8. Anxiety disorders

Anxiety disorders are characterized by their predominant symptoms of anxiety and avoidant behavior.

Panic Disorder

DSM-IV CATEGORIES

300.01 Panic disorder without agoraphobia

300.21 Panic disorder with agoraphobia

300.22 Agoraphobia without history of panic disorder

The primary characteristic of panic disorder is the presence of recurring, unexpected panic attacks, defined as distinct periods of extreme fear or terror. There's a period of at least 1 month's duration after the attack in which the client experiences extreme concern about having more attacks, worries about the consequences of the attack, or manifests behavioral changes related to these attacks. The panic attacks aren't due to the physiologic effects of a substance or to a general medical condition. The usual age of onset is the late 20s, and about twice as many women as men are affected. Clients with panic disorder may concurrently experience a depressive disorder or a psychoactive substance use disorder, with dependence on alcohol or anxiolytics commonly occurring.

An unexpected panic attack is one that isn't related to a situational trigger; it occurs spontaneously. Some people have situationally predisposed attacks associated with exposure to a specific circumstance. These attacks tend to be less common than the spontaneous type.

A panic attack lasts minutes, is usually unexpected, and doesn't occur in response to typical anxiety-provoking stimuli. The symptoms that accompany it mimic signs of severe cardiac or respiratory distress. An attack begins with an intense feeling of apprehension and impending doom. During the attack, the person feels powerless to control the developing symptoms. After several panic attacks, clients may begin to associate certain situations such as driving a car with an attack: because the same situation may not always precipitate an attack, clients also typically endure fear about the unpredictability of panic disorder.

Many clients with panic disorder develop agoraphobia, the fear of being in situations from which escape would be difficult or in which obtaining help for the symptoms of panic would be unlikely. Based on this fear, clients either restrict themselves to their homes, constantly require a companion when away from home, or endure unaccompanied visits to agoraphobic situations with great anxiety. It's common for agoraphobics to fear public transportation, crowds, bridges, standing in line, and being outside the home alone. Clients with agoraphobia without a history of panic disorder experience fear related to the occurrence of incapacitating or embarrassing paniclike symptoms or limited symptoms of panic rather than a full panic attack. Avoidance behaviors result from the client's attempts to prevent limited symptom panic attacks. In panic disorder without agoraphobia, women and men are affected equally; in panic disorder with agoraphobia, more women are affected than men. (For further information, see Symptoms of Panic Attack.)

Panic disorder runs in families. There's evidence that a disturbance in the levels of the neurotransmitters norepinephnne, serotonin, or gamma-aminobutyric acid can induce a panic attack. Abnormalities in lactate metabolism and alterations in the normal functioning of the respiratory system can trigger panic attacks in susceptible individuals.

COMMUNICATION STRATEGIES

• During a panic attack, have the client think about another subject rather than stay focused on the attack,
• Reassure clients that the nurse will remain with them and help them stay safe and that the attack will pass.
• Direct what is said toward changing the physiologic response (for example, take deep breaths).
• Draw the client out of the anxiety by moving the client from an internal state to an external state. This is done by helping the client relax and having the client think about another issue. This process helps the client mentally move the focus away from the anxiety.
• Don't ask about the attack because this increases the anxiety.
• At an appropriate time after the attack, talk with the client to facilitate understanding of the situation.

SYMPTOMS OF PANIC ATTACK
Intense chest pain Choking, dyspnea, or smothering sensations Diaphoresis Feelings of unreality about self or the environment Fear of dying or "going crazy Hot or cold flashes Nausea or abdominal distress Palpitations or tachycardia Paresthesia Vertigo, trembling, or unsteady feelings

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Situational or maturational crises History of family conflict and inadequate support systems Severe internal stress from many life changes Hereditary susceptibility History of mitral valve prolapse or thyrotoxicosis	Physiologic symptoms experienced during an attack Avoidance behaviors Inability to problem solve Use of psychoactive substances in order to socialize or endure fear of recurrent panic attacks Verbalization of strong fear of another attack

Long-Term Goal
The client will demonstrate the ability to manage the panic by a decrease in behaviors associated with the panic state.

Short-Term Goal #1:The client will talk about life stressors, particularly those associated with past panic attacks.

Interventions and Rationales

• Encourage the client to verbalize powerful, uncomfortable feelings, especially anxiety, guilt, fears, and frustrations. Unacknowledged, painful feelings are stressors: verbalizing uncomfortable feelings helps relieve stress.
• Help the client identify internal stressors that commonly occur before an attack. Before the client can gain control over the attacks, panic-associated stressors must be identified.
• Discuss and analyze the panic situation with the client, focusing on the external stimuli that triggered the attack. Analysis of the external stimuli associated with panic helps the client anticipate and eventually control the attacks.
• Discuss coping mechanisms, such as physical movement and slow deep-breathing exercises, and how they can be used to deal with the stressors associated with panic attack. The client needs to understand other methods of coping that can be used tc handle the intolerable anxiety associated with panic attacks.

Short-Term Goal #2: The client will exhibit behaviors that assist in controlling the panic state.

Interventions and Rationales

• Teach the client strategies for handling internal stressors, such as fear or uncertainty. Having knowledge about alternative ways to handle stress promotes control of behavior.
• Teach the client how to move from an internal to an external state in order to draw the client's attention away from himself This skill empowers the client to release anxiety through outward focus.
• Discuss the relation between anxiety and the physiologic response typically manifested in a panic attack. This action facilitates the client's insight into the connection between anxiety and the physical symptoms of a panic attack.
• Help the client learn to modify the automatic thoughts that accompany physical symptoms when the anxiety begins. The client needs to understand that the physiologic symptoms of anxiety-are followed by automatic thoughts that are distorted assessments of what is happening.
• Encourage the client to develop a support system and to seek help when signs and symptoms of anxiety begin. Developing and using a support system promote personal responsibility and recognition of the need for assistance in times of stress.

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
History of feelings of helplessness or hopelessness Depression Inability to please significant others Negativity in family of origin Past and current difficulties with interpersonal interactions	Verbalization of feelings of lack of control over self-care situations, or outcomes Hesitation or unwillingness to express true feelings Inability to make decisions Verbalization of feelings or inadequacy about role performance Outward display of signs or frustration, anger, resentment, guilt, or apathy

Long-Term Goal
The client will develop a sense of personal control over life situations as demonstrated by problem solving, decision making, and structuring the environment to meet personal needs.

Short-Term Goal #1:The client will establish personal goals for handling stressful situations and develop a system for meeting these goals.

Interventions and Rationales

• Have the client identify and discuss sources of frustration, anxiety, conflicts, and unmet needs. To develop problem-solving skills, the client must first identify the problems that cause negative feelings.
• Help the client establish simple, realistic goals for successfully adapting to or changing situations that cause stress. Unachievable goals create futility and potentiate the feeling of powerlessness.
• Develop a time line for implementing goals. Clients work bette' with an established structure to guide their efforts.
• Teach the client guidelines for problem solving and decision making, such as making a list of possible solutions and seeking feedback from others. Learning problem-solving and decision-making skills strengthens coping abilities.
• Provide feedback and continued opportunities for meeting or revising goals as needed. Feedback promotes insight about situations and enables the client to refine coping skills and strategies.

Short-Term Goal #2: The client will differentiate between controllable and uncontrollable situations and accept those that can't be changed.

Interventions and Rationales

• Help the client identify and discuss goals and needs that aren't being met. Discussion provides insight into difficult situations one helps identify strategies that may need modification to be effective.
• Help the client identify situations that can't be changed. By identifying situations that aren't controllable, the client avoids unnecessary frustration and a feeling of power lessness.
• Encourage the client to verbalize feelings about the situations that can't be personally controlled. Strong emotions can interfere with achieving realistic goals: therefore, the client needs to verba.-ize feelings rather than be overwhelmed by them.
• Help the client identify situations that can be changed. Identifying issues under the client's control assists the client in focusing on what is achievable.
• Encourage the client to work on modifying situations that can be changed. The client needs to experience achievement to reinforce actions directed toward change.
• Recommend participation in therapy and support groups. Group work helps the client reinforce gains and assume more self-care responsibility.

THERAPIES

Individual Therapy

• Explore the stimuli that trigger a panic attack.
• Teach the client ways to inhibit the anxiety response through problem solving and logical analysis.
• Help the client understand how thoughts, feelings, and situations can trigger the anticipatory response.
• Promote recognition of the self-limiting aspect of panic attacks so that the client can begin to develop a sense of control over them.
• Encourage the use of positive self-talk: "I can handle this anxiety. I can get through this."
• Facilitate insight into how a panic attack can be controlled and resolved.
• Discuss with the client how the use of alcohol, cocaine, amphetamines, caffeine, and nicotine can precipitate panic responses.
• Instruct the client about relaxation techniques to eliminate physical tensions that precede panic attacks.
• After the client achieves control over symptoms, explore with the client the underlying conflicts and stressors.
• Assess and monitor the client for coexisting symptoms of depression and possible suicidal tendencies.

Group Therapy

• Teach clients coping strategies for handling stressful life events.
• Provide opportunities to develop and try new ways of behaving and thinking about panic attacks.
• Encourage the clients to use the group for support and reassurance.
• Help clients to identify when anxiety is escalating and to take steps to interrupt its progression.

MEDICATIONS

• Ant anxiety drugs, typically benzodiazepines, are administered.
• Antidepressant drugs, particularly the selective serotonin reuptake inhibitors (and to a lesser degree the tricyclics), decrease the frequency and intensity of panic attacks. Low doses are used to avoid inadvertently increasing anxiety.
• Monoamine oxidase inhibitors are used for clients with severe panic disorder.
• Neuroleptic agents are sometimes prescribed. (See Appendix D for medication information.)

FAMILY CARE

• Educate family members about panic disorder and how to work with the client. Inform them of the panic disorder cycle: the panic attack, the anticipatory anxiety (generated from the client's fear of another attack occurring), and the phobic avoidance behavior (resulting in activity limitations because of the client's desire to avoid anxiety that may provoke an attack).
• Have the family develop effective communication skills to decrease underlying conflicts between members.
• Promote honest, open expression and discussion of feelings.
• Discuss how the client's illness has influenced family members.
• Teach family members how to identify their needs and ask for what they need from one another.

Phobias

DSM-IV CATEGORIES

300.29 Specific phobia (specify type: animal type/natural environment type/blood-injection-injury type/situational type, other type)

300.23 Social phobia (specify if: generalized)

A phobia is an irrational and disproportionate fear of an object or a situation. When the fear-inducing stimulus is anticipated, the client avoids the situation. Usually, the person is cognizant that the fear is unreasonable or excessive. The diagnosis of phobia is made only if the avoidant behavior causes problems in occupational functioning or social relationships or if the client is distressed about having the fear. No specific biological basis for phobias has been identified. Phobias run in families.

With social phobias, the client consistently fears being scrutinized by others or fears that a humiliating situation will occur in public. Several examples of social phobias are fear of saying something foolish, fear of eating or speaking in public, and fear of writing in front of others. The onset of social phobias typically occurs in late childhood or early adolescence, with more males than females being affected. Clients with social phobia disorder are likely to abuse psychoactive substances.

The diagnosis of specific phobia refers to the persistent fear of a specific object, such as a dog or snake, or positional situations, such as height, closed space, and airplane travel. Usually, the phobic situation is avoided. If the specific phobic stimulus is encountered, the client manifests an immediate and often severe anxiety response. With children, the anxiety may be expressed by crying, clinging, or having tantrums. In contrast to social phobias, the age of onset for specific phobias varies: they can begin in childhood or the middle adult years. Specific phobias are diagnosed more frequently in females than in males.

COMMUNICATION STRATEGIES

• Explain that the phobias are learned behaviors that can be unlearned.
• Discuss how new behaviors can be learned.
• Acknowledge the client's feeling of helplessness about the phobia.
• Help the client verbalize awareness that the response to the object or situation is excessive.

NURSING DIAGNOSIS: FEAR

Probable Causes	Defining Characteristics
Unconscious emotional conflict Displacement of anxiety Previous life experiences Knowledge deficit Sensory misperception	Physical and emotional manifestations of severe anxiety Verbalization of discomfort about the fearful object or situation Inability to perform activities of daily living Withdrawal from usual activities when fears become overwhelming Panic attacks

Long-Term Goal
The client will learn how to function when confronted with the phobic stimulus without experiencing severe or incapacitating anxiety.

Short-Term Goal #1:The client will verbalize fears and identify anxiety related to the phobia.

Interventions and Rationales

• Encourage the client to discuss the feared object or situation. Discussion of how the client perceives the phobia provides the baseline for developing a treatment program.
• Work with the client to identify the underlying conflict that's being displaced as a phobia. By identifying the underlying conflict and the anxiety it provokes, the client can connect the inner experience of anxiety to the phobia.
• Help the client identify and discuss thoughts and feelings that contribute to the fear. Verbalization of thoughts and feelings enables the client to explore the issues that are either suppressed (consciously put out of awareness) or unresolved.
• Identify whether the client is depressed, and intervene. A depressed client has difficulty concentrating and is unable to focus or, strategies to handle the phobic response. (For nursing interventions for major depression, refer to the section about depression in chapter 7. Mood Disorders.)
• Teach the client that the phobia is a symbolic representation (an object or a situation that is a substitution) of anxiety. Awareness that the phobia arises from anxiety helps the client to disconnect from the phobic response and focus attention on the problems that cause the anxiety.

Short-Term Goal #2: The client will participate in a de-sensitization program and demonstrate ways to cope with the phobia.

Interventions and Rationales

• Before beginning a desensitization program, assure the client that safety will be maintained. The client needs to feel secure ana safe to proceed with the program.
• Discuss the phobia in detail, focusing on the illogical or over reactive nature of the client's fears. Realistic assessment of a phobic stimulus helps the client reduce the fear reaction and participate more effectively in desensitization.
• Establish a systematic desensitization program. A desensitization program gradually exposes the client to the feared situation or object in a safe, supportive, and structured manner for the purpose of decreasing or eliminating the client's fear.
• Collaborate with the health care team to determine the appropriateness of other behavior modification techniques, such as reciprocal inhibition and implosion (see Behavior Modification Techniques Used in Treatment of Phobias). Techniques from behavioral psychotherapy have decreased or eliminated phobias.
• Teach coping skills, such as assertiveness, thought-stopping techniques, and problem solving. Using these skills enables the client to develop new ways of coping; awareness of negative self-talk empowers the client to replace it; development of problem-solving skills allows pursuit of alternatives to the phobia.
• Have the client learn and practice relaxation exercises and guided imagery. These strategies help decrease the client's anxiety level.
• Explore with the client the thoughts, feelings, or events that may precipitate a phobic response. Awareness of what precipitates a phobic reaction enables the client to learn alternative ways to handle the anxiety.

BEHAVIOR MODIFICATION TECHNIQUES USED IN TREATMENT OF PHOBIAS

SYSTEMATIC DESENSITIZATION -the creation of gradual, therapeutic, systematic exposure to the feared stimuli while the diem is encouraged to refrain from using the escape, avoidance, or ritualized response. IMPLOSION — bombarding or "flooding" the client with an exaggerated version of the phobic stimulus In order to reduce the phobic response. RECIPROCAL INHIBITION — overcoming conditioned tear response by introducing two situations simultaneously: the fear-provoking situation and another situation that is incompatible with tin feared one.

THERAPIES

Individual Therapy

• Work with client to identify the real source of anxiety that's been displaced as a phobia.
• Teach relaxation techniques to help control the anxiety.
• Develop a systematic desensitization program to help the client handle the identified fear.
• Help the client change negative thinking patterns. Explore fears and possible traumatic incidents that provoked the client's phobic response.

MEDICATIONS

• Benzodiazepines (antianxiety drugs) are used either alone or in combination with beta blockers. (Beta blockers decrease tachycardia, tremors, and diaphoresis.)
• Selective serotonin reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors are used for depression and anxiety accompanying the phobia.
• For treating social phobias, alprazolam (Xanax) is recommended in conjunction with behavior modification strategies. (See Appendix D for medication information.)

FAMILY CARE

• Encourage the family to identify and discuss problems and stressors that increase the client's anxiety.
• Help family members recognize initial symptoms of anxiety and panic and teach them how to intervene when the client's anxiety escalates.
• Teach the family ways to help the client control the phobia.
• Help the family develop a support system that promotes the client's independence and decreases the client's chances of obtaining secondary gains from the phobia.
• Initiate referrals to support groups and community resources that facilitate coping with anxiety.

Obsessive-Compulsive Disorder

DSM-IV CATEGORIES

300.3 Obsessive-compulsive disorder (specify if: with poor insight)

Obsessive-compulsive disorder is characterized by recurrent obsessions (intrusive and inappropriate thoughts, images, or impulses) and compulsions (repetitive, stereotyped behaviors performed in response to an obsession). The obsessions and compulsions generate intense stress, are time-consuming, and impair a person's level of functioning.

Obsessions may focus on anything, but clients commonly obsess about contamination, religion, doubt, violence, sexuality. and obscenities. Clients often attempt to ignore, suppress, or neutralize the persistent thoughts or images by substituting other thoughts or actions. They realize that their unwanted thoughts are illogical, yet they feel powerless to stop the intrusion of these thoughts.

Compulsions are the compelling actions that result from attempts to alleviate the obsessions. Although compulsions van. according to each individual, some of the more common behaviors include frequent hand washing, counting, checking, touching, masturbation, and self-mutilation. People use the compulsive behavior to deal with anxiety aroused by the obsession: however the action isn't purposeful and doesn't assist with handling the anxiety. Clients are aware that the compulsive behavior is excessive and not associated with pleasure while it is being carried out but it does provide relief from tension. Before engaging in the compulsion, the person attempts to resist performing the act. During this period of resistance, the tension continues to escalate until the person finally yields. Over time and with continued falure to avoid the compulsion, the person ceases to resist. Some clients have concurrent symptoms of depression. Obsessive-compulsive disorder may occur throughout life, but it usually De-gins in adolescence or young adulthood. The disorder occurs equally in females and males.

No specific biological basis for obsessive-compulsive disorder has been identified. Scientists believe that this disorder involves a brain dysfunction that can be treated with medication and therapy.

COMMUNICATION STRATEGIES

• Maintain a calm, concerned demeanor.
• Use concrete language and unambiguous remarks in all communications because obsessive clients may find it difficult to listen to opinions that are different from their own.
• Help the client recognize irrational thoughts and images related to the obsession.
• Direct the interaction in a positive way or verbally stop any interaction occurring around the obsession.
• Redirect circumstantial speech (detailed and lengthy discussion on a specific topic) in a kind and noncritical manner.
• Interject a statement about reality if the obsession is delusional.
• Explore how the client can control or cope with the persistent thoughts and impulses and the distress they cause.
• Address negative self-talk because the client may judge herself rather harshly.
• Examine how harmful perfectionist ideals are in terms of the client's self-esteem and social relationships.
• Discuss feelings of ambi valence, such as helping the client to accept that the existence of two opposing feelings about the same issue is common.
• Explore the use of compulsive behavior as a symbolic act used to cope with anxiety.

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Multiple life stressors Fears of inadequacy or failure Unrealistic view of situations or things Lack of role models to teach coping strategies Inadequate repertoire of coping responses	Extreme preoccupation with specific thoughts or ideas Verbalization of concerns about compulsive behaviors Inability to distract self from obsessions and compulsions Inability to problem solve Difficulty with interpersonal relationships

Long-Term Goal
The client will cope with anxiety by using alternative behaviors in place of ritualistic ones.

Short-Term Goal #1:The client will discuss the obsessive-compulsive behaviors and verbalize the anxiety about related life stressors.

Interventions and Rationales

• Encourage the client to express feelings and concerns about life stressors, fears, and anxieties. Direct discussion of anxieties can decrease the client's level of stress and begin to diminish ocses-sive thoughts and compulsive behaviors.
• Help the client identify how the disruptive thoughts and compulsive behaviors affect physical, emotional, and social functioning. The client needs to realistically evaluate the impact these thoughts or behaviors have on the ability to function.
• Explore the difference between thoughts and actions, and discuss the social consequences of the compulsive actions. The client must become aware of how the compulsions carry social recupercussions, while negative thoughts are personally self-defeating.

Short-Term Goal #2: The client will decrease or eliminate obsessive thinking and compulsive behavior.

Interventions and Rationales

• Help the client assess how ritualistic behavior impairs daily functioning. The more involved the client is with the ritualistic behavior, the more daily living activities are impaired.
• Help the client identify the situations that promote anxiety and precipitate ritualistic behaviors. Awareness of situations that provoke ritualistic behavior helps the client cope with the underlying anxiety.
• If the client engages in a compulsion during a nurse-client interaction, allow the client time to perform rituals and don't call attention to the rituals. Preventing or stopping the rituals causes the client's anxiety to escalate.
• Establish a structured daily routine that allows time for rituals. A structured schedule superimposes other activities into the clients daily routine and helps the client focus attention on nonritualistic behaviors.
• Gradually limit the time devoted to rituals as the client becomes involved in productive activities. The client must begin.to replace the ritualistic behaviors with behaviors that are constructive.
• Develop behavioral contracts based on the client's agreeing not to perform the ritual in exchange for certain rewards. Positive reinforcement promotes continued involvement in nonntualistic behaviors.
• Teach the client thought-stopping skills and relaxation techniques to decrease the incidents of obsessive thoughts and compulsive behaviors. These behavior modification skills give clients the tools to modify unwanted thoughts and behaviors.
• Provide pleasant distractions and realistic alternatives to the rituals, such as relaxation exercises and socializing. Learning new behaviors and alternative ways of coping decreases anxiety and reinforces positive changes.
• Have the client attend a support or therapy group. These groups give the client opportunities to verbalize feelings and fears and obtain feedback about coping strategies.

NURSING DIAGNOSIS: SELF-ESTEEM DISTURBANCE

Probable Causes	Defining Characteristics
Severe internal conflict Stressors during childhood Distorted perceptions History of poor interpersonal relationships Lack of support from family	Verbalization of negative thoughts about self Expression of feelings of guilt or shame Rejection or minimization of positive comments or feedback from others Hesitation to try new ideas or make changes Dependence on others

Long-Term Goal
The client will verbalize realistic expectations for self and demonstrate appropriate self-evaluations of own actions.

Short-Term Goal #1:The client will discuss how anxiety affects feelings about self and ability to function.

Interventions and Rationales

• Help the client discuss feelings and reactions about personal life situations and social events. This sets the stage for providing the client with feedback for problem solving.
• Help the client explore anxiety-provoking situations and examine personal behavior standards and rigid beliefs. By helping the client review standards and beliefs, the nurse can introduce the ideas of flexibility and acceptance of alternative ways of being.
• Help the client recall times when anxiety was handled in a satisfactory manner. Review of previous healthy coping experiences reinforces the client s strengths and prior coping skills.

Short-Term Goal #2: The client will identify appropriate goals and work to achieve them, as evidenced by verbalizing feelings about competency and self-worth.

Interventions and Rationales

• Help the client formulate goals for handling the anxiety related to social situations. Formulation of goals related to the experience of social anxiety helps the client feel comfortable in social situations.
• Develop strategies for handling the anxiety aroused in everyday life situations, such as getting on an elevator and shopping. Strategies for coping with anxious feelings provide structure and a sense of comfort when dealing with stressful situations.
• Teach the client how to laugh, use humor, and be appropriately playful rather than constantly maintaining a serious stance. The nurse can role-model playfulness and use humorous books and other materials to instill humor into otherwise common situations. This intervention presents reality and frees the client from unrealistic expectations and negative feelings about self
• Encourage the client to participate in treatment activities, interactions, and social events. The client needs to establish comfort in various situations in order to have less time available for obsessive thoughts and compulsive acts.
• Work with the client to accomplish personal goals related to lifestyle. The client needs to experience success and feelings of competency and adequacy with daily occurrences.

THERAPIES

Individual Therapy

• Identify and work with the client on ways to promote health because general health influences the client's state of anxiety.
• Teach the client effective ways to problem solve, be assertive, and communicate with others.
• Recognize the client's social, cultural, and spiritual beliefs, and differentiate them from the client's obsessions.
• Help the client explore the experience of anxiety, and develop strategies to promote the client's emotional well-being.
• Work with the client to develop insight into the underlying stressors associated with the anxiety.
• Instruct the client to use cue cards for restructuring thought patterns. Use positive statements that address the client's obsessions and compulsions. For example: "It's the obsessive-compulsive disorder, not me." "I trust myself" "I did it properly the first time."
• Facilitate the client's ability to use personal strengths and coping mechanisms that were effective in the past.

Behavioral Therapy

• Inform the client that obsessions and compulsions are learned responses to anxiety that can be unlearned.
• Help the client resist anxiety-provoking stimuli by taking positive actions that promote self-comfort.
• Teach the client thought-stopping techniques and other behavioral methods to counter obsessive thoughts and compulsive actions.
• Develop a desensitization program for handling the stress the client experiences around certain stimuli.
• Establish alternative rewards as the client demonstrates increasing control over the obsessive-compulsive behaviors.

MEDICATIONS

• Antianxiety agents, antipsychotics, and antidepressant medications such as clomipramine (Anafranil) are used to manage obsessive-compulsive disorder.
• Fluoxetine (Prozac), a selective serotonin reuptake inhibitor. is used for its antiobsessional effect.
• Fluvoxamine (Luvox), a selective serotonin reuptake inhibitor is used for the treatment of obsessive-compulsive disorder. (See Appendix D for medication information.)

FAMILY CARE

• Teach family members about anxiety and obsessive-compulsive behavior, treatment, and medication effects and adverse effects.
• Instruct the family to assist the client in handling anxiety and embarrassment through the use of relaxation exercises, guided imagery, and behavior modification techniques.
• Teach the family how to identify when anxiety is escalating and how to help the client cope effectively.
• Help family members communicate with one another and build or strengthen their relationships with one another.
• Advise the family about available resources and how to seek assistance when needed.

Posttraumatic Stress Disorder

DSM-IV CATEGORIES

309.81 Posttraumatic stress disorder (specify if: acute; chronic, specify if with delayed onset)

Posttraumatic stress disorder (PTSD) occurs after a person endures an extremely distressing event that's considered outside the range of common human experience. Examples of such events include natural disasters, rape, incest, criminal assault, domestic violence, concentration camp or cult experience, terrorist or hostage situations, military combat, and sudden destruction of one's home or community. Feelings resulting from exposure to such extraordinary stressors include profound fear, terror, and helplessness. After exposure to such a stressor, some people develop PTSD, a syndrome in which the traumatic event is persistently reexperienced in diverse ways. There may be recurrent or intrusive recollections, recurrent unpleasant dreams, a sudden feeling that the trauma is recurring, or intense emotional distress in response to situations that symbolize the original traumatic event. After the initial experience, the person attempts to avoid the thoughts, feelings, activities, or situations associated with the trauma. A numbing response (feelings of detachment from the external world or emotional distance from others) that wasn't present before the trauma may also be exhibited.

Sometimes psychogenic fugue, the inability to remember a significant piece of the trauma, occurs. There's also decreased interest in usual activities, a feeling of estrangement from others. and the inability to have caring or loving feelings. Young adults and adolescents suffering from PTSD see a foreshortened future and no expectations of a career, marriage, children, or a normal life span. Older adults have diminished expectations for the future. There is a manifestation of increased arousal, such as difficulty falling or staying asleep, angry outbursts, difficulty concentrating, hyper vigilance, exaggerated startle response, and physiologic reactions to situations that represent a facet of the trauma. The duration of PTSD is from hours to years after the trauma is experienced.

Acute PTSD is defined as duration of symptoms less than 3 months; chronic PTSD is defined as symptoms lasting 3 months or longer. With delayed-onset PTSD, at least 6 months have passed from the traumatic event to the onset of the symptoms PTSD may occur at any age, even during early childhood. With children, there may be a tendency not to discuss the trauma; this shouldn't be interpreted as the inability to remember what occurred. Children relive the past through repetitive action play They may exhibit other physical symptoms, such as headaches or stomachaches, in addition to the common symptoms of increased arousal. (For further information, see Symptoms Assoc:-atedwith Posttraumatic Stress Disorder.)

COMMUNICATION STRATEGIES

• Establish the setting for the interaction by sitting in the client s direct visual field and speaking in a clear, low, soothing voice.
• Listen attentively, and stay with the client as the trauma is shared.
• Validate the traumatic nature of the client's experience.
• Try to understand the loss of control inherent in the traumatic situation.
• Encourage the client to express thoughts and feelings.
• Help the client work through any guilt and begin work on self-forgiveness.
• Work with the client to separate from the traumatic experience and move on with life.
• Help the client reframe the negative labels placed on self as a result of survivor guilt.
• Help the client develop coping strategies to handle the anxiety aroused by the original trauma and regain control over life.

SYMPTOMS ASSOCIATED WITH POSTTRAUMATIC STRESS DISORDER
PHYSIOLOGIC SYMPTOMS
Dilated pupils Headaches Sleep pattern disturbances Tremors Hypertension Tachycardia or palpitations Diaphoresis with cold, clammy skin Hyperventilation Dyspnea	Smothering or choking sensation Nausea, vomiting, or diarrhea Stomach ulcers Dry mouth Abdominal pain Muscle tension or soreness Exhaustion or fatigue
PSYCHOLOGICAL SYMPTOMS
Anxiety Anger Depression Fears or phobias Survivor guilt Hypervigilance Nightmares or flashbacks Intrusive thoughts about the trauma Impaired memory Dissociative states Restlessness or irritability Strong startle response Substance abuse Self-hatred Feelings of estrangement	Feelings of helplessness, helplessness, or powerlessness Lack of Interest in life Inability to concentrate Difficulty communicating, caring, or expressing love Problems with relationships Sexual problems ranging from acting out to impotence Difficulty with intimacy Inability to trust Lack of impulse control Aggressive, abusive, or violent behavior, including suicide Thrill-seeking behaviors

NURSING DIAGNOSIS: POST TRAUMA SYNDROME

Probable Causes	Defining Characteristics
Endurance of a traumatic event Traumatic loss of a normal sense of personal safety Prolonged exposure to the trauma Mental illness existing before some overwhelming stressor Lack of coping skills and sources of support	Reliving the traumatic experience (flashbacks or nightmares) Verbalization about the traumatic event, especially survival guilt Emotional numbness Coping through substance abuse Self-directed or other directed violence

Long-Term Goal
The client will be able to confront situations and feelings related to the trauma that were previously avoided.

Short-Term Goal #1:The client will acknowledge the traumatic event and discuss feelings related to it.

Interventions and Rationales

• Identify signs of physical injury, and initiate appropriate medical treatment. Taking care of physical injuries related to the trauma ensures the client's safety and helps to reinforce the reality of the trauma.
• Discuss the traumatic event, and help the client define it as a trauma. The client needs validation that the event was indeed a situation beyond personal control.
• Encourage the client to talk about all feelings related to the trauma. Expression of feelings related to the trauma helps the client cope with the reality of the event.
• Encourage the client to explore specific feelings of survivor guilt, self-blame, or inadequacy. The client needs to realize that survival may have been due to chance and not related to any personal action or inaction. Additionally, the client needs to understand that acting self-protectively in the event of trauma is a normal human response to the need to survive.
• Try to differentiate between physical symptoms of the trauma and symptoms caused by anxiety or depression about the event. It's essential to differentiate between symptoms due to anxiety and symptoms due to physiologic problems because interventions differ.

Short-Term Coal #2: The client will deal effectively with feelings and develop control over symptoms related to the trauma.

Interventions and Rationales

• Work with the client to identify the symptoms of escalating anxiety and cope with it effectively. Early identification of escalating anxiety can enable the client to seek support before losing control.
• Teach the client self-relaxation techniques and other ways to cope effectively with anxiety, anger, guilt, recurring fear, and regret. The client needs to develop effective strategies for handling strong posttraumatic feelings rather than resort to substance abuse or acting out behaviors.
• Work with the client to deal with any physical effects of the trauma, such as scarring and disability. Physical effects are reminders of the trauma and can influence the client's daily life.
• Encourage the client to use spiritual beliefs and cultural traditions to provide comfort when feeling overwhelmed. Spiritual beliefs and cultural traditions may relieve intense anxiety or overwhelming feelings.
• Explore with the client ways to relabel thoughts by the use of cognitive reframing. This strategy helps the client move away from negative labels and allows the client to process the crisis.

NURSING DIAGNOSIS: POWERLESSNESS

Probable Causes	Defining Characteristics
History of trauma Personal reaction to stress Lack of sufficient coping skills and support system Consistent negative feedback from family of origin Lifestyle of helplessness	Verbalization of feelings of powerlessness over situation, outcome, or self-care Verbalization of feelings of depression and self-doubt Inability to perform usual roles Physical symptoms of displaced depression Inability to discuss feelings

Long-Term Goal
The client will verbalize having a sense of control over feelings and behaviors.

Short-Term Goal #1:The client will verbalize feelings about situations that are or aren't under personal control and accept those situations in which personal control isn't possible.

Interventions and Rationales

• Encourage the client to discuss feelings about current life situations, the trauma, and related stressors. Discussing feelings promotes the client's self-awareness of current reactions to anxiety.
• Talk about the client's sense of powerlessness and how stressors reinforce these feelings. By identifying how stressors reinforce feelings ofpowerlessness, the client can begin to see the patterns that trigger self-defeating behaviors.
• Through examination of personal preferences, beliefs, and values, help the client develop the self-awareness necessary for exercising self-control. Focusing on strengths and incorporating positive aspects of self into care can enhance the client's sense of personal power and control.
• Review life situations that the client can control. This reinforces the client's sense of personal power.
• Identify life situations that the client can't control. Focusing on circumstances beyond the client's control starts the process of dealing with unresolved issues and accepting personal limitations.

Short-Term Goal #2: The client will demonstrate the ability to problem solve by exhibiting behaviors appropriate to troublesome situations.

Interventions and Rationales

• Help the client identify situations in daily living in which the use of problem-solving skills reduces the feeling of powerlessness. This experience further enhances the ability to modify and actively participate in self-care, thus providing more problem-solving experiences.
• Teach and have the client practice problem-solving skills related to self-care activities and all other areas in which there are problems. This provides the client with the opportunity to accept some responsibilities with the benefit of guidance from the nurse.
• Work with the client to construct realistic goals and sub goals. The client often requires assistance with developing goals and breaking them into doable parts.
• Encourage the client to create a structured plan for self-care activities. A realistic plan of self-care facilitates success, moves the client away from ruminating on the trauma, and diminishes feelings ofpowerlessness.

NURSING DIAGNOSIS: RISK FOR SELF-DIRECTED VIOLENCE OR VIOLENCE DIRECTED AT OTHERS

Probable Causes	Defining Characteristics
Previous traumatic experiences History of family abuse or substance abuse History of violence as a way of problem solving Lack of support system Concurrent physical or neurologic problems	Limited ability to cope with stressors Acting out behaviors Verbal abuse of self or others Expression of overwhelming painful feelings Low tolerance for frustration

Long-Term Goal
The client will refrain from harming self or others.

Short-Term Goal #1:The client will verbalize aggressive feelings rather than act them out.

Interventions and Rationales

• Monitor the client's verbal and physical aggression against self and others. Immediate intervention is necessary if the client becomes violent to self or others.
• Discuss anxiety, aggressive feelings, and how escalating tension leads to hostility. Severe anxiety is often responsible for loss of control and the generation of hostile actions.
• Help the client explore the issues behind aggressive and vengeful feelings and impulses. Talking about anger lessens the tendency for the client to act on it.

Short-Term Goal #2: The client will demonstrate appropriate coping skills for handling severe distress.

Interventions and Rationales

• Help the client identify cues that indicate escalating frustration and tension that may lead to destructive behavior. Prompt identification of escalating tension can prevent the client from losing control and hurting self or others.
• Encourage the client to develop awareness of the nonverbal behaviors and verbal statements that indicate mounting anxiety. Self-awareness is the first step to facilitate self-control.
• Teach the client about physical outlets for anxiety. The safe channeling of physical energy enables the client to decrease anxiety in a constructive manner.
• Help the client learn assertiveness skills and appropriate expression of strong emotions. The skills of assertiveness and appropriate expression of emotion help the client solve problems as they arise and diffuse the potential for aggression.
• Work with the client to develop a tolerance for frustrations and disappointments. This intervention provides the client with time to handle a stressful situation and may prevent a violent episode.
• Encourage the client to request assistance from community resources, such as therapy or support groups, as one strategy to further develop coping skills. Ongoing assistance enables the client to be in control of stressful situations and assume responsibility for behavior.

THERAPIES

Individual Therapy

• Discuss the trauma thoroughly to obtain an accurate history of the event.
• Encourage the client to disclose thoughts and feelings to realistically appraise the client's reaction to the trauma.
• Determine the issues or themes that cause the client continued distress and are difficult to handle.
• Work on the anxiety and guilt behind the identified issues.
• Encourage expression of the pain and resentment resulting from the trauma.
• Address the fears, feelings, and memories associated with the trauma.
• Help the client share and then let go of the memories to bring closure to the stressful experiences.
• Work on the issue of self-control to enable the client to see that the extremes of excessive and inadequate control are detrimental to moving on with life.
• Work on changing the client's cognitive distortions about the trauma and the beliefs related to it.
• Address symptoms of depression and abuse of alcohol or other substances.

MEDICATIONS

• Antianxiety drugs, such as diazepam (Valium) and chlordiazepoxide (Librium), and antidepressants, such as imipramine (Tofranil) and phenelzine sulfate (Nardil), have sometimes been used in conjunction with psychotherapy and stress reduction techniques.
• Drug therapy is often not effective for a person with PTSD. (See Appendix D for medication information.)

FAMILY CARE

• Help the family understand that the client avoids emotional attachment in an attempt to protect himself from further losses.
• Begin to work with family members to express and accept one another's feelings and reactions about the trauma.
• Encourage family members or a significant other to discuss the trauma with the client during therapy because they may know little about the experience.
• Assist family members or a significant other to understand the origins and extent of PTSD.
• Address feelings of anxiety, grief and guilt related to the inability to function in family roles and relationships.
• Evaluate family interactions, concentrating on methods and patterns of communication.
• Assess dysfunctional family patterns, and identify why and how they are maintained.
• Teach effective ways to cope with stress responses and troublesome situations.
• Inform the family that when clients with PTSD are exposed to traumas that occur in the world at large, symptoms may exacerbate.
• Assess and intervene if domestic abuse or substance abuse is present.
• Discuss each family member's responsibilities to self and to the family unit.
• If applicable, inform the client and family about the available counseling and support groups.

Generalized Anxiety Disorder

DSM-IV CATEGORIES

300.02 Generalized anxiety disorder

293.89 Anxiety disorder due to ... [indicate the general medical condition] (specify if: with generalized anxiety/with panic attacks/with obsessive-compulsive symptoms)

300.00 Anxiety disorder NOS

The major characteristic of generalized anxiety disorder is unrealistic, excessive anxiety about a number of life situations; the anxiety must occur more than 50% of the time over a span of atleast 6 months. The person has a difficult time attempting to control the distress. Examples of a person's worries are excessive concern about harm happening to another person who is in no apparent danger and apprehension about finances when there s no valid reason for such concern. With children and adolescents the anxiety centers on social, academic, or athletic performance. Usually, symptoms are associated with the anxiety, such as motor tension, autonomic hyperactivity, vigilance, and scanning (constantly searching the environment for information related to the subject of worry). Before diagnosing this condition, other specific anxiety-related disorders, such as panic disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder, must be eliminated. The age of onset can be any time. But generalized anxiety disorder is commonly diagnosed in young adults during their 20s and 30s. Women are affected more than men by a 2:1 ratio. (For further information, see Symptoms Assc-ciatedwith Generalized Anxiety Disorder.)

Generalized anxiety disorder runs in families. Scientists believe that an imbalance among the neurotransmitters norepinephrine, serotonin, and gamma-aminobutyric acid may contribute to this disorder.

COMMUNICATION STRATEGIES

• Actively listen to the client, and encourage discussion of feeling.
• Reassure the client about safety, and verbalize that the nurse is concerned about the client's well-being.
• Use touch as appropriate to convey warmth and support. However, touch may be inappropriate for many clients, particularly those with poorly developed ego boundaries. Before initiating touch, evaluate whether its use will foster a more therapeutic relationship and help the client meet therapeutic goals.
• Help the client acknowledge the anxiety rather than deny or ntellectualize about it.
• Point out observations of behaviors that may indicate anxiety.
• Explore coping mechanisms and defensive behaviors.
• Discuss the expectations and needs that lead to the anxiety.

SYMPTOMS ASSOCIATED WITH GENERALIZED ANXIETY DISORDER
Motor tension Shakiness, nervousness, or restlessness Muscle pain or soreness Easy fatigability
Autonomic hyperactivity Shortness of breath or smothering feeling Palpitations and tachycardia Cold, clammy hands Dry mouth and difficulty swallowing Dizziness Nausea, diarrhea, or abdominal discomfort Frequent urination Hot flashes or chills Elevated blood pressure
Vigilance and scanning Edginess or hypervigilance Difficulty concentrating Exaggerated startle response Difficulty steeping Irritability or hypersensitivity

NURSING DIAGNOSIS: ANXIETY

Probable Causes	Defining Characteristics
Unconscious conflict about values and beliefs Situational or maturational crises Threats to self normal life roles, or ability to function Any illness or trauma perceived as life-threatening Unmet survival needs	Physiologic symptoms Apprehension, worry, or intense fear Verbalization of feelings of helplessness or inadequacy Concerns about changes in lifestyle Disorganized or disrupted thought patterns

Long-Term Goal
The client will experience fewer symptoms of anxiety and verbalize the ability to monitor feelings and behaviors.

Short-Term Goal #1:The client will identify the physical, emotional, and behavioral responses of anxiety.

Interventions and Rationales

• Observe the client for overt signs of anxiety. This action enables the nurse to assess the anxiety and establish priorities for care.
• Give the client the information needed to help identify physical, emotional, and behavioral symptoms as being anxiety-related. This information helps the client identify the symptoms of anxiety.
• Work with the client to identify sources of stress. This sets the stage for coping with stress and reducing the anxiety associated with unacknowledged stress.
• Help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. To modify the automatic response to stress, the client needs to connect the experience of anxiety with the unpleasant symptoms.
• Focus discussion on the types of stressors and their meaning. Gaining an understanding of the client's perception of the stressors can provide insight about ways to handle them.
• Advise the client not to use caffeine, nicotine, or alcohol to cope with anxiety. Nicotine and caffeine are stimulants; alcohol acts initially as a depressant but then requires increased use to achieve the same effect, potentially leading to alcohol abuse.

Short-Term Goal #2: The client will verbalize knowledge of effective coping skills.

Interventions and Rationales

• Help the client identify and explore effective coping mechanisms used in past situations. Establishing a baseline for the level of current functioning enables the nurse to build on the client's knowledge.
• Help the client identify and discuss ways of coping that are helpful or detrimental. The client needs to differentiate between positive and negative coping strategies and recognize optimal ways ofcoping.
• Teach the client the coping strategy of limiting worry time to a specified interval, for example, 15 minutes. This procedure helps the client set boundaries on worrying but doesn t deny the clients concerns.
• Introduce the client to new adaptive strategies for coping with anxiety, such as exercise and relaxation techniques. New coping strategies can facilitate the client's taking personal responsibility for making changes.
• Teach the client appropriate ways to label and express feelings. This promotes adaptive coping by labeling the feeling and discussing it.
• Teach the client problem-solving skills, such as formulating a goal and devising a plan to meet that goal. Being able to problem solve enhances the client's feelings of competency and control over situations.
• Encourage the client to use a journal to record feelings, behaviors, stressful events, and coping strategies used to address the anxiety. Documentation may help the client develop an increased awareness about the anxiety and evaluate how it affected overall functioning.
• Explore stressful situations associated with specific roles or activities, such as relationships, job, and special days. Identifying anxiety specific to certain situations enables the client to develop appropriate ways to counter it.

Short-Term Goal #3: The client will seek assistance from others when anxiety is either escalating or difficult to monitor.

Interventions and Rationales

• Explore with the client how to identify indicators of mounting anxiety. Being able to identify escalating anxiety enables the client to seek assistance before the anxiety is out of control.
• Provide the client with telephone numbers for mental health clinics or hot line services for crisis situations. Having this information facilitates the client's ability to obtain assistance when necessary.
• Administer ant anxiety medication as prescribed when the client's symptoms are interfering with ability to function, dedications can decrease physical symptoms and enhance the ability to deal with stress.
• Work with the client to establish a support system, including friends, family, community mental health facilities, and support groups. A support system provides the client with a vehicle for obtaining assistance when needed. Support groups can facilitate a positive sense of self encourage responsibility for mental health, and provide a place to share feelings and concerns.

NURSING DIAGNOSIS: KNOWLEDGE DEFICIT ABOUT COPING WITH ANXIETY

Probable Causes	Defining Characteristics
Lack of effective role models Lack of adequate coping skills Cognitive impairment Preoccupation with physiologic problems High level of anxiety	Verbalization of lack of knowledge about what to do Inability to act on information Inappropriate behaviors Anxiety over lack of information Difficulty problem solving

Long-Term Goal
The client will verbalize knowledge about coping with anxiety.

Short-Term Goal #1:The client will identify anxiety-provoking concerns or stressors and request information about effective ways to deal with the anxiety.

Interventions and Rationales

• Help the client identify and discuss areas of anxiety-associated worries and concerns, and encourage the client to identify patterns of repeated attempts to cope with anxiety. This enables the client to focus on specific areas in which increased knowledge would be helpful.
• Teach the client to identify, label, and talk about feelings. Many clients don t know how to label their own feelings and aren't accustomed to talking about them: the nurse can teach clients this skill.
• Work with the client to establish limits on unacceptable behavior toward self and others. The client must learn how to control behavior that poses a danger to self and others.
• Teach the client skills for handling immediate and unexpected distress, such as seeking help from others and thinking of different ways to handle the problem and then selecting the best or next best solution. The development of a strategy to handle immediate crisislike situations promotes the clients security and belief in self.
• Teach the client anxiety-reduction techniques, such as affective coping methods (hoping things can be changed, crying to release tension, working off tension, or obtaining help or comfort from others) and problem-focused coping methods (trying to maintain some control over the situation, getting another opinion, drawing on experience, or trying different ways of solving the problem). Knowledge of anxiety-reduction techniques enables the client to make decisions about the direction life will take.

Short-Term Goal #2: The client will practice skills that decrease anxiety and promote well-being.

Interventions and Rationales

• Help the client identify and discuss all the anxiety management skills that have been taught by the nurse. This enhances client awareness of anxiety-reducing measures.
• Work with the client to enhance problem-solving abilities by giving the client increasingly complex situations to master. Opportunities to practice problem solving enables the client to expand his existing level of coping skills.
• Work with the client to focus attention on stressors. Dealing with the present helps the client recognize and intervene quickly with anxiety-producing situations.
• Encourage the client to establish a routine for daily activities. A predictable environment assists in reducing anxiety about daily events.

THERAPIES

Individual Therapy

• Encourage the client to develop insight by exploring the symbolic meanings of the anxiety.
• Work with the client to identify situations that precipitate anxiety, cultivating different ways of handling the stressors.
• Teach and promote coping abilities and healthy lifestyle skills.
• Monitor for early signs of depression.

MEDICATIONS

• Antianxiety drugs are used to ameliorate symptoms of anxiety. (See Appendix D for medication information.)

FAMILY CARE

• Help the family understand the client's anxiety disorder and its physical, emotional, and behavioral components.
• Identify what family members must learn to effectively handle their own anxiety in addition to helping the client deal with personal anxiety.
• Assess the typical level of family functioning.
• Explore the possible ways that the client's behavior is disruptive to the family.
• Discuss the client's roles in the family and the problems that occur when these roles aren't fulfilled.
• Assess the family's ability to problem solve and handle urgent situations.
• Remind the family that the client may require assistance in monitoring diet, nutrition, sleep, and exercise.
• Teach the family not to take over for the client during periods of anxiety.
• Encourage the family to give attention to the client rather than to the client's symptoms; otherwise, the client may obtain a secondary gain from the distress.
• Make referrals as appropriate if the family needs additional assistance from community resources.