Anxiety. When is it too much?

Anxiety When is it too much? 22 Nursing made Incredibly Easy! September/October 2005

C E 2.5 ANCC/AACN CONTACT HOURS In a modern society full of pressures and conflicts, anxiety is a common component of the human condition. Anxiety disorders serious and disabling conditions require treatment. We ll explain the various types of anxiety disorders and describe how drugs and psychotherapy can help your patient emerge from a nightmarish existence warped by paralyzing fear. KATHRYN MURPHY, NP, CS, MSN Nursing Faculty Muskegon Community College Muskegon, Mich. The author has disclosed that she has no significant relationships with or financial interest in any commerical companies that pertain to this educational activity. ANXIOUS? AFRAID? If you re not, you aren t paying attention! Ever-increasing work assignments, sicker patients, growing piles of paperwork, conflicting responsibilities of work and family, and financial uncertainty are common stressors that keep many of us from getting a peaceful night s sleep. Let s face it: Stress is an inescapable part of modern living, and anxiety is a normal reaction to the constant tension in our lives. It may even be a positive factor because it can help give us the competitive edge we need to ace an exam, wow em in a job interview, or make a clutch hit in the final and deciding game in a ball tournament. But for millions of people, anxiety becomes maladaptive and negatively impacts their capacity to carry out even the simplest activities of daily living (ADLs). Fear becomes a constant, unwelcome companion, draining the joy out of life. In this article, I ll help you understand the various kinds of anxiety disorders and the treatments that are available. Been down so long it looks like up to me Just about everyone experiences some degree of anxiety at one time or another. So what separates normal routine anxiety from an anxiety disorder? Duration, for one thing. Normal anxiety disappears when the danger or stressor goes away exam over, time to relax. Abnormal anxiety persists when the stressor is no longer there, or even arises in the absence of a precipitating event. Abnormal anxiety prevents people from effectively functioning at work, at school, in social situations, and in personal relationships. Along with the paralyzing emotional fear, anxiety creates powerful physical symptoms too, including increased respiratory rate, heart rate, and blood pressure. Restlessness, diaphoresis, dizziness, light-headedness, and tremors may also occur. It s these continued physical manifestations that often propel the person to seek medical attention. According to the National Comorbidity Survey, a large government-funded study carried out in the early 1990s, one out of every four people exhibits symptoms of an anxiety disorder at some time in his or her life. Women are twice as likely as men to be affected. Anxiety disorders are the most prevalent mental illness in older adults and children. Nearly 9% of children suffer some significant disruption in daily functioning from anxiety, while over 17% exhibit milder symptoms (see Across the age spectrum). Why one person develops a full-blown mental illness and another doesn t isn t completely understood. External events and intrinsic biochemical imbalances are all believed to contribute to the development of anxiety disorders; many people exhibit a September/October 2005 Nursing made Incredibly Easy! 23

combination of these factors. A genetic component also seems to play a part in anxiety disorders, and family history may indicate a biological predisposition. For example, if an individual has a first-degree relative with an anxiety disorder, he s at increased risk for developing one too. Now let s look at the neurobiology of anxiety to help you understand what s happening in the body when anxiety strikes. Run for your life! Fear triggers an automatic, rapid-fire response before the rational mind even has a chance to think, Yikes! That truck s coming right for me! This unthinking reaction is coordinated by the amygdala. This small structure deep inside the brain is part of our primitive lizard brain, which also encompasses the thalamus and hypothalamus. The amygdala is the control center for the instinct to survive. Besides making the heart pound, the amygdala diverts blood from the digestive system to the muscles, floods the bloodstream with stress hormones (epinephrine and norepinephrine) and glucose, and suppresses the immune and pain response. The body s primed for a fight-or-flight response in less than a second. Some experts hypothesize that once a particular stimulus causes this cascade of events, the memory is hardwired into the amygdala so that the next time the threat s encountered, the response can be even quicker. It s an effective survival mechanism, but it s also why nondrug therapy, like cognitive therapy alone, doesn t work very well for anxiety; rational thought never gets a chance to kick in before the fear factor overwhelms the patient. Effective drug therapy aims to delay the amygdala-based response until the thinking mind can recognize the fact that no danger exists. Mixed messages Other factors may contribute to making the survival instinct run amok. Researchers have observed repeatedly that an imbalance of neurotransmitters in the brain contributes to anxiety disorders. Neurotransmitters are the chemical vehicles that allow the smooth transmission of impulses from one neuron to the next through the synapses (the junction between neurons). The major neurotransmitter systems involved in anxiety disorders are gamma-aminobutyric acid (GABA), norepinephrine, and serotonin. Here s how the process normally works. Neurotransmitters are produced in the neurons of the nervous system and stored in the synaptic vesicles until they re released. Afterwards, any neurotransmitters that go unused are sent back to storage through a reuptake mechanism in the presynaptic neurons. In anxiety, this process can break down. For example, serotonin may not be released in adequate amounts. Administering Across the age spectrum As you can see, anxiety is an equal opportunity condition. Children Anxiety disorders are the most common psychiatric disorders in children, but they re often unrecognized and untreated. Social phobia, separation anxiety, generalized anxiety disorder, and obsessive-compulsive disorder are the most common childhood anxiety disorders. Symptoms of anxiety disorders usually worsen over time and precede the onset of adult anxiety disorders, especially panic disorder. Older adults More than 11% of older adults have anxiety disorders, and these disorders often exist with other psychiatric disorders. If left untreated, anxiety disorders can complicate other medical conditions common in older adults, such as hypertension and diabetes. Consider a patient s age-related physiologic changes (reduced renal and hepatic function) when administering medications. Dosages may need to be reduced in patients with impaired renal and hepatic function. Because benzodiazepines can cause cognitive impairment, closely monitor older adults. September/October 2005 Nursing made Incredibly Easy! 25

Brain structures involved in the fight-or-flight response Amygdala (beneath overlying cortex) Hippocampus (beneath overlying cortex) Brain stem and cerebellum removed and brain rotated slightly medications that correct this chemical imbalance has been shown to alleviate anxiety symptoms. Also, GABA plays a role in regulating the release of norepinephrine. GABA is an inhibitory neurotransmitter associated with the relaxation response; its release decreases neuron excitability, which in turn may lessen anxiety. It s been hypothesized that anxiety disorders arise from increased activation of the autonomic nervous system (which controls organs and muscles in an involuntary, reflexive way) and arousal of the limbic system (the olfactory cortex, amygdala, and hippocampus), both of which pump up the individual for increased mental and physical demands. Activation of these systems leads to increased release of norepinephrine, which floods the neuronal synapses. The physical symptoms of anxiety increased heart rate, respirations, and blood pressure are normal and appropriate in certain situations. When these systems become hypersensitive and launch the fightor-flight response inappropriately, however, the patient is thrown into an abnormal state of chronic high anxiety. Now let s look at the types of anxiety disorders. First, though, I want to make sure you understand that assessing for an anxiety disorder isn t like looking for a broken bone. Anxiety is expressed in many different ways, not just by an awful sense of fear. A person with an anxiety disorder may complain of symptoms of depersonalization (the sense of observing oneself from the outside) and derealization (a change in perception of one s environment that makes it seem foreign or unfamiliar). He may say he feels like he s losing his mind or he s spaced-out. To further complicate matters, symptoms may vary among cultural and ethnic groups, according to cultural beliefs, customs, and health practices. Geographic differences are significant too. What a person who lives in Manhattan considers to be a normal level of anxiety is, more than likely, a notch or two more intense than what s perceived as normal by a resident of a small town in America s heartland. Keep these subtle and intangible variables in mind when you re assessing a patient for anxiety disorder. Assessing children for anxiety brings in yet another layer of difficulty because so many other psychiatric disorders have similar symptoms in kids. Restlessness and difficulty concentrating are symptoms that may be present in an anxiety disorder, but they can also indicate an anxious depressive state or attention deficit disorder. Certain tools specifically address the proper diagnosis of an anxiety disorder in children. For example, the Revised Children s Manifest Anxiety Scale (RCMAS) is designed to assess the level and nature of anxiety in children and adolescents ages 6 to 19. Takes all kinds The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR), the standard for diagnosing mental disorders, outlines the different 26 Nursing made Incredibly Easy! September/October 2005

Uh-oh...this feels like more than a fear of flying. categories of anxiety disorders. They are: acute stress disorder agoraphobia without panic disorder anxiety disorder not otherwise specified generalized anxiety disorder panic disorder with or without agoraphobia post-traumatic stress disorder obsessive-compulsive disorder social phobia specific phobia. All anxiety disorders have these symptoms in common: extreme fear in the absence of real threat, emotional distress that interferes with ADLs, and avoidance of situations that are seen as having the potential to trigger anxiety. Each type of anxiety disorder has its own unique set of symptoms, and treatments may vary for each category. Let s examine some of them more closely. Panic in the park and elsewhere Over 15% of the adult population experience a panic attack at some time in their lives; only 3.5% meet the full DSM-IV-TR criteria for panic disorder. Isolated panic attacks can occur under very specific circumstances, like when a woman with a fear of flying boards a plane or a painfully shy man is called on to propose a toast at a wedding reception. In panic disorder, the symptoms can appear suddenly without any triggering event. Patients are generally in their 30s when they re diagnosed with panic disorder. Severity of symptoms ranges from mild, with little effect on ADLs, to severe, with significant negative impact on ADLs. Frequency of panic attacks can range from several times a day to once every couple of months. Panic disorder exists with or without agoraphobia. When a person has agoraphobia too, he has a fear of being trapped in a situation or place where escape is difficult or impossible, causing panic. Agoraphobia can progress to the point where the person becomes isolated and incapable of leaving the safety of his home. Panic disorder without agoraphobia is defined in the DSM-IV-TR as: recurrent, unexpected panic attacks and at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: (1) persistent concern over having another panic attack, (2) worry about the implications or consequences of the panic attacks, or (3) a significant change in behavior related to the panic attacks absence of agoraphobia panic attacks that aren t related to an ingested substance or general medical condition panic attacks that aren t better explained by another anxiety disorder. This is really scary! Phobic disorders can be specific (formerly called simple phobia) or generalized (social phobia). Specific phobias are characterized by persistent, excessive, unreasonable fear in the presence or anticipation of a specific situation or object. The avoidance, anxious anticipation, or distress caused by the object of fear interferes significantly with the person s normal routine, job or school, and social interactions. Often the person feels distress about having the phobia. Social phobia, or social anxiety disorder, is extreme anxiety in social situations marked by an intense and persistent feeling of being closely scrutinized and judged in a negative way. The person fears and often avoids situations that he perceives as exposing him to embarrassment and humiliation. The nonprofit Social Phobia/Social Anxiety Association gives the example of a person who can t bear to stand in line at the supermarket because he has the overwhelming feeling that everyone s staring at him. September/October 2005 Nursing made Incredibly Easy! 27

did you know? Psychosurgery was in vogue as a treatment for mental illness, including severe anxiety, well into the 1970s. Earlier in the 20th century, frontal lobotomy was seen as a sort of panacea. This procedure is largely discredited today. Onset of social phobia disorder can begin as early as childhood. It s estimated that between 7% and 10% of the population suffers from social phobia disorder; it occurs equally in men and women. It s quiet too quiet! A patient with generalized anxiety disorder (GAD) is often described as a worrywart. This person will find something to worry about even when there isn t anything to worry about. So what distinguishes a normal worrywart from a person with GAD? Simply this: The pervasive, uncontrollable worrying interferes with the person s ADLs and creates significant distress. Symptoms like nervousness, anxiety, restlessness, tachycardia, shortness of breath, insomnia, and agitation are constant. GAD usually appears in the second decade of life and is chronic. Depression can often underlie GAD. Over and over again Obsessive-compulsive disorder (OCD) usually begins in adolescence or early adulthood and runs a chronic course. It presents equally in men and women. Let s look at each of the two parts. Obsessions are intrusive, recurrent thoughts, impulses, or images that interfere with ADLs and cause distress. Common obsessions in OCD include contamination, the need for order, the compulsion to steal, and sexual possessiveness. Compulsions are recurrent, irrational, infinitely repetitive behaviors, like hand-washing, hoarding, or housecleaning. Many people do have mild obsessive-compulsive tendencies, and their homes sparkle; when, however, the obsessions and compulsions are constant and overwhelming, interfere with daily functioning, and cause great distress, a diagnosis of OCD may be in order. Look back in anger Post-traumatic stress disorder (PTSD) is described in DSM-IV-TR as the development of specific symptoms after exposure to an extreme traumatic event or series of events that involves a threat to their own or another s life or physical integrity and that they respond to with feelings of intense fear, helplessness, or horror. The common image of a patient with PTSD is the soldier who s plagued by constant reminders of the horrors of war he witnessed in nightmares and flashbacks. (The Department of Veterans Affairs created the National Center for Post-Traumatic Stress Disorder in 1989.) People victimized by rape, child sexual abuse, or violent crime, or who ve survived a massive natural or manmade disaster or horrific accident may also suffer from PTSD. Survivors of such traumas often express guilt and question their own survival. These same events can cause PTSD in children. We ve looked at the types and characteristics of anxiety disorders. Now let s look at some of the treatments. We ll start with medical treatment. Chill pill A number of medications like benzodiazepines, beta-blockers, and certain antidepressants are quite effective in treating the symptoms of anxiety. The best drug to use mainly depends on the type of disorder. The following classes of drugs are used to treat anxiety: Benzodiazepines can effectively treat transient anxiety symptoms. Diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax), and chlordiazepoxide (Libritabs, Librium) are often used. They act on the GABA system, which helps to decrease neuronal excitability. They re used for short-term treatment of GAD, panic disorder, and social phobia, and are particularly effective in managing acute symptoms of panic attack. Common adverse effects include somnolence, slowed cognition, and abuse or dependency. Withdrawal symptoms can occur, so it s impor- 28 Nursing made Incredibly Easy! September/October 2005

These drugs can help anxious patients get back into the swing of things. tant for the patient to discontinue these medications gradually. Caution him not to drink alcohol, operate dangerous equipment, or drive, especially at the start of therapy. Buspirone (BuSpar) is in a class by itself literally. Its mechanism of action is unknown, but it exerts an effect similar to benzodiazepines in decreasing anxiety. Unlike benzodiazepines, though, it doesn t build up tolerance or create dependence; it s also less sedating. Although buspirone won t cause your patient to fall asleep behind the wheel, some patients experience persistent nausea, dizziness, light-headedness, headache, and excitement to the degree that they discontinue the drug and switch to another agent. Selective serotonin reuptake inhibitors (SSRIs) are often the first-line drug treatment for anxiety because of their effectiveness and the low adverse event profile. SSRIs most commonly used to treat anxiety disorders include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). SSRIs are effective in treating the broad spectrum of anxiety disorders. At high doses, SSRIs are even effective in treating the symptoms of OCD and PTSD, notoriously stubborn conditions. SSRIs can cause sexual dysfunction, gastrointestinal upset, mild sedation, or restlessness, especially at the beginning of therapy. For more persistent adverse effects, switching to another SSRI can alleviate the problematic effects. SSRIs can interact with other drugs. For example, fluvoxamine may increase levels of the anticoagulant warfarin (Coumadin) and increase bleeding. Refer to the prescribing information in the package insert for specific drug-drug interactions. Patients shouldn t abruptly stop taking an SSRI. If they do, they run the risk of discontinuation syndrome. This cluster of symptoms dizziness, headache, diarrhea, insomnia, irritability, nausea, tingling in the hands and face, mood lability, and lowered mood appears in up to a quarter of those patients. The syndrome usually begins 1 to 3 days after stopping SSRI therapy. Effective treatment is achieved within 24 hours by reinstating the drug. A slow taper is then instituted if the patient wishes to discontinue the drug. Also watch for serotonin syndrome, a life-threatening drug interaction that can occur when an SSRI is combined with another drug that increases the amount of serotonin, like a monoamine oxidase inhibitor. Symptoms include high temperature, restlessness, tachycardia, labile blood pressure, changes in mental status, diaphoresis, and tremors. If not recognized and treated, the result can be seizures, respiratory failure, coma, and death. Because serotonin syndrome progresses rapidly, it s important to be familiar with early signs and symptoms. Immediately discontinue all medications and notify the health care provider. The provider may order medications to block the SSRI effects and treat the hyperthermia and seizures. The cause of this syndrome isn t known. Newer selective serotonin and norepinephrine reuptake inhibitors (SSNRIs) like venlafaxine (Effexor XR) are useful in GAD. Some of the older tricyclic antidepressants used to treat anxiety disorders include clomipramine (Anafranil), desipramine (Norpramin), and imipramine (Tofranil). Tricyclic antidepressants are less expensive than the newer agents, but they produce a lot of adverse effects, including anticholinergic effects (dry mouth, dry eyes, constipation, weight gain, and sedation). Tricyclic antidepressants can also cause fatal cardiac arrhythmias, especially when taken in an overdose. Nevertheless, these medications can be effective in the treatment of panic disorder, PTSD, and September/October 2005 Nursing made Incredibly Easy! 29

Talking it out seems like a good way to get to the root of anxiety. phobic disorders. Clomipramine is one of the best treatments for relieving symptoms of OCD. Beta-blockers like propranolol (Inderal) can be an effective treatment for the physiologic symptoms of anxiety: By blocking the beta-adrenergic receptors in the sympathetic nervous system, they cause a relaxation response. Advise a patient taking a beta-blocker to get up slowly because of the possibility of orthostatic (postural) hypotension. Now let s see what nonpharmacologic treatment options are out there for your anxious patients. Talk the talk Psychotherapy, or talk therapy, in which a patient meets with a mental health professional to discuss issues and emotions, is a key component in the treatment of anxiety. Certain patients experiencing mild anxiety may do well with a course of psychotherapy alone. For treating most major anxiety, however, psychotherapy in combination with drug therapy has proven to be more effective. Some of the psychodynamic approaches used are behavioral therapy, cognitive therapy, cognitive-behavioral therapy, and psychodynamic therapy. Let s look more closely at some of the techniques used. The goal of behavioral therapy is to help the patient break the connection between anxiety-producing situations and the anxiety. Behavioral therapists believe that anxiety is a learned response to stressors. For example, a man who grew up with a father who had GAD may have learned from an early age to overreact to stressors. In therapy, the patient is taught to cope with difficult situations, unlearning the hyperresponse, often through controlled exposure to the triggering event or situation. Exposure therapy, a form of behavioral therapy, uses relaxation techniques to help the patient better tolerate proximity with anxiety-producing situations. For example, this approach could be used to treat a patient who s deathly afraid of riding in elevators. The therapist coaches the patient on how to use relaxation techniques, like diaphragmatic breathing and progressive muscle relaxation. The patient may at first just talk about riding in an elevator. Visits to the elevator bank of a high-rise building may occur, progress to a ride of a few floors duration, and culminate in repeated trips all the way up to the observation deck on top of the building and back down again to the lobby. By being exposed to the scary situation over and over in a safe, nonthreatening way, the patient is desensitized to the fear. Teaching the patient to calm his mind and body allows the rational mind to take over from the instinctive brain. Cognitive therapy teaches the patient how certain patterns of thinking can cause symptoms of anxiety by rendering a distorted picture of reality. Cognitive-behavioral therapy (CBT), a combination of cognitive and behavioral therapies, has a goal of eliminating unproductive or harmful thought patterns. The patient is taught to recognize realistic and unrealistic thoughts. As in behavioral therapy, the patient is given an active role in his treatment. According to CBT, psychological pain comes not from an event but from what an event means. For example, a patient with an anxiety disorder may exercise cognitive processes that interpret a routine inconvenience a flat tire as a catastrophe. Dry mouth, shaking hands, pounding heart, and a cold sweat accompany these anxious thoughts, and the patient may become so overwrought that he s incapable of rationally solving the difficulty. The therapist guides the patient to become able to recognize such a situation as something routine and minor that he s quite capable of solving. Psychodynamic therapy links anxiety to trauma or conflicts that happened in child- 30 Nursing made Incredibly Easy! September/October 2005

hood. For example, a patient who was abused as a child presents as an adult with PTSD. The therapist helps the patient make the link between the two. Rooting out the basis of the anxiety disorder may help the patient understand it better and gain a more positive outcome to therapy. All of the above techniques can be done in individual or group sessions. In group therapy, the patient benefits from the resources of both his therapist and other patients who have the same anxiety disorder. Fellow sufferers may provide practical suggestions on coping. Often it s good for the patient just to hear that others share his experiences and feelings. Mind-body connection Regardless of the health care setting where you practice, you may see plenty of folks with anxiety disorders patients and peers so it s important for you to learn to identify the symptoms of the various anxiety disorders and understand how medical and nonpharmacologic strategies work. Western medicine is gradually accepting the fact that the body and mind are inextricably bound. Anxiety, therefore, will affect not only your patient s emotional and mental well-being, but will also almost certainly impact his physical health. A patient with diabetes who also suffers from constant panic attacks, for example, will likely not have as positive an outcome as a patient without the stress of anxiety. Awakening to each new day with a feeling of happiness, not fear, can do all of us a world of good. Learn more about it American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, D.C., American Psychiatric Association, 2000. Can you recognize serotonin syndrome? Nursing made Incredibly Easy! 1(1):60-61, September/October 2003. Claassen JA, Gelissen HP. The serotonin syndrome. The New England Journal of Medicine. 352(23):2454-2456, June 2005. Hicks DW, Raza H. Facilitating treatment of anxiety disorders in patients with comorbid medical illness. Current Psychiatry Reports. 7(3):228-35, June 2005. Kaplan & Sadock s Comprehensive Textbook of Psychiatry, 8th edition. BJ Sadock, VA Sadock (eds.) Philadelphia, Pa., Lippincott Williams & Wilkins, 2005. Woodruff DW. SSRIs: Striking a delicate balance. Nursing made Incredibly Easy! 2(6):54-55. November/December 2004. C E Earn CE credit online: Go to http://www.nursingcenter.com/ce/nmie and receive a certificate within minutes. INSTRUCTIONS Anxiety: When is it too much? TEST INSTRUCTIONS To take the test online, go to our secure Web site at www.nursing center.com/ce/nmie. On the print form, record your answers in the test answer section of the CE enrollment form on page 47. Each question has only one correct answer. You may make copies of these forms. Complete the registration information and course evaluation. Mail the completed form and registration fee of $17.95 to: Lippincott Williams & Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will mail your certificate in 4 to 6 weeks. For faster service, include a fax number and we will fax your certificate within 2 business days of receiving your enrollment form. You will receive your CE certificate of earned contact hours and an answer key to review your results. There is no minimum passing grade. DISCOUNTS and CUSTOMER SERVICE Send two or more tests in any nursing journal published by LWW together and deduct $0.95 from the price of each test. We also offer CE accounts for hospitals and other health care facilities on nursingcenter.com. Call 1-800-787-8985 for details. PROVIDER ACCREDITATION: This Continuing Nursing Education (CNE) activity for 2.5 contact hours is provided by Lippincott Williams & Wilkins (LWW), which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center s Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 00012278, CERP Category A). This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.5 contact hours. LWW is also an approved provider of CNE in Alabama, Florida, and Iowa, and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified for Texas nursing continuing education requirements as Type 1. Your certificate is valid in all states. This means that your certificate of earned contact hours is valid no matter where you live. September/October 2005 Nursing made Incredibly Easy! 31

C E 2.5 ANCC/AACN CONTACT HOURS Anxiety: When is it too much? GENERAL PURPOSE: To familiarize the registered professional nurse with the different types of anxiety disorders and how they re treated. LEARNING OBJECTIVES: After reading the article and taking this test, you should be able to: 1. Discuss the etiology and pathophysiology of anxiety disorders. 2. Compare and contrast the types of anxiety disorders. 3. Describe treatment options for anxiety disorders. 1. Which of the following factors are related to the development of anxiety disorders? a. external events, intrinsic biochemical imbalances, and genetics b. only external events and intrinsic biochemical imbalances c. only external events and heredity 2. The instinct to survive begins in the a. sympathetic nervous system. b. endocrine system. c. amygdala. 3. The two hormones produced as part of the fight-orflight response are a. epinephrine and serotonin. b. epinephrine and norepinephrine. c. serotonin and gamma-aminobutyric acid (GABA). 4. It s theorized that anxiety disorders are resistant to cognitive therapies because a. the physiological response happens before thought occurs. b. the physiological response and cognitive processes are unrelated. c. the thought happens before the physiological response. 5. Mrs. R reports that she frequently feels she s observing her life instead of participating in it. The nurse documents that Mrs. R reports feelings of a. derealization. b. depersonalization. c. a panic attack. 6. All of the following statements about assessing patients with an anxiety disorder are true except a. patients from different ethnic cultures may exhibit different symptoms when suffering from an anxiety disorder. b. anxiety disorders can be more easily distinguished from other psychiatric or behavioral problems in children than in adults. c. the Revised Children s Manifest Anxiety Scale helps assess the level and nature of anxiety in children and adolescents. 7. Although there are a number of different types of anxiety disorders, they re all characterized by a. avoidance of situations that may trigger anxiety. b. a fear of being trapped in a situation where escape is impossible. c. feelings of intense fear after a traumatic event. 8. Mr. S seeks help because he feels a sense of panic whenever he needs to take an elevator. This symptom is an example of a. depersonalization. b. derealization. c. agoraphobia. 9. Mrs. T has social anxiety disorder, meaning she suffers from a fear of situations where a. she s unfamiliar with the other people. b. she could be judged negatively by others. c. she may encounter people whom she doesn t like. 10. Which is the best description of obsessive-compulsive disorder? a. a mental illness characterized by recurring phobias and actions that cause distress. b. a disorder in which repetitive thoughts, impulses, and behaviors interfere with daily functioning. c. an anxiety disorder characterized by pervasive uncontrollable worrying that interferes with activities of daily living. 11. Benzodiazepines are especially useful in the a. long-term treatment of obsessive-compulsive disorder. b. long-term treatment of agoraphobia. c. short-term treatment of panic attacks. 12. Mrs. V, recently diagnosed with generalized anxiety disorder, is changed from alprazolam (Xanax) to buspirone (BuSpar). Compared with alprazolam, buspirone is a. less likely to cause persistent nausea. b. more likely to stimulate the serotonin receptors. c. less sedating and less likely to cause dependence. 13. One of the few effective treatments for post-traumatic stress disorder is a. a selective serotonin reuptake inhibitor (SSRI) in high doses. b. benzodiazepines at the high end of the dosage scale. c. combination therapy with an SSRI and a monoamine oxidase (MAO) inhibitor. 14. Which symptoms may indicate SSRI discontinuation syndrome? a. palpitations and hypertensive episodes b. fever, tachycardia, and labile blood pressure c. dizziness, irritability, and tingling of the face and hands 15. A pianist suffers from cold, sweaty, trembling hands when she accompanies the choir. Which medication is the most likely to help her with her physiologic symptoms of anxiety? a. an SSRI like paroxetine (Paxil) b. a beta-blocker like propranolol (Inderal) c. an MAO inhibitor like tranylcypromine (Parnate) 16. Exposure therapy is a form of a. behavioral therapy. b. cognitive therapy. c. psychodynamic therapy. Turn to page 47 for the CE Enrollment Form. September/October 2005 Nursing made Incredibly Easy! 33