22 Nursing made Incredibly Easy! September/October 2005

AnxietyAnxietyWhen is it too much?

ANXIOUS? AFRAID? If you’re not, youaren’t paying attention!

Ever-increasing work assignments, sickerpatients, growing piles of paperwork, con-flicting responsibilities of work and family,and financial uncertainty are common stres-sors that keep many of us from getting apeaceful night’s sleep. Let’s face it: Stress isan inescapable part of modern living, andanxiety is a normal reaction to the constanttension in our lives. It may even be a positivefactor because it can help give us the com-petitive edge we need to ace an exam, wow‘em in a job interview, or make a clutch hit inthe final and deciding game in a ball tourna-ment.

But for millions of people, anxiety becomesmaladaptive and negatively impacts theircapacity to carry out even the simplest activi-ties of daily living (ADLs). Fear becomes aconstant, unwelcome companion, drainingthe joy out of life.

In this article, I’ll help you understand thevarious kinds of anxiety disorders and thetreatments that are available.

Been down so long it looks like up to meJust about everyone experiences some de-gree of anxiety at one time or another. Sowhat separates normal routine anxietyfrom an anxiety disorder? Duration, forone thing. Normal anxiety disappearswhen the danger or stressor goes away—

exam over, time to relax. Abnormal anxi-ety persists when the stressor is no longerthere, or even arises in the absence of aprecipitating event. Abnormal anxiety pre-vents people from effectively functioningat work, at school, in social situations, andin personal relationships.

Along with the paralyzing emotional fear,anxiety creates powerful physical symptomstoo, including increased respiratory rate,heart rate, and blood pressure. Restlessness,diaphoresis, dizziness, light-headedness, andtremors may also occur. It’s these continuedphysical manifestations that often propel theperson to seek medical attention.

According to the National ComorbiditySurvey, a large government-funded studycarried out in the early 1990s, one out ofevery four people exhibits symptoms of ananxiety disorder at some time in his or herlife. Women are twice as likely as men to beaffected.

Anxiety disorders are the most prevalentmental illness in older adults and children.Nearly 9% of children suffer some significantdisruption in daily functioning from anxiety,while over 17% exhibit milder symptoms(see Across the age spectrum).

Why one person develops a full-blownmental illness and another doesn’t isn’t com-pletely understood. External events andintrinsic biochemical imbalances are allbelieved to contribute to the development ofanxiety disorders; many people exhibit a

September/October 2005 Nursing made Incredibly Easy! 23

In a modern society full of pressures and conflicts, anxiety is acommon component of the human condition. Anxiety disorders—serious and disabling conditions—require treatment. We’ll explainthe various types of anxiety disorders and describe how drugs andpsychotherapy can help your patient emerge from a nightmarishexistence warped by paralyzing fear.KATHRYN MURPHY, NP, CS, MSNNursing 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 thiseducational activity.

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September/October 2005 Nursing made Incredibly Easy! 25

combination of these factors. A genetic component also seems to play a

part in anxiety disorders, and family historymay indicate a biological predisposition. Forexample, if an individual has a first-degreerelative with an anxiety disorder, he’s atincreased risk for developing one too.

Now let’s look at the neurobiology of anx-iety to help you understand what’s happen-ing in the body when anxiety strikes.

Run for your life!Fear triggers an automatic, rapid-fire re-sponse before the rational mind even has achance to think, “Yikes! That truck’s com-ing right for me!” This unthinking reactionis coordinated by the amygdala. Thissmall structure deep inside the brain ispart of our primitive “lizard brain,” whichalso encompasses the thalamus and hypo-thalamus.

The amygdala is the control center for theinstinct to survive. Besides making the heartpound, the amygdala diverts blood from thedigestive system to the muscles, floods thebloodstream with stress hormones (epineph-rine and norepinephrine) and glucose, andsuppresses the immune and pain response.The body’s primed for a fight-or-flightresponse in less than a second.

Some experts hypothesize that once a par-ticular stimulus causes this cascade ofevents, the memory is hardwired into theamygdala so that the next time the threat’sencountered, the response can be evenquicker. It’s an effective survival mechanism,but it’s also why nondrug therapy, like cog-nitive therapy alone, doesn’t work very wellfor anxiety; rational thought never gets achance to kick in before the fear factor over-whelms the patient. Effective drug therapyaims to delay the amygdala-based responseuntil the thinking mind can recognize thefact that no danger exists.

Mixed messagesOther factors may contribute to makingthe survival instinct run amok. Re-

searchers have observed repeatedly thatan imbalance of neurotransmitters in thebrain contributes to anxiety disorders.Neurotransmitters are the chemical vehi-cles that allow the smooth transmission ofimpulses from one neuron to the nextthrough the synapses (the junction be-tween neurons). The major neurotransmit-ter systems involved in anxiety disordersare gamma-aminobutyric acid (GABA),norepinephrine, and serotonin.

Here’s how the process normal-ly works. Neurotransmitters areproduced in the neurons of thenervous system and stored in thesynaptic vesicles until they’rereleased. Afterwards, any neuro-transmitters that go unused aresent back to storage through areuptake mechanism in the pre-synaptic neurons.

In anxiety, this process canbreak down. For example, sero-tonin may not be released in ade-quate amounts. Administering

As you cansee, anxietyis an equalopportunitycondition.

Across the age spectrumChildren• Anxiety disorders are the most common psychiatric disorders in chil-dren, but they’re often unrecognized and untreated.• Social phobia, separation anxiety, generalized anxiety disorder, andobsessive-compulsive disorder are the most common childhood anxi-ety disorders.• Symptoms of anxiety disorders usually worsen over time and pre-cede the onset of adult anxiety disorders, especially panic disorder.

Older adults• More than 11% of older adults have anxiety disorders, and these dis-orders often exist with other psychiatric disorders.• If left untreated, anxiety disorders can complicate other medical con-ditions common in older adults, such as hypertension and diabetes.• Consider a patient’s age-related physiologic changes (reduced renaland hepatic function) when administering medications. Dosages mayneed to be reduced in patients with impaired renal and hepatic function.• Because benzodiazepines can cause cognitive impairment, closelymonitor older adults.

26 Nursing made Incredibly Easy! September/October 2005

medications that correct this chemical imbal-ance has been shown to alleviate anxietysymptoms. Also, GABA plays a role in regu-lating the release of norepinephrine. GABAis an inhibitory neurotransmitter associatedwith the relaxation response; its releasedecreases neuron excitability, which in turnmay lessen anxiety.

It’s been hypothesized that anxiety disor-ders arise from increased activation of theautonomic nervous system (which controlsorgans and muscles in an involuntary,reflexive way) and arousal of the limbic sys-tem (the olfactory cortex, amygdala, and hip-pocampus), both of which pump up the indi-vidual for increased mental and physicaldemands. Activation of these systems leadsto increased release of norepinephrine,which floods the neuronal synapses.

The physical symptoms of anxiety—increased heart rate, respirations, and bloodpressure—are normal and appropriate incertain situations. When these systemsbecome hypersensitive and launch the fight-

or-flight response inappropriately, however,the patient is thrown into an abnormal stateof chronic high anxiety.

Now let’s look at the types of anxiety dis-orders. First, though, I want to make sureyou understand that assessing for an anxietydisorder isn’t like looking for a broken bone.Anxiety is expressed in many different ways,not just by an awful sense of fear. A personwith an anxiety disorder may complain ofsymptoms of depersonalization (the sense ofobserving oneself from the outside) andderealization (a change in perception ofone’s environment that makes it seem for-eign or unfamiliar). He may say he feels likehe’s losing his mind or he’s “spaced-out.”

To further complicate matters, symptomsmay vary among cultural and ethnic groups,according to cultural beliefs, customs, andhealth practices. Geographic differences aresignificant too. What a person who lives inManhattan considers to be a normal level ofanxiety is, more than likely, a notch or twomore intense than what’s perceived as nor-mal by a resident of a small town inAmerica’s heartland. Keep these subtle andintangible variables in mind when you’reassessing a patient for anxiety disorder.

Assessing children for anxiety brings inyet another layer of difficulty because somany other psychiatric disorders have simi-lar symptoms in kids. Restlessness and diffi-culty concentrating are symptoms that maybe present in an anxiety disorder, but theycan also indicate an anxious depressive stateor attention deficit disorder. Certain toolsspecifically address the proper diagnosis ofan anxiety disorder in children. For example,the Revised Children’s Manifest AnxietyScale (RCMAS) is designed to assess thelevel and nature of anxiety in children andadolescents ages 6 to 19.

Takes all kindsThe Diagnostic and Statistical Manual ofMental Disorders, 4th edition, text revision(DSM-IV-TR), the standard for diagnosingmental disorders, outlines the different

Brain structures involved in the fight-or-flight response

Brain stem and cerebellum removed and brainrotated slightly

Amygdala(beneath overlying cortex)

Hippocampus(beneath overlying cortex)

September/October 2005 Nursing made Incredibly Easy! 27

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 agora-phobia■ post-traumatic stress disorder■ obsessive-compulsive disorder■ social phobia■ specific phobia.

All anxiety disorders have these symp-toms in common: extreme fear in the absenceof real threat, emotional distress that inter-feres with ADLs, and avoidance of situationsthat are seen as having the potential to trig-ger anxiety. Each type of anxiety disorderhas its own unique set of symptoms, andtreatments may vary for each category. Let’sexamine some of them more closely.

Panic in the park…andelsewhereOver 15% of the adult population experi-ence a panic attack at some time in theirlives; only 3.5% meet the full DSM-IV-TRcriteria for panic disorder. Isolated panic at-tacks can occur under very specific circum-stances, like when a woman with a fear offlying boards a plane or a painfully shyman is called on to propose a toast at awedding reception. In panic disorder, thesymptoms can appear suddenly withoutany triggering event.

Patients are generally in their 30s whenthey’re diagnosed with panic disorder.Severity of symptoms ranges from mild,with little effect on ADLs, to severe, withsignificant negative impact on ADLs.Frequency of panic attacks can range fromseveral times a day to once every couple ofmonths.

Panic disorder exists with or without ago-raphobia. When a person has agoraphobiatoo, he has a fear of being trapped in a situa-tion or place where escape is difficult orimpossible, causing panic. Agoraphobia canprogress to the point where the person

becomes isolated and inca-pable of leaving the safetyof his home.

Panic disorder withoutagoraphobia is defined inthe DSM-IV-TR as:■ recurrent, unexpected panic attacks andat least one of the attacks has been fol-lowed by 1 month (or more) of one (ormore) of the following: (1) persistent con-cern over having another panic attack, (2) worry about the implications or conse-quences of the panic attacks, or (3) a sig-nificant change in behavior related to thepanic attacks■ absence of agoraphobia■ panic attacks that aren’t related to aningested substance or general medicalcondition■ panic attacks that aren’t better ex-plained by another anxiety disorder.

This is really scary!Phobic disorders can be specific (formerlycalled simple phobia) or generalized (so-cial phobia). Specific phobias are character-ized by persistent, excessive, unreasonablefear in the presence or anticipation of aspecific situation or object. The avoidance,anxious anticipation, or distress caused bythe object of fear interferes significantlywith the person’s normal routine, job orschool, and social interactions. Often theperson feels distress about having thephobia.

Social phobia, or social anxiety disorder, isextreme anxiety in social situations markedby an intense and persistent feeling ofbeing closely scrutinized and judged in anegative way. The person fears and oftenavoids situations that he perceives asexposing him to embarrassment andhumiliation. The nonprofit SocialPhobia/Social Anxiety Association givesthe example of a person who can’t bear tostand in line at the supermarket because hehas the overwhelming feeling that every-one’s staring at him.

Uh-oh...this feelslike more than a

fear of flying.

Onset of social phobia disorder can beginas early as childhood. It’s estimated thatbetween 7% and 10% of the population suf-fers from social phobia disorder; it occursequally in men and women.

It’s quiet…too quiet!A patient with generalized anxiety disorder(GAD) is often described as a “worry-wart.” This person will find something toworry about even when there isn’t any-thing to worry about. So what distin-guishes a normal worrywart from aperson with GAD? Simply this: The perva-sive, uncontrollable worrying interfereswith the person’s ADLs and creates signif-icant distress. Symptoms like nervousness,anxiety, restlessness, tachycardia, short-ness of breath, insomnia, and agitation areconstant. GAD usually appears in the sec-ond decade of life and is chronic. Depres-sion can often underlie GAD.

Over and over againObsessive-compulsive disorder (OCD) usuallybegins in adolescence or early adulthoodand runs a chronic course. It presentsequally in men and women. Let’s look ateach of the two parts.

Obsessions are intrusive, recurrentthoughts, impulses, or images that interferewith ADLs and cause distress. Commonobsessions in OCD include contamination,the need for order, the compulsion to steal,and sexual possessiveness. Compulsions arerecurrent, irrational, infinitely repetitivebehaviors, like hand-washing, hoarding, orhousecleaning. Many people do have mildobsessive-compulsive tendencies, and theirhomes sparkle; when, however, the obses-sions and compulsions are constant andoverwhelming, interfere with daily function-ing, and cause great distress, a diagnosis ofOCD may be in order.

Look back in angerPost-traumatic stress disorder (PTSD) is de-scribed in DSM-IV-TR as the develop-

ment of specific symptoms after exposureto an extreme traumatic event or series ofevents that “involves a threat to theirown or another’s life or physical integrityand that they respond to with feelings ofintense fear, helplessness, or horror.” Thecommon image of a patient with PTSD isthe soldier who’s plagued by constant re-minders of the horrors of war he wit-nessed in nightmares and flashbacks.(The Department of Veterans Affairs cre-ated the National Center for Post-Trau-matic Stress Disorder in 1989.) People vic-timized by rape, child sexual abuse, orviolent crime, or who’ve survived a mas-sive natural or manmade disaster or hor-rific accident may also suffer from PTSD.Survivors of such traumas often expressguilt and question their own survival.These same events can cause PTSD inchildren.

We’ve looked at the types and characteris-tics of anxiety disorders. Now let’s look atsome of the treatments. We’ll start with med-ical treatment.

Chill pillA number of medications—like benzodi-azepines, beta-blockers, and certain antide-pressants—are quite effective in treatingthe symptoms of anxiety. The best drug touse mainly depends on the type of disor-der. The following classes of drugs areused to treat anxiety:■ Benzodiazepines can effectively treattransient anxiety symptoms. Diazepam(Valium), lorazepam (Ativan), alprazolam(Xanax), and chlordiazepoxide (Libritabs,Librium) are often used. They act on theGABA system, which helps to decreaseneuronal excitability. They’re used forshort-term treatment of GAD, panic disor-der, and social phobia, and are particu-larly effective in managing acute symp-toms of panic attack. Common adverseeffects include somnolence, slowed cogni-tion, and abuse or dependency. With-drawal symptoms can occur, so it’s impor-

28 Nursing made Incredibly Easy! September/October 2005

did youknow?Psychosurgery wasin vogue as a treat-ment for mentalillness, includingsevere anxiety, wellinto the 1970s.Earlier in the 20thcentury, frontallobotomy was seen as a sort ofpanacea. This pro-cedure is largelydiscredited today.

September/October 2005 Nursing made Incredibly Easy! 29

tant for the patient to discontinue thesemedications gradually. Caution him not todrink alcohol, operate dangerous equip-ment, or drive, especially at the start oftherapy. ■ Buspirone (BuSpar) is in a class by it-self—literally. Its mechanism of action isunknown, but it exerts an effect similar tobenzodiazepines in decreasing anxiety.Unlike benzodiazepines, though, it doesn’tbuild up tolerance or create dependence;it’s also less sedating. Although buspironewon’t cause your patient to fall asleep be-hind the wheel, some patients experiencepersistent nausea, dizziness, light-headed-ness, headache, and excitement to the de-gree that they discontinue the drug andswitch to another agent.■ Selective serotonin reuptake inhibitors(SSRIs) are often the first-line drug treat-ment for anxiety because of their effective-ness and the low adverse event profile.SSRIs most commonly used to treat anxi-ety disorders include citalopram (Celexa),escitalopram (Lexapro), fluoxetine(Prozac), sertraline (Zoloft), paroxetine(Paxil), and fluvoxamine (Luvox). SSRIsare effective in treating the broad spec-trum of anxiety disorders. At high doses,SSRIs are even effective in treating thesymptoms of OCD and PTSD, notoriouslystubborn conditions.

SSRIs can cause sexual dysfunction, gas-trointestinal upset, mild sedation, or restless-ness, especially at the beginning of therapy.For more persistent adverse effects, switch-ing to another SSRI can alleviate the prob-lematic effects.

SSRIs can interact with other drugs. Forexample, fluvoxamine may increase levels ofthe anticoagulant warfarin (Coumadin) andincrease bleeding. Refer to the prescribinginformation in the package insert for specificdrug-drug interactions.

Patients shouldn’t abruptly stop taking anSSRI. If they do, they run the risk of discon-tinuation syndrome. This cluster of symp-toms—dizziness, headache, diarrhea, insom-

nia, irritability, nausea, tingling in the handsand face, mood lability, and lowered mood—appears in up to a quarter of those patients.The syndrome usually begins 1 to 3 daysafter stopping SSRI therapy. Effective treat-ment is achieved within 24 hours by rein-stating the drug. A slow taper is theninstituted if the patient wishes to dis-continue the drug.

Also watch for serotonin syn-drome, a life-threatening druginteraction that can occur when anSSRI is combined with anotherdrug that increases the amount ofserotonin, like a monoamine oxidaseinhibitor. Symptoms include hightemperature, restlessness, tachycar-dia, labile blood pressure, changes inmental status, diaphoresis, andtremors. If not recognized and treated,the result can be seizures, respiratoryfailure, coma, and death. Because serotoninsyndrome progresses rapidly, it’s importantto be familiar with early signs and symp-toms. Immediately discontinue all medica-tions and notify the health care provider.The provider may order medications toblock the SSRI effects and treat the hyper-thermia and seizures. The cause of this syn-drome isn’t known.■ Newer selective serotonin and norepi-nephrine reuptake inhibitors (SSNRIs) likevenlafaxine (Effexor XR) are useful inGAD.■ Some of the older tricyclic antidepres-sants used to treat anxiety disorders in-clude clomipramine (Anafranil), de-sipramine (Norpramin), and imipramine(Tofranil). Tricyclic antidepressants are lessexpensive than the newer agents, but theyproduce a lot of adverse effects, includinganticholinergic effects (dry mouth, dryeyes, constipation, weight gain, and seda-tion). Tricyclic antidepressants can alsocause fatal cardiac arrhythmias, especiallywhen taken in an overdose. Nevertheless,these medications can be effective in thetreatment of panic disorder, PTSD, and

These drugs canhelp anxiouspatients getback into the

swing of things.

30 Nursing made Incredibly Easy! September/October 2005

phobic disorders. Clomipramine is one ofthe best treatments for relieving symptomsof OCD. ■ Beta-blockers like propranolol (Inderal)can be an effective treatment for the physi-ologic symptoms of anxiety: By blockingthe beta-adrenergic receptors in the sym-pathetic nervous system, they cause a re-laxation response. Advise a patient takinga beta-blocker to get up slowly because ofthe possibility of orthostatic (postural)hypotension.

Now let’s see what nonpharmacologictreatment options are out there for your anx-ious patients.

Talk the talkPsychotherapy, or “talk therapy,” in

which a patient meets with a mentalhealth professional to discuss issuesand emotions, is a key component in

the treatment of anxiety. Certain pa-tients experiencing mild anxiety may dowell with a course of psychotherapyalone. For treating most major anxiety,however, psychotherapy in combinationwith drug therapy has proven to be more

effective. Some of the psychodynamic ap-proaches used are behavioral therapy, cog-nitive therapy, cognitive-behavioral ther-apy, and psychodynamic therapy. Let’slook more closely at some of the tech-niques used.■ The goal of behavioral therapy is tohelp the patient break the connection be-tween anxiety-producing situations andthe anxiety. Behavioral therapists believethat anxiety is a learned response to stres-sors. For example, a man who grew upwith a father who had GAD may havelearned from an early age to overreact tostressors. In therapy, the patient is taughtto cope with difficult situations, unlearn-ing the hyperresponse, often through con-trolled exposure to the triggering event orsituation.

Exposure therapy, a form of behavioraltherapy, uses relaxation techniques to help

the patient better tolerate proximity withanxiety-producing situations. For example,this approach could be used to treat a patientwho’s deathly afraid of riding in elevators.The therapist coaches the patient on how touse relaxation techniques, like diaphragmat-ic breathing and progressive muscle relax-ation. The patient may at first just talk aboutriding in an elevator. Visits to the elevatorbank of a high-rise building may occur,progress to a ride of a few floors’ duration,and culminate in repeated trips all the wayup to the observation deck on top of thebuilding and back down again to the lobby.By being exposed to the scary situation overand over in a safe, nonthreatening way, thepatient is desensitized to the fear.

Teaching the patient to calm his mind andbody allows the rational mind to take overfrom the instinctive brain.■ Cognitive therapy teaches the patienthow certain patterns of thinking can causesymptoms of anxiety by rendering a dis-torted picture of reality.■ Cognitive-behavioral therapy (CBT), acombination of cognitive and behavioraltherapies, has a goal of eliminating unpro-ductive or harmful thought patterns. Thepatient is taught to recognize realistic andunrealistic thoughts. As in behavioral ther-apy, the patient is given an active role inhis treatment.

According to CBT, psychological paincomes not from an event but from what anevent means. For example, a patient with ananxiety disorder may exercise cognitiveprocesses that interpret a routine inconve-nience—a flat tire—as a catastrophe. Drymouth, shaking hands, pounding heart, anda cold sweat accompany these anxiousthoughts, and the patient may become sooverwrought that he’s incapable of rationallysolving the difficulty. The therapist guidesthe patient to become able to recognize sucha situation as something routine and minorthat he’s quite capable of solving. ■ Psychodynamic therapy links anxiety totrauma or conflicts that happened in child-

Talking it outseems like agood way to

get to the rootof anxiety.

September/October 2005 Nursing made Incredibly Easy! 31

hood. For example, a patient who wasabused as a child presents as an adultwith PTSD. The therapist helps the patientmake the link between the two. Rootingout the basis of the anxiety disorder mayhelp the patient understand it better andgain a more positive outcome to therapy.

All of the above techniques can be done inindividual or group sessions. In group thera-py, the patient benefits from the resources ofboth his therapist and other patients whohave the same anxiety disorder. Fellow suf-ferers may provide practical suggestions oncoping. Often it’s good for the patient just tohear that others share his experiences andfeelings.

Mind-body connectionRegardless of the health care setting whereyou practice, you may see plenty of folkswith anxiety disorders—patients andpeers—so it’s important for you to learn toidentify the symptoms of the various anxi-ety disorders and understand how medicaland nonpharmacologic strategies work.

Western medicine is gradually accepting

the fact that the body and mind are inextri-cably bound. Anxiety, therefore, will affectnot only your patient’s emotional and men-tal well-being, but will also almost certain-ly impact his physical health. A patientwith diabetes who also suffers from con-stant panic attacks, for example, will likelynot have as positive an outcome as apatient without the stress of anxiety.Awakening to each new day with a feelingof happiness, not fear, can do all of us aworld of good. ■

Learn more about itAmerican Psychiatric Association. Diagnostic and StatisticalManual of Mental Disorders, 4th edition, text revision.Washington, D.C., American Psychiatric Association, 2000.

Can you recognize serotonin syndrome? Nursing madeIncredibly Easy! 1(1):60-61, September/October 2003.

Claassen JA, Gelissen HP. The serotonin syndrome. The NewEngland Journal of Medicine. 352(23):2454-2456, June 2005.

Hicks DW, Raza H. Facilitating treatment of anxiety dis-orders in patients with comorbid medical illness. CurrentPsychiatry Reports. 7(3):228-35, June 2005.

Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 8thedition. BJ Sadock, VA Sadock (eds.) Philadelphia, Pa.,Lippincott Williams & Wilkins, 2005.

Woodruff DW. SSRIs: Striking a delicate balance. Nursingmade Incredibly Easy! 2(6):54-55. November/December 2004.

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Anxiety: When is it too much?

TEST INSTRUCTIONS• To take the test online, go to our secure Web site at www.nursingcenter.com/ce/nmie.• On the print form, record your answers in the test answer section ofthe CE enrollment form on page 47. Each question has only one cor-rect answer. You may make copies of these forms.• Complete the registration information and course evaluation. Mailthe completed form and registration fee of $17.95 to: LippincottWilliams & Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ08723. 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 businessdays of receiving your enrollment form. • You will receive your CE certificate of earned contact hours and ananswer key to review your results. There is no minimum passing grade.

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PROVIDER ACCREDITATION:This Continuing Nursing Education (CNE) activity for 2.5 contacthours is provided by Lippincott Williams & Wilkins (LWW), which isaccredited as a provider of continuing education in nursing by theAmerican Nurses Credentialing Center’s Commission onAccreditation and by the American Association of Critical-Care Nurses(AACN 00012278, CERP Category A). This activity is also providerapproved by the California Board of Registered Nursing, ProviderNumber CEP 11749 for 2.5 contact hours. LWW is also an approvedprovider of CNE in Alabama, Florida, and Iowa, and holds the follow-ing provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All ofits home study activities are classified for Texas nursing continuingeducation requirements as Type 1. Your certificate is valid in allstates. This means that your certificate of earned contact hours isvalid no matter where you live.

September/October 2005 Nursing made Incredibly Easy! 33

1. Which of the following factors are related to thedevelopment of anxiety disorders? a. external events, intrinsic biochemical imbalances, and

geneticsb. only external events and intrinsic biochemical imbalancesc. only external events and heredity

2. The instinct to survive begins in thea. sympathetic nervous system.b. endocrine system.c. amygdala.

3. The two hormones produced as part of the fight-or-flight 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 tocognitive therapies becausea. 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 observingher life instead of participating in it. The nurse documentsthat Mrs. R reports feelings of a. derealization. b. depersonalization.c. a panic attack.

6. All of the following statements about assessing patientswith an anxiety disorder are true excepta. 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 inadults.

c. the Revised Children’s Manifest Anxiety Scale helps assessthe level and nature of anxiety in children and adolescents.

7. Although there are a number of different types ofanxiety 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 panicwhenever he needs to take an elevator. This symptom isan example of a. depersonalization.b. derealization. c. agoraphobia.

9. Mrs. T has social anxiety disorder, meaning she suffersfrom 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-compulsivedisorder?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 uncontrol-

lable worrying that interferes with activities of daily living.

11. Benzodiazepines are especially useful in thea. 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 anxietydisorder, 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-traumaticstress 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 discontinuationsyndrome? a. palpitations and hypertensive episodesb. fever, tachycardia, and labile blood pressurec. dizziness, irritability, and tingling of the face and hands

15. A pianist suffers from cold, sweaty, trembling handswhen she accompanies the choir. Which medication is themost likely to help her with her physiologic symptoms ofanxiety? 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.

Anxiety: When is it too much?GENERAL PURPOSE: To familiarize the registered professional nurse with the different types of anxiety disorders and how they’retreated. LEARNING OBJECTIVES: After reading the article and taking this test, you should be able to: 1. Discuss the etiology andpathophysiology of anxiety disorders. 2. Compare and contrast the types of anxiety disorders. 3. Describe treatment options foranxiety disorders.

Turn to page 47 for the CE Enrollment Form.

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