Chpt 18- Anxiety

Evidence based nursing care for panic disorders

Individuals often first seek help in the emergency department for their physical symptoms, but they are told that there are no life-threatening cardiac or neurologic causes for the severe physical symptoms. Although no laboratory tests exist to confirm anxiety disorders, a careful clinical assessment will reveal the presence of an anxiety disorder. Mental Health Nursing Assessment A comprehensive nursing assessment includes overall physical and mental status, suicidal tendencies and thoughts, cognitive thought patterns, avoidance behavior patterns, and family and cultural factors. Patients can be encouraged to keep a daily log of the severity of anxiety and the frequency, duration, and severity of panic episodes. This log will be a basic tool for monitoring progress as symptoms decrease. Panic attack assessment- identify characteristics of panic attack and individuals strengths and problems Physical Health Assessment Key assessment areas of physical health include the use of legal or illegal substances that could have precipitated the panic attack, sleep patterns, activity levels, and health conditions. Substance Use. Caffeine, pseudoephedrine, amphetamines, cocaine, or other stimulants are associated with panic disorder and may stimulate a panic attack. Tobacco use can also contribute to the risk for panic symptoms. Many individuals with panic disorder use alcohol or central nervous system (CNS) depressants in an effort to self-medicate anxiety symptoms; withdrawal from CNS depressants may produce symptoms of panic. Sleep Patterns. Sleep is often disturbed in patients with panic disorder. In fact, panic attacks can occur during sleep, so the patient may fear sleep for this reason. Nurses should closely assess the impact of sleep disturbance because fatigue may increase anxiety and susceptibility to panic attacks. Physical Activity. Panic disorder can be improved through active participation in a routine exercise program. If the patient does not exercise routinely, define the barriers to it. If exercise is avoided because of chronic muscle tension, poor muscle tone, muscle cramps, general fatigue, exhaustion, or shortness of breath, the symptoms may indicate poor physical health. Medications. Several medications can cause anxiety. Bronchodilators, oral contraceptives, amphetamines (i.e., methylphenidate), steroids, thyroid medication, and several other medications can increase anxiety. Additionally, medicines that contain caffeine such as some pain and anti-inflammatory agents, decongestants (i.e., phenylephrine), and some illegal drugs (cocaine) also increase anxiety. Other Physical Assessment Areas. Recent changes in physical status should be assessed. For example, pregnant patients should be assessed carefully for an underlying panic disorder. Although pregnancy may actually protect the mother from developing panic symptoms, postpartum onset of panic disorder requires particular attention. During a time that tremendous effort is spent on family, postpartum onset of panic disorder negatively affects lifestyle and decreases self-esteem in affected women, leading to feelings of overwhelming personal disappointment.

Hamilton Rating Scale for Anxiety

Max Hamilton designed this scale to help clinicians gather information about anxiety states. The symptom inventory provides scaled information that classifies anxiety behavior and assists the clinician in targeting behaviors and achieving outcome measures. Provide a rating for each indicator based on the following scale: 0 = None 1 = Mild 2 = Moderate 3 = Severe 4 = Severe, grossly disabling

Panic attacks

Panic attacks are a major finding in panic disorder. A panic attack is a sudden, discrete period of intense fear or discomfort that reaches its peak within a few minutes and is accompanied by significant physical discomfort and cognitive distress Panic attacks usually peak in about 10 minutes but can last as long as 30 minutes before returning to normal functioning. 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 (being detached from oneself), and a decreased ability to communicate. Usually, feelings of impending doom or death, fear of going crazy or losing control, and desperation ensue. The physical symptoms can mimic those of a heart attack. Individuals often seek emergency medical care because they feel as if they are dying, but most have negative cardiac workup results. People experiencing panic attacks may also believe that the attacks stem from an underlying major medical illnes

Panic disorder and generalized anxiety psychoeducation

Psychopharmacologic agents (anxiolytics or antidepressants) if ordered, including drug action, dosage, frequency, and possible adverse effects Breathing control measures Nutrition Exercise Progressive muscle relaxation Distraction behaviors Exposure therapy Time management Positive coping strategies

Common phobias

Acrophobia: fear of heights Agoraphobia: fear of open spaces Ailurophobia: fear of cats Algophobia: fear of pain Arachnophobia: fear of spiders Brontophobia: fear of thunder Claustrophobia: fear of closed spaces Cynophobia: fear of dogs Entomophobia: fear of insects Hematophobia: fear of blood Microphobia: fear of germs Nyctophobia: fear of night or dark places Ophidiophobia: fear of snakes Phonophobia: fear of loud noises Photophobia: fear of light Pyrophobia: fear of fire Topophobia: fear of a place, like a stage Xenophobia: fear of strangers Zoophobia: fear of animal or animals Phobias must be evaluated from ethnic or cultural background Anxiolytics helps short term of phobic anxiety, but no evidence confirms that they affect the course of disorders Treatment: Exposure therapy

agrophobia (anxiety disorder)

Agoraphobia is fear or anxiety triggered by about two or more situations such as using public transportation, being in open spaces, being in enclosed places, standing in line, being in a crowd, or being outside of the home alone When these situations occur, the individual believes that something terrible might happen and that escape may be difficult. The individual may experience panic-like symptoms or other embarrassing symptoms (e.g., vomiting, diarrhea) Agoraphobia leads to avoidance behaviors. Such avoidance interferes with routine functioning and eventually renders the person afraid to leave the safety of home. Some affected individuals continue to face feared situations but with significant trepidation (i.e., going in public only to pay bills or to take children to school). Agoraphobia may occur with panic disorder but is considered a separate disorder.

Evaluation of care

Although many researchers consider panic disorder a chronic, long-term condition, the positive results from outcome studies should be shared with patients to provide encouragement and optimism that patients can learn to manage these symptoms. Outcome studies have demonstrated success with panic control treatment, CBT therapy, exposure therapy, and various medications specific to certain symptoms. Continuum of Care As with any disorder, a continuum of patient care across multiple settings is crucial. Patients are treated in the least restrictive environment that will meet their safety needs. As the patient progresses through treatment, the environment of care changes from an emergency or inpatient setting to outpatient clinics or individual therapy sessions. Integration With Primary Care Some groups are more likely to seek out care in primary care rather than in mental health clinics. People with anxiety disorders are often treated in the primary care environment particularly those who experience panic disorder. Because panic attacks mimic cardiac difficulties, it is important that the patient continues to seek health care monitoring with medical clinicians.

Defense mechanism to help decrease anxiety

Altruism Satisfies internal needs through helping others. Prevents examination of underlying fears or concerns. Denial Avoids feelings associated with recognizing a problem. Avoidance of major problem that should be addressed. Displacement By taking out frustrations on an unsuspecting or vulnerable person, animal, or object, anxiety is reduced and the individual is protected from anticipated retaliation from the source of the frustration. Does not deal with problem and inappropriately expresses feelings toward a more vulnerable person or object. Intellectualization Able to analyze events in a distant, objective, analytical way. Inability to acknowledge feelings that may be interfering with relationships. Projection By assigning unwanted thoughts, feelings, or behaviors to another person or object, the individual does not have to acknowledge undesirable or unacceptable thoughts or feelings. Does not acknowledge undesirable or unwanted feelings or thoughts and can act on inaccurate interpretation of the other person's thoughts and behaviors. Rationalization Avoids anxiety by explaining an unacceptable or disappointing behavior or feeling in a logical, rationale way. May protect self-esteem and self-concept. Avoids the reality of a situation which may be detrimental to the individual. Reaction Formation Reduces anxiety by taking the opposite feeling. Hides true feelings, which may be appropriate in many situations. Unable to acknowledge personal feelings about others, which leads to negative consequences. Regression When stressed, abandons effective coping strategies and reverts to behaviors used earlier in development. These strategies are comfortable and may be effective. May reengage in detrimental behaviors such as smoking, drinking, or inappropriate interpersonal responses leading to ineffective coping. Repression Avoids unwanted thoughts and anxiety by blocking thoughts, experiences from conscious awareness. Cannot recall traumatic events that should be addressed to be healthy (i.e., rape). Sublimation Avoids anxiety and channels maladaptive feelings or impulses into socially acceptable behaviors. Maintains socially acceptable behavior. By not recognizing maladaptive feelings, the individual cannot address underlying feelings. Suppression Reduces anxiety by intentionally avoiding thinking about disturbing problems, wishes, feelings, or experiences. Useful in many situations such as test-taking situations. Avoiding problem situation prevents finding a solution to the problem.

Xanax

Anti Anxiety Increase effect of γ-aminobutyrate Short term relief of anxiety symptoms of depression related anxiety, panic attacks with or without agoraphobia S/E Transient mild drowsiness, initially; sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, anger, hostility, restlessness, headache, confusion, crying, constipation, diarrhea, dry mouth, nausea, and possible drug dependence WARNINGS: Contraindicated in patients with psychosis, acute narrow-angle glaucoma, shock, acute alcoholic intoxication with depressed vital signs, pregnancy, labor and delivery, and breastfeeding. Use cautiously in patients with impaired hepatic or renal function and severe debilitating conditions. Risk for digitalis toxicity if given concurrently with digoxin. Increased CNS depression if taken with alcohol, other CNS depressants, and propoxyphene (Darvon) Education Avoid using alcohol, sleep-inducing drugs, and other OTC drugs Take the drug exactly as prescribed and do not stop taking the drug without consulting your primary health care provider Take the drug with food if gastrointestinal upset occurs Avoid driving a car or performing tasks that require alertness if drowsiness or dizziness occurs Report any signs and symptoms of adverse reactions Notify your primary health care provider if severe dizziness, weakness, or drowsiness persists or if rash or skin lesions, difficulty voiding, palpitations, or swelling of the extremities occurs

Benzodiazepines therapy

Antipanic effect- faster onset than antidepressants Alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin) Carry risk for withdrawal symptoms upon discontinuation Panic disorders through SSRIs for first line treatment of panic disorders Administering and Monitoring Benzodiazepines. Treatment may include administering benzodiazepines concurrently with antidepressants for the first 4 weeks and then tapering the benzodiazepine to a maintenance dose. This strategy provides rapid symptom relief but avoids the complications of long-term benzodiazepine use. Benzodiazepines with short half-lives do not accumulate in the body, but benzodiazepines with half-lives of longer than 24 hours tend to accumulate with long-term treatment, are removed more slowly, and produce less intense symptoms on discontinuation of use Short-acting benzodiazepines, such as alprazolam, are associated with rebound anxiety, or anxiety that increases after the peak effects of the medication have decreased. Medications with short half-lives (alprazolam, lorazepam) should be given in three or four doses spaced throughout the day, with a higher dose at bedtime to allay anxiety-related insomnia. Clonazepam, a longer-acting benzodiazepine, requires less frequent dosing and has a lower risk for rebound anxiety. Because of their depressive CNS effects, benzodiazepines should not be used to treat patients with comorbid sleep apnea. In fact, these drugs may actually decrease the rate and depth of respirations. Exercise caution in older adult patients for these reasons. Discontinuing medication use requires a slow taper during a period of several weeks to avoid rebound anxiety and serious withdrawal symptoms. Benzodiazepines are not indicated in the chronic treatment of patients with substance abuse but can be useful in quickly treating anxiety symptoms until other medications take effect. Symptoms associated with withdrawal of benzodiazepine therapy are more likely to occur after high doses and long-term therapy. They can also occur after short-term therapy. Withdrawal symptoms manifest in several ways, including psychological (e.g., apprehension, irritability, agitation).

Anxiety

Anxiety is part of many emotional problems and mental disorders. At one time, most mental conditions with anxiety aspects were categorized as "anxiety disorders," but today anxiety disorders have been redefined. Trauma-stressor-related disorder and obsessive-compulsive disorder (OCD), both previously identified as anxiety disorders, are now categorized as separate disorders Anxiety is an unavoidable human condition that takes many forms and serves different purposes. Anxiety can be positive and can motivate one to act, or it can produce paralyzing fear, causing inaction. "Normal anxiety" is described as being of realistic intensity and duration for the situation and is followed by relief behaviors intended to reduce or prevent more anxiety (Peplau, 1989). A "normal anxiety response" is appropriate to the situation and can be used to help the individual identify which underlying problem has caused the anxiety.

Mood

Anxious mood Worries, anticipation of the worst, fearful anticipation, irritability Tension Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax Fear Of dark, strangers, being left alone, animals, traffic, crowds Insomnia Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking; dreams, nightmares, night terrors Intellectual (cognitive) Difficulty concentrating, poor memory Depressed mood Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swings Somatic (sensory) Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, prickly sensation Somatic (muscular) Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone Cardiovascular symptoms Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat Respiratory symptoms Pressure or constriction in chest, choking feelings, sighing, dyspnea Gastrointestinal symptoms Difficulty in swallowing, gas, abdominal pain, burning sensation, abdominal fullness, nausea, vomiting, looseness of bowels, loss of weight, constipation Genitourinary symptoms Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence Autonomic symptoms Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair Behavior at interview Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, belching, brisk tendon jerks, dilated pupils, exophthalmos

Associated findings

Associated Findings Nocturnal panic attack (waking from sleep in a state of panic) Constant or intermittent feelings of anxiety related to physical and mental health Pervasive concerns about abilities to complete daily tasks or withstand daily stressors Excessive use of drugs or other means to control panic attacks Associated Physical Examination Findings Transient tachycardia Moderate elevation of systolic blood pressure Associated Laboratory Findings Compensated respiratory alkalosis (decreased carbon dioxide, decreased bicarbonate levels, almost normal pH) Other Targets for Treatment Loss or disruption of important interpersonal or occupational activities Demoralization Possible major depressive episode

Emergency care

Because individuals with panic disorder are likely to first present for treatment in an emergency department or primary care setting, nurses working in these settings should be involved in early recognition and referral. Consultation with a psychiatrist or mental health professional by the primary care physician can decrease both costs and overall patient symptoms. Several interventions may be useful in reducing the number of emergency department visits related to panic symptoms. Psychiatric consultation and nursing education can be provided in the emergency department to explore other avenues of treatment. Remembering that the patient experiencing a panic attack is in crisis, nurses can take several measures to help alleviate symptoms, including the following: Stay with the patient and maintain a calm demeanor. (Anxiety often produces more anxiety and a calm presence will help calm the patient.) Reassure the patient that you will not leave, that this episode will pass, and that he or she is in a safe place. (The patient often fears dying and cannot see beyond the panic attack.) Give clear concise directions using short sentences. Do not use medical jargon. Walk or pace with the patient to an environment with minimal stimulation. (The patient in panic has excessive energy.) Administer prn (i.e., as-needed) anxiolytic medications as ordered and appropriate. (Pharmacotherapy is effective in treating those patients with acute panic attack.) After the panic attack has resolved, allow the patient to vent his or her feelings. This often helps the patient in clarifying his or her feelings.

Etiology

Brain abnormalities in "fear network"(amygdala, hippocampus, thalamus, midbrain, pons, medulla, and cerebellum) and changes in volume in different brain areas) Serotonin and Norepinephrine Serotonin and norepinephrine are both implicated in panic disorders. Norepinephrine effects act on those systems most affected by a panic attack—the cardiovascular, respiratory, and gastrointestinal systems. Serotonergic neurons are distributed in central autonomic and emotional motor control systems regulating anxiety states and anxiety-related physiologic and behavioral responses Gamma-Aminobutyric Acid Gamma-aminobutyric acid (GABA) is the most abundant inhibitory neurotransmitter in the brain. GABA receptor stimulation causes several effects, including neurocognitive effects, reduction of anxiety, and sedation. GABA stimulation also results in increased seizure threshold. Abnormalities in the benzodiazepine-GABA-chloride ion channel complex have been implicated in panic disorder Hypothalamic-Pituitary-Adrenal Axis Research implicates a role of the hypothalamic-pituitary-adrenal (HPA) axis in panic disorders (Quagliato & Nardi, 2018). A current explanation is that as stress hormones are activated, anxiety increases, which can lead to a panic attack

Teaching progressive muscle relaxation

Choose a quiet, comfortable location where you will not be disturbed for 20 to 30 minutes. Your position may be lying or sitting, but all parts of your body should be supported, including your head. Wear loose clothing, taking off restrictive items, such as glasses and shoes. Begin by closing your eyes and clearing your mind. Moving from head to toe, focus on each part or your body and assess the level of tension. Visualize each group of muscles as heavy and relaxed. Take two or three slow abdominal breaths, pausing briefly between each breath. Imagine the tension flowing from your body. Each muscle group listed below should be tightened (or tensed isometrically) for 5 to 10 seconds and then abruptly released; visualize this group of muscles as heavy, limp, and relaxed for 15 to 20 seconds before tightening the next group of muscles. There are several methods to tighten each muscle group and suggestions are provided below. Each muscle group may be tightened two to three times until relaxed. Do not overtighten or strain. You should not experience pain. Hands: tighten by making fists Biceps: tighten by drawing forearms up and "making a muscle" Triceps: extend forearms straight, locking elbows Face: grimace, tightly shutting mouth and eyes Face: open mouth wide and raise eyebrows Neck: pull head forward to chest and tighten neck muscles Shoulders: raise shoulders toward ears Shoulders: push shoulders back as if touching them together Chest: take a deep breath and hold for 10 seconds Stomach: suck in your abdominal muscles Buttocks: pull buttocks together Thighs: straighten legs and squeeze muscles in thighs and hips Calves: pull toes carefully toward you, avoid cramps Feet: curl toes downward and point toes away from your body Finally, repeat several deep abdominal breaths and mentally check your body for tension. Rest comfortably for several minutes, breathing normally, and visualize your body as warm and relaxed. Get up slowly when you are finished.

Wellness challenges for person with anxiety

Coping effectively with daily stresses without excessive worry Strategies: Develop a daily schedule, allow time to relax, avoid trying to multitask, deep breathing, mindfulness Satisfying and enriching workStrategies: Choose activities that are consistent with your skills and knowledge, consider other possibilities if job is too stressful Incorporate physical activity, healthy foods, and adequate sleep into daily lifeStrategies: Schedule regular physical activity, make a weekly menu of healthy meals, establish healthy sleep hygiene routines Developing a sense of connection, belong, and a support systemStrategies: Join a support group, seek out recreational activities with friends and families Expanding a sense of purpose and meaning in lifeStrategies: Focus on goals, values and beliefs, read inspiring stories or essays

Target symptoms

Discrete period of intense fear or discomfort with four (or more) of the following symptoms that develop abruptly and reach a peak within 10 minutes: Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feelings of choking Chest pain or discomfort Nausea or vomiting Feeling dizzy, unsteady, light-headed, or faint Derealization (feeling of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Fear of dying Paresthesias (numbness or tingling sensations) Chills or hot flushes Great apprehension about the outcome of routine activities and experiences Loss or disruption of important interpersonal relationships Demoralization Possible major depressive episode

Anxiety effect on body

During a perceived threat, rising anxiety levels cause physical and emotional changes in all individuals. A normal emotional response to anxiety consists of three parts: physiologic arousal, cognitive processes, and coping strategies. Physiologic arousal, or the fight-or-flight response, is the signal that an individual is facing a threat. Cognitive processes decipher the situation and decide whether the perceived threat should be approached or avoided. Coping strategies are used to resolve the threat The factors that determine whether anxiety is a symptom of a mental disorder include the intensity of anxiety relative to the situation, the trigger for the anxiety, and the particular symptom clusters that manifest the anxiety

Recovery oriented care

Exposure Therapy Many of the treatment approaches used for panic disorder are effective for phobias. Exposure therapy is the treatment of choice for phobias. The patient is repeatedly exposed to real or simulated anxiety-provoking situations until he or she becomes desensitized and anxiety subsides. Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT) is a highly effective tool for treating individuals with panic disorder. It has been considered the first-line treatment for those with panic and other anxiety disorders and is often used in conjunction with medications, including the selective serotonin reuptake inhibitors (SSRIs), in treating those with panic disorder (Bandelow et al., 2015). The goals of CBT include helping the patient to manage his or her anxiety and correcting anxiety-provoking thoughts through interventions, including cognitive restructuring, breathing training, and psychoeducation. Integration With Primary Care Coordination of care between mental health and primary leads to safer and management of anxiety disorders care services. Primary care providers are often asked to treat the physical consequences of anxiety such as hypertension and obesity (DeJesus et al., 2016). Anxiety can be caused by physical health issues such as immune, metabolic, and cardiovascular problems. Many prescription and nonprescription drugs can cause anxiety such as asthma, blood pressure, steroid, and thyroid medications. Without coordination of care, the clinicians will not be able to make a meaningful assessment which could lead to the wrong treatment.

Psychosocial factors

Family Factors Marital and parental functioning can be adversely affected by panic disorder. During the assessment, the nurse should try to grasp the patient's understanding of how panic disorder with or without severe avoidance behavior has affected his or her life along with that of the family Cultural Factors. Cultural competence calls for the understanding of cultural knowledge, cultural awareness, cultural assessment skills, and cultural practice. Therefore, cultural differences must be considered in the assessment of panic disorder. Different cultures interpret sensations, feelings, or understandings differently. For example, symptoms of anxiety might be seen as witchcraft or magic Several cultures do not have a word to describe "anxiety" or "anxious" and instead may use words or meanings to suggest physical complaints Asian herbs OTC can induce panic by increase HR, BMR, BP, and sweating Identifying Strengths. During the assessment, the patient's strengths will emerge. For example, a patient may tell you that he does not drink alcohol or use tobacco. Another may relate that he would like to exercise. Still another patient has a supportive partner or family member. The nurse can support these positive behaviors as the care plan is established.

Diagnostic and nursing care

GAD is characterized by excessive worry and anxiety (apprehensive expectation) for at least 6 months. The anxiety does not usually pertain to a specific situation; rather, it concerns several real-life activities or events. Ultimately, excessive worry and anxiety cause great distress and interfere with the patient's daily personal or social life. Nursing Care Nursing care for the person with GAD is similar to the care of the individual with a panic disorder. In many instances, antidepressants and an antianxiety agent will be prescribed. Nursing interventions should focus on helping the person target specific areas of anxiety and reducing the impact of the anxiety

Generalized anxiety disorders

Generally speaking, patients with generalized anxiety disorder (GAD) feel frustrated, disgusted with life, demoralized, and hopeless. They may state that they cannot remember a time that they did not feel anxious. They experience a sense of ill-being and uneasiness and a fear of imminent disaster. Over time, they may recognize that their chronic tension and anxiety are unreasonable.

Anxiety across lifespan

Go unnoticed by caregivers due to misdiagnosed because of mimic of cardiac or pulmonary rather than psychological Children and teens Anxiety disorders are among the most common conditions of children and adolescents. If left untreated, symptoms persist and gradually worsen and sometimes lead to suicidal ideation and suicide attempts, early parenthood, drug and alcohol dependence, and educational underachievement later in life Separation anxiety disorder (i.e., excessive fear or anxiety concerning separation from home or attachment figures) usually first occurs in childhood. Affected children experience extreme distress when separated from home or attachment figures, worry about them when separated from them, and worry about untoward events (i.e., getting lost) and what will happen to them. Rare disorder seen in childhood is selective mutism in which children do no initiate speech or respond when spoken to by others Children with disorder are often anxious when asked to speak in school- suffer academic impairment because of inability to communicate with others OA Generally speaking, the prevalence of anxiety disorders declines with age. However, in the older adult population, rates of anxiety disorders are as high as mood disorders, which commonly co-occur. This combination of depressive and anxiety symptoms has been shown to decrease social functioning, increase somatic (physical) symptoms, and increase depressive symptoms In one study, nearly half of primary care patients with chronic pain had at least one attendant anxiety disorder. Detecting and treating anxiety is an important component of pain management OA at risk for suicide

Teaching Breathing Techniques

Hyperventilation is common. Often, people are unaware that they take rapid shallow breaths when they become anxious. Teaching patients breathing control can be helpful. Focus on the breathing and help them to identify the rate, pattern, and depth. If the breathing is rapid and shallow, reassure the patient that exercise and breathing practice can help change this breathing pattern. Then, assist the patient in practicing abdominal breathing by performing the following exercises: Instruct the patient to breathe deeply by inhaling slowly through the nose. Have him or her place a hand on the abdomen just beneath the rib cage. Instruct the patient to observe that when one is breathing deeply, the hand on the abdomen will actually rise. After the patient understands this process, ask him or her to inhale slowly through the nose while counting to five, pause, and then exhale slowly through pursed lips. While the patient exhales, direct attention to feeling the muscles relax, focusing on "letting go." Have the patient repeat the deep abdominal breathing for 10 breaths, pausing between each inhalation and exhalation. Count slowly. If the patient complains of light-headedness, reassure him or her that this is a normal feeling while deep breathing. Instruct the patient to stop for 30 seconds, breathe normally, and then start again. The patient should stop between each cycle of 10 breaths and monitor normal breathing for 30 seconds. This series of 10 slow abdominal breaths followed by 30 seconds of normal breathing should be repeated for 3 to 5 minutes. Help the patient to establish a time for daily practice of abdominal breathing. Abdominal breathing may also be used to interrupt an episode of panic as it begins. After patients have learned to identify their own early signs of panic, they can learn the four-square method of breathing, which helps divert or decrease the severity of the attack. Patients should be instructed as follows: Advise the patient to practice during calm periods and to begin by inhaling slowly through the nose, count to four, and then hold the breath for a count of four. Direct the patient to exhale slowly through pursed lips to a count of four and then rest for a count of four (no breath). Finally, the patient may take two normal breaths and repeat the sequence. After patients practice the skill, the nurse should assist them in identifying the physical cues that will alert them to use this calming technique.

Family interventions

In addition to learning the symptoms of panic disorder, nurses should have information sheets or pamphlets available concerning the disorder and any medications prescribed. Parents, especially single parents, will need assistance in child-rearing and may benefit from services designed to provide some respite. Moreover, the entire family will need support in adjusting to the disorder. A referral for family therapy is indicated, because involving the entire family in the therapy process is imperative. Families experience the symptoms, treatments, clinical setbacks, and recovery from chronic mental illnesses as a unit. Misunderstandings, misconceptions, false information, and the stigma of mental illness, singly or collectively, impede recovery efforts.

Epidemiology and Risk factors

Increased risk is associated with being female; middle aged; of low socioeconomic status; and widowed, separated, or divorced. The estimates of isolated panic attacks may affect 22.7% of the population. Panic disorders occur in several cultures, but the panic symptoms may be experienced differently across racial/ethnic group Family history, substance and stimulant use or abuse, smoking tobacco, and severe stressors are risk factors for panic disorder. People who have several anxiety symptoms and those who experience separation anxiety during childhood often develop panic disorder later in life. Early life traumas, a history of physical or sexual abuse, socioeconomic or personal disadvantages, and behavioral inhibition by adults have also been associated with an increased risk for anxiety disorders in children

Wellness strategies

Individuals with panic disorder, especially those with significant anxiety sensitivity, may need assistance in reevaluating their lifestyle. Time management can be a useful tool. In the workplace or at home, underestimating the time needed to complete a chore or being overly involved in several activities at once increases stress and anxiety. Procrastination, lack of assertiveness, and difficulties with prioritizing or delegating tasks intensify these problems. Writing a list of chores to be completed and estimating time to complete them provide concrete feedback to the individual. Crossing out each activity as it is completed helps the patient to regain a sense of control and accomplishment. Large tasks should be broken into a series of smaller tasks to minimize stress and maximize sense of achievement. Rest, relaxation, and family time—frequently omitted from the daily schedule—must be included.

Inpatient focused care and community care

Inpatient settings provide control for the stabilization of the acute panic symptoms and initiation of recovery-oriented strategies. Medication use is often initiated here because patients who show initial panic symptoms require in-depth assessment to determine the cause. As recovery begins, crisis stabilization, medication management, milieu therapy, and psychotherapies are introduced, and outpatient discharge linkage appointments are set. Nurses are more directly involved in treatment, conducting psychoeducation groups on relaxation and breathing techniques, symptom management, and anger management. Advanced practice nurses conduct CBT and individual and family psychotherapy. In addition, medication monitoring groups reemphasize the role of medications, monitor for side effects, and enhance treatment compliance overall.

Phobias

Irrational fear that leads to compelling avoidance Present in anxiety disorders and develop into specific phobia disorder Defense mechanism and anxiety Reduce anxiety by preventing or diminishing unwanted thoughts and feelings The first step is identifying a person's use of defense mechanisms. The next step is determining whether the reasons the defense mechanisms are being used support healthy coping or are detrimental to a person's health. What may be healthy for one person may be unhealthy for another.

Teaching nutritional interventions

Maintaining regular and balanced eating habits reduces the likelihood of hypoglycemic episodes, light-headedness, and fatigue. To help teach the patient about healthful eating and ways to minimize physical factors contributing to anxiety: Advise the patient to reduce or eliminate substances in the diet that promote anxiety and panic, such as food coloring, monosodium glutamate, and caffeine (withdrawal from which may stimulate panic). Patients need to plan to reduce caffeine consumption and then eliminate it from their diet. Many OTC remedies are now used to boost energy or increase mental performance; some of these contain caffeine. A thorough assessment should be made of all OTC products used to assess the potential of anxiety-provoking ingredients. Instruct the patient to check each substance consumed and note whether symptoms of anxiety occur and whether the symptoms are relieved by not consuming the product.

Nursing interventions based on degrees of anxiety

Mild Assist patient to use the energy anxiety provides to encourage learning. Moderate Encourage patient to talk: to focus on one experience, to describe it fully, and then to formulate the patient's generalizations about that experience. Severe Allow relief behaviors to be used but do not ask about them. Encourage the patient to talk: ventilation of random ideas is likely to reduce anxiety to a moderate level. Panic Stay with the patient. Allow pacing and walk with the patient. No content inputs to the patient's thinking should be made by the nurse. (They burden the patient, who will distort them.) Be direct with the fewest number of words: e.g., "Drink this" (give liquids to replace lost fluids and to relieve dry mouth); "Say what's happening to you," "Talk about yourself," or "Tell what you feel now" (to encourage ventilation and externalization of inner, frightening experience). Pick up on what the patient says, e.g., Patient: "What's happening to me—how did I get here?" Nurse: "Say what you notice." Use short phrases to the point of the patient's comment. Do not touch the patient; patients experiencing panic are very concerned about survival, are experiencing a grave threat to self, and usually distort intentions of all invasions of their personal space.

Anxiety levels

Mild Perceptual field widens slightly. Able to observe more than before and to see relationships (make connection among data). Learning is possible. Is aware, alert, sees, hears, and grasps more than before. Usually able to recognize and identify anxiety easily. Moderate Perceptual field narrows slightly. Selective inattention: does not notice what goes on peripheral to the immediate focus but can do so if attention is directed there by another observer. Sees, hears, and grasps less than previously. Can attend to more if directed to do so. Able to sustain attention on a particular focus; selectively inattentive to contents outside the focal area. Usually able to state, "I am anxious now." Severe Perceptual field is greatly reduced. Tendency toward dissociation: to not notice what is going on outside the current reduced focus of attention; largely unable to do so when another observer suggests it. Sees, hears, and grasps far less than previously. Attention is focused on a small area of a given event. Inferences drawn may be distorted because of inadequacy of observed data. May be unaware of and unable to name anxiety. Relief behaviors generally used. Panic (e.g., terror, horror, dread, uncanniness, awe) Perceptual field is reduced to a detail, which is usually "blown up," i.e., elaborated by distortion (exaggeration), or the focus is on scattered details; the speed of the scattering tends to increase. Massive dissociation, especially of contents of self-system. Felt as enormous threat to survival. Learning is impossible. Says, "I'm in a million pieces," "I'm gone," or "What is happening to me?" Perplexity, self-absorption. Feelings of unreality. Flights of ideas or confusion. Fear. Repeats a detail. Many relief behaviors used automatically (without thought). The enormous energy produced by panic must be used and may be mobilized as rage. May pace, run, or fight violently. With dissociation of contents of self-system, there may be a very rapid reorganization of the self, usually going along pathologic lines (e.g., a "psychotic break" is usually preceded by panic).

SNRI

Monitor- SSRIs should not be given with MAOIs Drugs that interact with benzodiazepines include the TCAs and digoxin; interaction may result in increased serum TCA or digoxin levels. Alcohol and other CNS depressants, when used with benzodiazepines, increase CNS depression. Their concomitant use is contraindicated. Histamine-2 blockers (e.g., cimetidine) used with benzodiazepines may potentiate sedative effects. Monitor closely for effectiveness in patients who smoke; cigarette smoking may increase the clearance of benzodiazepines. The side effects of benzodiazepine medications generally include headache, confusion, dizziness, disorientation, sedation, and visual disturbances. Sedation should be monitored after beginning medication use or increasing the dose. The patient should avoid operating heavy machinery until the sedative effects are known. Concurrent use of SSRIs and the MAOIs is contraindicated. These antidepressants should not be given together. Teaching Points. Warn patients to avoid alcohol because of the chance of CNS depression. In addition, warn them not to operate heavy machinery until the sedative effects of the medication are known.

Anxiety symptoms

PHYSICAL SYMPTOMS Cardiovascular Sympathetic Palpitations Heart racing Increased blood pressure Parasympathetic Actual fainting Decreased blood pressure Decreased pulse rate Respiratory Rapid breathing Difficulty getting air Shortness of breath Pressure of chest Shallow breathing Lump in throat Choking sensations Gasping Spasm of bronchi Neuromuscular Increased reflexes Startle reaction Eyelid twitching Insomnia Tremors Rigidity Spasm Fidgeting Pacing Strained face Unsteadiness Generalized weakness Wobbly legs Clumsy motions Skin Flushed face Pale face Localized sweating (palm region) Generalized sweating Hot and cold spells Itching Gastrointestinal Loss of appetite Revulsion about food Abdominal discomfort Diarrhea Abdominal pain Nausea Heartburn Vomiting Eyes Dilated pupils Urinary Tract Parasympathetic Pressure to urinate Increased frequency of urination AFFECTIVE SYMPTOMS Edgy Impatient Uneasy Nervous Tense Wound-up Anxious Fearful Apprehensive Scared Frightened Alarmed Terrified Jittery Jumpy COGNITIVE SYMPTOMS Sensory-Perceptual Mind is hazy, cloudy, foggy, dazed Objects seem blurred or distant Environment seems different or unreal Feelings of unreality Self-consciousness Hypervigilance Thinking Difficulties Cannot recall important things Confused Unable to control thinking Difficulty concentrating Difficulty focusing attention Distractibility Blocking Difficulty reasoning Loss of objectivity and perspective Tunnel vision Conceptual Cognitive distortion Fear of losing control Fear of not being able to cope Fear of physical injury or death Fear of mental disorder Fear of negative evaluations Frightening visual images Repetitive fearful ideation BEHAVIORAL SYMPTOMS Inhibited Tonic immobility Flight Avoidance Speech dysfluency Impaired coordination Restlessness Postural collapse Hyperventilation

Diagnostic for Panic attacks

Panic disorder is a chronic condition that has several exacerbations and remissions during the course of the disease. The disabling panic attacks often lead to other symptoms, such as phobias. Other diagnostic symptoms include palpitations, sweating, shaking, shortness of breath or smothering, sensations of choking, chest pain, nausea or abdominal distress, dizziness, derealization or depersonalization, fear of going crazy, fear of dying, paresthesias, and chills or hot flashes

Panic disorder

Panic is an extreme, overwhelming form of anxiety often experienced when an individual is placed in a real or perceived life-threatening situation. Panic is normal during periods of threat but is abnormal when it is continuously experienced in situations that pose no real physical or psychological threat. Some people experience heightened anxiety because they fear experiencing another panic attack. This type of panic interferes with the individual's ability to function in everyday life and is characteristic of panic disorder. The onset of panic disorder is typically between 20 and 24 years of age. The disorder usually surfaces in childhood but may not be diagnosed until later. Panic disorder is treatable, but studies have shown that even after years of treatment, many people remain symptomatic. In some cases, symptoms may even worsen

Comorbidity

Patients may experience more than one anxiety disorder, depression, eating disorder, substance use or abuse, or schizophrenia Although people with panic disorder are thought to have more somatic complaints than the general population, panic disorder does correlate with some medical conditions, including vertigo, cardiac disease, gastrointestinal disorders, asthma, and those related to cigarette smoking. Diagnostic Criteria Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:Note: The abrupt surge can occur from a calm state or an anxious statePalpitations, pounding heart, or accelerated heart rateSweatingTrembling or shakingSensations of shortness of breath or smotheringFeelings of chokingChest pain or discomfortNausea or abdominal distressFeeling dizzy, unsteady, light-headed, or faintChills or heat sensationsParesthesias (numbness or tingling sensations)Derealization (feelings of unreality) or depersonalization (being detached from oneself)Fear of losing control or "going crazy"Fear of dyingNote: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms At least one of the attacks has been followed by 1 month (or more) of one or both of the following:Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy")A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations) The disturbance is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders) The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder)

Psychosocial interventions

Peplau (1989) devised general guidelines for nursing interventions that might be successful in treating patients with anxiety. These interventions help the patient attend to and react to input other than the subjective experience of anxiety. They are designed to help the patient focus on other stimuli and cope with anxiety in any form Distraction After patients can identify the early symptoms of panic, they may learn to implement distraction behaviors that take the focus off the physical sensations. Some activities include initiating conversation with a nearby person or engaging in physical activity (e.g., walking, gardening, or housecleaning). Performing simple repetitive activities such as snapping a rubber band against the wrist, counting backward from 100 by 3s, or counting objects along the roadway might also deter an attack. Reframing Reframing is a cognitive technique that can change the way a situation, event, or person is viewed and reduce the impact of anxiety-provoking thoughts. People with anxiety disorders often view themselves negatively and use "should statements" and "negative labels." Should statements lead to rigid rules and unrealistic expectations. By encouraging patients to avoid the use of should statements and reframe their views, they can change their beliefs to be more realistic. For example, if a patient says, "I should be a better parent" or "I'm a useless failure," the nurse could ask the person to identify the positive aspects of parenting and other successes.

Recovery oriented care

Persons with a panic disorder may inadvertently cause excessive fears, phobias, or excessive worry in other family members. Families may limit social functions to prevent a panic attack. Those affected need a tremendous amount of support and encouragement from significant others. Teamwork and Collaboration: Working Toward Recovery Nurses are pivotal in providing a safe and therapeutic inpatient environment and teaching patients strategies for managing anxiety and fears. The nurse also administers prescribed medication, monitors its effects, and provides medication education. Advanced practice nurses, licensed clinical social workers, or licensed counselors provide individual psychotherapy sessions as needed. Often, a clinical psychologist gives psychological tests and interprets the results to assist in diagnosing and treating the panic disorder. Panic Control Treatment Panic control treatment involves intentional exposure (through exercise) to panic-invoking sensations such as dizziness, hyperventilation, tightness in the chest, and sweating. Identified patterns become targets for treatment. Patients are taught to use breathing training and cognitive restructuring to manage their responses and are instructed to practice these techniques between therapy sessions to adapt the skills to other situations. Systematic Desensitization Systematic desensitization, another exposure method used to desensitize patients, exposes the patient to a hierarchy of feared situations that the patient has rated from least to most feared. The patient is taught to use muscle relaxation as levels of anxiety increase through multisituational exposure. Planning and implementing exposure therapy require special training. Because of the multitude of outpatients in the treatment for panic disorder and agoraphobia (discussed later in the chapter), exposure therapy is a useful tool for home health psychiatric nurses. Outcomes of home-based exposure treatment are similar to clinic-based treatment outcomes. Implosive Therapy Implosive therapy is a provocative technique useful in treating panic disorder and agoraphobia in which the therapist identifies phobic stimuli for the patient and then presents highly anxiety-provoking imagery to the patient, describing the feared scene as dramatically and vividly as possible. Flooding is a technique used to desensitize the patient to the fear associated with a particular anxiety-provoking stimulus. Desensitizing is done by presenting feared objects or situations repeatedly without session breaks until the anxiety dissipates. For example, a patient with ophidiophobia (i.e., a morbid fear of snakes) might be presented with a real snake repeatedly until the patient's anxiety decreases.

Interventions

Positive Self-Talk During states of increased anxiety and panic, individuals can learn to counter fearful or negative thoughts by using another cognitive approach. Positive self-talk involves planning and rehearsing positive coping statements "This is only anxiety, and it will pass," "I can handle these symptoms," and "I'll get through this" are examples of positive self-talk. These types of positive statements can give the individual a focal point and reduce fear when panic symptoms begin. Handheld cards that offer positive statements can be carried in a purse or wallet so the person can retrieve them quickly when panic symptoms are felt Psychoeducation Psychoeducation programs help to teach patients and families about the symptoms of panic. Individuals with panic disorder legitimately fear going crazy, losing control, or dying because of their physical symptoms. Attempting to convince a patient that such fears are groundless only heightens anxiety and impedes communication. Information and physical evidence (e.g., electrocardiogram results, laboratory test results) should be presented in a caring and open manner that demonstrates acceptance and understanding of his or her situation.

Psychosocial theories

Psychoanalytic and Psychodynamic Theories Psychodynamic theories examine anxiety that develops after separation and loss. Many patients link their initial panic attack with recent personal losses. However, at this point the empirical evidence remains inadequate for a psychodynamic explanation. It remains unclear why some patients develop panic disorder whereas others with similar experiences develop other disorders Cognitive Behavioral Theories Learning theory underlies most cognitive behavioral explanations of panic disorder. Classic conditioning theory suggests that one learns a fear response by linking an adverse or fear-provoking event, such as a car accident, with a previously neutral event, such as crossing a bridge. One becomes conditioned to associate fear with crossing a bridge. Applying this theory to people with panic disorder has limitations. Phobic avoidance is not always developed secondary to an adverse event. Further development of this theory led to an understanding of interoceptive conditioning, an association between physical discomfort, such as dizziness or palpitations, and an impending panic attack. For example, during a car accident, the individual may experience rapid heartbeat, dizziness, shortness of breath, and panic. Subsequent experiences of dizziness or palpitations, unrelated to an anxiety-provoking situation, incite anxiety and panic. Furthermore, people with panic disorder may misinterpret mild physical sensations (e.g., sweating, dizziness) as being catastrophic, causing panic as a result of learned fear (catastrophic interpretation). Some researchers hypothesize that individuals with a low sense of control over their environment or with a particular sensitivity to anxiety are vulnerable to misinterpreting normal stress. Controlled exposure to anxiety-provoking situations and cognitive countering techniques has proven successful in reducing the symptoms of panic.

Psychosocial assessment

Self-Report Scales. Self-evaluation is difficult in panic disorder. Often the memories of the attack and its triggers are irretrievable. Several tools are available to characterize and rate the patient's state of anxiety Hamilton Rating Scale for Anxiety Mental Status Examination. During a mental status examination, individuals with panic disorder may exhibit anxiety symptoms, including restlessness, irritability, poor concentration, and apprehensive behavior. Disorganized thinking, irrational fears, and a decreased ability to communicate often occur during a panic attack. Assess by direct questioning whether the patient is experiencing suicidal thoughts, especially if he or she is abusing substances or is taking antidepressant medications. Cognitive Thought Patterns. Catastrophic misinterpretations of trivial physical symptoms can trigger panic symptoms. After they have been identified, these thoughts should serve as a basis for individualizing patient education to counter such false beliefs Several studies have found that individuals who feel a sense of control have less severe panic attacks. Individuals who fear loss of control during a panic attack often make the following type of statements: "I feel trapped." "I'm afraid others will know or that I'll hurt someone." "I feel alone. I can't help myself." "I'm losing control." These individuals also tend to show low self-esteem, feelings of helplessness, demoralization, and overwhelming fears of experiencing panic attacks. They may have difficulty with assertiveness or expressing their feelings.

Panic attacks

Similar to cardiac emergencies In a panic disorder, recurrent unexpected panic attacks are followed by persistent concern about experiencing subsequent panic attacks. Because of fear of future attacks, these affected individuals modify normal behaviors to avoid future attacks Panic attacks are either expected with an obvious cue or trigger or unexpected with no such obvious cue. The first panic attack is usually associated with an identifiable cue (e.g., anxiety-provoking medical conditions, such as asthma, or in initial trials of illicit substance use), but subsequent attacks are often unexpected without any obvious cue Panic attacks not only occur in panic disorder but can also occur in other mental disorders such as depression, bipolar disease, eating disorders, and some medical conditions such as cardiac or respiratory disorders

Social anxiety disorder or social phobia

Social anxiety disorder involves a persistent fear of social or performance situations in which embarrassment may occur. Exposure to a feared social or performance situation nearly always provokes immediate anxiety and may trigger panic attacks. People with social anxiety disorder fear that others will scrutinize their behavior and judge them negatively. They often do not speak up in crowds out of fear of embarrassment. They go to great lengths to avoid feared situations. If avoidance is not possible, they suffer through the situation with visible anxiety People with social anxiety disorder appear to be highly sensitive to disapproval or criticism, tend to evaluate themselves negatively, have poor self-esteem, and a distorted view of their personal strengths and weaknesses. They may magnify their personal flaws and underrate any talents. They often believe others would act with more assertiveness in a given social situation. Women are more likely to have social anxiety disorder, but both men and women tend to have difficulties with dating and with sexual relationships Generalized social anxiety disorder is diagnosed when the individual experiences fears related to most social situations, including public performances and social interactions. These individuals are likely to demonstrate deficiencies in social skills and their phobias interfere with their ability to function People with social anxiety disorder fear and avoid only one or two social situations. Classic examples of such situations are eating, writing, speaking in public, or using public bathrooms. The most common fears for individuals with social anxiety disorder are public speaking, fear of meeting strangers, eating in public, writing in public, using public restrooms, and being stared at or being the center of attention. Pharmacotherapy is a relatively new area of research in treating patients with social anxiety disorder. SSRIs are used to treat those with social anxiety disorder because they significantly reduce social anxiety and phobic avoidance. Benzodiazepines are also used to reduce anxiety caused by phobias. Providing referrals for appropriate psychiatric treatment is a critical nursing intervention.

Specific phobia

Specific phobia disorder is marked by persistent fear of clearly discernible, circumscribed objects or situations, which often leads to avoidance behaviors. Phobic objects can include animals (e.g., spiders, snakes), natural environment (e.g., heights, storms), blood injection injury (e.g., fear of blood, injections), and situational (e.g., elevators, enclosed spaces). The lifetime prevalence rates range from 7% to 9%, and the disorder generally affects women twice as much as men It has a bimodal distribution, peaking in childhood and then again in the 20s. The focus of the fear in specific phobia may result from the anticipation of being harmed by the phobic object. For example, dogs are feared because of the chance of being bitten or automobiles are feared because of the potential of crashing. The focus of fear may likewise be associated with concerns about losing control, panicking, or fainting on exposure to the phobic object. Anxiety is usually felt immediately on exposure to the phobic object; the level of anxiety is usually related to both the proximity of the object and the degree to which escape is possible. For example, anxiety heightens as a cat approaches a person who fears cats and lessens when the cat moves away. At times, the level of anxiety escalates to a full panic attack, particularly when the person must remain in a situation from which escape is deemed to be impossible. Fear of specific objects is fairly common and the diagnosis of specific phobia is not made unless the fear significantly interferes with functioning or causes marked distress. Assessment differentiates simple phobia from other diagnoses with overlapping symptoms.

Priority of nursing care

Suicide prevention is the first priority when caring for a person with a panic disorder. People with panic disorder are often depressed and consequently are at high risk for suicide. Adolescents with panic disorder may be at higher risk for suicidal thoughts or may attempt suicide more often than other adolescents As many as 15% of patients with panic disorder commit suicide; women with both panic disorder and depression or panic disorder and substance abuse are especially at risk Once the nurse establishes that there is no indication of a risk for suicide, the nurse assesses whether the individual may be depressed, lonely, and socially isolated. Panic attacks may be unpredictable, leading the person to be fearful of another attack. Self-esteem may be low as feelings of powerlessness emerge. The patient may be experiencing physical panic symptoms such as dizziness and hyperventilation. Because the whole family is affected by one member's symptoms, the family's needs may need to be considered. The patient's strengths should be considered in planning care. For example, the person may be motivated to gain more control through making lifestyle changes. There may be evidence of family support. Outcomes will depend upon the particular health care issue and the interventions that are agreed upon by the patient and nurse.

Teach relaxations techniques Promote increase physical activity

Teaching the patient relaxation techniques is another way to help individuals with panic and anxiety disorders. Some are unaware of the tension in their bodies and first need to learn to monitor their own tension. Isometric exercises and progressive muscle relaxation are helpful methods to learn to differentiate muscle tension from muscle relaxation. This method of relaxation is also useful when patients have difficulty clearing the mind, focusing, or visualizing a scene, which are often required in other forms of relaxation, such as meditation. Box 18.6 provides one method of progressive muscle relaxation. Physical exercise can effectively decrease the occurrence of panic attacks by reducing muscle tension, increasing metabolism, increasing serotonin levels, and relieving stress. Exercise programs reduce many of the precipitants of anxiety by improving circulation, digestion, endorphin stimulation, and tissue oxygenation. In addition, exercise lowers cholesterol levels, blood pressure, and weight. After assessing for contraindications to physical exercise, assist the patient in establishing a routine exercise program. Engaging in 10- to 20-minute sessions on treadmills or stationary bicycles two to three times weekly is ideal during the winter months. Casual walking or bike riding during warmer weather promotes health. Help the patient to identify community resources that promote exercise.

SNRI-serotonin and norepinephrine reuptake inhibitors

The SNRIs increase levels of both serotonin and norepinephrine by blocking their reuptake presynaptically. Classified as antidepressants, the SNRIs are also used in anxiety disorders. Venlafaxine is the most commonly used SNRI Reduce severity of panic and anticipatory anxiety No abruptly discontinued

Pharmacologic- SSRIs

The SSRIs are recommended as the first drug option in the treatment of patients with panic disorder. They have the best safety profile, and if side effects occur, they tend to be present early in treatment before the therapeutic effect takes place. Hence, the SSRIs should be started at low doses and titrated every 5 to 7 days. Antidepressant therapy is recommended for long-term treatment of the disorder and antianxiety as adjunctive treatment The SSRIs produce anxiolytic effects by increasing the transmission of serotonin by blocking serotonin reuptake at the presynaptic cleft. The initial increase in serotonergic activity with SSRIs may cause temporary increases in panic symptoms and even panic attacks. After 4 to 6 weeks of treatment, anxiety subsides, and the antianxiety effect of the medications begins Increase serotonin decreases norepinephrine- lessen CV symptoms of tachycardia and increase BP associated with panic attacks S/E-Nausea, sexual dysfunction, insomnia, suicidality

Clinical course

The onset of GAD is insidious. Many patients complain of being chronic worriers. GAD affects individuals of all ages. About half of the individuals with GAD report an onset in childhood or adolescence, although onset after 20 years of age is also common. Adults with GAD often worry about matters such as their job, household finances, health of family members, or simple matters (e.g., household chores or being late for appointments). The intensity of the worry fluctuates and stress tends to intensify the worry and anxiety symptoms Patients with GAD may exhibit mild depressive symptoms, such as dysphoria. They are also highly somatic, with complaints of multiple clusters of physical symptoms, including muscle aches, soreness, and gastrointestinal ailments. In addition to physical complaints, patients with GAD often experience poor sleep habits, irritability, trembling, twitching, poor concentration, and an exaggerated startle response. People with this disorder often are seen in a primary care setting with somatic symptoms

Anxiety disorders

The primary symptoms of anxiety disorders are fear and anxiety. Even though symptoms of anxiety disorders can be found in healthy individuals, an anxiety disorder is diagnosed when the fear or anxiety is excessive or out of proportion to the situation. An individual's ability to work and interpersonal relationships may be impaired. Anxiety disorders are differentiated by the situation or objects that provoke fear, anxiety, or avoidance behavior and related cognitive thoughts Women experience anxiety disorders more often than men by a 2:1 ratio. Anxiety disorders may also be associated with other mental or physical comorbidities such as heart disease, respiratory disease, and mood disorders

Therapeutic relationships

The therapeutic relationship is a critical aspect of helping the person work toward recovery. These individuals may appear to be very nervous or anxious throughout the interaction. The nurse should help the patient relax and be comfortable with discussing fears and anxiety. A calm, understanding approach in a comfortable environment will help the person relax and be willing to engage in a therapeutic relationship. Establishing Mental Health and Wellness Goals The course of panic disorder culminates in phobic avoidance as the affected person attempts to avoid situations that increase panic. Even though identifying and avoiding anxiety-provoking situations are important during therapy, drastically changing lifestyle to avoid situations does not aid recovery. Goals and interventions that focus on developing a healthy lifestyle, supporting a sense of accomplishment and control, and reducing anxiety and panic are particularly helpful in reducing the number and severity of the attacks. Wellness Challenges. Many of the strategies that promote wellness are the same that are used to treat anxiety. For the person who is anxious or fearful, the individual may be more comfortable with a gradual incorporation of the strategies. Many wellness strategies for the person who is anxious should focus on physical health.