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Chapter 25: Anxiety Disorders: Management of Anxiety, Phobia, and Panic
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Anxiety Uncomfortable feeling of apprehension or dread in response to internal or external stimuli Physical, emotional, cognitive, and behavioral symptoms (refer to Box 25.1) Normal vs. abnormal Factors that determine if anxiety is a symptom of mental disorder: Intensity of anxiety relative to situation Trigger for anxiety Symptom clusters manifested (refer to Table 25.1)
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Overview of Anxiety Disorders
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 decreases with age
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Anxiety Disorders Panic disorder Generalized anxiety disorder (GAD)
Phobias
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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
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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 (refer to Key Diagnostic Characteristics 25.1)
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Epidemiology Risks: female; middle aged; low socioeconomic status, and widowed, separated or divorced Higher rates in whites than in 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
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Etiology Biologic theories Genetic factors Neuroanatomic theories
Biochemical theories Serotonin and norepinephrine; GABA Hypothalamic–pituitary–adrenal (HPA) axis Psychological and social theories Psychoanalytic and psychodynamic theories Cognitive behavioral theories
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Question Is the following statement true or false?
Panic is considered abnormal regardless of the situation and degree of threat.
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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.
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Interdisciplinary Treatment of Panic Disorder
Safe and therapeutic environment Medication and monitoring of effects Individual psychotherapy Psychological testing Priority care issues: safety because of a high risk for suicide
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Nursing Management for the Biologic Domain
Assessment Rule out life- threatening medical causes; symptom evaluation Substance use Sleep patterns Physical activity Nursing diagnoses Anxiety Risk for Self-Harm Social Isolation Powerlessness Ineffective Family Coping
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Nursing Management for the Biologic Domain (cont.)
Pharmacologic interventions (refer to Table 25.4) SSRIs, SNRIs TCAs MAOIs Benzodiazepines Interventions Breathing control Nutritional planning Relaxation techniques (See Box 25.7) Increased physical activity
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Nursing Management for the Psychological Domain
Nursing diagnoses Anxiety Risk for Self- Directed Violence Social Isolation Powerlessness Ineffective Family Coping Assessment Self-report scales (refer to Table 25.5) Mental status exam Cognitive thought patterns: catastrophic misinterpretations (refer to Table 25.3)
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Nursing Management for the Psychological Domain (cont.)
Interventions Trigger identification Distraction techniques Positive self-talk Panic control treatment Exposure therapy; systematic desensitization; implosion therapy CBT Psychoeducation (refer to Box 25.10) BT
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Nursing Management for the Social Domain
Nursing diagnoses Social Isolation Powerlessness Impaired Social Interaction Risk for Loneliness Interrupted Family Processes Assessment Family factors Cultural factors
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Nursing Management for the Social Domain (cont.)
Interventions Lifestyle reevaluation Time management Prioritizing or lists
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Panic Disorder: Emergency Care
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
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Question Which agent would a nurse least likely expect to administer to a patient experiencing panic disorder? Fluoxetine Sertraline Imipramine Buspirone
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Answer D. Buspirone Buspirone is more likely to be prescribed for a patient experiencing generalized anxiety disorder. Fluoxetine, sertraline, and imipramine are used to treat panic disorder.
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Generalized Anxiety Disorder
Feelings of frustration, disgust with life, demoralization, and hopelessness Sense of ill-being and uneasiness and fear of imminent disaster
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Epidemiology May also have a 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 also common
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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 Significant impairment in daily personal or social life
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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
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Nursing Management for the Biologic Domain
Assessment Symptoms Diet and nutrition Sleep patterns Nursing diagnoses Insomnia Spiritual Distress Role Conflict
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Nursing Management for the Biologic Domain (cont.)
Interventions Psychopharmacology Benzodiazepines (most common) Paroxetine, imipramine, venlafaxine Buspirone (BuSpar) Beta-blockers Teaching about medications
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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.
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Answer False. To be diagnosed with GAD, a person must experience excessive worry and anxiety for at least 6 months.
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Nursing Management for the Psychosocial and Social Domains
Assessment and intervention Similar to those for panic disorder Combination of Relaxation techniques Supportive therapies Cognitive therapies
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Other Anxiety Disorders
Specific phobia Persistent fear of clearly discernible, circumscribed objects or situations leading to avoidance behavior (refer to Box 25.12) 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
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