Chapter 25 Anxiety Disorders Management of Anxiety Phobia

Chapter 25: Anxiety Disorders: Management of Anxiety, Phobia, and Panic

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) Copyright © 2018 Wolters Kluwer · All Rights Reserved

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

Anxiety Disorders • Panic disorder • Generalized anxiety disorder (GAD) • Phobias Copyright ©

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

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) Copyright © 2018 Wolters Kluwer · All Rights Reserved

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question Is the following statement true or false? • Panic is considered abnormal regardless

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. Copyright © 2018 Wolters Kluwer · All Rights Reserved

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Management for the Biologic Domain • Nursing diagnoses • Assessment – Rule out lifethreatening medical causes; symptom evaluation – Anxiety – Substance use – Powerlessness – Sleep patterns – Ineffective Family Coping – Physical activity – Risk for Self-Harm – Social Isolation Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Management for the Biologic Domain (cont. ) • Interventions – Breathing control – Pharmacologic interventions (refer to Table 25. 4) – Nutritional planning • SSRIs, SNRIs – Relaxation techniques (See Box 25. 7) • TCAs – Increased physical activity • Benzodiazepines • MAOIs Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Management for the Psychological Domain • Nursing diagnoses • Assessment – Self-report scales (refer to Table 25. 5) – Mental status exam – Cognitive thought patterns: catastrophic misinterpretations (refer to Table 25. 3) – Anxiety – Risk for Self. Directed Violence – Social Isolation – Powerlessness – Ineffective Family Coping Copyright © 2018 Wolters Kluwer · All Rights Reserved

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) Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Management for the Social Domain • Nursing diagnoses • Assessment – Family factors – Social Isolation – Cultural factors – Powerlessness – Impaired Social Interaction – Risk for Loneliness – Interrupted Family Processes Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Management for the Social Domain (cont. ) • Interventions – Lifestyle reevaluation –

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question Which agent would a nurse least likely expect to administer to a patient experiencing panic disorder? A. Fluoxetine B. Sertraline C. Imipramine D. Buspirone Copyright © 2018 Wolters Kluwer · All Rights Reserved

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. Copyright © 2018 Wolters Kluwer · All Rights Reserved

Generalized Anxiety Disorder • Feelings of frustration, disgust with life, demoralization, and hopelessness • Sense of ill-being and uneasiness and fear of imminent disaster Copyright © 2018 Wolters Kluwer · All Rights Reserved

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Management for the Biologic Domain • Assessment – Symptoms – Diet and nutrition – Sleep patterns • Nursing diagnoses – Insomnia – Spiritual Distress – Role Conflict Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Management for the Biologic Domain (cont. ) • Interventions – Psychopharmacology • Benzodiazepines (most common) • Paroxetine, imipramine, venlafaxine • Buspirone (Bu. Spar) • Beta-blockers – Teaching about medications Copyright © 2018 Wolters Kluwer · All Rights Reserved

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. Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer False. • To be diagnosed with GAD, a person must experience excessive worry

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved

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 Copyright © 2018 Wolters Kluwer · All Rights Reserved