Anxiety and Panic Disorders: Nursing Care and Treatment

1. Chapter 16, Anxiety and Panic Disorders: Nursing Care of Persons with Anxiety andPanic

2. Anxiety • Uncomfortable feeling of apprehension or dread in response to internal or external stimuli • Physical, emotional, cognitive, and behavioral symptoms (Box 16.1) • Normal versus abnormal • Factors that determine whether anxiety is a symptom of mental disorder: • Intensity of anxiety relative to the situation • Trigger for anxiety • Symptom clusters manifested (Table 16.1)

3. Defense Mechanisms • Used to reduce anxiety by: • Preventing or diminishing unwanted thoughts and feeling • May be helpful but problematic if overused • Identify use of a particular mechanism • Determine whether use is healthy or unhealthy • What is healthy for one may be unhealthy for another • See Box 16.2

4. Overview of Anxiety Disorders • Primary symptoms are fear and anxiety • Most common of the psychiatric illnesses; chronic and persistent • Women experience anxiety disorders more often than men • Association with other mental or physical comorbidities such as depression, heart disease,and respiratory disease • Most common condition of adolescents • Prevalence decreasing with age • See Box 16.3

5. Anxiety Disorders Across the Life-Span • Prompt identification, diagnosis, and treatment may be difficult for special populations • If left untreated in children and adolescents, symptoms persist and gradually worsen and sometimes lead to: • Separation anxiety disorder and/or mutism • Suicidal ideation and suicide attempts • Early parenthood • Drug and alcohol dependence • Educational underachievement later in life

6. Anxiety Disorders Across the Life-Span (cont.) • In the older adult population, rates of anxiety disorders are as high as mood disorders • This combination of depressive and anxiety symptoms leads to decrease in social functioning, increase in somatic (physical) symptoms, and increase in depressive symptoms • Because the older adult population is at risk for suicide, special assessment of anxiety symptoms is essential

7. Panic Disorder • Extreme, overwhelming form of anxiety often experienced when an individual is placed in a real or perceived life-threatening situation • Panic normal during periods of threat; abnormal when continuously experienced in situations of no real physical or psychological threat • Panic attacks: sudden, discrete periods of intense fear or discomfort accompanied by significant physical and cognitive symptoms • Panic attacks usually peak in about 10 minutes but can last as long as 30 minutes before returning to normal functioning

8. Panic: Clinical Course • Onset between 20 to 24 years of age • The physical symptoms include palpitations, chest discomfort, rapid pulse, nausea, dizziness, sweating, paresthesias (burning, tickling, pricking of skin with no apparent reason), trembling or shaking, and a feeling of suffocation or shortness of breath • Cognitive symptoms include disorganized thinking, irrational fears, depersonalization, and poor communication • Feelings of impending doom or death, fear of going crazy or losing control, and desperation ensue

9. Diagnostic Criteria • Recurrent and unexpected panic attacks and 1 month or more after an attack of one of the following: • Persistent concern about having another attack • Worry about implications of attack or consequences • Significant changes in behavior because of fear of the attacks • With agoraphobia (fear of open spaces) • Without agoraphobia (Key Diagnostic Characteristics 16.1)

10. Epidemiology • Risks: female; middle aged; low socioeconomic status, and widowed, separated, or divorced • Higher rates in whites than other races • Other risk factors: family history, substance and stimulant use or abuse, smoking tobacco, severe stressors • Several anxiety symptoms + experience of separation anxiety during childhood  panic disorder later in life • Comorbidity: anxiety disorder(s), depression, eating disorder, substance abuse, schizophrenia

11. Etiology • Biologic theories • Genetic factors • Neuroanatomic theories • Biochemical theories • Serotonin and norepinephrine; GABA • Hypothalamus–pituitary–adrenal (HPA) axis • Psychological and social theories • Psychoanalytic and psychodynamic theories • Cognitive behavioral theories • Interoceptive conditioning

12. Question Is the following statement true or false? • Panic is considered abnormal regardless of the situation and degree of threat.

13. Answer False. • Panic is considered normal during periods of threat; it is considered abnormal when it is continuously experienced in situations of no real physical or psychological threat present.

14. Teamwork and Collaboration • Safe and therapeutic environment • Medication and monitoring of effects • Individual psychotherapy • Psychological testing • Priority care issues: safety because of a high risk for suicide

15. Treatments • Panic control treatment • Systematic desensitization • Implosive therapy • Exposure therapy • Cognitive behavioral therapy • Pharmacologic interventions • SSRIs • Benzodiazepine

16. Nursing Management for the Biologic Domain • Assessment • Rule out life-threatening medical causes; symptom evaluation • Substance use • Sleep patterns • Physical activity • Medications • Nursing diagnoses • Anxiety • Risk for Self-Harm • Social Isolation • Powerlessness • Ineffective Family Coping

17. Nursing Management for the Biologic Domain (cont.) • Interventions • Breathing control • Nutritional planning • Relaxation techniques (Box 16.6) • Increased physical activity • Psychopharmacology (Table 16.4) • SSRIs, SNRIs • TCAs • MAOIs • Benzodiazepines

18. Nursing Management for the Psychological Domain • Assessment • Self-report scales (Box 16.5 and Table 16.2) • Mental status examination • Cognitive thought patterns: catastrophic misinterpretations • Nursing diagnoses • Anxiety • Risk for Self-Harm • Social Isolation • Powerlessness • Ineffective Family Coping

19. Nursing Management for the Psychological Domain (cont.) • Interventions • Trigger identification • Distraction techniques • Reframing • Positive self-talk • Panic control treatment • Exposure therapy; systematic desensitization; implosion therapy • CBT • Psychoeducation

20. Nursing Management for the Social Domain • Assessment • Family factors • Cultural factors • Strengths • Nursing diagnoses • Social Isolation • Impaired Social Interaction • Risk for Loneliness • Interrupted Family Processes

21. Nursing Management for the Social Domain (cont.) • Interventions • Lifestyle reevaluation • Time management • Prioritizing or lists

22. Panic Disorder: Emergency Care • Symptoms similar to cardiac emergencies • Stay with the patient • Reassure him or her that you will not leave • Give clear, concise directions • Assist the patient to an environment with minimal stimulation • Walk or pace with the patient • Administer PRN anxiolytic medications • Afterward allow the patient to vent his or her feelings

23. Question Which agent would a nurse likely expect to administer as a first-line medication to a patient experiencing mild panic disorder? • Fluoxetine • Sertraline • Paroxetine • Alprazolam

24. Answer A, B, and C. • Fluoxetine, sertraline, and paroxetine are SSRIs and are used to treat panic disorder. Alprazolam is a benzodiazepine used, in combination with SSRIs, to treat a severely distressed patient.

25. Generalized Anxiety Disorder • Feelings of frustration, disgust with life, demoralization, and hopelessness • Sense of ill-being and uneasiness and fear of imminent disaster

26. Epidemiology • Affecting nearly 4% of the population; lifetime prevalence rate of 5% • 25% have GAD and a primary or comorbid diagnosis • Twice as common in women than in men • Insidious onset • Individuals of all ages affected • Typical onset (more than half) in childhood and adolescence; onset after age 20 years also common

27. Diagnostic Criteria • Excessive worry and anxiety for at least 6 months; anxiety related to a number of real-life activities or events • Patient with little or no control over the worry • At least three of the following along with excessive worry: sleep disturbance, easy fatigability, restlessness, poor concentration, irritability, and muscle tension • Significant impairment in daily personal or social life

28. Etiology • Biologic theories • Neurochemical theories • Genetic theories • Psychological theories • Cognitive behavioral theory: inaccurate environmental danger assessment • Psychoanalytic theory: unresolved unconscious conflicts • Sociologic theories • Possible contribution of high-stress lifestyle and multiple stressful events

29. Nursing Management for the Biologic Domain • Assessment • Symptoms • Diet and nutrition • Sleep patterns • Nursing diagnoses • Insomnia • Spiritual distress • Role conflict

30. Nursing Management for the Biologic Domain (cont.) • Interventions • Psychopharmacology • Benzodiazepines (most common) • Paroxetine, imipramine, venlafaxine • Anxiolytics • β-blockers • Teaching about medications • See Box 16.10

31. Other Anxiety Disorders • Specific phobia • Persistent fear of clearly discernible, circumscribed objects or situations leading to avoidance behavior (Box 16.11) • Blood injection, injury phobia • Anxiolytics for short-term relief of anxiety • Exposure therapy (treatment of choice) • Social phobia • Persistent fear of social or performance situation in which embarrassment may occur • SSRIs to reduce social anxiety and phobic avoidance

32. Other Anxiety Disorders (cont.) • Agoraphobia • Persistent fear of clearly discernible, circumscribed objects or situations leading to avoidance behavior • Anxiolytics for short-term relief of anxiety • Exposure therapy (treatment of choice)

33. Question Is the following statement true or false? • To meet the diagnostic criteria, a person with GAD must experience excessive worry and anxiety for a minimum of 3 months.

34. Answer False. • To be diagnosed with GAD, a person must experience excessive worry and anxiety for at least 6 months.