1.Generalized Anxiety Disorder (GAD) 2. Panic Disorder. 3. Phobic Disorders (agoraphobia – social phobia – specific phobia)

UNIT: VIII
Nursing Management of Patient with
Neurotic, Stress Related and Somatoform
Disorders
ANXIETY DISORDERS
1. Generalized Anxiety Disorder (GAD)
2. Panic Disorder.
3. Phobic Disorders (agoraphobia – social phobia – specific
phobia).
Class 1
Prof. S. Anand
BBCON
1

Objectives (as per your syllabus)
At the end of this class, Students can able to
1. Define the ICD 10 and DSM-IV
2. Define Anxiety
3. Explain Generalized Anxiety Disorder (GAD)
4. Explain Panic Disorder.
5. Explain Phobic Disorders (agoraphobia – social phobia – specific phobia).
6. Nursing Assessment-History, Physical and mental assessment of Anxiety
disorder
7. Treatment modalities and Nursing management of patients with Anxiety
disorder
2

ICD 10 and DSM-IV
•The ICD-10 Classification of Mental and Behavioural Disorders (World
Health Organisation, Geneva) is part of the 10th edition of the
International Classification of Disease. This appendix follows the
common abbreviation of ICD-10. It is the international system used by
the majority of clinical psychiatrists in Great Britain.
•The Diagnostic and Statistical Manual of Mental Disorders (fourth
edition) (American Psychiatric Association Washington DC).
References to it in this appendix follow the common abbreviation of
DSM-IV. It is a system devised mainly by and for workers in the USA.
However UK psychiatrists were consulted in its formulation.
3

Anxiety
•Anxiety is a normal human feeling of apprehension in certain
threatening situations. Mild degree of anxiety in our life in our life is
unavoidable and is not considered abnormal.
4

main differences between normal and
abnormal anxiety.
NORMAL ANXIETY ABNORMAL ANXIETY
Proportional apprehension to the external stimulus Apprehension is out of proportion to the external
stimulus
Features of anxiety are few. Features are multiple
Anxiety is not severe and not prolonged. Anxiety is prolonged or severe (or both).
Attention is focused on the external threat rather than
on the person’s feelings.
Attention is focused also on the person’s response to
the threat (e.g. palpitation).
5

Anxiety can be:
•Trait anxiety (part of personality character) in which a person has a
habitual tendency to be anxious in a wide range of different
circumstances (longitudinal view).
•State anxiety in which anxiety is experienced as a response to
external stimuli (cross – sectional view).
6

Features of Anxiety
Psychological Physical
excessive apprehension chest :
 chest discomfort
 difficulty in inhalation
fearful anticipation cardiovascular :  palpitation  awareness of missed
beats  cold extremities
feeling of dread
neurological :  headache – dizziness  tinnitus –
numbness  tremor – blurred vision
worrying thoughts
gastrointestinal :  disturbed appetite  dysphagia –
epigastric discomfort  nausea – vomiting  disturbed
bowel habits
hypervigilance
genitourinary :  urine frequency and urgency  libido 
impotence  dysmenorrheoea
feeling of restlessness musculoskeletal :  muscle and joint pain
sensitivity to noise sleep:  insomnia  bad dreams
difficulty concentrating skin :  sweating – itching – hot /cold skin.
subjective report of memory deficit
7

Anxiety disorders
•Anxiety disorders are abnormal states in which the most striking
features are worry, dread and physical symptoms of anxiety that
indicate a hyperactive autonomic nervous system and are not caused
by an organic brain disease, medical illness or psychiatric disorder
8

Anxiety disorders include:
1. Generalized Anxiety Disorder (GAD)
2. Panic Disorder.
3. Phobic Disorders (agoraphobia – social phobia – specific phobia).
4. Obsessive Compulsive Disorder (OCD)
5. Acute and post traumatic stress disorders
9

1. Generalized Anxiety Disorder (GAD).
•Excessive worry about number of events and circumstances (in
DSM-IV for at least 6 months duration). The person finds it difficult to
control the worry, which is accompanied by other features of anxiety
(physical and psychological). Features cause clinically significant
distress or functional impairment (social, occupational…). Sleep is
often intermittent and accompanied by unpleasant dreams or night
terrors. Patient may wake unrefreshed, or may have difficulty in
falling asleep. If early morning waking is present, it should suggest the
possibility of major depression ( which may be associated with
anxiety symptoms ).
10

Mental State Examination (MSE):
• Strained face with furrowed brow and frequent blinking.
• Tense posture, tremulous and restless.
• Sweating (forehead, hands, feet).
• Difficulty in inhalation.
11

Symptoms that may be associated with
generalized anxiety disorder:
• Panic attacks (see later).
• Mild depressive symptoms.
• Hypochondrical thoughts (see later).
• Depersonalization and derealization.
12

Epidemiology:
•One year prevalence rate: 3 %.
•Life time prevalence rate: 5 %.
• Women > men.
• Often begins in early adult life, but may occur for the first time in
middle age.
• There is a considerable cultural variation in the expression of
anxiety.
• Frequent in primary care and other medical specialties.
13

Aetiology:
•Generalized anxiety disorder appears to be caused by stressors acting
on a personality predisposed by a combination of genetic and
environmental influences in childhood. Maladaptive patterns of
thinking may act as maintaining factors. Anxiety as a trait has a
familial association.
14

Differential Diagnosis:
1. Anxiety disorder due to medical conditions:
• Hyperthyroidism
• Hypoglycemia
• Hypocalcaemia
• Phaeochromocytoma
• Paroxysmal tachycardia
• Hypoxaemia /anaemia.
15

2. Depressive Disorder: When anxiety and depressive symptoms
coexist, the diagnostic criteria may be met for both depressive
disorder and generalized anxiety disorder. Anxiety is a common
symptom in depressive disorder. It is conventional to make the
diagnosis on the basis of the severity of symptoms and by the order in
which they appeared. Ask any anxious patient routinely about
symptoms of depression including depressive thinking, and when
appropriate, suicidal ideation.
16

3. Substance-Induced Anxiety Disorder: Intoxication with CNS
stimulants (e.g. amphetamine).
Withdrawal from CNS depressants (e.g. alcohol).
4. Panic Disorder (see later).
5. Adjustment Disorders.
6. Psychotic Disorders (e.g. mania).
17

Course and Prognosis:
•The course is often chronic, fluctuating and worsen during times of
stress. Symptoms may diminish as patient gets older. Over time,
patient may develop secondary depression (not uncommon if left
untreated). When patient complains mainly of physical symptoms of
anxiety and attributes these symptoms to physical causes, he
generally seems more difficult to help. Poorer prognosis is associated
with severe symptoms and with derealization, syncopal episodes,
agitation and hysterical features.
18

Management:
• Ruling out possible organic causes.
• Reassurance that symptoms are not due to a serious physical disease.
• Explanation of the nature of the illness.
• Help the patient to deal with, or adjust to, any ongoing problem.
• Reduction of caffeine intake (coffee, tea, cola … )
• Cognitive – behaviour therapy:
•  Relaxation training.
•  Anxiety management training : relaxation with cognitive therapy to control
worrying thoughts, through identifying and changing the automatic faulty
thoughts.
19

Drug Treatment:
• Benzodiazepines for a short period (2 – 4 weeks) to avoid the risk of
dependence.
• Buspirone: as effective as benzodiazepines and is much less likely to
cause dependence. No cross-tolerance with benzodiazepines.
• Antidepressants have been used to treat anxiety. No risk of
dependence. They act more slowly than benzodiazepines but with
equivalent effect.
• Beta-adrenergic antagonists are used to treat some physical
features of anxiety (palpitation, tremor … ).
20

MIXED ANXIETY AND DEPRESSIVE DISORDER
• Anxiety and depressive features are both present but neither set of
features, considered separately, is severe enough to make a diagnosis
of depressive disorder or anxiety disorder as a primary diagnosis.
• Seen commonly in clinical practice.
• Features of anxiety and depression may arise together because :
• many stressful events combine elements of loss (associated with
depression) and danger (associated with anxiety).
• the antecedent causes may be similar.
21

Management:
As in generalized anxiety disorder
• antidepressants indicated are either - Tricyclics (e.g. imipramine 25
mg – 150 mg). - Monoamine oxidase inhibitors (e.g. moclobemide
150-450 mg). or - Specific serotonin reuptake inhibitors (e.g.
citalopram 20 mg).
22

2. PANIC DISORDER
•It is characterized by recurrent unexpected panic attacks about which
there is persistent concern or anticipatory anxiety for at least one
month.
•Panic Attack: A discrete period of sudden onset of intense fear or
discomfort that builds up to a peak rapidly (usually in 5-15 minutes)
and is often accompanied by a sense of imminent danger or
impending doom and an urge to escape.
23

There are some somatic and cognitive
symptoms that accompany fear. These
include:
•Palpitation ● Sensations of shortness of breath
• Feeling o choking ● Chest pain
• Shaking ● Tremor ● Chills or hot flushes ● Sweating
• Paraesthesia
• Feeling dizzy, unsteady or faint
• Fear of going mad, dying or losing control.
• Derealization (feelings of unreality) or depersonalization (being
detached from one self)
24

Panic attacks (as attacks, not as a disorder) can occur
in a variety of psychiatric disorders other than panic
disorder:
• Generalized anxiety disorder
• Phobias
• Stress disorders (acute & post traumatic)
• Substance abuse
• Depressive disorders
• Obsessive Compulsive Disorder (OCD)
• Mitral Valve Prolapse (MVP) is more common in patients with panic disorder
(40-50 %) than in general population (6 – 20 %). Whether this association has
a causal relationship it is not clear. In determining the differential diagnostic
significance of a panic attack, it is important to consider the context in which
the panic attack occurs. There are three characteristic types of panic attacks
with different relationships between the onset of the attack and the presence
or absence of situational triggers.
25

1. Unexpected panic attacks: not associated with a situational trigger
(spontaneous) essential for the diagnosis of panic disorder
2. Situationally bound panic attacks: occur immediately on exposure
to, or in anticipation of, the situational cue ( trigger ).
•associated with specific phobia (e.g. seeing a snake).
•associated with panic attacks.
3. Situationally predisposed panic attacks:
•more likely to occur on exposure to (but are not invariably associated
with) the situational trigger. (e.g. Attacks are more likely to occur
while driving.)
26

Epidemiology:
• Women > men
• Lifetime prevalence is 1 – 3 % (throughout the world).
• One-year prevalence rates 1 – 2 %. Age at onset: bimodal
distribution, with one peak in late adolescence and a second smaller
peak in the mid 30s
27

Aetiology:
•Genetic basis (panic disorder occurs more often among relatives).
• The biochemical hypothesis (panic attacks can be induced by
chemical agents like sodium lactate, and can be reduced by drugs like
imipramine).
• Panic disorder develops in a person with poorly regulated
autonomic responses to stressors when he becomes afraid of the
consequences of symptoms of autonomic arousal.
• The neurotransmitters involved are noradrenaline and serotonin.
• Locus coeruleus is essential for anxiety expression (alarm system in
the body).
28

Course and Prognosis:
• The usual course is chronic but waxing and waning.
• Some patients recover within weeks.
• Others have a prolonged course (those symptoms persist for 6
months or more).
• Prognosis is excellent with therapy.
29

Treatment:
• Attention to any precipitating or aggravating personal or social
problems.
• Support and reassurance.
• Cognitive therapy: eliciting and correcting the patient’s wrong
assumptions and beliefs about the origin, meaning, and consequence
of symptoms.
30

Drugs:
•Tricyclic antidepressants  Selective Serotonin reuptake inhibitors
• imipramine: start with small dose (e.g. 25 mg) then increase
gradually , guided by the symptom control. Patient may require 150
mg. or more. fluvoxamine (50 - 150 mg / day)
• clomipramine has been found to be at least as effective as
imipramine (in small doses).
• citalopram (20 – 40 mg / day)  Benzodiazepines alprazolam (2 – 6
mg / day), but there is a high risk of dependence.
31

2a. HYPERVENTILATION SYNDROME
• It is a manifestation of anxiety of panic attacks characterized by recurrent
episodes of hyperventilation (rapid, usually shallow breathing) associated
with a variety of physical sensations:
• Pericordial pain.
• Palpitation.
• Headache.
• Nausea and gastrointestinal discomfort.
• Dizziness and vertigo.
• Paraesthesia. Carpopedal spasm and tetany may develop. These
symptoms increase the patient’s fear and support the patient’s conviction
that he is in imminent danger. In some cases the respiratory rate is not
increased but the patient has repeated habitual sighing which may induce
hyperventilation syndrome.
32

Pathophysiology:
•Under certain stressful settings autonomic arousal occurs as an
immediate response to acute fear. Hyperventilation leads to
hypocapnia and respiratory alkalosis (loss of carbon dioxide), which
brings into play a number of buffer reactions to maintain the PH in
the blood. The reactions result in a fall in serum ionized calcium levels
and reflex vasoconstriction that affects the CNS, skin, respiratory, gut
and other systems.
33

Bronchial asthma (difficulty in exhaling).
•In hyperventilation syndrome, patient has a sensation of being unable
to fill his lungs.
•2. Cardiopulmunary disease (e.g. pulmonary embolism).
•3. Metabolic disorder (e.g. diabetic ketosis).
•4. Salicylate overdosed (metabolic acidosis).
34

Management:
• Rule out possible organic causes.
• Reassurance
• Breathing bag (rebreathe carbon dioxide) for few minutes. Avoid
giving oxygen.
• Small doses of benzodiazepine (e.g. diazepam 5 – 10 mg IV) to
reduce apprehension and fear.
• Treat any underlying psychological problems.
35

3. PHOBIC DISORDERS
Phobic disorders are characterized by:
intense dread of certain objects or situations, beyond voluntary
control.
being out of proportion to the demands of the situation and cannot
be reasoned away.
avoidance or endurance with distress.
significant distress and/or functional impairment (social, occupational
…).
a disturbance not due to a general condition, substance abuse or a
mental disorder.
36

3a,AGORAPHOBIA
•Literally it means fear of open spaces (misleading term). Although
fear of open spaces is common, agoraphobic patients have anxiety
about being in places from which escape seems difficult or help may
not be available in case of sudden incapacitation (places cannot be
left suddenly without attracting attention e.g. a place in the middle of
a row in mosque).
37

Common feared and avoided situations:
• Overcrowding: a social situation (mass of people), shops and
markets.
• Distance from home: travelling away.
• Confinement: closed spaces, e.g. elevators (claustrophobia) bridges,
public transport.
38

Features:
• Anxiety about fainting and / or loss of control when patient is away from
home, in crowds, or in situations that they cannot leave easily.
• Anxiety symptoms identical to those of any other anxiety state (see
physical and psychological features of anxiety).
• Anticipatory anxiety (hours before the individual enters the feared
situation).
• Other symptoms that can accompany agoraphobia : depersonalization
and derealization. obsessional thoughts related to the feared situation.
• Depressive symptoms may arise (> 30 % of cases) as a consequence of the
limitations to normal life caused by phobia.  As the condition progresses,
patients with agoraphobia may become increasingly dependent on some of
their relatives or spouse for help with activities that provoke anxiety (such
as shopping).
39

Epidemiology:
• Women – men : 2 : 1
• Onset: most cases begin in the early or middle twenties, though
there is a further period of high onset in the middle thirties.
• Both of these ages are later than the average onset of specific
phobia (childhood) and social phobias (late teenagers or early
twenties).  Prevalence : ● one year prevalence: Men : about 2 %.
Women : about 4 %. ● Life time prevalence: 6 – 10 %.
40

Aetiology:
Personality: anxious, dependent (overprotected in childhood,
separation anxiety…)
Biological predisposition to respond with anxiety (possibly because
defective normal inhibitory mechanisms).
Conditioning: avoidance learning.
Often precipitated by major life events.
Psychodynamic factors: repression, displacement and symbolization.
41

Treatment:
Cognitive-Behaviour Therapy:
 detailed inquiry about the situations that provoke anxiety and how much they
are avoided.
 hierarchy is drown up (from the least – to the most anxiety provoking).
 the patient is then taught to relax (relaxation training).
 exposure : the patient is persuaded to enter the feared situation (to confront
situations that he generally avoids).
 the patient should cope with anxiety experienced during exposure and try to
stay in the situation until anxiety has declined.
 when one stage is accomplished the patient moves to the next stage.
 negative cognitive assumptions are challenged.
 the patient is trained to overcome avoidance (escape during exposure will
reinforce the phobic behaviour).
42

• Drugs:
• Antidepressants: imipramine – clomipramine – MAOI, (e.g.
•moclobemide) – SSRI
• Anxiolytics: e.g. alprazolam (there is a risk of dependence).
•Prognosis:
• If not treated early, agoraphobia can be chronic disabling disorder
•complicated by depressive symptoms.
• House-bound housewife syndrome may develop a severe stage of
•agoraphobia when the patient cannot leave the house at all.
43

Agoraphobia and Panic Disorder
Agoraphobia and panic disorder can occur together (in > 60 % of cases)
In DSM IV panic disorder takes precedence and the following
categories have been considered :
• Panic Disorder with Agoraphobia.
• Panic Disorder without Agoraphobia.
• Agoraphobia without history of Panic Disorder.
In ICD – 10 categories include :
• Agoraphobia with panic disorder.
• Agoraphobia without panic disorder.
• Panic disorders (moderate – severe).
44

3b,SOCIAL PHOBIA
• The essential problem here is a marked persistent inappropriate fear and
• anxiety (with physical and psychological features) when a person is
exposed
• to unfamiliar people or to a possible scrutiny by others in social or
• performance situations in which embarrassment may occur. The person
has
• anticipatory anxiety. Such situations are avoided (wholly or in part) or else
• endured with distress. The problem leads to significant interference with
• functioning (social, occupational, academic…).
45

The most common feared situations
• Gatherings (e.g. meetings, parties).
• Speaking to authority figures or in public (e.g. leading prayers,
•lecturing).
• Performing under scrutiny (e.g. serving coffee or tea to guests).
46

Features:
• The symptoms are the same as those of generalized anxiety
•disorder.
• Common complaints: palpitation, trembling, sweating, and
•blushing.
• The response may take a form of panic attack (situationally
•bound or situationally predisposed).
• Negative thoughts about performance (others will judge them
•to be anxious, weak, stupid, inarticulate…).
• Avoidance of the situation or endurance with distress.
47

Associated Features:
• Hypersensitivity to criticism and negative evaluation or
•rejection (avoidant personality traits).
• Other phobias.
48

Complications:
• Secondary depression.
• Alcohol or stimulant abuse to relieve anxiety and enhance
•performance.
• Deterioration in functioning (underachievement in school, at
•work, and in social life).
49

Epidemiology:
• Age: - late teenage or early twenties.
- may occur in children.
• Lifetime prevalence : 3 – 13 %
• In the general population, most individuals fear public speaking and less
than half fear speaking to strangers or meeting new people.
• Only 8 – 10 % are seen by psychiatrists.
• Reports from Saudi Arabia suggested that social phobia is a notably
common disorder among Saudis, and social phobic compose 80 % of phobic
disorders.
• Social and cultural differences have some effect on social phobia in terms
of age at treatment, duration of illness and some social situations.
50

Aetiology:
• Genetic factors: some twins studies found genetic basis for social
phobia.
• Social factors: excessive demands for social conformity and
concerns about impression a person is making on others, (high
cultural superego increases shame feeling), some Arab cultures are
judgmental and impressionistic.
• Behavioural factors: sudden episode of anxiety in a social situation
followed by avoidance.
• Cognitive factors: exaggerated fear of negative evaluation and
feelings that other people will be critical.
51

• Other phobias, however, multiple phobias can occur together.
• Generalized anxiety disorder.
• Panic disorder.
• Depressive disorder primary or secondary to social phobia.
• Patients with persecutory delusions avoid certain social
•situations.
• Avoidant personality disorder may coexist with social phobia
•(axis II diagnosis).
52

Treatment:
A. Psychological:
1. Cognitive-Behaviour Therapy:
• Exposure to feared situations is combined with anxiety management
(relaxation training with cognitive techniques designed to reduce the
effects of anxiety-provoking thoughts).
• It is the treatment of choice for social phobia.
2. Social Skill Training: how to initiate, maintain and end conversation.
3. Assertiveness Training: how to express feelings and thoughts directly
and appropriately.
53

B. Drugs:
1. Beta-adrenergic antagonists help to control palpitation and tremor.
2. Benzodiazepines (e.g. alprazolam): small divided doses for short time
(to avoid the risk of dependence).
3. Antidepressants:
• Specific serotonin reuptake inhibitors (e.g. fluoxetine)
or
•Monoamine oxidase inhibitors (e.g. moclobemide).
54

Prognosis:
•If not treated, social phobia often lasts for several years and the
episodes gradually become more severe with increasing avoidance.
When treated properly the prognosis is usually good.
55

3c, SPECIFIC PHOBIA
Also called: Simple Phobia.
•The central problem is irrational and persistent fear of a specific
object or situation (other than those of agoraphobia and social
phobia ) accompanied by strong desire to avoid the object or the
situation, with absence of other psychiatric problems.
56

Common feared objects and Situations
• Animals (including spiders).
• Storms and thunder.
• Heights (acrophobia), flying.
• Closed spaces (claustrophobia).
• Injury, blood, hospitals.
• Illness, death.
57

Epidemiology;
•It is common in the general population though not necessarily among
those seeking treatment (less than 20 % of patients are seen by
psychiatrists).
• Animal phobia: common in children and women.
• Most specific phobias occur equally in both sexes.
• Most specific phobias of adult life are a continuation of childhood
phobias. A minority begins in adult life (usually in relation to a highly
stressful experience).
58

Aetiology:
• It tends to run in families (? genetic or environmental).
• Modelling: (observing the reaction in another person, usually a
•parent).
• Pairing of a specific object or situations with the emotions of fear
•and panic.
59

• Obsessive compulsive disorder (some patients have fear and
avoidance of specific objects e.g. dirt, knives). Both can be diagnosed
if criteria are met.
• Depressive disorder: some patients with specific phobia seek help
for long standing problem when a depressive disorder makes them
less able to tolerate their phobic symptoms.
• Social phobia and agoraphobia.
60

Treatment:
• Behaviour therapy (exposure technique).
• Drugs (e.g. benzodiazepines, beta adrenergic antagonists) before
exposure sessions.
61

Prognosis:
• If started in adult life after stressful events the prognosis is usually
good.
• If started in childhood, it usually disappears in adolescence but may
continue for many years.
62

Examples of NANDA Nursing
Diagnoses: Anxiety Disorders
• Anxiety related to impending divorce as evidenced by client's
• apprehension, lack of self-confidence, and statement of
• inability to relax
• Impaired Verbal Communication related to decreased
• attention secondary to obsessive thoughts
• Ineffective Coping related to poor self-esteem and feelings of
• hopelessness secondary to chronic anxiety
• Post-Trauma Syndrome related to physical and sexual assault
• Powerlessness related to obsessiveâ€“compulsive behavior
• Disturbed sleep pattern related to excessive hyperactivity
• secondary to recurring episodes of panic
• Impaired Social Interaction related to high anxiety secondary
• to fear of open places
63

EXAMPLES OF STATED OUTCOMES:
ANXIETY DISORDERS
• The client will verbalize feelings related to anxiety.
• The client will relate decreased frustration with
• communication.
• The client will demonstrate an improved ability to express
• self.
• The client will express optimism about the present.
• The client will socialize with at least one peer daily.
• The client will express confidence in self.
• The client will verbalize a reduction in frequency of
• flashbacks.
• The client will identify factors that can be controlled by self.
• The client will identify stimuli that precipitate the onset of
• acute anxiety.
64

Screening Tools and Assessment Scales
• Various screening tools are available for use in the clinical
• setting. The mnemonic DREAMS (Box 21-2) and the acronym
• HARM (Box 21-3) are used to assist nurses in the recognition of
• PTSD. The Yale Brown Obsessive Compulsive Scale (Y-BOCS) also
• is useful in facilitating diagnosis by identifying thought processes
• and behavior patterns common to OCD. Other examples of
• assessment tools used to evaluate the presence of anxiety include
• the Hamilton Anxiety Rating Scale, the Liebowitz Social Anxiety
• Scale, the Sheehan Disability Scale, the Global Assessment Scale,
• and the Obsessiveâ€“Compulsive Disorder Screener (Davidson,
• 2001; Pavlovich-Danis, 2000; Silver & Gound, 2002).
65

•Clients with anxiety disorders often receive unnecessary medical
•tests that lead to excessive costs, misdiagnosis, and unnecessary
•procedures and treatments. However, a true medical illness must
•be ruled out. As noted earlier in this chapter, anxiety can occur
•secondary to a medical condition such as emphysema,
•hyperthyroidism, or cardiac arrhythmias, or as an adverse effect
•to medication.
66

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67

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22. Title: Basic Concepts of Psychiatric-Mental Health Nursing, 6th
EditionCopyright 2005©‫آ‬ Lippincott Williams & Wilkins > Front of
Book > Editors Louise Rebraca Shives MSN, ARNP, CNS Psychiatricâ
€“Mental Health Nurse Practitioner and Clinical Nurse Specialist
Consultant in Long-Term Care, Legal Nurse Consultant, Orlando
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1.Generalized Anxiety Disorder (GAD) 2. Panic Disorder. 3. Phobic Disorders (agoraphobia – social phobia – specific phobia)

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