Selective serotonin reuptake inhibitors (SSRIs) are often the first line of treatment for anxiety because of their effectiveness and low risk of adverse reactions. SSRIs are effective in treating all types of anxiety disorders, including panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. The SSRIs used to treat anxiety disorders include fluoxetine, sertraline, paroxetine, and fluvoxamine. Adverse reactions include sexual dysfunction, gastrointestinal upset, mild sedation, and restlessness. Often these adverse reactions decrease after 2 to 4 weeks on the medication. For persistent adverse reactions, switching from one SSRI to another may alleviate them.
Although considered safe, SSRIs do pose these risks:
* discontinuation syndrome—the patient may experience such signs and symptoms as dizziness, headache, diarrhea, insomnia, irritability, nausea, and lowered mood if she abruptly stops taking the medication
* drug interactions—taking an SSRI with warfarin or certain medications used to treat cardiac disorders or diabetes can increase one medication level and decrease the other
* serotonin syndrome—this potentially fatal reaction to medications that elevate serotonin levels can cause tremor, diarrhea, hyperthermia, agitation, tachycardia, labile BP, changes in mental status, and diaphoresis; a patient with severe serotonin syndrome can develop seizures, respiratory failure, and coma.
If your patient is prescribed an SSRI, stress that it may take 4 to 6 weeks of therapy before the full benefits are realized. Warn her not to abruptly stop taking the medication to avoid discontinuation syndrome. Pregnant women should avoid paroxetine due to increased risk of birth defects.
Tricyclic antidepressants, such as amitriptyline, clomipramine, desipramine, imipramine, and nortriptyline, may be used to treat panic disorder, posttraumatic stress disorder, and phobic disorders. In fact, clomipramine is one of the most effective drugs for relieving symptoms of obsessive-compulsive disorder. These older antidepressants are less expensive than newer agents, but have more adverse reactions, including high anticholinergic effects such as dry mouth, dry eyes, constipation, weight gain, and sedation. Teach your patient to drink plenty of fluids and increase dietary fruit and fiber to avoid constipation. These medications may cause fatal cardiac arrhythmias, especially when taken as an overdose in suicidal patients. The patient should be monitored for hypoglycemia and hyperglycemia. Tricyclic antidepressants are contraindicated in patients with glaucoma or benign prostatic hyperplasia.
Can we talk?
Psychotherapy, or talk therapy, is vital in the treatment of anxiety. If a patient is experiencing only mild anxiety, it may be an effective treatment on its own without the need for medication. However, most patients with an anxiety disorder have better outcomes with a combination of psychotherapy and medications. Some of the psychotherapeutic approaches used to treat anxiety disorders include cognitive-behavioral therapy, psychodynamic therapy, and group therapy.
Cognitive-behavioral therapy is both cost effective and efficacious in the treatment of anxiety disorders. The goal is to change the automatic thoughts that occur spontaneously and contribute to dysfunctional thinking. Behavioral therapists believe that emotions are a learned response to stressors. A person with an anxiety disorder may have faulty cognitive processes that interpret each event as a catastrophe. For example, a person experiences car trouble on a snowy road. A person with an anxiety disorder starts to think of all the negative things that can occur as a result of the car trouble. These thoughts increase anxious feelings. A person without an anxiety disorder will view the stressor of car trouble realistically, planning how to get help to get the car fixed. The two different conclusions are influenced by each person's automatic thoughts that influence her conclusions and emotional responses.
The behavioral therapist uses cognitive restructuring to help the patient identify the habitual unhealthy ways in which she reacts to situations. By pointing out errors of thinking and logic that contribute to dysfunctional behavior, the therapist assists the patient to change her thinking about the situation and, thus, her emotional response.
Psychodynamic therapy links anxiety to trauma or conflicts that happened in childhood. For example, a person with posttraumatic stress disorder may have been abused as a child and now lacks self-esteem as an adult. The therapist helps the patient establish a link between the abuse and her current feelings. Exploring how past events and traumas affect different aspects of her life is also important in this type of therapy.
Group therapy allows a person to meet with others who are also experiencing the same anxiety disorder. Being able to share feelings with others helps the patient to heal, and getting suggestions from people with a similar disorder can help her cope with events or relationships. Knowing that she isn't the only one feeling anxious is an additional source of support.
Guided exposure therapy is commonly used for patients with specific phobias. For example, teaching relaxation and imagery techniques and educating the patient about her problem, treatment, and signs of relapse can help her manage panic disorder.
EMDR is a newer short-term therapy for anxiety disorders based on the different functions of the right and left sides of the brain. A therapist gently encourages the patient to pinpoint a problem or event that she'll focus on during multiple sessions. During each therapy session, she focuses on a distressing image she associates with the event and identifies negative emotions and sensations while shifting her gaze from side to side. As she uncovers thoughts and feelings associated with the event, the therapist works to redirect her eye movements that accompany the recalled experience. Redirecting eye movements helps her release accompanying emotions. The technique is continued until her dysfunctional emotions are neutralized and positive feelings or thoughts replace it. For example, EMDR may help someone suffering from posttraumatic stress disorder who flashes back to the negative feelings associated with the trauma during daily events. The therapy aims to redirect those negative feelings and decrease her symptoms.
Patients with an anxiety disorder can be identified in any healthcare setting. Your nursing interventions include assessing and protecting your patient, administering medications and monitoring their effects and her response to treatment, and teaching her and her family about the disorder.
* Take a health history and perform a thorough physical assessment. The patient's health history should cover personal and family history of mental illness, suicide, or substance abuse, which is strongly linked to any type of mental illness.
* Perform a mental status exam.
* Evaluate suicide risk and follow facility policy to protect the patient if she has an increased risk.
* Become familiar with the medications used to treat anxiety disorder, including their actions and potential adverse reactions.
* Check for drug interactions if the patient is taking other medications.
* Administer medications and make sure the patient takes them as ordered.
* Teach the patient and her family (with her permission) about the disorder: The nature of the illness, expected effects of medications, signs and symptoms of relapse, and the importance of continuing treatment are key issues to cover. Also teach her not to abruptly stop taking her medication, even if she feels better.
* Suggest resources such as the National Alliance on Mental Illness (http://www.nami.org) where the patient and her family can learn more about the disorder and its treatment and get support.
Serious but treatable
Anxiety disorder is a serious illness, but it can be effectively treated with the many therapeutic options available today. By understanding the signs and symptoms of the different types of anxiety disorders and taking appropriate steps to help your patient manage them, you'll improve her prognosis and help her live a more normal life.
Assessing anxiety in children
Assessment of anxiety disorders in children is often difficult because many other psychiatric disorders share similar symptoms. Restlessness, difficulty concentrating, and increased aggression are some of the symptoms present in a child experiencing an anxiety disorder, but these may also be indicative of anxious depression or attention deficit disorder. Diagnostic tools available to aid in the proper diagnosis of anxiety disorders in children include the Revised Children's Manifest Anxiety Scale, the Children's Assessment Scale, and the Yale-Brown Obsessive Compulsive Scale.
DSM-IV-TR classification of anxiety disorders
* panic disorder
* generalized anxiety disorder
* posttraumatic stress disorder
* obsessive-compulsive disorder
* social phobia
* specific phobia.
Physical manifestations of anxiety
* Increased respiration
* Increased heart rate
* Increased BP
* Increased alertness
did you know?
The Agency for Healthcare Research and Quality in a new report summarizes findings from mental health research published between 2007 and 2009, including studies on mental health-related hospital stays. To read the report, go to http://www.ahrq.gov/research/mentalhth.pdf.
On the Web
These online resources may be helpful to your patients and their families:
* American Psychiatric Association: http://www.psych.org
* Anxiety Disorders Association of America: http://www.adaa.org
* Mayo Clinic: http://www.mayoclinic.com/health/generalized-anxiety-disorder/DS00502
* MedlinePlus: http://www.nlm.nih.gov/medlineplus/anxiety.html
* National Alliance on Mental Illness: http://www.nami.org
* National Institute of Mental Health: http://www.nimh.nih.gov/health/publications/anxiety-disorders/complete-index.shtml
* National Mental Health Information Center: http://mentalhealth.samhsa.gov/publications/allpubs/ken98–0045.
Learn more about it
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