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Mild

A person's ability to perceive reality is brought into sharp focus. A person sees, hears, and grasps more information, and problem solving becomes more effective. A person with mild anxiety is usually able to work effectively towards a goal and examine alternatives. They can identify issues that are disturbing and producing anxiety. Physical symptoms such as restlessness, mild irritability, or mild tension-relieving behaviors such as nail biting and finger tapping may be present.

Moderate

As anxiety escalates, the patient's perceptual field narrows, leading to selective inattention. The ability to think clearly is somewhat hampered, but learning and problem solving can still take place, though they may benefit from the guidance of others. Physical symptoms may include tension, pounding heart, increased pulse and respiration, and other mild somatic symptoms. Voice tremors may be noticed. Mild to moderate anxiety levels can be viewed as a signal that something in the person's life needs attention.

Severe

The perceptual field of a person experiencing severe anxiety is greatly reduced. A person with severe anxiety may become overly focused on one particular detail or may attend to superficial, scattered details. The person may have difficulty noticing events occurring in the environment, even when they are pointed out. Learning and problem solving are significantly affected at this level. Behavior tends to be automatic and aimed at reducing or relieving the anxiety. Often the individual complains of increased severity of somatic symptoms. The most classic experiences are hyperventilation and a sense of dread or impending doom.

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*Impaired social interaction related to anxiety in social situations, as evidenced by staying away from others, minimal conversation, and discomfort around people.

*Impaired Decision-Making related to overwhelming anxiety

as evidenced by Indecisiveness, Inability to problem-solve

* Ineffective Breathing Pattern related to panic/anxiety

as evidenced by Hyperventilation, Shortness of breath, and

Chest tightness

*Insomnia related to anxiety, excessive worry

as evidenced by Difficulty falling/staying asleep,

Reports of fatigue and Restlessness at night

*Impaired Social Interaction related to anxiety in social settings as evidenced by Avoidance of others,

Difficulty communicating, and Isolation

* Helplessness related to the perceived lack of control over a situation. As evidence by Lack of participation in care, Pt will state "Nothing I do matters"

*Disturbed Thought Processes related to severe anxiety or panic as evidenced by Inability to focus or make decisions,

Disorganized thinking, and Racing thoughts

* Ineffective Coping related to inability to manage stressors

as evidenced by Crying, withdrawal

Substance use or maladaptive behaviors, and

Verbalization of inability to cope

*Anxiety Related to Stressors (hospitalization, illness, environment),Threat to self-concept or health status, and Unfamiliar situations As evidenced by (AEB):Restlessness, nervousness, Increased HR, BP, RR,Verbalization of worry or fear and Difficulty concentrating

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Selective Serotonin norepinephrine reuptake inhibitors (SNRIs): blocks the reuptake of serotonin and norepinephrine, which increases the levels in the brain

duloxetine

venlafaxine

selective serotonin reuptake inhibitors (SSRIs): blocks the reuptake of serotonin which increases the levels in the brain.

citalopram

escitalopram

fluoxetine

fluoxetine

paroxetine

sertraline

treatment for generalized anxiety, panic, agoraphobia, and social anxiety.

Potential side effects: jitteriness, nausea, restlessness, headache, fatigue, changes in appetite, changes in weight, tremors, sweating, QTC prolongation, sexual dysfunction, diarrhea, constipation, hyponatremia, serotonin syndrome

Non-benzodiazepine Anxiolytic- Mechanism of action: Binds to serotonin and dopamine receptors.

* Example: Buspirone

* delayed onset (3 weeks +), reduces symptoms of GAD, less sedating than benzodiazepines, no physiological or psychological dependence. Potential side effects: dizziness, nausea, headache, nervousness, insomnia, light-headedness, and excitability

Tricyclic Antidepressants (TCA): MoA blocks reuptake of serotonin/norepinephrine, intensify effects of neurotransmitters.

* EX: Clomipramine, Desipramine, Doxepin, imipramine, nortriptyline

* Side effects: anticholinergic, somnolence, dizzy, cardiovascular effects, weight gain, nausea, headaches, sexual dysfunction.

Benzodiazepines are CNS depressants that increase neurotransmitter activity and indicated for short term use only. They enhance the action of GABA and slow neuronal transmission.

* Over time medication tolerance can develops, with a high risk for addiction or dependency, sudden discontinuation of the medication can cause withdrawal symptoms.

Benzodiazepines has a common side effect of sedation, which increases fall risks. Avoid alcohol, opioids, or other CNS depressants because the sedation effect can be compounded and be fatal.

Avoid caffeine and antacids which can decrease the desired effect of the drug. Benzodiazepines increase the risk of congenital anomalies, especially in the first trimester. Educate patient to take the medication with meals to reduce GI discomfort.

alprazolam, oxazepam, triazolam, lorazepam, diazepam, clonazepam, chlordiazepoxide

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Physical cues

These are things you can physically notice in the body. This includes trouble sleeping from constant worry, skin damage from picking or excessive washing, and spending so much time on rituals that normal daily routines get disrupted.

Emotional cues

These are the feelings the person is experiencing. They may feel anxious, scared, overwhelmed, or constantly uneasy. They might also feel hopeless, powerless, or have low self-esteem and feel bad about themselves.

Cognitive cues

These relate to how the person is thinking. They may have trouble concentrating, experience intrusive or obsessive thoughts, think negatively, or constantly worry that something bad will happen. They might also have distorted thoughts about their body or situation.

Behavioral cues

These are actions you can observe. The person may avoid certain places or situations, repeat behaviors or rituals, withdraw from others, struggle with work or relationships, or neglect self-care because of their compulsions.

Subjective cues

These are what the person says about their experience. They might report feeling anxious or out of control, describe intrusive thoughts or fears, express hopelessness or low self-worth, or say that their thoughts and behaviors are taking over their life.

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Table 11.5 - Page 148

* Cognitive-Behavioral Therapy (CBT)

- Focuses on identifying, challenging, and neutralizing unhelpful thoughts

* Acceptance and Commitment Therapy

- Combines behavioral and cognitive-behavioral techniques

Accept problematic emotions, then commit to making changes in behavior; considered an adjunct to other forms of therapy. Helps people calm their emotions and may enhance the effects of therapy

* Relaxation Techniques

- Deep breathing

- Guided imagery

- Progressive relaxation

- Autogenic training

- Self-hypnosis

- Meditation

- Aerobic exercise

* Biofeedback

- Uses a device that provides feedback on physiology, measuring things such as blood pressure, mug

tension, and brain wave activity

* Mindfulness-Based Stress Reduction (MBSR)

- Detach from anxious thoughts through awareness. identifying tension, understanding thinking patterns and learning how to deal with difficult emotions

*Aversion Techniques

- Undesirable behavior is associated with unpleasant stimulus

* Flooding

- Prolonged exposure to fear or threat

*Systematic Desensitization (sometimes called Exposure

Therapy)

- Gradually exposes a person to a feared object or situation until free of incapacitating anxiety

* Exposure and Response Prevention

- Evidence-based for phobias, OCD, and anxiety. Desensitizes people to their fears by repeatedly facing fears and learning to manage uncomfortable thoughts and emotions

Additional Actions:

Encourage problem-solving

Encourage learning and discussion

Help the patient identify sources of stress

Promote coping strategies

Use short, simple directions

Help the patient focus on one task

Reduce environmental stimuli

Encourage deep breathing or relaxation techniques

Stay calm and supportive