MALADAPTIVE PATTERNS OF BEHAVIOR

A. ANXIETY

I. ANXIETY RESPONSE

ANXIETY is a vague feeling of dread or apprehension.

It is a response to external or internal stimuli (behavioral, emotional, cognitive, and

physical symptoms).

Anxiety is a phenomenon of human existence which every individual experience at times

to a lesser or greater degree. It is a subjective experience which is not confined to the mentally
disturbed.

Anxiety at a certain level may serve as a normal response to alert the person experiencing
it to protect the self against anything which may threaten the person’s mental security motivating
defensive behaviors which are consciously or unconsciously aimed to reduce or alleviate anxiety’s
associated discomfort

Normal anxiety is a healthy reaction necessary for survival. Anxiety provides the energy
needed to carry out the tasks involved in living and striving toward goals. Anxiety motivates people
to make and survive change. It prompts constructive behaviors, such as studying for an
examination, being on time for a job interview, preparing for a presentation, and working toward
a promotion.

II. PREDISPOSING / RISK FACTORS and PRECIPITATING FACTORS

PREDISPOSING / RISK FACTORS:

A. Biological Factors
1. Genetic
• Numerous studies substantiate that anxiety disorders tend to cluster in
families.
• Genetic variants have been identified that are associated with increased
risk for anxiety and obsessive-compulsive disorders. Twin studies
demonstrate the existence of a genetic component to both panic disorder
and OCD.
• First-degree biological relatives of those with OCD or phobias have a
higher frequency of these disorders than exists in the general population.

2. Neurobiological
• The amygdala - alerts the brain to the presence of danger and brings about
fear or anxiety to preserve the system. Memories with emotional
significance are stored in the brain and have been implicated in phobic
responses such as fear of snakes, heights, or open spaces.

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 • The Limbic System - anatomic pathways provide the transmission
structure for the electrical impulses that occur when anxiety-related
responses are sent or received.
• Neurotransmitters – a chemical released by Neurons that convey
electrical messages. The neurochemicals that regulate anxiety include
epinephrine, norepinephrine, dopamine, serotonin, and gamma-
aminobutyric acid (GABA). GABA, an inhibitory neurotransmitter that
puts a brake on excitatory neurotransmitters, is commonly the focus of
pharmacological therapy for anxiety symptoms. GABA slows neuron
activity, which plays a role in lowering anxiety. It is believed that people
with too little GABA may suffer from anxiety disorders.

B. Psychological Factors
1. Psychodynamic theories suggest that unconscious childhood conflicts are the
basis for future symptom development. Sigmund Freud posited that anxiety results
when threatening repressed ideas or emotions are close to breaking through from
the unconscious mind into the aware and conscious mind. Freud also suggested
that ego-defense mechanisms are used to keep anxiety at manageable levels. The
use of defense mechanisms may result in overuse of behavior that is not wholly
adaptive because of its rigidity and repetitive nature. Harry Stack Sullivan believed
that anxiety is linked to the emotional distress caused when early needs go unmet
or disapproval is experienced (interpersonal theory). He also suggested that
anxiety is “contagious,” being transmitted to the infant from the mother or
caregiver. Thus the anxiety felt early in life becomes the prototype for anxiety
responses when unpleasant events occur later in life.
2. Behavioral theories suggest that anxiety is a learned response to specific
environmental stimuli (classical conditioning). An example of classical conditioning
is a boy who is anxious in the presence of his abusive mother. He then generalizes
this anxiety as a response to all women. Conditioning can be reversed through the
influence of safe and loving female friends and significant others. The social
learning model suggests that anxiety is learned through the modeling of parents or
peers. For example, a mother who is fearful of thunder and lightning and hides in
closets during storms may transmit her anxiety to her children. These children
continue to imitate this fearful behavior into adult life. Such individuals can unlearn
this behavior by observing others who react normally to a storm by lighting candles
and telling stories.
3. Cognitive theorists believe that anxiety disorders are caused by distortions in an
individual’s thoughts and perceptions. Because individuals with such distortions
exaggerate any mistake and believe that they will have catastrophic results, they
experience acute anxiety. People who tend to perceive events and situations as
being potentially dangerous may be overly responsive and become anxious or
even experience panic attacks.

PRECIPITATING STRESSORS
A. Stressor
An internal stimulus (chemical or biological agent) or external stimulus (environmental
condition, or an event) seen as causing tension to an organism.

Psychologically speaking, a stressor can be events or environments that individuals might

consider demanding, challenging, and threatening individual safety
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 B. Stress - Result of Stressor
EUSTRESS - sometimes used to refer to what can be considered "good" stress

Motivates people to continue participating in and enjoying activities and events that require
effort, but ultimately promote their physical and emotional well-being

C. Crisis
A state of acute emotional upset that includes a temporary inability to cope by means of
one's usual problem-solving methods

Typically lasts for 4-6 weeks, no more than 6-8 weeks because a person cannot remain
for too long in a state of acute emotional upset

Stages of Crisis:

a. Precrisis -
The person is exposed to stressors
There may be warning signs of stress or none at all
The person is in equilibrium
b. Impact - the person experience the stressor
• High level of stress, confusion, anxiety
• Inability to reason logically
• Inability to apply problem-solving behavior
• Inability to function socially, helplessness
• Chaos, Possible panic
c. Crisis - Use coping skills to deal with the stressor
• Denial of problem
• Rationalization about cause of the situation
• Projection of feelings of inadequacy onto others
• (may last a brief or prolonged period of time)
d. Resolution - When coping is effective: integration occurs
• The person perceives the crisis situation in a positive way
• Successful problem-solving occurs
• Anxiety lessens, Self-esteem rises
• Social role is resumed
• When coping attempts fail: disequilibrium occurs
• Tension and anxiety resurface as reality is faced
• Feelings of depression, self-hate, and low self-esteem may occur
e. Postcrisis
• May be at a higher level of adaptation and maturity due to acquisition of
new positive coping skills
• May function at a restricted level in one or all spheres of the personality
due to denial, repression, or ineffective mastery of coping

Types of Crisis:
a. Maturation crisis (Developmental crisis)
The crisis origin is embedded in a person's struggles with transition from one
life stage (or role) to another

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 It can be anticipated but not necessarily prepared for (ex. Graduation,
Retirement)

b. Situational crisis
The crisis origin is a sudden, random, shocking, and often catastrophic event
that can't be anticipated or controlled that largely affects a person's identity and
roles (ex. Death of husband, Loss of Job)

c. Adventitious crisis (Social crisis)

A crisis of disaster that is not a part of everyday life. It is unplanned or
accidental.

Adventitious crises include natural disasters, national disasters, and crimes of

violence.

Classification Based on Severity of Crisis:

a. Class 1: Dispositional or situational crisis

- acute response to an external crises with a need of immediate action
Husband abuses wife, wife goes to ER

b. Class 2: Transitional or maturational crisis

- occurs during normal growth and development.
Ex. Inability to adjust with college
Experiencing a planned pregnancy

c. Class 3: Traumatic Crisis

- due to a sudden, unexpected, external stress
Ex. Loss of a home during an earthquake
Rape

d. Class 4: Maturational or developmental crisis

- involving an internal stress and psychosocial issues,
Ex. Questioning one’s sexual identity
Lack of ability to achieve emotional independence / intimacy

e. Class 5: Situational crisis

- due to a preexisting psychopathology
Ex. Depression or anxiety, that interferes with activities of daily living (ADL) or
various areas of functioning

f. Class 6: Psychiatric emergency

Ex. Attempted suicide, drug overdose, or extreme agitation, resulting in
unpredictable behavior or the onset of an acute psychotic disorder

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 Characteristics of Crisis:

a. Self-limiting (4 to 6 weeks)
b. Crisis resolved in any of three ways
a. Returns to pre-crisis level of functioning
b. Begins to function at a higher level of functioning
c. Regresses at a lower level of functioning

Crisis Intervention:
a. An active but temporary entry into the life situation of an individual, a family, or
a group during a period of stress (Mitchell &Resnik, 1981).
b. It is an attempt to resolve an immediate crisis when a person’s life goals are
obstructed and usual problem-solving methods fail.
c. The client is called on to be active in all steps of the crisis intervention process,
including clarifying the problem, verbalizing feelings, identifying goals and
options for reaching goals, and deciding on a plan.
d. TYPES OF CRISIS INTERVENTION:
1. Directive intervention - To take temporary control and responsibility for the
situation
2. Supportive intervention - Collaborative and non-directive
e. GOALS OF CRISIS INTERVENTION
1. To decrease emotional stress and protect the client from additional stress
2. To assist the client in organizing and mobilizing resources or support
systems to meet unique needs and reach a solution for the particular
situation or circumstance that precipitated the crisis.
3. Enable the individual to understand the relationship of past life experiences
to current stress;
4. Reduce the risk of chronic maladaptation;
5. Promote adaptive family dynamics
6. To return the client to a pre-crisis or higher level of functioning

III. DEFINING CHARACTERISTICS OF ANXIETY

FEAR ANXIETY
Involves intellectual appraisal of a An emotional response to threat
threatening stimulus
Use of Ego Defense Coping Disequilibrium in Ego Defense Coping
Mechanism Mechanism
A result of a physical or A result of unresolved FEAR
psychological exposure to a
threatening

Anxiety occurs once selfhood, self-esteem, identity existence or security is threatened. It may be
connected with the fear of punishment, disapproval, rejection, withdrawal of love, disruption of a
relationship, isolation or loss of body functioning.

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 CONTINUUM OF ANXIETY RESPONSE

Adaptive Response Maladaptive Response

Anticipation Mild Moderate Severe Panic

IV. LEVELS OF ANXIETY

1. Mild Anxiety – normal.

The person is on the alert, sees, hears and grasps more than previously. An
individual experiencing it does not have to manage anxiety by using defense
mechanisms which force it out of conscious awareness. Normal individual
recognized and faced situational circumstances as motivating forces to strive,
produce growth and creativity.

Sphere of Awareness / Perceptual Field: OPEN

2. Moderate Anxiety – considerably abnormal

The person focuses only on immediate concern. The anxious person hears, sees
and grasps less of what is going on outside the sphere of awareness but can be
directed towards through the intervention of another individual.

Sphere of Awareness / Perceptual Field: NARROWING

3. Severe Anxiety – abnormal, Free-floating anxiety

The person’s focus is upon many scattered details associated with elements
causing conflicts. All behavior is aimed at relieving anxiety and much direction is
needed to focus on another area. Cannot function effectively

Sphere of Awareness / Perceptual Field: GREATLY REDUCED

4. Panic –
Highest level of anxiety leading to irrational behavior. Disorganization of one’s
behavior characterized by dread, terror and awe. The person is unable to do things
even with direction

Sphere of Awareness / Perceptual Field: CLOSED & DREAD

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 *A CLOSER LOOK ON SPHERE OF AWARENESS / PERCEPTUAL FIELD OF A PERSON
EXPERIENCING ANXIETY

1. Mild Anxiety – person is functional and productive and normal.

STUDY

HELP IN HOUSEHOLD LOCKDOWN DUE

ON LINE SELLING
CHORES TO
PANDEMIC

PLANTING
KEEPING SELF HEALTHY

Sphere of Awareness / Perceptual Field: OPEN

2. Moderate Anxiety – considerably abnormal.

DISTRACTED
STUDY

ALTERED SLEEP LOCKDOWN DUE GAMING AS DIVERSION

TO
PANDEMIC

EAT A BIT

Sphere of Awareness / Perceptual Field: NARROWING

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 3. Severe Anxiety – abnormal, free floating

CANNOT FOCUS
ON STUDIES

INSOMNIAC LOCKDOWN DUE AVOIDANT

TO
PANDEMIC

Sphere of Awareness / Perceptual Field: GREATLY REDUCED

4. PANIC –

CANNOT FOCUS ON STUDIES

LOCKDOWN DUE
TO
PANDEMIC
INSOMNIAC AVOIDANT

SELF ISOLATION

Sphere of Awareness / Perceptual Field: CLOSED AND DREAD

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V. MANIFESTATIONS AND DISCOMFORTS OF ANXIETY

A. Mild Level of Anxiety:

Cognitive Response-
Sharpened senses
Effective problem-solving
Increased learning ability
Affective /Behavioral Response
Irritability
Increased motivation
Physiological Response-
Restlessness
Fidgeting
GI Butterflies
Difficulty Sleeping
Hypersensitivity (noise)

B. Moderate Level of Anxiety

Cognitive Response-
Use of automatism
Loss of concentration
Selectively attentive
Affective /Behavioral Response
Impatient
Tense
Uneasy
Startled reaction
Physiological Response-
Muscle tension
Diaphoresis
Pounding pulse
Headache
Dry mouth
High pitch voice
Faster rate of speech
GI upset
Frequent urination

C. Severe Level of Anxiety

Cognitive Response-
Blocking of thoughts
Diminished productivity
Confusion
Affective /Behavioral Response
Awe, dread, terror
Cries, Ritualistic behavior
Cannot complete tasks

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 Physiological Response-
Severe headache
Nausea, vomiting
Diarrhea
Trembling
Rigid stance
Vertigo
Pale
Tachycardia
Chest pain

D. Panic Level
Cognitive Response-
Flashbacks/Nightmares
Distorted perceptions
Loss of rational thoughts
Doesn’t recognize danger
Can’t communicate verbally
Possible hallucination and
Delusion
Affective /Behavioral Response
May be suicidal
Physiological Response-
May bolt and run or
Totally mute & immobile
Dilate pupils
Increased VS
Flight, Fight, or Freeze

VI. ANXIETY DISORDERS

An unresolved anxiety may become a pathological anxiety disorder. An adjustment

disorder wherein the patient may feel helpless and uncomfortable due to inherent conflict. DSM-
V or Diagnostic and Statistical Manual of Mental Disorder and the American Psychiatric
Association (2013) include the following as anxiety disorders:

Panic disorder with or without Agoraphobia

Generalized anxiety disorder
Post-Traumatic Stress Disorder
Obsessive-compulsive disorder
Dissociation
Separation anxiety disorder
Social anxiety disorder (social phobia)

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 A. Panic Disorder with or without phobia– pathological fear of an object, place and people
that is symbolical in nature. Most common among patients with this anxiety disorder has
agoraphobia.
Other Examples:
a. Ablutophobia – fear of washing and bathing
b. Claustrophobia – enclosed place
c. Erythrophobia – red
d. Gynephobia – Women
e. Androphobia - men
f. Xenophobia – strangers
g. Alektorophobia – chicken / poultry
h. Photophobia – light
i. Arachnophobia - spider
j. Cacophobia – ugly
k. Haptephobia – touch
l. Ombrophobia – rain
m. Pyrophobia – fire
n. Thanatophobia – death
o. Tokophobia - pregnancy

B. Generalized Anxiety Disorder – chronic state of at least 6 months. Persistence of

moderate level of anxiety with excessive worrying. The person finds it difficult to control
the worry and experiences at least three of the following symptoms: restlessness, fatigue,
difficulty of concentrating, irritability, muscle tension and sleep disturbance.

C. Posttraumatic Stress Disorder – The person has been exposed to a traumatic event in
which both of the following were present:
• The person has experienced, witnessed or been confronted with an event that involved
actual or threatened death or serious injury
• The person’s response involved intense fear, helplessness or horror. The traumatic
event is reexperienced in mind.
• Other Criteria:
o Persistent Avoidance of Stimuli Associated with the Trauma & Numbing of
General Responsiveness
o Persistent Symptoms of Increased Arousal
o Duration of Disturbance is more than one month
o Disturbance causes distress and dysfunction

D. Obsessive – Compulsive disorder – Repression mechanism is not successful thus

resorting to other defense mechanism such as regression, undoing or reaction formation.

Obsessions are defined as thoughts, impulses, or images that persist and recur so that
they cannot be dismissed from the mind even though the individual attempts to do so.
Obsessions often seem senseless to the individual who experiences them (ego-dystonic),
and their presence causes severe anxiety.

Compulsions are ritualistic behaviors an individual feels driven to perform in an attempt

to reduce anxiety or prevent an imagined calamity. Performing the compulsive act
temporarily reduces anxiety, but because the relief is only temporary, the compulsive act

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 must be repeated again and again. Although obsessions and compulsions can exist
independently of each other, they most often occur together.

Examples of Compulsive behaviors:

a. Checkers
b. Washer and cleaners
c. Orderers, counters, arrangers
d. Hoarders
e. Violent thoughts against others
f. Doubt and sinners – afraid of punishments

• A related set of anxiety disorders results in abnormal selective over attention or

obsessions:
o Body dysmorphic disorder
o Hoarding disorder
o Trichotrillomania (hair pulling) disorder
o Excoriation (skin picking) disorder

E. Disassociation – also known as depersonalization disorder with a feeling of

estrangement from an environment and assumes two or more distinct personality
whenever faced with a provoking anxiety situation. Also known as Acute Stress Disorder.

F. Separation Anxiety Disorder

o Separation anxiety is a normal part of infant development that begins around 8

months of age, peaks about 18 months, and begins to decline after that.
o People with separation anxiety disorder exhibit developmentally inappropriate
levels of concern being away from a significant other. There may be fear that
something horrible will happen to the other person and that it will result in
permanent separation.
o The anxiety is so intense that it distracts sufferers from their normal activities and
causes sleep disruptions and nightmares.
o Recently, clinicians have begun to recognize an adult form of separation anxiety
disorder that may begin either in childhood or in adulthood.
o Subject of attachment—a parent, a spouse, a child, or a friend—may become
alienated due to the constant neediness and clinginess. Adults with this disorder
often have extreme difficulties in romantic relationships and are more likely to be
unmarried.
o Characteristics of adult separation anxiety disorder include harm avoidance, worry,
shyness, uncertainty, fatigability, and a lack of self-direction (Mertol & Alkin, 2012).
It is accompanied by a significant level of discomfort and disability that impairs
social and occupational functioning and does not respond well to the most popular
type of psychotherapy, cognitive-behavioral therapy.
o This problem is typically diagnosed before the age of 18 after about a month of
symptoms.
o Females are more likely to be affected. Environmental stresses such as a
significant loss through death of a relative or pet, separation from significant others,
or a change in environment by moving or immigration can bring about symptoms
of this disorder.

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 o Adults, with Separation Anxiety Disorder commonly coexists with other
maladaptive patterns of behaviors too such as: depressive disorders, bipolar
disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive
disorder, and personality disorders.

G. Social Anxiety Disorder

o Also called social phobia, is characterized by severe anxiety or fear provoked by
exposure to a social or a performance situation that could be evaluated negatively
by others.
o Situations that trigger this distress include fear of saying something that sounds
foolish in public, not being able to answer questions in a classroom, looking
awkward while eating or drinking in public, and performing badly on stage.
o People with social anxiety disorder avoid these social situations. If they are unable
to avoid them, they endure the situation with intense anxiety and emotional
distress.
o Small children with this disorder may be mute, nervous, and hide behind their
parents. Older children and adolescents may be paralyzed by fear of speaking in
class or interacting with other children. The worry over saying the wrong thing or
being criticized immobilizes them.
o Fear of public speaking is the most common manifestation of social anxiety
disorder.
o Risk factors for social anxiety disorder include childhood mistreatment and adverse
childhood events. The trait of shyness is also strongly heritable. Having parents
who are shy carries a double risk of genetic transmission and parental modeling.
Chronic social isolation may increase the risk for major depression. Substance use
disorders are common and may be related to the social isolation and inhibition of
this illness. Bipolar disorder and body dysmorphic disorder are also comorbid.
o In children, comorbidities include high functioning autism and selective mutism.

(TRIAD OF PSYCHOSIS – 3Ds VS NEUROTIC ANXIETY)

Dereism
Disorganization of Personality
Distorted Reality

VII. NURSING DIAGNOSIS & TREATMENT PLANS

1. Moderate / Severe/Panic level of Anxiety
2. Ineffective individual coping mechanism
3. Low Self-esteem
4. Powerlessness
5. Alteration in role performance
6. Self-care deficit
7. Sleep Disturbance
8. Risk for injury / Self-Mutilation

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Sample:
Signs and Symptoms Nursing Diagnosis Outcomes
Separation from significant other, concern Anxiety (moderate, Monitors intensity of anxiety, uses
that a panic attack will occur, exposure to severe, panic) relaxation techniques, decreases
phobic object or situation, presence of environmental stimuli as needed,
obsessive thoughts, fear of panic attacks, controls anxiety response, maintains
preoccupation with perceived physical flaws, role performance
apprehension about losing prized
possessions, pulling hair or picking skin
Unable to attend social functions or take Ineffective coping Identifies ineffective coping patterns,
employment, anxiety interferes with the ability asks for assistance, seeks information
to work, avoidance behaviors (phobia, about illness and treatment, identifies
agoraphobia), inordinate time taken for multiple coping strategies, modifies
obsession and compulsions lifestyle as needed
Exaggerated negative perception of physical Chronic low self-esteem Verbalizes self-acceptance,
appearance, ashamed of the appearance of communicates openly, increases
the house due to hoarding activity, believes confidence, describes a positive sense
that others are disgusted with his of self-worth
appearance, embarrassment about the hair or
skin condition
Skin excoriation related to rituals of excessive Self-mutilation Identifies feelings that lead to impulsive
washing, excessive picking at the skin, or actions, practices self-restraint of
pulling hair out compulsive behavior
From Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). Nursing diagnoses—Definitions and classification 2015-2017. Oxford, UK: Wiley
Blackwell. Copyright © 2014, 1994-2012 by NANDA International. Used by arrangement with John Wiley & Sons Limited; Moorhead, S.,
Johnson, M., Maas, M. L., & Swanson, E. (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby.

Guidelines for Basic Nursing Interventions:

1. Establish a trusting NP relationship
2. Self-awareness / insight into the anxiety
3. Safety / protection of patient
4. Modify environment / External control
5. Attitude therapy
6. Encourage activity (ADL – Self Care) and relaxation techniques
a. Guide patients throughout the planned activities
b. Guide patients through slow, deep breathing exercises along with progressive
muscle relaxation

7. Treatment modalities – psychotherapy

a. Use counseling, milieu therapy, promotion of self-care activities, and
psychobiological and health teaching interventions as appropriate
b. Community Support:
• Identify community resources that can offer the patient specialized
treatment proven to be highly effective for people with a variety of anxiety
disorders.
• Identify community support groups for people with specific anxiety
disorders and their families.
8. Pharmacotherapy

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Sample Interventions with Rationale

Nursing Diagnosis: Anxiety (Moderate) related to situational event or psychological stress as

evidenced by increased in vitals signs, moderate discomforts, narrowing of perceptual fields and
selective in attention

INTERVENTION RATIONALE
Help the patient identify anxiety. “Are you comfortable It is important to validate observations with the patient,
right now?” name the anxiety, and start to work with the patient to
lower anxiety
Anticipate anxiety-provoking situations. Escalation of anxiety to a more disorganizing level is
prevented.
Use nonverbal language to demonstrate interest (e.g., your head). Verbal and nonverbal messages should be
lean forward, maintain eye contact, nod your head). consistent. The presence of an interested person
provides a stabilizing focus.
Encourage the patient to talk about his or her feelings When concerns are stated aloud, problems can be
and concerns discussed and feelings of isolation decreased.
Avoid closing off avenues of communication that are When staff anxiety increases, changing the topic or
important for the patient. Focus on the patient’s concerns offering advice is common but leaves the person
isolated.
Ask questions to clarify what is being said. “I’m not sure Increased anxiety results in scattering of thoughts.
what you mean. Give me an example.” Clarifying helps the patient identify thoughts and
feelings.
Help the patient identify thoughts or feelings before the The patient is assisted in identifying thoughts and
onset of anxiety. “What were you thinking right before feelings, and problem solving is facilitated.
you started to feel anxious?”
Encourage problem solving with the patient.∗ Encouraging patients to explore alternatives increases
sense of control and decreases anxiety.
Assist in developing alternative solutions to a problem The patient is encouraged to try out alternative behaviors
through role play or modeling behaviors and solutions.
Explore behaviors that have worked to relieve anxiety in The patient is encouraged to mobilize successful coping
the past. mechanisms and strengths
Provide outlets for working off excess energy (e.g., Physical activity can provide relief of built-up tension,
walking, playing ping-pong, dancing, exercising). increase muscle tone, and increase endorphin levels.
∗Patients experiencing mild to moderate anxiety levels can problem solve .

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PHARMACOTHERAPY: ANXIOLYTICS
A. DRUG CLASSIFICATION AND LIST:
• FDA Approved Drugs for Anxiety Disorders: Food and Drug Administration. (2016). FDA label repository.
Retrieved from labels.fda.gov; Burchum, J., & Rosenthal, L. (2016). Lehne’s pharmacology for nursing care (9th
ed.). St Louis, MO: Elsevier.

1. Minor tranquilizer - for short term anxiety

a. Benzodiazepines – high potential for abuse and dependence, therefore must
be used as short-term not exceeding 4 to 6 weeks
Diazepam (valium)
Chlorazapate (Tranxene)
Chlordiazepoxide (Librium)
Clonazepam (Klonopin)
Lorazepam (Ativan)
Oxazepam (Serax)
b. Non-Benzodiazepines
Buspirone (BuSpar)
Meprobamate (Miltown, Equanil)

2. ANTIDEPRESSANTS - For treatment of long-term anxiety

a. SSRI – Selective Serotonin Reuptake Inhibitor antidepressant
SSRI are considered the first line of defense in most anxiety and obsessive-
compulsive–related disorders
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Escitalopram (Lexapro)
Sertraline (Zoloft)
b. SNRI – Serotonin Norepinephrine Reuptake Inhibitor
SNRI is quite successful in the treatment of several anxiety disorders
Venlafaxine (Effexor)
Duloxetine (Cymbalta) *effective in the treatment of Generalized Anxiety
Disorder
c. Tricyclic Antidepressant – increases NE & Serotonin
Imipramine (Tofranil)
Clomipramine (Anafranil)
d. MAOIs - Monoamine oxidase inhibitors are reserved for treatment-resistant
conditions because of the risk of life-threatening hypertensive crisis if the
patient does not follow dietary restrictions

Patients cannot eat foods containing tyramine and must be given specific
dietary instructions. The risk of hypertensive crisis also makes the use of
MAOIs contraindicated in patients with comorbid substance use disorders

3. For physiological symptoms:

a. CARDIO MEDS
• Clonidine (Catapres) – Beta blocker
• Propanolol (Inderal) – Alpha adrenergic agonist
b. ANTICONVULSANT
• Gabapentin (Neurontin)
• Pregabalin (Lyrica)
Prepared by Prof. Amelia Z. Manaois for PLM College of Nursing to be used as Instructional Material only for the Lecture in Maladaptive
Patterns of Behavior. Refrain from reproducing this material without the consent of the preparer and the PLM-CN
 c. ANTIHISTAMINE
d. ANTIPSYCHOTICS

B. SIDE EFFECTS
1. Suicidal tendencies
2. Depression, hallucination, confusion, agitation, bizarre behavior, amnesia
3. Drowsiness, lethargy and headache
4. Tremors, EPS
5. Rash and itching
6. Sensitivity to light

C. CONTRAINDICATIONS / EXTREME CAUTION:

1. Suicidal tendencies
2. Depressed VS and LOC
3. Pregnancy, lactation
4. Liver and kidney problem
5. Person operating machines
6. Extremes in age

VIII. EVALUATION

Identified outcomes serve as the basis for evaluation. In general, evaluation of outcomes for
patients with anxiety disorder deals with questions such as the following:
• Is the patient experiencing a reduced level of anxiety?
• Does the patient recognize symptoms as anxiety related?
• Does the patient continue to display signs and symptoms such as obsessions,
compulsions, phobias, worrying, or other symptoms of anxiety disorders?
• If still present, are they more or less frequent? More or less intense?
• Is the patient able to use new behaviors to manage anxiety?
• Does the patient adequately perform self-care activities?
• Can the patient maintain satisfying interpersonal relations?
• Is the patient able to assume usual roles?

References:
• Margaret Jordan Halter, Varcaroli’s Foundations of Psychiatric-Mental Health Nursing, 8th
edition, 2018
• Shiela L. Videbeck, Psychiatric Mental Health Nursing 6th edition 2011.
• Stuart and Sundeen, Principles and Practice of Psychiatric Nursing.

Prepared by Prof. Amelia Z. Manaois for PLM College of Nursing to be used as Instructional Material only for the Lecture in Maladaptive
Patterns of Behavior. Refrain from reproducing this material without the consent of the preparer and the PLM-CN
CRITICAL THINKING EXERCISES:

1. Which goal should be addressed initially when providing care for 40-year-old Jose who is
diagnosed with posttraumatic stress disorder (PTSD)?
a. Jose will be able to identify feelings through the use of behavioral therapy.
b. Jose will have access to protective resources available through social services.
c. Jose will demonstrate the effective use of relaxation techniques to restore a sense of
control over disturbing thoughts.
d. Jose will demonstrate an understanding of the personal human response to traumatic
events.

2. The nurse is providing care for a patient demonstrating behaviors associated with moderate levels
of anxiety. What question should the nurse ask initially when attempting to help the patient
deescalate their anxiety?
a. “Do you know what will help you manage your anxiety?”
b. “Do you need help to manage your anxiety?”
c. “Can you identify what was happening when your anxiety began to increase?”
d. “Are you feeling anxious right now?”

3. To maximize the therapeutic effect, which lifestyle practice should the nurse discourage for a
patient who has been recently prescribed an antianxiety medication?
a. Eating high protein foods.
b. Using acetaminophen without first discussing it with a healthcare provider
c. Taking medications after eating dinner or while having a bedtime snack
d. Buying a large coffee with sugar and extra cream each morning on the way to work

4. In a parent teacher conference, the school nurse meets with the parents of a profoundly shy 8-
year-old girl. The parents hold hands, speak softly, respond briefly, and have poor eye contact.
The nurse recognizes that the child is most likely exposed to parental modeling and:
a. The inherited shyness trait
b. A lack of affection in the home
c. Severe punishment by the parents
d. Is afraid to say something foolish

5. Isabel is a straight-A student, yet she suffers from severe test anxiety and seeks medical attention.
The nurse interviews Isabel and develops a plan of care. The nurse recognizes effective teaching
about mild anxiety when Isabel states:
a. “I would like to try a benzodiazepine for my anxiety.”
b. “If I study harder, my anxiety level will go down.”
c. “Mild anxiety is okay because it helps me to focus.”
d. “I have fear that I will fail at college.”

6. A homebound patient diagnosed with agoraphobia has been receiving therapy in the home. The
nurse evaluates patient teaching is effective when the patient states:
a. “I may never leave the house again.”
b. “Having groceries delivered is very convenient.”
c. “My risk for agoraphobia is increased by my family history.”
d. “I will go out again, someday, just not today.”

Prepared by Prof. Amelia Z. Manaois for PLM College of Nursing to be used as Instructional Material only for the Lecture in Maladaptive
Patterns of Behavior. Refrain from reproducing this material without the consent of the preparer and the PLM-CN
 7. On admission, which assessment finding is true on patient who is suffering from Generalized
Anxiety Disorder?
a. Patient states that he is always worried about his work
b. Patient had unexplainable fear of people in his work place
c. Patient experience nightmares and flashbacks
d. Patient has recurrent thoughts of ending his life

8. Marina periodically has acute panic attacks. These attacks are unpredictable and have no apparent
association with a specific object or situation. During an acute panic attack, Marina may
experience:
a. Heightened concentration
b. Decreased perceptual field
c. Decreased cardiac rate
d. Decreased respiratory rate
9. The nurse describes a client as anxious. Which of the following statement about anxiety is true?
a. Anxiety is usually pathological
b. Anxiety is directly observable
c. Anxiety is usually harmful
d. Anxiety is a response to a threat
10. Crisis does not last indefinitely but usually exists for:
a. 2 weeks
b. 4-6 weeks
c. 6 months
d. One year

Critical Thinking Part 1: Answer the questions by selecting the right answer from the choices
After answering each question, compare your answer on the correct answers provided below this page.

Critical thinking part 2: Analyze what rationale supports the right answer
(1c, 2c, 3d, 4a,5c,6c,7a,8b,9d,10b)
Prepared by Prof. Amelia Z. Manaois for PLM College of Nursing to be used as Instructional Material only for the Lecture in Maladaptive
Patterns of Behavior. Refrain from reproducing this material without the consent of the preparer and the PLM-CN