GENERALISED ANXIETY DISORDER

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1. SEMINAR ON GENERALISED ANXIETY DISORDER BY:- MR. SUNIL KUMAR FINAL YEAR M.SC B.V.C.O.N.PUNE

2. ANXIETY DEFINITION:- A FEELING OF WORRY, NERVOUSNESS, OR UNEASE ABOUT SOMETHING WITH AN UNCERTAIN OUTCOME.

3. ANXIETY DISORDER Anxiety disorder: A chronic condition characterized by an excessive and persistent sense of apprehension, with physical symptoms such as sweating, palpitation, and feelings of  stress.

4. CLASSIFICATION OF ANXIETY DISORDER Panic disorders Generalised anxiety disorders Phobic disorders Obsessive-compulsive disorders Post-traumatic stress disorders Related disorders

5. Generalised anxiety disorder (GAD) is usually characterised by chronic anxiety unrealistic and excessive anxiety and worry, that is uncomfortable to the point of interfering with daily life. A person with GAD worries excessively and feels highly anxious at least 50 per cent of the time for six months or more.

6. ETIOLOGY OF GAD As with many mental health conditions, the exact cause of generalized anxiety disorder isn't fully understood, but it may include genetics as well as other risk factors. RISK FACTORS- These factors may increase the risk of developing generalized anxiety disorder: Personality.  A person whose temperament is timid or negative or who avoids anything dangerous may be more prone to generalized anxiety disorder than others are. Genetics.  Generalized anxiety disorder may run in families. Being female.  Women are diagnosed with generalized anxiety disorder somewhat more often than men are.

7. MEDICAL CONDITION:- The following medical conditions have been associated to a greater degree with individuals who suffer from GAD than in general population: Abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes. Acute myocardial infarction. Phenochromocytomas. Substance intoxication and withdrawal (cocaine, alcohol, marijuana, opioids). Hypoglycaemia. Caffeine intoxication. Mitral valve prolapses. Complex partial seizures .

8. SIGN AND SYMPTOMS OF GAD The symptoms of generalized anxiety disorder fluctuate. You may notice better and worse times of the day. Not everyone with generalized anxiety disorder has the same symptoms. But most people with GAD experience a combination of a number of the following emotional, behavioural, and physical symptoms.

9. EMOTIONAL SYMPTOMS OF GENERALIZED ANXIETY DISORDER Constant worries running through your head Feeling like your anxiety is uncontrollable; there is nothing you can do to stop the worrying Intrusive thoughts about things that make you anxious; you try to avoid thinking about them, but you can’t An inability to tolerate uncertainty; you need to know what’s going to happen in the future A pervasive feeling of apprehension or dread

10. BEHAVIOURAL SYMPTOMS OF GENERALIZED ANXIETY DISORDER Inability to relax, enjoy quiet time, or be by yourself Difficulty concentrating or focusing on things Putting things off because you feel overwhelmed Avoiding situations that make you anxious

11. PHYSICAL SYMPTOMS OF GENERALIZED ANXIETY DISORDER Feeling tense; having muscle tightness or body aches Having trouble falling asleep or staying asleep because your mind won’t quit Feeling edgy, restless, or jumpy Stomach problems, nausea, diarrhoea

12. ICD-10 criteria ICD-10 Generalized anxiety disorder "F41.1" Note: For children different criteria may be applied (see F93.80 ). A period of at least six months with prominent tension, worry and feelings of apprehension, about everyday events and problems . B. At least four symptoms out of the following list of items must be present, of which at least one from items (1) to (4 ).

13. Autonomic arousal symptoms ( 1) Palpitations or pounding heart, or accelerated heart rate . ( 2) Sweating . ( 3) Trembling or shaking . ( 4) Dry mouth (not due to medication or dehydration ).

14. Symptoms concerning chest and abdomen ( 5) Difficulty breathing. ( 6) Feeling of choking. ( 7) Chest pain or discomfort. ( 8) Nausea or abdominal distress (e.g. churning in stomach).

15. Symptoms concerning brain and mind ( 9) Feeling dizzy, unsteady, faint or light-headed . ( 10) Feelings that objects are unreal (derealisation), or that one's self is distant or "not really here" ( depersonalization ) . ( 11) Fear of losing control, going crazy, or passing out . 12 ) Fear of dying . General symptoms ( 13) Hot flushes or cold chills . ( 14) Numbness or tingling sensations.

16. Symptoms of tension ( 15) Muscle tension or aches and pains . ( 16) Restlessness and inability to relax . ( 17) Feeling keyed up, or on edge, or of mental tension . ( 18) A sensation of a lump in the throat, or difficulty with swallowing .

17. Other non-specific symptoms ( 19) Exaggerated response to minor surprises or being startled . ( 20) Difficulty in concentrating, or mind going blank, because of worrying or anxiety . ( 21) Persistent irritability . ( 22) Difficulty getting to sleep because of worrying.

18. DIFFERENCE B/W NORMAL WORRY AND GAD NORMAL “WORRY” Your worrying doesn’t get in the way of your daily activities and responsibilities . You’re able to control your worrying . Your worries, while unpleasant, don’t cause significant distress . Your worries are limited to a specific, small number of realistic concerns . Your bouts of worrying last for only a short time period . GENERALISED ANXIETY DISORDER Your worrying significantly disrupts your job, activities , or social life . Your worrying is uncontrollable . Your worries are extremely upsetting and stressful. You worry about all sorts of things, and tend to expect the worst . You’ve been worrying almost every day for at least six months.

19. DIAGNOSTIC CRITERIA FOR GAD To help diagnose generalized anxiety disorder, your health provider may :- Do a physical exam to look for signs that your anxiety might be linked to an underlying medical condition Order blood or urine tests or other tests, if a medical condition is suspected Ask detailed questions about your symptoms and medical history Use psychological questionnaires to help determine a diagnosis

20. DSM-5 criteria for generalized anxiety disorder include: Excessive anxiety and worry about several events or activities most days of the week for at least six months Difficulty controlling your feelings of worry Anxiety or worry that causes you significant distress or interferes with your daily life

21. At least three of the following symptoms in adults and one of the following in children : Restlessness, Fatigue, Trouble concentrating, Irritability, Muscle tension or Sleep problems Anxiety that isn't related to another mental health condition, such as panic attacks or post-traumatic stress disorder (PTSD), substance abuse, or a medical condition

22. Generalized anxiety disorder often occurs along with other mental health problems, which can make diagnosis and treatment more challenging. Some disorders that commonly occur with generalized anxiety disorder include: Phobias Panic disorder Depression Substance abuse PTSD

23. TREATMENT AND DRUGS:- The two main treatments for generalized anxiety disorder are psychotherapy and medications. You may benefit most from a combination of the two. It may take some trial and error to discover which treatments work best for you.

24. PSYCHOTHERAPY Also known as talk therapy or psychological counselling, psychotherapy involves working with a therapist to reduce your anxiety symptoms. It can be an effective treatment for generalized anxiety disorder. Cognitive behavioural therapy is one of the most effective forms of psychotherapy for generalized anxiety disorder. Generally a short-term treatment, cognitive behavioural therapy focuses on teaching you specific skills to gradually return to the activities you've avoided because of anxiety. Through this process, your symptoms improve as you build on your initial success.

25. MEDICATIONS The drugs used for GAD will be : Benzodiazepines Buspirone (anti-anxiety medication ) Alpidem ( Alpidem  ( Ananxyl ) is an anxiolytic drug from the imidazopyridine family, related to the more well-known sleeping medication zolpidem ) Tricyclic drug or beta-adrenergic antigens (e.g., propranolol).

26. NURSING MANAGEMENT:- The assessment for GAD will be on the basis of following essential features of disorders: Excessive anxiety and worry about a number of events that the individual finds difficulty to control Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind “going black” Irritability Muscle tension Sleep disturbance (difficulty – falling or staying asleep or restless, unsatisfying sleep).

27. NURSING DIAGNOSIS Panic anxiety related to real or perceived threat to biological integrity or self- concept evidenced by any or all of the physical symptoms identified by the DSM-IV-TR as being descriptive of GAD. Powerless related to impaired cognition evidenced by verbal expressions of no control over life situation and nonparticipation in decision making related to own care or life situation. Hopelessness Impaired social communication Irritability

28. PLANNING: The following criteria may be used for measurement of outcomes in the care of the client with GAD . The same may be used as an objective, in which the client: Is able to recognise signs of escalating anxiety. Is able to intervene so that anxiety does not reach the panic level. Is able to discuss long-term plan to prevent panic anxiety when stressful situation occurs. Practices techniques of relaxation daily.

29. Engages in physical exercise three time a week Perform activity of daily living independently. Express satisfaction for independent functioning. Is able to maintain anxiety at manageable level without use of medication. Is able to participant in decision making, thereby maintaining control over life situation. Verbalised acceptance of life situations over with he or she has no control.

30. IMPLEMENTATION:- Maintain safety for the client and the environment. Assess own level of anxiety and make a conscious effort to remain calm. Anxiety is readily transferable from one person to another person. Recognise the client’s use of relief behaviours (pacing writing of hands) as indicators of anxiety. Early intervention help to manage anxiety before symptoms escalate to more serious levels. Inform the client of the important of limiting caffeine, nicotine, and other central nervous system stimulant. Limiting these substances prevents/ minimizes physical symptoms of anxiety, such as rapid heart rate.

31. Teach the client to distinguish between that is connected to identifiable objects or sources (illness prognosis, hospitalization known stressors) and anxiety for which there is no immediate identifiable objects or source. Knowledge of anxiety and its related components increases the client control over the disorders.

32. Instruct the client in the following anxiety reducing strategies. These help lessen anxiety in a variety of ways and distract the client from focusing on the anxiety. Progressive relaxation technique Mindful meditation Slow deep-breathing exercise Focusing on a single object in the room Listening of soothing music and relaxation tapes -Visual imagery or natural related DVD productions

33. HELP THE CLIENT build on coping methods that the client used to manage anxiety in the past. Coping methods that were previously successful with generally be affective in subsequently situation. Activate the client to identify support persons who will help the client perform personal tasks and activities that current circumstances make difficulty (such as a partial hospitalization program or a short stay hospitalization). A strong support system will help the client avoid anxiety-provoking situations/activities.

34. Assist the client in gaining control of overwhelming feelings and impulses through brief direct verbal interactions. Individual interactions executed at appropriate intervals will reduce/manage client’s anxious feeling/impulses. Help the client structure the environment so that it is less noisy. A less stimulating environment creates a calming stress-free atmosphere that reduces anxiety.

35. Assess the presence and degree of depression and suicidal ideation in all clients with anxiety and related disorders. A through assessments result in early intervention that will possibly prevent self-harm. Administer anxiolytic (antianxiety) medication as a least restrictive measure. Medication is often the first appropriate method to reduce debilitating anxiety. Help the client to understand the importance of the medication regimen and to take it as prescribed. Medication is an effective addition to other psychosocial therapeutic interventions when necessary.

36. A CASE OF GAD A case of 50 years old man, MR. RP was admitted to the Psychiatric Hospital for treatment of a generalised anxiety disorder. On clinical initial assessment, the student nurse noted that Mr RP was 1. Quite restless 2. Sitting on the edge of the bed. 3. Fidgeting with his gown. 4. He constantly rearranged his personal items on the bedside stand. 5. Complaints of dizziness, an upset stomach, insomnia and frequency of urination noted. 6. Mr.RP appears to be easily distracted as people walk into the room. 7. He was impatient with the student nurse taking vitals signs. His hands are cold and clammy and the radial pulse was 120 beats/min.

37. During post clinical conference, the students nurse shared her feelings of irritation about RP. She also state that the client’s anxiety was “infectious” and that she found herself becoming tense although she tried to remain calm during the admission procedure. Another student stated that she would have given RP a sedative first to allow him to settle down and then would have attempted to carry out initial assessment. The group discuss interpersonal reaction with persons who exhibit clinical symptoms or GA. And how easy it would be to avoid contact with the patient.

38. RESEARCH According to pim cuijpers at all, in their study The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons, researcher Although psychotherapy and antidepressant medication are efficacious in the treatment of depressive and anxiety disorders, it is not known whether they are equally efficacious for all types of disorders, and whether all types of psychotherapy and antidepressants are equally efficacious for each disorder ..

39. So researcher conducted a meta-analysis of studies in which psychotherapy and antidepressant medication were directly compared in the treatment of depressive and anxiety disorders RESULT:- The overall effect size indicating the difference between psychotherapy and pharmacotherapy after treatment in all disorders was g=0.02 (95% CI: −0.07 to 0.10), which was not statistically significant. So researcher got both are effective but there is no comparison between both.

40. REFERENCE :- Louise R. Basics Conceptsof Psychiatric-Mental Health Nursing.6 th ed. Philadelphia.Williams and Wilkins.2005.p.300-3. Mary A. Psychiatric Nursing: Contemporary Practice.2 nd ed.Philadelphia.Williams and Wilkins.2002.p.491-8 BT Basavanthappa.Essentials of Mental Health Nursing.New Delhi.Jaypee Brothers Medical Publishers.2011.p.334-8 BT Basavanthappa.Essentials of Mental Health Nursing.New Delhi.Jaypee Brothers Medical Publishers.2000.p.13.1-10. https://en.wikipedia.org/wiki/Anxiety_disorder http://www.medicinenet.com/script/main/art.asp?articlekey=9948 http://www.adaa.org/generalized-anxiety-disorder-gad