Anxiety Disorders and Panic Disorders Nursing Care Guide

Everyone gets anxious under stress. Anxiety disorders are different: the fear is excessive, irrational, and disruptive, and it does not switch off when the trigger passes. The pattern is a prolonged, dysfunctional reaction to stress shaped by genetics, development, and life experience. Across the group, the two threads are anxiety symptoms and avoidance behavior.

Types of Anxiety Disorders

• Panic disorder (with or without agoraphobia). Recurrent, unpredictable panic attacks with intense apprehension, fear, or terror, often a sense of impending doom, plus intense physical discomfort.
• Agoraphobia without history of panic disorder. The DSM-IV-TR (APA, 2000) defines it as fear of places or situations where escape might be difficult or help unavailable if an incapacitating or embarrassing symptom develops.
• Social phobia. Persistent fear of behaving or performing in front of others in a humiliating or embarrassing way.
• Specific phobia. Formerly simple phobia, marked by persistent fear of specific objects or situations.
• Obsessive-compulsive disorder. Involuntary recurring thoughts or images the person cannot ignore, plus a recurring impulse to perform a seemingly purposeless act.
• Posttraumatic stress disorder. Physiological and behavioral symptoms following a psychologically traumatic event outside the range of usual human experience.
• Acute stress disorder. Symptoms like PTSD, but they must subside within 4 weeks of the stressor.
• Anxiety disorder due to a general medical condition. Symptoms judged to be the direct physiological consequence of a medical condition.
• Substance-induced anxiety disorder. The DSM-IV-TR (APA, 2000) describes prominent anxiety symptoms judged to be caused by the direct physiological effects of a substance.

OCD, PTSD, and acute stress disorder are no longer classed as anxiety disorders in the current DSM. They sit in their own chapters (obsessive-compulsive and related; trauma and stress-related), but the DSM-5 keeps them sequential because the link to anxiety is close.

Pathophysiology

In the CNS, the major mediators appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Other neurotransmitters and peptides, such as corticotropin-releasing factor, may also be involved. Peripherally, the autonomic nervous system, especially the sympathetic branch, drives many of the symptoms.

Statistics and Incidences

Anxiety disorders are the most common psychiatric disorder in the United States. Lifetime prevalence among American adults is 28.8%. Social anxiety disorder is the most common of the group, with an early onset (by age 11 years in about 50% and by age 20 years in about 80% of those affected) and it raises the risk of later depression and substance abuse. Prevalence of specific anxiety disorders varies by country and culture; the median prevalence of social anxiety disorder in Europe is 2.3%. The female-to-male ratio for any lifetime anxiety disorder is 3:2.

Causes

• Biochemical. Increased norepinephrine in panic and generalized anxiety disorders; abnormal elevations of blood lactate also noted in panic disorder.
• Genetic. More common among first-degree biological relatives than in the general population.
• Medical or substance-induced. Triggered by various medical conditions or ingested substances.
• Psychodynamic theory. Anxiety arises when the ego cannot mediate conflict between the superego and the id.
• Cognitive theory. Faulty, distorted, or counterproductive thinking patterns accompany or precede maladaptive behaviors and emotional disorders.

Clinical Manifestations

Pounding, rapid heart rate. Choking or smothering sensation. Difficulty breathing. Chest pain. Dizziness or faintness. Increased perspiration. Numbness or tingling in the extremities. Trembling. Fear of dying or going crazy. Sense of impending doom. Feelings of unreality (derealization or depersonalization).

Assessment and Diagnostic Findings

When other medical causes are suspected, work them up to identify or exclude them:

• EEG, lumbar puncture, and head/brain imaging. Rule out CNS disorder with EEG, lumbar puncture, and brain CT as history dictates.
• Electrocardiography. Rule out cardiac disorders with ECG or treadmill ECG.
• Tests for infection. Rapid plasma reagent test, lumbar puncture, or HIV testing.
• Arterial blood gas analysis. Confirms hyperventilation and excludes hypoxemia or metabolic acidosis.
• Chest radiography. Excludes other causes of dyspnea with chest pain.
• Thyroid function. Hyperthyroidism is one of the most common medical causes of anxiety.

Medical Management

Treatment is usually pharmacotherapy, psychotherapy, or both. Cognitive therapy helps patients see how automatic thoughts and false beliefs drive exaggerated emotional and behavioral responses. Behavioral therapy uses graded exposure to anxiety-provoking stimuli until the patient is desensitized. On diet, caffeine (coffee, tea, colas) should be discontinued.

Pharmacologic Management

Antidepressants are the drugs of choice, especially newer agents with a safer profile and easier use than older tricyclics.

• SSRIs. First-line for long-term management, with control gained gradually over a 2 to 4 week course depending on dose increases.
• SNRIs. Reuptake inhibition of serotonin and norepinephrine helps across mood and anxiety disorders.
• Atypical antidepressants. Even without FDA approval for a given anxiety disorder, these can help; mirtazapine acts as an alpha-2 antagonist, raising synaptic norepinephrine and serotonin while blocking some postsynaptic serotonergic receptors that mediate excess anxiety.
• Tricyclic antidepressants. Complex drugs with central and peripheral anticholinergic effects plus sedation.
• Benzodiazepines. Used with antidepressants as adjuncts, especially for acute situational anxiety and adjustment disorder where pharmacotherapy is expected to run 6 weeks or less, and for rapid control of anxiety attacks.
• Antianxiety agents. Buspirone is non-sedating and unrelated to benzodiazepines, barbiturates, and other sedative-hypnotics, with fewer cognitive and psychomotor effects, which makes it preferable in elderly patients.
• Anticonvulsant. The GABA derivative pregabalin (Lyrica).
• Antihypertensive agent. Beta-blockers can blunt the physiological symptoms and help with situational or performance anxiety on an as-needed basis.
• MAOIs. Most commonly prescribed for social phobia.
• Antipsychotic agent. Atypical and typical antipsychotics serve mainly as augmentation and are second-line in generalized anxiety disorder.

Nursing Management

Nursing Assessment

• History. Patients usually seek care after several panic attacks and often cannot name a trigger.
• General appearance and motor behavior. May look entirely normal or show anxiety if they fear an imminent attack.
• Mood and affect. May be anxious, worried, tense, depressed, serious, or sad.
• Thought processes and content. During an attack the patient may believe they are dying, losing control, or going insane, and may even consider suicide.
• Sensorium and intellectual process. During an attack the patient may be confused and disoriented and unable to take in or respond to environmental cues.

Nursing Diagnosis

Anxiety related to unconscious conflict about essential values and life goals or situational or maturational crises. Fear related to phobic stimulus. Ineffective coping related to underdeveloped ego or punitive superego. Powerlessness related to fear of disapproval. Social isolation related to panic-level anxiety.

Nursing Care Planning and Goals

Within 1 week the patient will verbalize ways to interrupt escalating anxiety, and by discharge will recognize the onset of anxiety and intervene before reaching the panic stage.

Nursing Interventions

• Stay calm and non-threatening. Anxiety is contagious and transfers between staff and patient.
• Assure safety. Convey safety through your physical presence; do not leave the patient alone during an attack.
• Be clear and concise. Use simple words and brief messages; an intensely anxious patient can take in only the most elementary communication.
• Provide a non-stimulating environment. Dim lighting, few people, simple decor; stimulation raises anxiety.
• Administer medications as prescribed. Give tranquilizing medication as ordered and assess for effectiveness and adverse effects.
• Recognize precipitating factors. Once anxiety drops, explore likely causes; recognizing precipitants is the first step to interrupting escalation.
• Encourage verbalization. Have the patient talk through the traumatic experience under nonthreatening conditions, work through guilt, and understand that most people would have responded the same way.

Evaluation

The patient holds anxiety at a level where problem solving is possible, can verbalize signs of escalating anxiety, and can demonstrate techniques to stop the progression to panic.

Documentation Guidelines

Document individual findings (affecting factors, interactions, nature of social exchanges, specific behaviors), cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and progress toward the desired outcome.