Anxiety Flashcards
what is anxiety
apprehension, uneasiness, uncertainty, or dread from real or perceived threats
what is fear
reaction to specific danger
what is normal anxiety necessary for?
survival
mild anxiety
adaptive
can provide motivation
ex: studying night before for exam, waiting until the last minute to do anything)
signs/symptoms- irritability, restlessness, seeking attention, reassurance
moderate anxiety
narrowed perceptual field
doesn’t see everything around only focused on anxiety
alertness and communication are intensified, focused
everything else is blocked out except what caused anxiety
able to follow directions but so focused they may not hear you speaking to them the first time
severe anxiety
perceptual field blocked, distorted
extremely hyperactive
panic anxiety
profound fear, terror, urge to fight or flee
never leave client alone at risk for self harm
interventions for mild to moderate anxiety
reduce clients anxiety level
calm presence
recognize distress
listen
explore behaviors that alleviate anxiety
evaluate past coping skills
temporarily relieve anxiety
help client identify anxiety
anticipate anxiety provoking situations
nonverbal communication
talk about feelings/concerns
clarify what is being said
problem solving
develop alternate solutions
** interfere with moderate so avoid escalation to panic
severe to panic interventions
safety
remain with individual
calm manner, use clear, simple statements, repeat if necessary
low-pitched voice and speak slowly
quiet environment with minimal stimulation
reinforce reality
need for medication
assess for suicide risk
defenses against anxiety
coping styles
protect people from anxiety
maintain self-image by blocking feelings, conflicts, memories
can be healthy or unhealthy
types of defense mechanisms
compensation
conversion
denial
displacement
dissociation
identification
intellectualization
projection
rationalization
reaction formation
regression
repression
splitting
sublimation
suppression
undoing
adaptive responses to anxiety
problem-solving
talking
crying
sleeping
exercising
deep breathing
imagery
relaxation
maladaptive responses to anxiety
obsessive-compulsive behaviors
aggressive acting-out
withdraw
excessive eating, drinking, spending, gambling, drug use, sexual activity
blaming
negative self-talk
basic principles of anxiety disorders
strong genetic predisposition
symptoms being in childhood (6 yrs) and early adulthood
recognizes thoughts/behaviors are irrational and emotion is an over reaction
behaviors are used to reduce/ manage/ experience of overwhelming anxiety
allow continuation of behavior until other strategies are in place to manage anxiety
Generalized Anxiety Disorder (GAD)
chronic condition
anxiety for more than 6 months
excessive uncontrolled unrealistic worry
muscle tension, autonomic hyperactivity, startle, difficulty concentrating
excessive worry about every day life, events, or conflict
cant relax and startle easy
clinical course of GAD
interferes with daily life and relationships
insidious onset
all ages
onset after 20 most common
mild depressive symptoms
highly somatic, muscle aches, soreness, GI complaints, exaggerated startle response
present to primary care with somatic complaints
a sense of ill-being and uneasiness and fear imminent disaster
women more affected than men
risk factors of GAD
unresolved conflicts
cognitive misinterpretations
life stressors
genetic predisposition
behavioral inhibition: shyness, fear, or becoming withdrawn in unfamiliar situations
comorbidity of GAD
MDD
social phobia
specific phobia
panic disorder
dysthymia
alcoholism
at least one additional psychiatric diagnosis
treatment of GAD
a combination of psychotherapy and medication (must have both)
CBT
antidepressants
buspirone
benzo’s
antidepressants
1st line- SSRI
SNRI
TCA
MAOI
benzos
considerations of antidepressants
safety (increased SI) with SSRI and SNRI
assess suicide risk
4-8 weeks to work
can increase dose
switch drug or class
add second drug
SSRI’s
fluoxetine
paroxetine
sertraline
citalopram
escitalopram
drugs are considered 1st choice, less severe and fewer side effects, few drug-drug/food interactions
side effects of SSRI’s
sexual dysfunction
increase in anxiety resolves in 2-4 weeks
therapeutic benefit reached in 3-4 weeks
avoid MAOI
smoking decreases effects
SNRI’s
blocks activity of serotonin and norepinephrine
duloxetine
venlafaxine
desvenlafaxine
adverse effects of SNRI’s
nausea, headache, anorexia, insomnia, somnolence, sexual dysfunction, withdraw syndrome, sweating, blurred vision, increased LFT’s (duloxetine)
contraindicated with MAOI
TCA’s
amitriptyline
imipramine
2-6 weeks for therapeutic effects
inexpensive
adverse effects of TCA’s
sedation
orthostatic hypotension
anticholinergic effects
sexual dysfunction
cardiac toxicity
abrupt withdraw may cause nausea, headache, vertigo
significant drug-drug interaction with MAOI- causes HTN crisis
Fatal overdose
MAOI
phenelzine
tranylcypromine
isocarboxazid
used less often
treats refractory depression but works better for atypical depression
most serious side effect HTN crisis when taken with tyramine
adverse effects of MAOI
food/drug interactions- avoid tyramine foods (aged cheese, smoked meats, yeast, red wine)
CNS stimulation
orthostatic hypotension
can lead to rapid increases in BP, stroke, coma
significant drug/drug interactions with antihypertensive, SSRI, indirect-acting sympathomimetics (ephedrine), TCA, meperidine
bupropion
atypical antidepressant
stimulant effect, decreased appetite
1-3 weeks for effect
doesn’t tend to affect libido or sexual function
buspar
anti-anxiety medication
used in patients sensitive to SSRI tx
relieves anxiety with less drowsiness and abuse potential
non habit forming and low toxicity
beta blockers
propranolol, atenolol
help manage short-term physical symptoms of anxiety by lowering BP and HR
benzo’s
clonazepam
alprazolam
lorazepam
diazepam
may be used in initial stage of treatment
rapid onset (hours) high tolerability
abrupt discontinuation can trigger severe withdraw and intense rebound anxiety
side effects of benzo’s
sedation
ataxia
impaired coordination
slurred speech
memory impairment and dizziness
high risk for falls
alcohol can potentiate effects
guidelines for benzo’s
lowest dose necessary
monitor for sedation and risk of falls
restrict caffeine use
avoid alcohol and other sedatives, alcohol can be fatal
don’t discontinue abruptly
enhances action of GABA
promotes sleep
promotes amnesia (flunitrazepam- date rape drug)
teratogenic
teaching about anti-anxiety meds
do not change dose or frequency without approval
unsafe to handle heavy equipment
alcohol can potentiate depressant effects
caffeine and nicotine decrease effects
avoid becoming pregnant, excreted in breast milk
MAOI’s require special diet
cessation of Benzo’s and antidepressants may cause withdraw
take meds after meals
non-pharm tx for relaxation
deep breathing
physical exercise
progressive relaxation
mental imagery
meditation
biofeedback
GAD in children
excessive unrealistic fear about past and future, weather, school, health, family, finances
treatment: paroxetine, buspirone
can start as early as 6 years old
separation anxiety disorder
normal part of infant development
8 months of age and peaks at 18 months
exhibit developmentally inappropriate levels of concern over being away from significant other
fear of something horrific happening
interferes with normal activities, causes sleep disturbances, nightmares, and physical symptoms
adults: symptoms manifest as harm avoidance, worry, shyness, uncertainty, lack of self direction, impaired social and occupational functioning
phobic disorders
persistent fear attached to a specific object, activity or situation that is out of proportion
compelling desire to avoid anxiety causing thing
always anticipated
agoraphobia
most severe and persistent phobic disorder
fear of being alone or in public places without escape
feared places are avoided
starts late adolescence or early adulthood
females
fear, anxiety, or avoidance cause clinical distress/impairment in social, occupational, or other areas of functioning
associated with adverse childhood events, stressful life events, overprotective and emotional cool families, genetic component
treatment of agrophobia
SSRI
antidepressants
short term benzo’s
CBT
desensitization and flooding
desensitization
gradually introduced to anxiety/fear object or experience
taught relaxation techniques at each step when anxiety becomes overwhelming
flooding
exposed to a large amount of an undesirable stimulus to decrease anxiety
learns through prolonged exposure that survival is possible and anxiety diminishes
social phobia
social anxiety
provoked by exposure to a social or performance situation that could be evaluated negatively by others
intense fear of being criticized by others
fear of humiliation
withdraw from situations
can worry days/weeks before dreaded situation
may interfere with work school
causes: inherited traits, amygdala plays role in fear response, may be learned behavior
risk factors for social phobia
childhood mistreatment and adverse childhood events
shyness
having parents that are shy
SSRI’s and Benzo’s are used to treat
specific phobia
persistent irrational fear of a specific object, activity or situation that leads to avoidance of the object, activity or situation
provokes immediate fear or anxiety and is avoided
fear and anxiety is out of proportion to actual danger
common phobias include dogs, spiders, heights, storms, water, blood, closed spaces, tunnels, bridges, birds and insects
meds have not proven beneficial
treatment choice psychotherapy/desensitization/ flooding
panic disorder
chronic condition characterized by panic attacks
suspended normal functioning
perceptual field severely limited
feelings of impending doom, fear of dying, fear of loosing control, or going crazy
can occur out of the blue
chest pain, discomfort, palpitations, pounding heart, accelerated HR, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of chocking, paresthesia, dizziness
overwhelming stress can induce circulating stress hormones which stimulate glutamate
women more likely to experience panic disorder with agoraphobia
panic disorder is characterized by what two psychological symptoms
anticipatory anxiety- fearful expectation of panic anxiety onset
avoidance anxiety- personal strategies used to increase feeling of control and decrease the risk of panic anxiety
treatment of panic disorder
CBT
anti-depressants- SSRI’s, SNRI, TCA, MAOI
Benzo’s- second line
emergency care for panic disorder
rule of life threatening illness- especially cardiac
stay with patient
reassure them that you will not leave
give clear direction
minimal stimulation
administer PRN anti-anxiety medications
OCD
repetitive unwanted thoughts/ obsession’s
repeated activities/ rituals compulsions
time consuming
distressing to family and friends
onset in early 20’s to mid 30’s
females
females have higher incidence of checking and cleaning rituals, onset early 20’s
symptoms are gradual
obsession’s/compulsions are time consuming causing impairment in social, occupational functioning
cognition may be impaired
stress can increase symptoms
sexual and physical abuse in childhood or trauma increases risk
genetics are strongly associated with OCD
obessions
unwanted intrusive and persistent thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind
obsession’s often seem senseless
obsessions experienced or expressed are often not consistent with the individuals self perception or usual thought pattern causing extreme distress
compulsions
performed repeatedly
ritualistic
goal of preventing or relieving anxiety and distress caused by obsession’s
temporarily reduces anxiety
ex: handwashing, touching things in sequence, counting things, locking and unlocking doors
OCD treatment
very difficult to treat
SSRI’s (clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline)
CBT
exposure thearpy
EMDR
transcranial magnetic stimulation (TMS)
DBS
OCD treatment in children
clomipramine
fluvoxamine
fluoxetine
sertraline
behavior therapy
exposure therapy
CBT
body dysmorphic disorder
preoccupation with one or more perceived defect or flaw
performed repetitive behaviors like checking mirrors, excessive grooming, skin picking, reassurance seeking)
intrusive un-wanted, time consuming, difficult to control
most common age of onset 12-13 years
high risk of suicide
treatment of body dysmorphic disorder
CBT
SSRI’s
alternative therapies including biofeedback, meditation and relaxation
hoarding disorder
difficulty in discarding or parting with possessions, regardless of value
distress or impairment in social, occupational or other areas of functioning
affects both male and females
emerge in adolescence, being to interfere in functioning in the 20’s and significantly impairs functioning in 30’s
experience MDD and/or anxiety disorders
SAFETY is a big concern
trichotillomania
hair pulling disorder
recurrent hair pulling, scalp, eyebrows and eyelides/lashes
causes distress or impairment in social, occupational, or other areas of functioning
women
adolescence coinciding with or following puberty
treatment includes both behavior therapy and pharmacotherapy with SSRI’s
signs and symptoms of trichotillomania
repeatedly pulling hair out, scalp, eyebrows, eyelashes
increasing sense of tension before pulling, and when resisting pulling
sense of pleasure after pulling
noticeable hair loss
hair pulling, biting, chewing or eating pulled hair can cause bowel blockage
playing with pulled hair or rub it across lips
significant distress or problems with work, school or in social situations related to pulling out your hair
self-injury behaviors
also pick their skin, bite nails or chew lips
pull hair in private and generally try to hide the disorder from others
excoriation disorder (skin picking)
skin picking resulting in skin lesions
face, arms and hands
skin rubbing, squeezing, lancing, or biting
women
during adolescence coinciding with puberty
often seen with OCD and trichotillomania
treatment is combination of SSRI and CBT
PTSD
directly experiencing a traumatic event
witnessing in person, learning about traumatic event
experiencing repeated or extreme exposure
does not include exposure to electronic media like television, movies or photographs
can occur a month following an exposure, but symptom delay of months or years is not uncommon
symptoms of PTSD
four core symptoms ( re-experiencing symptoms, avoidance, arousal and reactivity, cognitive and mood symptoms)
re-experiencing symptoms
flashbacks
bad dreams
frightening thoughts
avoidance symptoms
staying away from places, events, or objects that are reminders of traumatic experiences
avoiding thoughts or feeling related to the traumatic event
arousal and reactivity symptoms
being easily startled
feeling tense or on edge
difficulty sleeping
angry outbursts
cognition and mood symptoms
trouble remembering key features of the traumatic event
negative thoughts about oneself or the world
distorted feelings like guilt and blame
loss of interest in enjoyable activities
PTSD risk factors
pre-trauma factors- lower socioeconomic status, parental neglect, person or family psychiatric disease, female, poor social support
peri-trauma factors- severity, intensity, frequency, and duration of trauma, initial severity of person’s reaction to trauma, unpredictability and uncontrollability of the trauma
post-trauma factors- lack of social support, life stress, failure for early identification and treatment
women are twice as likely than men to develop PTSD
PTSD treatment
trauma focused psychotherapy- exposure, CPT, eye movement desensitization and reprocessing (EMDR)
meds: SSRI- sertraline, paroxetine, fluoxetine
SNRI- Venlafaxine
EMDR (eye movement desensitization and reprocessing)
recalling stressful past events and reprogramming the memory to give a positive spin
uses rapid eye movements to facilitate the process of EMDR
comorbidity’s in PTSD
have one or more mental health illnesses
depression
anxiety disorders
substance use disorders
acute stress disorder (ASD)
occurs with first month of exposure to extreme trauma, combat, rape, physical assault, near death experience or witnessing a murder
symptoms begin 3 days to one month following the traumatic event
person continually re-experience the event, avoids situations that remind him/her of the event and has increased anxiety and excitation that negatively affects lifestyle
must have at least 3 of the following- numbing, detachment, reduction of awareness of ones surroundings, derealization, depersonalization, dissociate amnesia
usually resolves within 2-28 days following exposure to trauma
if symptoms continue beyond 1 months diagnosis is changed to PTSD
** this differs from PTSD because they disassociate
PTSD in children
18 and younger
symptoms of traumatic stress can be confused with symptoms of ADHD
treatment depends on childs age, symptoms, and general health
early diagnosis and treatment is important
CBT, EMDR
currently no FDA approved meds for children
SSRI’s may improve social and school functioning
compensation
counterbalance perceived deficiencies by emphasizing strengths
ex: woman anonymously donates to her colleague’s GoFundMe
conversion
the unconscious transformation of anxiety into a physical symptom with no organic cause
ex: almost always a pathological defense
denial
escaping unpleasant, anxiety-causing thoughts, feelings, wishes, or needs by ignoring their existence
ex: Man reacts to loved ones death by saying no, I don’t believe you to initially protect himself from the overwhelming news
displacement
the transference of emotions associated with a particular person, object, or situation to another nonthreatening person, object, or situation
ex: a child yells at his teddy bear after being bullied at school all day
dissociation
a disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself.
ex: an art student is able to mentally separate herself from a noisy environment as she becomes absorbed in her work
indentification
attributing to oneself the characteristics of another person or group. May be conscious or nonconscious
ex: an 8yr old girl dresses up like her teacher and puts together a pretend classroom for her friends
intellectualization
events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing
ex: despite loosing his farm in a tornado, a man leads his child to safety
projection
the unconscious rejection of emotionally unacceptable features and attributing them to others
no example this is considered an immature defense mechanism
rationalization
justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener
ex: employee says “ I didn’t get a raise because my manager doesn’t like me”
reaction formation
unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite emotion or behavior.
ex: recovering alcoholic constantly talks about the evils of drinking
regression
reverting to earlier, more primitive and child like pattern of behavior that may or may not have been exhibited previously
ex: a 4yr suddenly starts sucking his thumb and asking for a baby bottle
repression
unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness
ex: after a marital fight, a man forgets his wife’s birthday
sublimation
an unconscious process of transforming negative impulses into less damaging and even productive impulses
ex: a woman who is mad at her boss channels her feelings into housework until her house is sparkling clean
suppression
the conscious decision to delay addressing a disturbing situation or feeling
undoing
a person makes up for a regrettable act or communication
ex: after flirting with her male secretary, a woman buys her husband concert tickets
