Anxiety Disorders: Panic Disorder Exemplar

Anxiety

  • Anxiety is a normal and adaptive emotion that is part of everyday life.
  • It is a subjective experience that occurs across the lifespan.
  • Normal anxiety is transient and nonpathological.
  • Anxiety becomes a diagnosable psychiatric disorder when it is severe, chronic, and impacts functioning.

What is Anxiety?

  • Anxiety is a feeling of apprehension, uneasiness, uncertainty, or vague dread resulting from a perceived threat, usually related to an unspecified or unknown danger.
  • Severe/chronic anxiety can erode feelings of self-esteem and personal worth.
  • Clinical attention is needed when:
    • Anxieties are disproportionate to the threat.
    • Anxiety is severe and enduring.
    • Anxiety disrupts normal functioning.
  • Coping strategies and defense mechanisms are protective factors against anxiety.

Levels of Anxiety

  • None to Mild Anxiety
    • Thoughts are logical, able to concentrate and problem-solve.
    • Appears calm and in control.
    • Produces an increase in awareness and alertness.
    • Motivates learning and is associated with daily life.
  • Moderate Anxiety
    • Speech rate and volume is increased, patient becomes wordy.
    • Can still focus and problem solve.
    • Restless with frequent body movements and gestures.
    • Sensory stimuli perception is dulled and client becomes hesitant.
    • Can still do motivated learning.
  • Severe Anxiety
    • Verbalization of emotional pain, e.g., "I need help."
    • Impaired concentration and problem-solving ability.
    • Selective attention and uni-focused.
    • Tremors, increased motor activity such as pacing or wringing of hands.
    • Perception may be distorted.
    • Stimulated fight-or-flight response.
  • Panic
    • Behavior may be angry, withdrawn, or aggressive with clinging and/or crying.
    • Unable to concentrate or problem-solve; no longer rational or thinking logically.
    • Loss of control and ability to function; feels overwhelmed and helpless.
    • Grossly distorted perceptions; unable to tell the difference between real and unreal.
    • Requires immediate intervention.

Anxiety Disorders: Dave's Case

  • Dave is a 41-year-old male referred by his primary care physician after presenting to the ER with difficulty breathing.
  • His physician could not find a medical explanation for his symptoms, leaving Dave feeling confused, stressed, and angry.
  • Over the last 6 months, Dave has had several instances of intense fear that peaks within a few minutes.
  • During these instances, he experiences sweating, heart palpitations, chest pain and discomfort, and shortness of breath.
  • Dave worries that he might die during these episodes.
  • As a result, Dave has persistent worry about having another attack and avoids unfamiliar places and people where it may be difficult to get help.

Stress vs. Anxiety

  • Stress
    • Generally a response to an external cause (e.g., taking a big test, arguing with a friend).
    • Goes away once the situation is resolved.
    • Can be positive or negative (e.g., inspires you to meet a deadline or causes you to lose sleep).
  • Anxiety
    • Generally internal, your reaction to stress.
    • Usually involves a persistent feeling of apprehension or dread that doesn't go away and interferes with how you live your life.
    • Is constant, even if there is no immediate threat.
  • Both Stress and Anxiety
    • Can affect your mind and body.
    • Symptoms: excessive worry, uneasiness, tension, headaches or body pain, high blood pressure, loss of sleep.

Stress vs. Anxiety - Short Term vs. Long Term

  • Stress
    • Short term (SPAN).
    • In response to a recognized threat.
    • Cause/Origin: may not have an identifiable trigger.
    • Symptoms: moodiness, irritability, restlessness or anger, loneliness.
  • Anxiety
    • Can linger.
    • Symptoms: faster heartbeat, tenseness, dizziness, nausea, faster breathing, sweating, anxious thoughts, nervousness, general, diarrhea or constipation, unhappiness, a feeling of being overwhelmed, a feeling of unease or dread.

Types of Anxiety Disorders

  • Separation anxiety: A severe reaction to separation from an attachment figure, with concern that this figure will be harmed. Only a concern if not part of normal development. (children around 6 years)
  • Specific phobic disorder: Marked and unreasonable fear or anxiety of objects or situations (e.g., animals, blood, injection, or places) (Childhood around 8 years)
  • Agoraphobia: Marked and excessive fears about leaving home, entering closed or open public places, crowds, or transportation (Late adolescence around 20 years)
  • Social anxiety: Marked unreasonable fear or anxiety of scrutiny or judgement by other people (Early adolescences around 15 years)
  • Selective Mutism: Consistent failure to speak in situations for which there is an expectation to speak, despite language competence. (childhood, often < 5 years)
  • Generalized Anxiety Disorder: Marked uncontrollable and anxious worry and fears about everyday events and problems. (adulthood around 30 years)
  • Panic Disorder: Recurrent, unexpected panic attacks with sustained mental manifestations (e.g., fear, fear of losing control, feeling of alienation. (adulthood around 25 years)

Risk Factors for Anxiety Disorders

  • A history of anxiety or other mental illnesses in biological relatives (gene-environment interaction).
  • Temperamental traits of shyness or behavioral inhibition in childhood.
  • More common in females and children/young adults.
  • Exposure to stressful and negative life or environmental events in early childhood or adulthood.
  • Some physical health conditions, such as thyroid problems or heart arrhythmias, or caffeine or other substances/medications, can produce or aggravate anxiety symptoms.

Consequences of Anxiety

Depending on the continuum of anxiety:

  • Cognitive impairment
  • Psychic pain due to warding off the anxiety
  • Impaired ability to complete ADLs
  • Behaviors – isolation, impulsivity, etc.
  • Substance use or abuse
  • Impairment in occupational, social, or academic
  • Can result in a lifetime of disability
  • Risk for injury (to self or others)

Clinical Presentation: Panic Attack

  • Focus on Panic Attack as our exemplar.
  • Episode of intense fear (usually without a trigger) typically peaking within 10 minutes; most common symptom is palpitations.
  • As part of diagnosis, need to have at least 4 of the physical/psychological symptoms in the DSM-5:
    • Palpitations, accelerated heart rate, sweating, trembling, SOB, chest pain, feeling dizzy (light-headed), fear of losing control, fear of dying, numbness or tingling sensations, hot/cold sensations.
  • Also need to show persistent worry about an additional panic attack and significant change in behavior related to the attacks

Assessment

  • Subjective:
    • Health history with risk factors.
    • Determine the scope and level of anxiety.
    • Identify past or current stressors and client’s appraisal of stressor(s).
    • Assess support systems.
    • Review past or current medical diagnoses, substance use, medications, and history of mental health problems.
    • Assess current symptoms; use of validated screening tools such as “Severity Measure for Panic Disorder”.
  • Objective:
    • May require testing to rule out medical conditions with similar presentations (e.g., endocrine, cardiopulmonary conditions, etc).

Severity Measure for Panic Disorder

  • A questionnaire used to determine a preliminary diagnosis or upon receiving a diagnosis of panic disorder.
  • Completed by the adult client.
  • Asks about thoughts, feelings, and behaviors about panic attacks in the past 7 days.
  • Symptoms of a panic attack include: a racing heart, shortness of breath, dizziness, sweating, and fear of losing control or dying.
  • Scoring:
    1. Review the score of each item.
    2. If 3 or more items are left unanswered, the total score should not be calculated.
    3. Sum the raw scores on the 10 items to obtain a total raw score, and then divide by 10 (or the number of items answered) to produce your Average Total Score.
    4. The Average Total Score reduces the overall score to a 5-point scale: none (0), mild (1), moderate (2), severe (3), or extreme (4).

Therapies and Treatments

  • Medication and Psychotherapy are first-line treatments.
  • SSRIs are considered the first approach, titrated slowly to decrease initial activation and used for up to 12 months before tapering to reduce relapse risk.
  • Psychotherapy and relaxation therapies:
    • Cognitive-behavioral therapy
    • Mindfulness
  • Complimentary and alternative therapies (evidence base is incomplete):
    • Music therapy, aromatherapy, acupuncture, massage
  • Lifestyle/self-help: Physical exercise, avoiding triggers like caffeine, improving sleep quality.

Teaching and Compassionate Listening

  • Importance of slow deep breathing in the face of hyperventilation; breathing with the patient in an attack may be helpful.
  • Help patient connect feelings before the attack with onset of attack: “Can you identify what you were feeling right before the attack?”
  • Explain physical symptoms of anxiety; sensations similar to other physical problems, like heart attack.
  • Teach positive self-talk, “I can control my anxiety”.
  • Discuss effective treatments and teach patient and family about medications that may have been ordered.

Interventions in an Acute Panic Attack

  • Therapeutic use of self (nurse must remain calm).
  • Establish rapport - Be present, but not intrusive.
  • Use concrete and simple language.
  • Decrease environmental stimuli.
  • Stay with the client; do not leave alone.
  • Ensure client safety, when applicable (i.e., one-on-one, close observation, seclusion, suicide precautions).
  • Grounding: 5 things to see, 4 to hear, 3 to touch, 2 to smell, 1 thing to taste.