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NR 507 Edapt Week 5 Anxiety Disorders
Introduction to Anxiety
Disorders
Anxiety is the most common mental disorder in the United States, affecting 19.1% or 40 million adults over the age of 18 (Anxiety & Depression Association of America [ADAA], 2022). Anxiety occurs when the amygdala senses trouble. This “trouble” appears as a real or imagined threat, activating neurotransmitters, flooding the body with stress hormones, and activating the fight-or-flight response. While a state of arousal is normal in the presence of a perceived threat, when symptoms of anxiety persist in the absence of threatening stimuli or become overwhelming to the point of impacting an individual's daily functioning, an anxiety disorder may develop. The Diagnostic and Statistical Manual for Mental Health (DSM-5-TR) is the authoritative publication on mental health disorders (American Psychiatric Association [APA], 2022). This manual outlines the criteria that must be present for each mental health disorder to be diagnosed. The PDR is a manual that provides information on medications. The ICD-10 is a series of codes for classifying conditions and billing insurance. The Nursing Diagnosis Handbook contains diagnoses not specific to mental health issues. Adrenaline is a neurotransmitter involved in the fight-or-flight response. Stress triggers adrenaline release, which leads to clinical manifestations associated with anxiety. Corticotropin-releasing hormone release contributes to anxiety but not fight or flight response. Cortisol is a stress hormone, and glutamate is released during exercise, excitement, and sex, producing euphoric effects.
Complete the following sentence by choosing from the list of options. Gamma-aminobutyric acid is the major inhibitory neurotransmitter that helps regulate dopamine levels. Gamma-aminobutyric acid (GABA) is the major inhibitory neurotransmitter in the brain that helps regulate dopamine levels (not cortisol or glutamate). Alterations can lead to stress and anxiety. Adrenaline and acetylcholine are excitatory neurotransmitters, not inhibitory. Neurotransmitters Adrenaline – fight or flight – produced in stressful situations. Increases heart rate and blood flow, leading to physical boost and heightened awareness. Noradrenaline – concentration – affects attention and responding actions in the brain. Contracts blood vessels, increasing blood flow. Dopamine – pleasure – feelings of pleasure, also addiction, movement and motivation. People repeat behaviors that lead to dopamine release. Serotonin – mood – contributes to well-being and happiness. Helps sleep cycle and digestive system regulation. Affected by exercise and light exposure.
When alterations affect GABA, serotonin also acts as an inhibitory neurotransmitter (found in the raphe nuclei). Alterations in serotonin will affect the serotonin-reuptake transporter and the post-synaptic serotonin receptors. This alteration results in the client experiencing an increased sensitivity to stress, leading to anxiety. Reductions of glutamate activity in the hippocampus can also contribute to increased stress and anxiety. Glutamate regulation is important for memory, cognition, and mood regulation. The role of gamma-aminobutyric acid (GABA) is central to the regulation of anxiety (not bipolar or depression), and this neurotransmitter is the target of benzodiazepine (not antidepressant or mood stabilizer) medication therapy used to treat anxiety disorders. Drugs that modulate GABA receptors include benzodiazepines, barbiturates, neuroactive steroids, intravenous and inhalational anesthetics, and ethanol.
Types of Anxiety Disorders
There are various types of anxiety disorders, including the following:
- Generalized anxiety disorder : Generalized anxiety disorder (GAD) is characterized by increased, persistent, unreasonable anxiety about everyday situations involving money, work, family, and relationships. Normal day-to-day activities can provoke anxiety.
- Social anxiety disorder : Social anxiety disorder (SAD) involves the fear of being negatively judged by others, affecting an individual’s ability to perform daily activities. Fear of judgment may prevent the person from attending certain events or participating in social activities.
- Panic Disorder : Panic disorder is characterized by a “panic attack” in which an individual experiences stress and intense fear that something bad will happen. An imminent threat or danger is also perceived. These feelings are often accompanied by physiological symptoms such as heart palpitations, dizziness, or shortness of breath. The symptoms typically peak within the first ten to twenty minutes, but some may last for hours. The individual will sometimes describe the feeling of having a heart attack or some other life-threatening illness. A panic attack can be unpredictable because clients can experience it in familiar places where there are no real threats. This can further increase anxiety as the individual begins to anticipate when the next panic attack might happen. Panic disorder occurs when a person experiences repeated panic attacks, usually accompanied by fears about future attacks. The DSM-5-TR (American Psychiatric Association [APA], 2022) characterizes a panic attack as an abrupt onset of 4 of 13 symptoms: pounding heart or fast heart rate, chest pain or discomfort, sweating, trembling, shortness of breath, nausea, dizziness, chills, numbness, feels like “choking,” detached feelings of oneself, fear of losing control, or fear of death. Some of the symptoms may happen together, making it difficult to analyze. For example, it would be unusual for a client who is sweaty, feeling dizzy, and having chills not to tremble. Some symptoms include physical manifestations, while others include thoughts and ideas. Symptoms of Panic Attacks
- Palpitations, pounding heart, or accelerated heart rate
- Trembling or shaking
- Paresthesia (numbness or tingling sensations)
- Sensations of shortness of breath or smothering
- Derealization (feelings of unreality) or depersonalization (feeling detached from oneself)
- Feelings of choking
- Chest pain or discomfort
Anxiety is only an indicator of an underlying
mental health disorder when feelings become
excessive, consume one’s thoughts, and interfere
with activities of daily living.
Management of Care
Before establishing a diagnosis and treatment plan, the nurse practitioner (NP) must consider the situational threat, clinical manifestations, risk factors, differential diagnoses, and DSM-5-TR diagnostic criteria (American Psychiatric Association [APA], 2022). Comorbid conditions must also be considered. Anxiety is often comorbid with major depression as well as medical conditions such as chronic pulmonary obstructive disease (COPD), asthma, and diabetes. Individuals with anxiety are also at higher risk for alcoholism and substance abuse compared to the general population (Cackovic et al., 2023).
Anxiety Disorder Risk Factors
Various risk factors are known to predispose a client to an anxiety disorder. Symptoms of anxiety often start during childhood or adolescence (World Health Organization [WHO], 2023). Risk factors may include the following:
- genetics and family history
- history of trauma, such as acts of violence, war, abuse/assault, neglect, or abandonment
- adverse childhood experiences (ACEs)
- financial, work-related, or family issues
- history of mental illness
- history of self-harm, such as self-mutilation (e.g., cutting)
- hormonal imbalance
- excessive threats, perceived or actual
- substance abuse/misuse
- loneliness
- personality traits, such as shyness, oversensitivity, or moral rigidness
- physical illness – feelings of anxiety are sometimes the first signs of an underlying issue
- traumatic brain injuries (TBIs)
- gender – biological women are more likely, for reasons unknown
Special Consideration: Often, the first challenge in assessing anxiety in older adults is that they have trouble relating to the idea of being anxious. Some older adults find various ways to cope with unresolved anxiety in healthy ways, such as getting help, examining the roots of anxieties, and working to resolve them. Others are less equipped to do so and deny their anxiety or distract themselves with means that do not really reduce anxiety. Clinical manifestations arise from increased autonomic activity, including an increased heart rate, blood pressure, and respiration. Clients may also develop a heightened state of awareness. When fear and anxiety become overwhelming and impact the client’s daily activities, thoughts, and emotions, anxiety disorders can develop. Psychological clinical manifestations can also predispose clients to physical symptoms as well, such as digestive problems (overeating or undereating), muscle aches due to tension soreness, and difficulty sleeping. Lack of sleep can also significantly impact the individual’s health and well-being, leading to chronic fatigue. Symptoms of anxiety include fatigue, irritability, muscle tension, trouble concentrating, trouble sleeping, restlessness, nightmares, frequent urination, upset stomach, poor performance at school, and fidgeting.
Anxiety Disorder Clinical
Manifestations
Anxiety Differential Diagnosis Medication side effects
- Levodopa
- MAOIs
- Tricyclic antidepressants
- Thyroid hormones
- Caffeine
- Sympathomimetics Substance use/misuse
- Alcohol
- Illicit drugs Cognitive or psychiatric disorders
- Alzheimer's disease
- Parkinson disease
- Major depressive disorder Medical illnesses
- Hyperthyroidism
- Angina
- Dysrhythmia
- Anemia
Nonpharmacological
Treatment for Anxiety
Anxiety Disorder Treatment
Clients with anxiety disorders are three to five times more likely to see a healthcare provider and six times more likely to be hospitalized for a psychiatric disorder compared to others without an anxiety disorder (Anxiety & Depression Association of America [ADAA], 2022). Anxiety is a treatable diagnosis and may include various treatment modalities, including the following:
- Psychotherapy – This includes cognitive behavioral therapy (CBT) and psychoanalysis. These types of therapy aid individuals in thinking and acting differently when reacting to stressful situations.
- Medications – Benzodiazepines (psychoactive drugs) provide a calming effect. Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin- norepinephrine reuptake inhibitors (SNRIs), help regulate serotonin levels in the brain to help elevate mood. Monoamine oxidase inhibitors (MAOIs) should only be considered if the client can adhere to the medication regimen , follow dietary restrictions, and discontinue the use of antidepressants. Although CBT and medications demonstrate similar short-term effectiveness, CBT and other forms of psychotherapy have significant long-term advantages. Psychotropic medications may also have unwanted adverse effects that include tolerance, dependence, and withdrawal symptoms.
Psychodynamic Continuum
Supportive therapy is focused on stabilization through anxiety reduction, defense stabilization, and improved problem solving. The psychotherapist may choose therapeutic techniques from anywhere on the continuum as the client needs change. Psychoanalysis is directed at interpreting unconscious conflict and gaining insight.
The client’s fear of judgment by others interferes with her relationship with her fiancé and future in- laws. She also has persistent avoidance of social situations and became paralyzed with fear on the cusp of meeting her fiancé's parents. Chrystyn is experiencing anxiety and emotional distress related to specific social situations. She does not report psychological trauma or an underlying medical condition per history. Before establishing a diagnosis and treatment plan, the NP must consider the situational threat, clinical manifestations, risk factors, differential diagnoses, and DSM-5-TR diagnostic criteria (American Psychiatric Association [APA], 2022). The NP should also inquire about the length of time of emotional distress or any disruption of the normal routine as part of establishing diagnostic criteria for an anxiety disorder. Medication adherence is not relevant at this time.
Social anxiety disorder (SAD) involves the fear of being negatively judged by others, which affects a client’s ability to perform routine activities. Fear of judgment may prevent the client from attending certain events or participating in other social activities. Treatment options for this disorder include psychotherapy (most commonly used is cognitive behavioral therapy [CBT]), medications, or both. Benzodiazepines, such as lorazepam, provide a calming effect. Antidepressants, such as sertraline, help regulate serotonin levels in the brain to help elevate mood. Nonpharmacological recommendations, such as relaxation techniques, are also considered. Crisis intervention or hospital admission is unnecessary as this is not an acute event warranting life- saving interventions. An NP providing primary care for a client with a new mental health concern should consult and collaborate with a mental health provider, such as a mental health NP or psychiatrist. Specialists in mental health have the knowledge, skills, and expertise to initiate the plan of care, including providing treatment options. Educating the client’s future in-laws or family is not the highest priority. The client would need to be educated on their new diagnosis. Prescribing treatment is not the priority before consulting a specialist.
It is most important to communicate therapeutically, encouraging the client to express their feelings and discuss concerns. Once the nurse practitioner (NP) hears the client’s feedback, follow-up questions can be asked, and teaching can be implemented to help alleviate the client’s concerns. Administering antianxiety medications is not an immediate intervention.
