Document Sample
      (Lecture Series)
                  Lecture No. 5
    School of Nursing – Faculty of Medical Sciences
        University College Sedaya International
I. Overview / Theories

A. Anxiety. A state of apprehension, dread, uneasiness, or
   uncertainty generated by a real or perceived threat whose
   actual source is unidentifiable
   1. Anxiety is an emotional, subjective response
       a. Anxiety is commonly experienced by all human beings
       b. Anxiety involves feelings of apprehension, worry, uneasiness
          or dread
       c. Acute anxiety is also known as state anxiety
       d. Chronic anxiety is also known as trait anxiety
       e. Primary anxiety is related to psychological factors
       f. Secondary anxiety results as a reaction to a physical health

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2. Fear: a reaction to a specific danger
3. Stress: a state of imbalance between demands placed on an
   individual and the individual’s ability to deal with the demands
4. Stressors: an internal or external event or situation that leads to
   feelings of anxiety
    • Stressors are precipitating event that originate from the
      individual’s internal or external environment Physical illness,
      hospitalizations, and medical treatment can be stressors
    • It is not the stressor that causes anxiety, it is the person’s
      perception of the stressor that leads to anxious feelings
    • Individuals appraise stressors based on their past experiences,
      peer group practices, social circumstances and current
5. Burnout: a state of mental or physical exhaustion that is caused by
   excessive and prolonged stress.

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I. Overview / Theories

B. Anxiety can be a healthy adaptive reaction when it alerts
   the person to impending threats
C.     Anxiety is considered pathological when it is
     disproportionate to the risk, continues after the threat is no
     longer existing.
D. Anxiety exists on a continuum
     1. Mild
         •     Associated with the tension of everyday life
         •     The person is alert, the perceptual field is increased, and learning is
         •     Physiological responses are within normal limits
         •     The effect is positive
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2. Moderate
    •   Focus is on immediate concerns
    •   The perceptual field is narrowed
    •   Low-level sympathetic arousal occurs
    •   Tension and fear are experienced
3. Severe
    • Focus is on specific details and behavior is directed toward
      relieving anxiety
    • The perceptual field is significantly reduced, and learning
      cannot occur
    • The SNS is aroused
    • Severe emotional distressed is aroused

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   4. Panic
         •    Associated with dread and terror
         •    Details are blown out of proportion, the personality is disorganized,
              and the person is unable to function
         •    Physiological arousal interferes with more activities
         •    Overwhelming emotions caused regression to primitive or childish
E. General adaptation Syndrome (GAS): An automatic physical reaction to stress
   mediated by the sympathetic NS; has 3 distinct stages – alarm, resistance, and
    1. Stress is viewed as a nonspecific body response to any demand
    2. Alarm is the initial response to a stressor
         •    As a result of hormonal activity, generalized physical arousal
              develops and physical and psychological defenses are mobilized
         •    The flight or fight reaction, an automatic psychological state or high
              anxiety mediated by the SNS occurs.

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         •   Increased alertness is focused on the immediate task or threat
         •   The level of anxiety is mild to moderate
3. Resistance occurs when the body mobilizes resources to combat stress
         •   The body stabilizes and adapts to stress, but functions below optimal
         •   COPING, efforts to manage specific demands that are appraised as
             threatening, and defense mechanisms, unconscious psychological
             responses designed to diminish or to delay anxiety and protect the
             person are used
         •   Psychosomatic symptoms begin to develop
         •   The level of anxiety is moderate to severe
4. Exhaustion occurs when adaptation resources are depleted
         •   Results from inability to cope with overwhelming or long-lasting
         •   Thinking becomes disorganized and illogical

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          •   The person may experience sensory misperceptions, delusions,
              hallucinations and reduced orientation to reality.
          •   The level of anxiety is sever to panic
          •   Physical illness and even death can occur if the period of exhaustion
              is prolonged
F. Anxiety is related to how a person appraises stressors
   1. Events may be appraised as beneficial, benign or stressful
   2. Primary appraisal is used to evaluate personal and environmental; factors or
   3. Secondary appraisal is used to determine how to cope with the anxiety
   generated by a stressful event.

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II. Etiology

A. Several theories have been postulated to account for a
   predisposition to anxiety
B. One's theoretical viewpoint affects the selection of treatment modalities
C. Biological factors
     1. Anxiety results from improper functioning of the body systems involved
        in the normal stress response
     2. Predisposition to the development of anxiety appears to be partially
        related to genetic factors
     3. Hyperactivity of the autonomic nervous system is associated with anxiety
     4. Several neurotransmitters have been associated with anxiety
          •   A low level of gamma-amino butyric acid (GABA), a
              neurotransmitter that inhibits the reactivity of neurons, is associated
              with anxiety

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•   Norepiniphrine is associated with the flight-or-fight reaction
•   The person’s cognitive ability, level of education, and language
    ability should be considered when formulating individualized
    assessment questions
•   Panic attacks, sudden episodes of sxs such as dizziness, dyspnea,
    tachycardia, palpitations, and feelings of impending doom and death,
    have been related to high levels of norepinephrine
•   Obsessive-compulsive disorder is associated with high levels of
•   Cholecystokinin, a neuropeptide that functions as a neurotransmitter,
    maybe related to the etiology of panic disorders.

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5. Changes in the structure and function of the brain are associated with
    •    anxiety appears to have its origin in the limbic system or the
        midline of the brainstem
    • Heightened activity in the cortex has been associated with
      obsessive thinking

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D. Psychodynamic Factors
   1. Anxiety is a warning of danger
         •   Primary anxiety begins in response to the stimulation and trauma of
         •   Subsequent anxiety represents a conflict between the instinctual
             drive (id) and the conscience (superego)
    2. Anxiety and the personality are closely related
    3. Symptoms of anxiety are a result of threatening unconscious mental
    4. Fear of punishment and pain lead to anxiety
    5. Unconscious repression of instinctual sexual drives may cause anxiety

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     6. Three types of anxiety have been identified
        a. Reality anxiety is a painful affective experience related to the
        perception of danger in the external environment
        b. Moral anxiety is related to feeling of guilt and shame
        c. Neurotic anxiety is related to threat to instincts
E. Interpersonal Factors
   1. All human behavior is directed toward the attainment of satisfaction and
   security; anxiety occurs when individual’s needs are not met
   2. Anxiety is a response to external environment factors arising out of contact
   with other human beings
          •   Anxiety id first conveyed from mother to infant
          •   Subsequent anxiety arises from fear of rejection, separation from
              significant others, and from feelings of inferiority

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   3. Symptoms of anxiety are a result of conflicts between individuals and their
   families, coworkers and friends
   4. Mild or moderate levels of anxiety maybe expressed as anger
   5. Severe anxiety produces confusion, forgetfulness, and decrease learning
   6. Individuals with poor self-esteem are more susceptible to anxiety than the
   individuals with good self-esteem

   1. response to stressors are often the result of learned or conditioned behavior
   2. Anxiety may result from the inability to achieve desired goals
         •   Experimental psychologists believe that anxiety begins with the
             attachment of pain to a specific stimulus
         •   Learning theorists believe individuals who have experienced intense
             fears early in life are likely to be anxious later in life

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   3. anxiety may be generalized from specific stressors to similar objects and
   4. When individuals experience too many life changes over a short period of
   time they may be unable to adjust and display dysfunctional or maladaptive

G. Other theories
   1. Social theorists emphasize the role of social condition , such as socio-
   economic status and racial inequalities, in the development of anxiety
   2. Intrapersonal theorists believe an external locus of control and fear of future
   dangers contribute to the development of anxiety
   3. Cognitive theorists believe unrealistic ideas and thoughts lead to anxiety
   4. feminist theorists believe are likely to develop anxiety because they are
   taught to be dependent, passive and submissive

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III. Assessment

A. Because stress affects each individual differently, the s/s
   of anxiety are varied and numerous
B. Assessment should include data to determine the level
   and stage of anxiety
C. Several rating scales and diagnostic tools (Hamilton
   Anxiety Scale)
D. Anxiety disorders are seen in all setting

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• E. Assessment should include internal and external
  stressors and the individual’s specific and objective reactions
  to the stressors
• F. Biological, psychological and social factors b should be
   • Biological assessment should include appearance, substance
     use, sleep patterns, nutrition, physical acuity, sexual function
     and menstrual cycle
   • Psychological assessment should include thought and
     behavioral patterns, mood and affect, self-esteem, coping
     patterns, defense mechanisms, orientation to time, place and
     person, memory, insight and suicide potential
   • Social assessment should include interpersonal relationships,
     support systems, diversion activities, ethnicity and cultural

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G. Assessment should focus on the physical affective, cognitive, social and
   spiritual symptoms of stress
    1. The physical signs of anxiety include: BP, resp, and HR increased; sweaty
       palms, diaphoresis, dilated pupils, dyspnea or hyperventilation, vertigo or
       light-headedness, blurred vision, urinary frequency, headache, sleep
       disturbance, muscle weakness or tension, anorexia, nausea and vomiting
         •    Physiologic symptoms of anxiety often mimic the symptoms of
             physical illness
         •   Abnormal laboratory findings, including elevated ACTH, cortisol,
             catecholamine levels and hyperglycemia may be evidence of anxiety
         •   Individuals may not associate the physical signs of anxiety with
             stress and may believe they have physical health problems
    2. Affective symptoms include depression, irritability, apathy, crying,
       hypercriticism, and feelings of guilt, anger, worthlessness,
       apprehension and helplessness

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3. Cognitive symptoms include an inability to concentrate,
indecisiveness, inability to learn and listen, lack of interest, and social
4. Social symptoms include changes in the quality and quantity of
communications, fear of social interactions, and social withdrawal.

5. Spiritual symptoms include feelings of hopelessness and despair,
fear of death, and inability to find life meaningful.

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IV. Nursing Dx / Analysis

B. Fear related to phobic stimulus
C. Ineffective individual     coping        pattern   related   to
   ritualistic behaviors
D. Powerlessness related to lifestyle of helplessness…
E. Social isolation related to panic level of anxiety…

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V. Planning and Implementation

A. Coping Strategies
B. Psychopharmacology
C. Individual and Group Therapy
D. Behavior Modification

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VI. Evaluation/Outcomes

A. Complete remission of symptoms
B. Evaluation should focus on changes
C. Standardized rating scale
D. Logging of daily experiences

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Terema kasih

    Lecture NO. 4

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