NCP Generalized Anxiety Disorder

DSM-IV

300.02 Generalized anxiety disorder

Although some degree of anxiety is normal in life’s stresses, anxiety can be adaptive or maladaptive. Problems arise when the client has coping mechanisms that are inadequate to deal with the danger, which may be recognized or unrecognized. The essential feature of this inadequacy is unrealistic or excessive anxiety and worries about life circumstances. Anxiety disorders are the most common of all major groups of mental disorders in the United States, sharing comorbidity with major depression and substance abuse, increasing the client’s risk of suicide.

ETIOLOGICAL THEORIES

Psychodynamics

The Freudian view involves conflict between demands of the id and superego, with the ego serving as mediator. Anxiety occurs when the ego is not strong enough to resolve the conflict. Sullivanian theory states that fear of disapproval from the mothering figure is the basis for anxiety. Conditional love results in a fragile ego and lack of self-confidence. The individual with anxiety disorder has low self-esteem, fears failure, and is easily threatened.

Dollard and Miller (1950) believe anxiety is a learned response based on an innate drive to avoid pain. Anxiety results from being faced with two competing drives or goals.

Cognitive theory suggests that there is a disturbance in the central mechanism of cognition or information processing with the consequent disturbance in feeling and behavior. Anxiety is maintained by this distorted thinking with mistaken or dysfunctional appraisal of a situation. The individual feels vulnerable, and the distorted thinking results in a negative outcome.

Biological

Although biological and neurophysiological influences in the etiology of anxiety disorders have been investigated, no relationship has yet been established. However, there does seem to be a genetic influence with a high family incidence.

The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.

Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes, acute myocardial infarction, pheochromocytomas, substance intoxication and withdrawal, hypoglycemia, caffeine intoxication, mitral valve prolapse, and complex partial seizures.

Family Dynamics

The individual exhibiting dysfunctional behavior is seen as the representation of family system problems. The “identified patient” (IP) is carrying the problems of the other members of the family, which are seen as the result of the interrelationships (disequilibrium) between family members rather than as isolated individual problems.

It is recognized that multiple factors contribute to anxiety disorders.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Restlessness, pacing anxiously, or, if seated, restlessly moving extremities

Feeling “keyed up”/“on edge,” unable to relax

Easily fatigued

Difficulty falling or staying asleep; restlessness, unsatisfying sleep

Circulation

Heart pounding or racing/palpitations; cold and clammy hands; hot or cold spells, sweating; flushing, pallor

High resting pulse, increased blood pressure

Ego Integrity

Excessive worry about a number of events/activities, occurring more days than not for at least 6 months

Complains vociferously about inner turmoil, has difficulty controlling worry

May demand help

Facial expression in keeping with level of anxiety felt (e.g., furrowed brow, strained face, eyelid twitch)

May report history of threat to either physical integrity (illness, inadequate food and housing, etc.) or self-concept (loss of significant other; assumption of new role)

Elimination

Frequent urination; diarrhea

Food/Fluid

Lack of interest in food, dysfunctional eating pattern (e.g., responding to internal cues other than hunger)

Dry mouth, upset stomach, discomfort in the pit of the stomach, lump in the throat

Neurosensory

Absence of other mental disorder, such as depressive disorder or schizophrenia

Motor tension: shakiness, jitteriness, jumpiness, trembling, muscle tension, easily
startled

Dizziness, lightheadedness, tingling hands or feet

Apprehensive expectation: anxiety, worry, fear, rumination, anticipation of misfortune to self or others, inability to act differently (feeling stuck)

Excessive vigilance/hyperattentiveness resulting in distractibility, difficulty in concentrating or mind going blank, irritability, impatience

Free-floating anxiety usually chronic or persisting over weeks/months

Pain/Discomfort

Muscle aches, headaches

Respiratory

Increased respiratory rate, shortness of breath, smothering sensation

Sexuality

Women twice as likely to be affected as men

Social Interactions

Significant impairment in social/occupational functioning

Teaching/Learning

Age of onset usually 20s and 30s

DIAGNOSTIC STUDIES

Drug Screen: Rules out drugs as contribution to cause of symptoms.

Other diagnostic studies may be conducted to rule out physical disease as basis for individual symptoms (e.g., ECG for severe chest pain, echocardiogram for mitral valve prolapse; EEG to identify seizure activity; thyroid studies).

NURSING PRIORITIES

1. Assist client to recognize own anxiety.

2. Promote insight into anxiety and related factors.

3. Provide opportunity for learning new, adaptive coping responses.

4. Involve client and family in educational/support activities.

DISCHARGE GOALS

1. Feelings of anxiety recognized and handled appropriately.

2. Coping skills developed to manage anxiety-provoking situations.

3. Resources identified and used effectively.

4. Client/family participating in ongoing therapy program.

5. Plan in place to meet needs after discharge.