CENTRAL PHILIPPINE UNIVERSITY

COLLEGE OF NURSING
The First Nursing School in the Philippines, 1906
Iloilo City, Philippines 5000
Tel. No. (63-33) 3291971 to 79 Local 1037 / 2133
Website: [Link] | Email: nursing@[Link]

Lecture Notes on
NCM 3218
(Care of Clients with Maladaptive Patterns of Behavior-Acute/Chronic)

ANXIETY DISORDERS

ANXIETY
 response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical
symptoms
 A vague sense of impending doom, an apprehension or a sense of dread, to the lay person it is
described as ‘nervousness’
 Types:
1. Anticipatory – “what will happen next” fears
2. Signal – response to a perceived threat/danger
3. Anxiety Trait – component of personality that has been present over a long period
4. Anxiety state – result of a stressful situation in which the person loses control of his/her
emotions
5. Free-floating – always present and is accompanied by a feeling of dread

 Classifications

1|Anxiety Disorders – Prof. Borlado

ANXIETY DISORDERS
 diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change
but becomes chronic and permeates major portions of the person’s life, resulting in maladaptive
behaviors and emotional disability

ETIOLOGY
1. Genetic Factors
 5-http gene
 15%-20% OCD - immediate family
 40% agoraphobia - relative

2. Biologic
 GABA Deficiency
 Serotonin Deficit/Imbalance
 Over/Underactivated Norepinephrine

3. Cognitive Theory
 Learned/conditioned response

4. Psychoanalytic
 unresolved, unconscious conflicts

5. Sociocultural
 Difficulty adapting to everyday social and cultural demands

I. ANXIETY DISORDERS
A. Panic Disorder
 Discrete period of intense fear or discomfort in the absence of real danger
 Sudden onset of symptoms, peaking within 10 minutes
 Onset: late adolescence (20’s) and the mid-30’s

 Triggers:
 injury
 illness
 interpersonal conflicts
 ingestión of stimulants
2|Anxiety Disorders – Prof. Borlado
  Interventions:
 Medications: Ativan 0.5mg IV; Benzodiazepines; SSRI, TCA, MAOI
 CBT
 Provide non-threatening, supportive environment
 Educate on thought substitution, meds s/e, stress response & management
 Reduce caffeine
 Be empathetic and non-argumentative

B. Panic Disorder with Agoraphobia

 anxiety about being in places or situations for fear of having a panic attack or panicky feelings
 Features:
 Avoidance
 Agoraphobia
 Anticipatory Anxiety
 Interventions:
 Medication - Benzodiazepines; Buspirone, SSRI, Beta Blockers, TCA’s
 CBT - client education and awareness; breathing and relaxation techniques

C. Phobias
 uncontrollable, persistent irrational fear of an object or situation that impairs normal functioning
of a person
 Typically displays:
 Anticipatory anxiety
 Avoidance behavior
 Categories:
 Agoraphobia   fear of being alone in public places
 Specific Phobia  marked, persistent fear that is excessive or unreasonable, cued by
the presence or anticipation of a specific object or situation
(1) natural environment
(2) blood-injcetion
(3) situational
(4) animal
(5) others
 Social Phobia  also referred to as social anxiety disorder, is a compelling desire to
avoid situations in which others may criticize a person
 Treatment:
 Psychotherapy:
- Behavioral therapy
- Systematic desensitization
- Flooding
- Psychodynamic (insight-oriented)

 Medications:
- Panic Disorder -Benzodiazepines (Lorazepam)
- Social Phobia -Clonazepam

 Patient Education
- Teach what anxiety is & helping client identify anxiety responses
- Teach relaxation techniques, goal setting
- Discuss methods to achieve goals, and help the client to visualize phobic
situation

3|Anxiety Disorders – Prof. Borlado

 D. Generalized Anxiety Disorder
W – worries excessively
O – out-of-control, out-of proportion worry
R – restlessness
R – rigidity/inflexibility
I – irritability
E – easy fatigability
R – rule out substance abuse or other medical conditions as the cause
S – sleep disturbance

 Etiology
 Genetic
 Behavioral
 Environmental

E. Obsessive-Compulsive Disorder
 characterized by recurrent obsessions or compulsions or a combination of both, that interferes
with normal life
 onset: 20 years old but can occur as early as 2 years old
 Etiology:
 Stress
 Genetics
 Interpersonal Relationship
 Group A Streptococcal Infection
 Treatment:
 SSRI; Clomipramine
 Behavior Therapy
- relaxation
- neurosurgery
- calm and supportive environment

4|Anxiety Disorders – Prof. Borlado

 F. Post-Traumatic Stress Disorder (PTSD)
 can occur in a person who has witnessed an extraordinarily terrifying and potentially deadly
event
T – tragic exposure
R – re-experiencing episode
A – avoidance of recall
U – unable to function or the symptoms interfere with daily fucntion
M – month long duration (approximate) of the symptoms
A – arousal experiences
S – sleep pattern disturbance

 Onset:
 Acute – less tan 3 months after the event
 Chronic - beyond 3 months
 Delayed - 6 months or more

 Duration:
 Acute - 1 to 3 months
 Chronic - 3 months or more

 Clinical symptoms:
 Behavioral: hyperalertness, tend to abuse drugs, isolation,triggering events create a
cycle of reminders
 Affective: irritable, tense and restless, labile, guilt feelings numbing of emotions, feel
detached from others
 Cognitive: memory of traumatic events may be relieved by amnesia, flashbacks,
nightmares, dreams, illusions

 Interventions:
 SRI (Sertraline); Beta blockers (Propanolol)
 non-stimulating, calm/tranquil environment
 hospitalization (suicidal/homicidal)
 coping strategies, stress management, relaxation techniques
 counselling
 NO caffeine
 empathetic, supportive & non-threatening home environment

G. Acute Stress Disorder

 Onset: during or immediately after the trauma
 Duration: 2 days (resolved by 4 weeks)
 Symptoms:
 Avoidance of stimuli related to trauma
 Sleep disturbances, hypervigilance,startle response, irritability,decreased concentration
 Flashbacks through dreams , nightmares, illusion,derealization,
depersonalization,amnesia
 Defense mechanism: Denial, suppression, repression

H. Anxiety due to Medical Condition

 anxiety symptoms as the physiological consequence of another medical condition
 cause: noradrenergic or the serotonergic system

5|Anxiety Disorders – Prof. Borlado

 I. Medical Conditions caused by Psychological Factors
 Allergy
 Asthma
 Ulcers
 Sexual dysfunctions
 Backaches
 Acne, dermatitis, eczema
 High BP

J. General Interventions:
 Coping Assistance
 Behavior Therapy- Art, Music, Play (for children)
 Psychological Support
 Techniques to reduce anxiety
 Medications- Benzodiazepines, Beta blockers
 Encourage verbalization of feelings especially anger, shock, depression
 Be non-judgmental and honest
 Encourage writing a journal
 Expressive Therapy
 Sleep disturbance therapy

K. General Treatment:
 Behavioral/CBT
 Psychotherapy
 Supportive Family
 Stress Management Technique

II. SOMATOFORM DISORDERS

 presence of physical symptoms that suggest a medical condition without a demonstrable organic basis
 central features:
(1) physical symptoms
(2) psychological Factors
(3) symptoms not under client’s conscious control

ETIOLOGY
 Genetic and Biologic
- chemical imbalances (serotonin & endorphins)
- 10% to 20% of female first-degree relatives of people with this disorder

 Organ Specificity Theory

- person responds to stress primarily with physical manifestations in one specific organ or system

 Selye’s General Adaptation Syndrome

- “Fight or flight” response

 Familial/Psychosocial Theory
- characteristics of dynamic family relationships, such as parental teaching, parental example,
and ethnic mores

 Learning Theory
- person learns to produce a physiologic response to achieve a reward, attention, or some other
reinforcement

6|Anxiety Disorders – Prof. Borlado

 Type Description Occurence Characteristics
Body Dysmoprhic preoccupation with an adolescence  camouflaging
Disorder imagined or exaggerated through the third  comparing
defect in physical decade of life  scrutinizing
appearance  mirror gazing
 skin picking
 depressive syndrome

Somatization Disorder chronic, severe anxiety by 30 years of Pain symptoms

disorder in which a client age GI symptoms
expresses emotional Sexual symptoms
turmoil or conflict through Neurologic symptoms
significant physical
complaints

Conversion Disorder  involves motor or Subtypes:

sensory problems Motor symptoms
suggesting a neurologic Sensory symptoms
condition Seizures/convulsions
 la belle indifference Mixed presentation
 symptom benefits:
 primary gain
 secondary gain

Pain Disorder individual experiences 30’s to 40’s

significant pain without a
physical basis for pain

Hypochondriasis preoccupation with the early adulthood  impaired social or

fear that one has a occupational functioning
serious disease (disease
conviction) or will get a
serious disease (disease
phobia)

Undifferentiated characterized by one or

Somatoform Disorder more unexplained
physical symptoms of at
least 6 months' duration,
which are below the
threshold for a diagnosis
of somatization disorder

INTERVENTIONS:
 Focus on Anxiety reduction
 Diversional activity, anxiolytic medications
 Do not reinforce the sick role by not being overly attentive
 Explore possible links between the symptoms and the emotions, past experiences or evoking thoughts
 Establish a written contract that will redirect client’s thoughts and feelings
 Allow the person to discuss physical complaints
7|Anxiety Disorders – Prof. Borlado
  Matter of fact attitude
 Psychotherapy
 Relaxation Training
 Hypnotherapy

III. DISSOCIATIVE DISORDERS

 Dissociation - becomes separated from reality
 essential feature: disruption in the usually integrated functions of consciousness, memory, identity, or
environmental perception

Type Description Occurence

Dissociative Amnesia  psychogenic amnesia common in young adults
 inability to recall an extensive amount of
important personal information because of
physical or psychological trauma
 Predisposing factors:
 intolerable life situation
 unacceptability of certain impulses or acts
 threat of physical injury or death
 Can be described as:
 Circumscribed
 Selective
 Generalized
 Systematized
 Continuous
 Clinical features:
 perplexity
 disorientation
 purposeless wandering

Dissociative Fugue episodes of suddenly leaving the home or place of adulthood

work without any explanation, traveling to another
city, and being unable to remember his or her past
or identity

Dissociative Identity  multiple personality disorder early childhood or later

Disorder  displays two or more distinct identities or
personality states that recurrently take control
of his or her behavior
 “host” - dominant personality
 “alter” - any personality that is displayed in the
clinical setting

Depersonalization  persistent or recurrent feeling of being adolescence and young

Disorder detached from his or her mental processes or adulthood
body
 Predisposing Factors:
 fatigue
 meditation
 hypnosis
 anxiety
 physical pain
 severe stress
8|Anxiety Disorders – Prof. Borlado
  depression

INTERVENTIONS
 Assure patient that he is not to blame for behaviors that occur during dissociative states.
 Assure that staff will remain with him during overwhelming anxiety.
 Listen actively and help patient identify effective coping methods.
 Assist patient to utilize alternative coping methods. (provide opportunities for patients to vent anger,
fear, shame, doubt. Engage patient in physical activities that require energy and concentration.
Encourage patient to write thoughts, feelings, fears in a diary.
 Praise the patient for the use of effective coping.
 Refrain from passing judgment on the patient, instead let the patient know he/she is worthwhile.

9|Anxiety Disorders – Prof. Borlado