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Anxiety and Panic Disorders: Nursing Care and Treatment

Learn about anxiety and panic disorders, their symptoms, triggers, and treatment options. Understand the impact of anxiety across the lifespan and how to provide effective nursing care.

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Anxiety and Panic Disorders: Nursing Care and Treatment

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  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.

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