalities

Neurological Disorders - Brain tumors - Cerebral syphilis - Cerebrovascular disorders - Encephalopathies - Epilepsy (especially temporal lobe epilepsy) - Postconcussive syndrome - Vertigo - Akathisia

 Environmental factors

Transactional model of Stress / Adaptation

Transactional model of Stress / Adaptation

Symptoms

Diagnosis
DSM IV The symptoms must have occurred more days than not for atleast 6 months and must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Excessive anxiety and worry (apprehensive expectation), occurring more-days-than-not for at least 6 months, about a number of events or

 The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more-days-than-not for the past 6 months). 1. restlessness or feeling keyed up or on edge 2. being easily fatigued 3. difficulty concentrating or mind going blank 4. irritability 5. muscle tension 6. sleep disturbance (difficulty falling or staying

 The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism), and does not occur exclusively during a mood disorder, psychotic disorder, or a pervasive developmental disorder.

ICD 10 Complaints of continuous feelings of nervousness, trembling, muscular tension, sweating, light headedness, palpitations, dizziness, and epigastric discomfort are common. Fears that the sufferer or a relative will shortly become ill or have an accident are often expressed, together with a variety of

 The sufferer must have primary symptoms of anxiety most days for at least several weeks at a time, and usually for several months. These symptoms should usually involve elements of: a) apprehension (worries about future misfortunes, feeling "on edge", difficulty in concentrating, etc.)

 (b)motor tension (restless fidgeting, tension headaches, trembling, inability to relax); and (c)autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnoea, epigastric discomfort, dizziness, dry mouth, etc.).

 In children, frequent need for reassurance and recurrent somatic complaints may be prominent. The transient appearance (for a few days at a time) of other symptoms, particularly depression, does not rule out generalized anxiety disorder as a main diagnosis, but the sufferer must not meet the full criteria for depressive episode (F32.-), phobic

Differential Diagnosis

Treatment Modalities
Individual Psychotherapy

Treatment Modalities
Cognitive therapy

Treatment Modalities
Behavior Therapy - Systematic Desensitization - Implosion Therapy (Flooding)

Treatment Modalities
Psychopharmacology - Anxiolytics - Antidepressants - Antihypertensive Agents - Other Agents

DRUG
Selective serotonin reuptake inhibitors

DAILY DOSAGE RANGE (mg)

Paroxetine Fluoxetine Sertraline Citalopram Fluvoxamine

2040 2060 50200 2040 100300

DRUG

DAILY DOSAGE RANGE (mg)

Serotonergic and noradrenergic reuptake inhibitors Venlafaxine extended release (XR)

75 - 225

DRUG

DAILY DOSAGE RANGE (mg)

Benzodiazepines Alprazolam Clonazepam Lorazepam Diazepam

2-6 1-3 4-10 15-20

DRUG

DAILY DOSAGE RANGE (mg)

Tricyclic Antidepressants Imipramine 75-300

DRUG

DAILY DOSAGE RANGE (mg)

Atypical antidepressants Trazodone 150 - 600

DRUG

DAILY DOSAGE RANGE (mg)

Azapirones Buspirones 30-60

DRUG

DAILY DOSAGE RANGE (mg)

Azapirones Buspirones 30-60

NURSING MANAGEMENT
ASSESSMENT

Nursing Diagnosis

Anxiety related to real or perceived threat to biological integrity or self concept as evidenced by various physical and psychological manifestations. Powerlessness related to impaired cognition as evidenced by verbal expressions of lack of control over life situations and non participation in decision making related to own care or significant life issues.

Ineffective role performance related to poor concentration, worrying thoughts and apprehension as evidenced by inability to fulfill usual patterns of responsibility. Ineffective individual coping related to persistent anxiety, fatigue, and difficulty in concentrating as evidenced by irrational thoughts and fear.

Alternative Treatments
Acupuncture Aromatherapy Breathing Exercises Exercise Meditation Nutrition and Diet Therapy Vitamins Self Love

Acupuncture
Caused by the imbalance of chi coming about by keeping emotions in for too long Emotion effects the chi to move in an abnormal way: when fearful it goes to the floor, when angry the neck and shoulders tighten Redirects the chi into a balanced flow, releases tension in the muscles, increases flow of blood, lymph, and nerve impulses to affected areas Takes 10-12 weekly sessions

Aromatherapy
Calming Effect: vanilla, orange blossom, rose, chamomile, and lavender Reducing Stress: Lavender, sandalwood, and nutmeg Uplifting Oils: Bergamot, geranium, juniper, and lavender Essential Oil Combination: 3 parts lavender, 2 parts bergamot, and 1 part sandalwood

Exercise
Benefits: symbolic meaning of the activity, the distraction from worries, mastery of a sport, effects on self image, biochemical and physiological changes associated with exercise, symbolic meaning of the sport Helps by expelling negative emotions and adrenaline out of your body in order to enter a more relaxed, calm state to deal with issues and conflicts

Meditation
Cultivates calmness to create a sense of control over life Practice: Sit quietly in a position comfortable to you and take a few deep breaths to relax your muscles, next choose a calming phrase (such as om or that with great significance to you), silently repeat the word or phrase for 20 minutes

Nutrition and Diet Therapy

Foods to Eat: whole grains, bananas, asparagus, garlic, brown rice, green and leafy veggies, soy products, yogurt Foods to Avoid: coffee, alcohol, sugar, strong spices, highly acidic foods, foods with white flour Keep a diary of the foods you eat and your anxiety attacks; after awhile you may be able to see a correlation East small, frequent meals

Vitamins
B-Vitamins stabilize the bodys lactate levels which cause anxiety attacks (B-6, B-1, B-3) Calcium (a natural tranquilizer) and magnesium relax the nervous system; taken in combination before bed improves sleep Vitamin C taken in large doses also has a tranquilizing effect Potassium helps with proper functioning of adrenal glands Zinc has a calming effect on the nervous system

Self Love
The most important holistic treatment of all Laugh: be able to laugh at yourself and with others; increases endorphin levels and decreases stress hormones Let go of frustrations Do not judge self harshly: dont expect more from yourself than you do others Accept your faults