Anxiety Disorders & Panic Attacks

Anxiety Disorders

• Includes Anxiety Disorders, OCD and Traumatic Stress Disorders

Levels of Anxiety

• Mild: Perceptual field widens slightly, leading to increased observability and learning capability.
• Moderate: Perceptual field narrows slightly with selective attention; individuals can focus if directed.
• Severe: Perceptual field is greatly reduced; individuals can't notice outside factors and cannot be redirected.
• Panic: Perceptual field is reduced to a detail, which is usually elaborated by distortion or focused on scattered details.

Panic Attacks: Nursing Assessment and Interventions

• Panic attacks are sudden, discrete periods of intense fear or discomfort.
• Symptoms develop abruptly and peak within 10 minutes, generally lasting 30 minutes.

Assessment for Panic Attacks

• Four or more of these symptoms present:
• Palpitations
• Rapid pulse
• Sweating
• Trembling/shaking
• Shortness of breath/sensation of smothering
• Feelings of choking
• Chest pain/discomfort
• Nausea or abdominal distress
• Dizziness, lightheadedness, or feeling faint

Cognitive Symptoms of Panic Attacks

• Derealization: Feelings of unreality.
• Depersonalization: Feeling detached from oneself.

Other Symptoms to Assess for During Panic Attacks

• Fear of losing control or going crazy
• Fear of dying
• Paresthesias: Abnormal sensations, such as tingling or prickling
• Chills or hot flashes

Interventions for Panic Attacks

• Distraction: Diverting the patient's mind from physical sensations, such as listening to music or going for a walk.
• Reframing: Cognitive technique used to change the way a sensation, event, or person is viewed to reduce anxiety.
• Positive Self-Talk: Using positive coping statements.

Treatments for Anxiety Disorders

• Benzodiazepines:
• Increase the affinity of GABA.
• Carry a risk of withdrawal.
• Often administered concurrently with an SSRI or SNRI for the first 4 weeks, then tapered off to a maintenance dose.
• Do NOT administer with TCAs; can result in increased TCA serum levels.
• Common side effects include headache, confusion, dizziness, disorientation, sedation, visual disturbances leading to dependence, withdrawal, and tolerance.
• Examples include Lorazepam (Ativan), Alprazolam (Xanax), and Clonazepam (Klonopin).

Signs and Symptoms of Anxiety Disorders

• Generalized Anxiety Disorder (GAD) involves excessive anxiety and worry (apprehensive expectation).
• Occurs more days than not for at least 6 months about a number of events and/or activities.
• Patients find it difficult to control their worry.
• Patients may say “I feel like I’m going crazy”

Medication Treatments: Benzodiazepines

Lorazepam (Ativan)

• Indication: Anxiety disorder, pre-procedural sedation, and seizures.
• MOA: Depresses the CNS by potentiating GABA.
• Adverse Effects: Drowsiness, lethargy, slurred speech, forgetfulness, confusion, respiratory depression, bradycardia, and hypotension.
• Nursing Considerations:
• In cases of toxicity or overdose, Flumazenil (Romazicon) is the antidote.
• Should not be used in patients with seizure disorders, as it may induce seizures.

Alprazolam (Xanax)

• Indication: GAD, panic disorder, and anxiety associated with depression; used as an adjunct with acute mania and acute psychosis.
• MOA: CNS depression, mediated by GABA.
• Adverse Effects: Drowsiness, lethargy, and depression.
• Nursing Considerations:
• Monitor CBC, as it may cause decreased hemoglobin and hematocrit.
• In cases of toxicity or overdose, Flumazenil (Romazicon) is the antidote.
• Should not be used in patients with seizure disorders, as it may induce seizures.
• Potential for dependence and tolerance.

Clonazepam (Klonopin)

• Indication: Panic disorder with or without agoraphobia and seizures. Unlabeled use includes sedation and adjunct management of acute mania, acute psychosis, and insomnia.
• MOA: Produces sedative effects in the CNS by stimulating GABA.
• Adverse Effects: Drowsiness, behavioral changes, suicidal thoughts, slurred speech, sedation, increased respiratory secretions, palpitations, urinary retention, and hepatitis.
• Nursing Considerations:
• Monitor CBC and LFT, which may cause increases in serum albumin, AST, and ALT.
• In cases of toxicity or overdose, Flumazenil (Romazicon) is the antidote.
• Should not be used in patients with seizure disorders, as it may induce seizures.

SSRIs (Selective Serotonin Reuptake Inhibitors)

• First-line treatment for anxiety disorders.
• Initiate at a low dose and titrate every 5-7 days until symptom relief is achieved.
• Initial increase in serotonin may cause a temporary increase in anxiety symptoms and panic.

Serotonin Syndrome

• Symptoms: Agitation or restlessness, confusion, rapid heart rate and BP, dilated pupils, twitching muscles, muscle rigidity, heavy sweating, and diarrhea.
• Treatment: STOP MED immediately. In severe cases, cyproheptadine (Periactin) prevents the body from making serotonin.

Fluoxetine (Prozac)

• Class: SSRI
• Indication: Panic Disorder, OCD, MDD, and Bulimia Nervosa; off-label use for Anorexia Nervosa, social anxiety disorder, and PTSD.
• MOA: Inhibits reuptake of serotonin in the CNS.
• Adverse Effects: NMS, serotonin syndrome, seizures, suicidal thoughts, anxiety, drowsiness, insomnia, abnormal dreams, mania/hypomania, visual disturbances, palpitations, QT interval prolongation, dry mouth, sexual dysfunction, urinary frequency, hyponatremia, and tremor.
• Nursing Considerations:
• Assess suicide risk and monitor for NMS and serotonin syndrome.
• May cause hypoglycemia in patients with diabetes mellitus.
• Monitor EKG.
• Start slow then titrate down.

Sertraline (Zoloft)

• Class: SSRI
• Indication: Panic disorder, OCD, PTSD, social anxiety disorder, MDD; off-label use for GAD.
• MOA: Serotonin reuptake inhibitor.
• Adverse Effects: Serotonin syndrome, suicidal thoughts, headache, fatigue, insomnia, confusion, pharyngitis, rhinitis, tinnitus, visual disturbances, altered taste, anorexia, sexual dysfunction, and urinary frequency tremor.
• Nursing Considerations:
• Assess for suicidal ideation and serotonin syndrome.
• May cause false positive urinary drug screening tests for benzodiazepines.
• May cause hyperglycemia in diabetes mellitus.

Paroxetine (Paxil)

• Class: SSRI
• Indication: Panic disorder, PTSD, MDD.
• MOA: Serotonin reuptake inhibitor.
• Adverse Effects: NMS, serotonin syndrome, SJS, suicidal thoughts, emotional lability, syncope, blurred vision, edema, hypertension, palpitations, tachycardia, dry mouth, taste disturbances, decreased libido, infertility, urinary frequency, and tremor. Nursing Considerations:
• Assess for signs and symptoms of NMS, serotonin syndrome, SJS, and SI.

Therapy Treatments for Anxiety

Specific Phobias

• Acrophobia: Fear of heights
• Ailurophobia: Fear of cats
• Arachnophobia: Fear of spiders
• Astraphobia: Fear of lightening
• Belonephobia: Fear of needles
• Brontophobia: Fear of thunder
• Cynophobia: Fear of dogs

Specific Types of Phobias

• Animal type
• Natural environment type
• Blood-injection-injury type
• Situational type
• Other type

Specific Phobias vs. Social Phobia

• Specific phobias involve fear of specific objects or situations that could conceivably cause harm. The person's reaction to them is excessive and irrational. Exposure to the phobic object produces overwhelming symptoms of panic, including palpitations, sweating, dizziness, and difficulty breathing.
• Social phobia involves a marked or persistent fear of social or performance situations where embarrassment may occur. Exposure to unfamiliar people can result in fear that they will act in a way that is embarrassing or humiliating. Children must demonstrate capacity for age-appropriate social relationships with familiar people, and anxiety must occur in peer settings.

Agoraphobia

• Fear of being in places or situations from which escape might be difficult or in which help might not be available in the event of panic-like symptoms or other incapacitating symptoms.
• Includes fear of traveling in public transportation, open spaces, shops/ theaters, crowds, and outside of the home.

OCD

Obsession vs. Compulsion

• Obsession involves recurrent thoughts, impulses, or images experienced as intrusive and stressful, unable to be expunged by logic or reasoning.
• Compulsion involves repetitive ritualistic behavior or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded event or situation.

Trichotillomania

• Hair pulling disorder that results in noticeable hair loss.
• Preceded by increasing tension, resulting in a sense of release or gratification.
• The disorder is not common, but it occurs more often in women than men.

Treatments for Trichotillomania

• Chlorpromazine
• Amitriptyline
• Lithium carbonate
• SSRI and pimozide
• Olanzapine

Hoarding Disorder

• Characterized by a persistent difficulty discarding possessions, regardless of their value.
• Excessive acquiring of items.
• More men than women are diagnosed.

Treatments and Interventions for Ineffective Impulse Control

• Convey a nonjudgmental attitude.
• Practice stress management techniques.
• Offer support and encouragement.

Treatments for Hoarding Disorder

• Antidepressants.

Body Dysmorphic Disorder

• Characterized by an exaggerated belief that the body is deformed or defective in some specific way.
• If a true defect is present, the person's concern is unrealistically exaggerated and grossly excessive.
• Symptoms of depression and obsessive-compulsive personality are common.

Traumatic Stress Disorders

• Includes Characteristics and examples of avoidance, inability to recall and reactivity

PTSD

• Includes Difference between acute stress disorder and PTSD.
• Includes Memory formation

Personality Disorders (PD)

• Inflexible and maladaptive personality traits and ingrained patterns of maladaptive behavior cause significant subjective distress.

Personality Disorder Clusters

• Cluster A ("MAD") includes paranoid, schizoid, and schizotypal disorders.
• Cluster B ("BAD") includes antisocial, borderline, histrionic, and narcissistic disorders (dramatic, emotional, erratic behavior).
• Cluster C ("SAD") includes avoidant, dependent, and obsessive-compulsive disorders (anxious, fearful).

Specific Hallmark Characteristics: Cluster A Disorders

• Paranoid PD: Paranoia WITHOUT other thought disorder (schizophrenia), distrust and suspiciousness of others. Includes 4 or more:
• Suspiciousness without basis
• Reluctance to confide in others
• Interpretation- threatening/ persistent grudges
• Perception
• Recurrent suspicion of infidelity
• Schizoid PD: Social detachment, restricted affect without S/S of thought disorder or ASD. Includes 4 or more:
  • Lacks desire or enjoyment of close relationships
  • Solitary activities
  • Little, if any, interest in sexual experiences with others
  • Little pleasure, if any, in activities
  • Lacks close friends
  • Indifferent to feedback from others
  • Emotional coldness, detachment, or flat affect
• Schizotypal PD: Odd, peculiar behaviors and social detachment, often comorbid with schizophrenia; social interpersonal deficits and significant discomfort with close relationships. Includes 5 or more:
• Ideas of reference
• Odd beliefs or magical thinking
• Unusual perceptual experiences, including bodily illusions -Odd thinking and speech

Hallmark characteristics of Cluster B Disorders

• Antisocial PD:
• Blatant disregard or violation of rights of others.
• Must be diagnosed with individual age 18 or older. In addition, there must be evidence of conduct disorder around age 15, and AS behavior does not occur in the context of mania or schizophrenia. Includes 3 or more:
• Failure to conform to social norms and lawful behavior
• Deceitfulness, exploitive, impulsive
• Irritable and aggressive, repeated fighting
• Reckless disregard for safety of others
• Consistent irresponsibility
• Lack of remorse, indifferent, emotionless behavior
• Borderline PD:
• A disorder of relationships/lack of sense of self, with instability in personal relationships, self-image, affect, and marked impulsivity. Diagnosis- Impulsivity including: At least 2 areas of spending, sex, substance abuse reckless driving, and binge eating plus recurrent suicidal thoughts, self harm and affective/mood instability (mood swings) Includes 5 or more:
• Frantic efforts to avoid real or imagined abandonment (a major problem)
• Unstable and intense interpersonal relationships marked by extremes of idealization and devaluation
• Identity disturbance, persistent and marked unstable self-image
• Affective/mood instability (mood swings)
• Histrionic PD: Excessive emotionality and attention-seeking. 5 or more required:
• Uncomfortable not being the center of attention, inappropriate sexually seductive or provocative behavior, rapidly shifting and shallow expression of emotion, uses physical appearance to draw attention to self, and believes relationships are more intimate than they really are. The diagnosis must be before the age of 40. About BPD: More common in females, rarely stands alone (depression, anxiety, substance abuse, and eating disorder, among others).
• Diagnostic: Rorschach Test and Wechsler IQ scale, These patients are survivors.
• Narcissistic PD: Grandiosity, needs attention, lacks empathy. 5 or more required:
  • Grandiose of self-importance, preoccupation with fantasies of unlimited success, power, brilliance, belief of being special, unique, understood only by other special, high-status people, requires excessive admiration, entitlement, interpersonally exploitative, lacks empathy, envious of others or believes others are envious of them.

Hallmark Characteristics of Cluster C Disorders

• Avoidant PD:
• Social inhibition, feelings of inadequacy, and hypersensitivity to negative feedback. Required of 4 or more:
• Preoccupied with criticism or rejection in social situations, Feelings of inadequacy are inhibiting in new interpersonal situations, views self as socially inept, unappealing or inferior to others, reluctant or avoids new activities for fear of embarrassment, avoids occupations that involve significant interpersonal contact due to fears of rejection or criticism, and is unwilling to get involved in intimate relationships because of fear of ridicule or shame.
• Dependant PD: Excessive need to be taken care of that leads to submissiveness, clinging behavior, and fears of separation. Required of 5 or more:
• Difficulty making decisions without reassurance or advice from others, needs others to assume responsibility for major areas of life, difficulty expressing disagreement due to fear of loss of support or approval, difficulty initiating projects or doing things on their own due to lack of self-confidence, excessive lengths to get nurturance and support from others (often will volunteer for unpleasant activities), is uncomfortable or helpless when alone because of significant fear of inability to care for oneself, has a strong need to jump into next relationship when one ends, and is unrealistically preoccupied with fears of having to care for oneself. OCPD
• Characterized by being overly conscientious, scrupulous, inflexible morals, values, and ethics along with being unable to discard objects, hoard money, and reluctant to delegate work as it may not meet standards. They include a preoccupation with rules, details, lists, and order, and is excessively devoted to work and productivity.
• Distinguish between Schizotypal/Schizoid PD and Schizophrenia
• Distinguish between OCD and OCPD

OCD vs OCPD

• OCD features Ego-dystonic (they recognize it's irrational and distressing) with a main drive for anxiety relief from compulsions causing distress d/t intrusive thoughts (obsessions). It's associated with desires to stop but cannot do so.
• In contrast, OCPD is Ego-syntonic (they see their behaviors as logical and beneficial), the main drive is a need for control and perfectionism which causes distress d/t perceived inefficiency or disorder. It's associated with seeing behavior as necessary and correct. OCD include repetitive rituals to relieve anxiety (e.g., excessive handwashing, counting) while OCPD includes overworking, hoarding, excessive list-making, being overly strict with moral codes.

Therapeutic Nursing Interventions and Treatments

• Cognitive behavioral therapy (CBT)
• Dialectical behavioral therapy
• Psychotherapy
• Pharmacology
• Family therapy
• Interpersonal therapy Substance use- dual diagnosis Psychopharmacology:
  • There are no specific medications for personality disorder, but medications may be used to treat symptoms associated with PD, such as antidepressant medications, mood stabilizing for aggression, anti-anxiety medications, and antipsychotic medication.

Nursing Interventions

• Nursing diagnosis: Impaired coping, impaired social functioning, alteration in cognitive functioning, risk for harm of self/others, nutrition deficit, sleep deficit, and self-care deficit.
• Nursing interventions: Safety #1 priority, consistency- same provider, routine, boundary setting, limit setting, appropriate self-disclosure, modifying impulsive behavior, focusing on strengths, social skills training, and anger management.
• Nurse's role necessitates self-awareness, labels, bias, and stigma to remain empathetic and set limits and to remain objective, and showing compassion. Challenges/obstacles for persons seeking treatment for Personality Disorders?

Substance Use Disorders

• Tolerance vs. Dependence:
• Tolerance refers to the body getting used to taking a substance and requiring higher doses.
• Dependence refers to the physical or psychological symptoms that occur that make someone feel like they must continue taking a substance.
• Enabling vs. Codependence: Come about as family/friends try to adapt to the behavior of the person using substances; they feel they are helping, yet they are contributing to the problem. Be sure to include family in the plan of care, as appropriate by HIPPA.

Alcohol Abuse

• Symptoms of intoxication: Slurred speech, unsteady gait. Lack of coordination, poor judgment, loss of memory, loss of prohibition, aggression, and impulsive behavior.
• Symptoms of overdose: May require a gastric lavage, ventilation, dialysis, and cardiac monitoring (ICU).
• Symptoms of alcohol withdrawal begin 6 to 72 hours after the sudden cessation or decrease in alcohol. Symptoms of withdrawal include N/V, elevated VS, anxiety, confusion, agitation, sweating, tremors, hallucinations (auditory, visual, tactile), and headache. Delirium, tremors, seizures, and convulsions (usually within 48 hours) may occur, generally peaking on day 2. If not properly managed by healthcare professionals, it can be life-threatening. Stabilize VS by monitoring ABCS, assesses for injury, BG and blood alcohol levels.
• Nursing Interventions: stabilize VS. Position for aspiration prevention to a left side recovery (recumbent) and allowing the person to "sleep it off", monitor closely. Medications: Benzodiazepine therapy is a 1st line option for symptom management, may be fixed dosing (round the clock) or titrated based on the CIWA-Ar score, administer banana bag and antiemetic medications. Also monitor blood glucose d/t malnutrition potential. Recovery: Naltrexone is usually daily for 3 months and Acamprosate can reduce craving, take 2 tabs 3x a day (not for pts with renal problems).

Opioid Withdrawal & Medication Treatments

• Severity of Withdrawal is related to different drugs. Symptoms:
  • Anxiety, restlessness, aches, pain in back and extremities (feels like influenza).
  • Longer time without the drug, symptoms worsen- yawning, runny nose, fever, N/V, dysphoria, insomnia- causes significant distress.
• Withdrawal peaks in about 2-3 days and subsides in 5-7 days or longer and must be assessed by the COWS assessment tool.
• Treatment: Methadone: used as a replacement for opioids (synthetic heroin); coming off heroin can take months or years Naltrexone (ReVia): blocks the effects of opioids; helps prevent digestion in overdose and can be used to reduce cravings during recovery Levomethadyl (Orlaam): helps with addiction to painkillers when other treatment options fail
• Be very careful with this drug as cardiac arrhythmias may occur 12 lead EKG placement Buprenorphine (Buprenex) & Zubsolv, Subutex Suboxone, and Orexo: all used in Opioid addiction

Severity of Opioid Overdose

• Very serious, life threatening.
• Symptoms: May become apathetic, drowsy, slurred speech, decreased, slow RR, pinpoint pupils (morphine). Treatment:
• Naloxone (Narcan): reverses the effects of opioids, give until symptoms improve
• May require ventilator support

Substances That Can Be Used/Misused & Symptoms

• Alcohol
• Opioids
• Hallucinogens:
• Similar symptoms of psychosis Elevated VS, hyperreflexia, dilated pupils, paranoia, and depression
• Intoxication: palpitations, tremors, diaphoresis
• Treatment:
  • Supportive (protect airway, decrease BP, and seizure precautions) Inhalants:
  • Extremely toxic and can damage the heart, kidneys, lungs, and brain
  • Symptoms: Dizziness, nystagmus, blurred vision, confusion, lack of coordination, and giggling (acting drunk)

Various Intoxicatons

• Marijuana
• Tobacco: Nicotine is the most addictive substance in the world Cessation treatment
• Varenicline
• Bupropien/ Wellbutrin
• Nicotine patch/gum

Nursing Education

• Nursing Process (Assessment, Diagnoses, Planning, Interventions and Evaluation)
• Risk of Harm to self or others
• Risk of ineffective breathing patterns

Nursing Interventions

• Implement withdrawal protocols and identifying and providing education on community services in addition to monitoring lab values
• Assess and evaluate nutritional status

Eating Disorders: Anorexia Nervosa

• Eating Disorders is defined by a refusal to maintain body weight at or above a minimally normal weight for age and height, along with fear of weight gain. These patient will deny their low body weight. Eating Disorders: is characterized Restricting type (starvation) last 3 months Severe weight loss/ starvation Intense fear of gaining weight or becoming fat Disturbance in the way in which body weight or shape is viewed Denial of low body weight & consequences More females affected BMI 17.5 or less- hospitalization Denies abnormal eating behavior Turns away food in order to cope Preoccupation with losing more and more weight Underweight

Bulimia Nervosa

• Binge eating followed by purging last 3 months resulting from a lack of control to stop eating
• Self-induced vomiting with or without misuse of laxatives. diuretics, enemas, or other medications. Also, fasting, or excessive exercise is seen
• Usually normal to slightly overweight patients; BMI more than 17.5
• Two types: Purging of foods Assessment reveals Russel's signs (teeth marks on knuckles). Gum recession/decay, and Sialadenosis (“chipmunk cheeks")
• Patient has normal weight to slightly overweight and recognizes abnormal eating behavior d/t preoccupation

Binge Eating Disorder

• Characterized as a food addiction caused by eating large amounts of food over short period of time.
• More commonly affected are adults of 45-55 y/o Risk factors, Weight gain increases risk for DM, HTN, and CA Likely to be similar to people with anorexia and bulimia but not quite meet the diagnostic criteria and vomit after eating small amounts of food

Eating Disorders: Treatment

An (BMI less than 18.5 is diagnostic for Anorexia) and a few behaviors may observed include self harm and being consumed with guilt and shame:

• Signs, symptoms and behaviors you may observe in a person with an eating disorder.
• Psychological problems and physiological problems commonly seen with each type of eating disorder Lanugo (fine downy hair on arms, face and torso) see text book.
• Know important labs the nurse should review and why (as discussed in class) – what problems arise from these metabolic and electrolyte deficiencies?:
• Electrolyte imbalance, Cardiovascular, GI, Endocrine, musculoskeletal, fatigue, and iron deficiency etc.
• Hpokalemia, anemia (low RBC), immune (low WMC), metabolic panel, Mg, Na, and Ca values, etc. Treatment of the clinical presentation:
• Bradycardia/ hypotension/ chest pain/ heart palpitations
• SOB, bradycardia, and breath smells of vomit Refeeding Syndrome, massive electrolyte shifts as body adjust

Nursing Diagnosis

Mental status- assess suicide risk Vital signs, height, weight (same clothes, same time) Skin, hair, nails Head, neck, mouth Promote sleep Intake and output Small frequent meals/ scheduled Clothing- check clothing, pockets Visitors- check food Massive electrolyte shifts as body adjust Go SLOW Promote weight gain supervise all meals

Nursing Therapy and Treatment

• CBT
• Group Therapy- excellent for adolescents
• Psychotherapy, family therapy