Panic Disorder Phobias
Panic Disorder Phobias
Panic Disorder Phobias
DSM-IV
PANIC DISORDER/PHOBIAS
300.01 Panic disorder without agoraphobia
300.21 Panic disorder with agoraphobia
300.22 Agoraphobia without history of panic disorder
300.23 Social phobia
300.29 Specific phobia
ETIOLOGICAL THEORIES
Psychodynamics
Phobic object may symbolize the underlying conflict, although there is not
always a clear connection. Personal perceptions, life experiences, and cultural
values color the meaning of the symbol for the client.
The freudian view is that anxiety feelings stem from loss of love and support
from the mothering figure, which increases the client’s dependency needs. The
client combats the diffuse intolerable anxiety by an exaggerated use of
displacement on a particular object or situation, which makes the anxiety more
manageable.
Phobic partners may develop in the family; these are “helpers” who stand by
and participate in maintaining phobic behavior, protecting phobic client from acute
panic and anxiety. Participation of partner furthers the unconscious wish of phobic
client to be taken care of and to be in control.
Biological
(Refer to CP: Generalized Anxiety Disorder.)
Temperament may be a factor in that some fears are innate. These fears
represent a part of the overall characteristics with which one is born that influence
how the individual responds to specific situations throughout his or her life.
Research suggests irregularities in the synthesis and release of norepinephrine
and/or hypersensitivity of receptors for neurotransmitters (including serotonin and
gamma-aminobutyric acid [GABA]), or an interaction between norepinephrine
transmitters. The trigger may lie in the locus coeruleus located in the brainstem.
There also may be a genetic susceptibility to either an excess or deficiency of CO 2
levels and a sensitivity to lactate associated with the panic attack.
Family Dynamics
(Refer to CP: Generalized Anxiety Disorder.)
Food/Fluid
Nausea/abdominal distress
Neurosensory
May exhibit one of three types of phobias:
Agoraphobia: Fears any situation in which individual may feel helpless or
humiliated if a panic attack should occur and client cannot readily escape from
public view
Specific/Simple Phobia: Fear involving specific objects such as spiders or snakes
or situations such as heights, darkness, or closed spaces
Social Phobia: Fear of talking or writing in public and/or eating, blushing, urinating,
etc.; fear of these behaviors resulting in public scorn
Preoccupied with bodily symptoms and feelings of terror
Feelings of faintness, dizziness, or lightheadedness; trembling/shaking; paresthesias
(numbness or tingling sensations)
May experience brief periods of delusional thinking, hallucinations, inability to test
reality
Depersonalization or derealization
Pain/Discomfort
Chest pain or discomfort
Respiratory
Shortness of breath (dyspnea); smothering sensations, choking; hyperventiliation,
labored breathing
Sexuality
Occurs more frequently in women than in men
May avoid sexual involvement because of fear of arousal, particular sexual acts,
and/or relationships
Social Interactions
More common among people who have experienced an early traumatic loss, such as
the death of a parent
Manipulates environment and depends on others to avoid confrontation with the
object or situation
Some constriction of life activities present
Teaching/Learning
Usually begins in late teens or early adulthood (panic attacks rare after age 65)
Attacks may be associated with magic or witchcraft
No history of a physical disorder (e.g., hyperthyroidism, hypoglycemia), although
mitral valve prolapse is common
May report other disorders such as major depression, somatization disorder,
schizophrenia, personality disorder
Increased rate of alcohol abuse
DIAGNOSTIC STUDIES
Drug Screen: Identifies drugs that may be used by client to reduce anxiety, rules
out drugs that may produce symptoms.
Other diagnostic studies may be conducted to rule out physical disease as a basis
for individual symptoms, e.g.:
EEG: To rule out epilepsy, other neurological disorders.
EKG: In the presence of severe chest pain to rule out cardiac conditions.
Thyroid Studies: To rule out hyperthyroidism.
NURSING PRIORITIES
1. Provide for physical safety.
2. Assist client to recognize onset of anxiety.
3. Help client learn alternative responses.
4. Assist with desensitization to phobic object/situation, if present.
5. Promote involvement of client/family in group or community support activities.
DISCHARGE GOALS
1. Stays in feared situation even when discomfort is experienced.
2. Identifies techniques to lower/keep fear at manageable level.
3. Confronts the phobia and is desensitized to the stimulus.
4. Demonstrates greater independence and an increasingly freer lifestyle.
5. Plan in place to meet needs after discharge.
(Refer to CP: Generalized Anxiety Disorder for needs/concerns in addition to the following NDs.)
ACTIONS/INTERVENTIONS RATIONALE
Independent
Encourage discussion of the phobia. Investigate Only when a difficulty is acknowledged can it be
sexual concerns, noting problems expressed (e.g., dealt with. Note: Phobic reaction to sex
may
sex is a duty/obligation that is not enjoyed by theindicate a problem of incest/sexual abuse.
client).
Provide for client’s safety (e.g., a secure environment, In severe anxiety, client fears total
disintegration
staying with the client, letting the client know theand loss of control.
nurse will provide for safety).
Suggest that the client substitute positive thoughts Emotion connected to thought, and
changing to a
for negative ones. more positive thought can decrease the level of
anxiety experienced. This also gives the client an
situation. Provide for practice sessions (e.g., accustomed to the feeling of relaxation, enabling
role-play), deal with phobic reactions in real- the individual to handle feared object/situation.
life situations.
Encourage client to set increasingly more difficultDevelops confidence and movement toward
goals. improved functioning and independence.
Collaborative
Administer antianxiety medications as indicated: Biological factors may be involved in
benzodiazepines, e.g., alprazolam (Xanax), phobic/panic reactions, and these medications
clonazepam (Klonopin), diazepam (Valium), (particularly Xanax) produce a rapid calming
lorazepam (Ativan), chlordiazepoxide (Librium), effect and may help client change behavior by
oxazepam (Serax). keeping anxiety low during learning and
desensitization sessions. Addictive tendencies of
CNS depressants need to be weighed against
benefit from the medication.
Involve in interoceptive exposure therapy as Alters client’s response to internal sensations as
appropriate, with client holding breath, client learns that the feelings associated with
panic
hyperventilating and inhaling CO2, or receiving do not indicate impending disaster.
sodium lactate injections as indicated.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Establish and maintain a trusting relationship by Therapeutic skills need to be directed toward
listening to the client; displaying warmth, answering putting the client at ease, because the
nurse who is
questions directly, offering unconditional acceptance; a stranger may pose a threat to the highly
anxious
being available and respecting the client’s use of client.
personal space.
Be aware and in control of own feelings; explore the The nurse’s anxiety can be communicated
to the
cause of own anxiety and use this understanding client, which only adds to the client’s sense of
therapeutically. terror. Discussion of these feelings can provide a
role model for the client and show a different
way
of dealing with them.
Provide simple, clear explanations and instructions. During period of increased anxiety, client
may
have difficulty focusing on/comprehending
communications.
Support the client’s defenses initially. The client uses defenses in an attempt to deal
with
an unconscious conflict, and giving up these
defenses prematurely may cause increased
anxiety.
Verbally acknowledge the reality of the pain of the The symptoms that the client is
experiencing
client’s present coping mechanism (panic) without relieve some of the intolerable anxiety felt
by the
focusing on the symptoms that are being expressed. client. If client is unable to release this
tension, the
anxiety will only increase, possibly causing client
to lose control.
Provide feedback about behavior, stressors, and Sets groundwork for dealing with anxiety when
coping responses. Validate what you observe with client is calmer. Includes client in plan of
care,
the client. providing sense of control/self-worth.
Emphasize relationship between physical and Client needs to be aware of mind-body
emotional health, and reinforce that this is an area relationship and the physiological
changes that
to be explored when client feels better. cause discomfort.
Observe for increasing anxiety. Assume a calm Early detection and intervention facilitate
manner, decrease environmental stimulation, and modifying client’s behavior by changing
the
provide temporary isolation as indicated. environment and the client’s interaction with it,
to
minimize the spread of anxiety.
Assist client/family to recognize and modify Recognition of causes/relationships provides
situations that cause anxiety when precipitating opportunity to intervene before anxiety escalates
factor can be identified. (Note: Simple phobias are or loss of control occurs.
usually specific and object-centered; this is not so
with all phobic disorders.)
Determine/discuss use of alcohol and other drugs. May be used to reduce anxiety/avoid
panic
attacks and can lead to abuse. (Refer to Ch. 5,
Substance-Related Disorders.)
Note diagnosis of mitral valve prolapse. This cardiac abnormality affects between Qr
and
Qw of panic disorder clients. Heart palpitations
resulting from the failure of the valve to close
properly can increase anxiety and trigger panic
attacks.
Determine use of caffeine-containing beverages. These clients may be more sensitive to the
anxiety-
producing effects of caffeine, which may
precipitate panic/anxiety attacks.
Suggest supportive physical measures, such as Provides physical relaxation and helps client
warm baths/whirlpool, massage. manage anxiety/maintain control.
Encourage interest in outside activity through the Increases participation in life while
decreasing the
following actions: amount of time and energy available for
maladaptive coping mechanisms.
Share an activity with the client; This is emotionally supportive and reinforces
socially acceptable behavior.
Provide for physical exercise/activity of some Uses energy in constructive ways. Endorphins
(the
type within client toleration; body’s naturally produced “narcotics”) induce
feelings of wellness/euphoria and are thought to
be released during exercise. Note: Use exercise
therapy with caution, as half of clients have
increased anxiety with exercise.
Structure the client’s day with a list of planned Provides opportunity to experience success,
which
activities realistic to client’s capabilities. Include enhances self-esteem and increases self-
confidence.
others in providing client care and support.
Identify signs/symptoms of escalating anxiety and Helps client become proactive in
interrupting
appropriate responses (e.g., relaxation, stopping progression of anxiety to panic. Enhances sense
of
negative self-talk). control.
Assess suicidal ideation. These individuals have an increased rate of
suicide/suicide attempts. This is of particular
concern when therapeutic treatment of major
depression lifts client’s mood to the point at
which she or he can act on suicidal thoughts.
Discuss side effects of medications, noting reactions Side effects of antianxiety medications
may cause
that may occur (e.g., drowsiness, ataxia, confusion, concern heightening anxiety and may
require
headache, slurred speech, lethargy, giddiness, evaluation/treatment.
dizziness, vertigo, and impaired visual
accommodation).
Involve in cognitive behavioral techniques such as Cognitive restructuring corrects
misconceptions
rational-emotive therapy and self-instruction. and develops self-confidence.
Collaborative
Administer medication as indicated:
Antianxiety agents, e.g., alprozolam (Xanax), Provides relief from the immobilizing effects of
lorazepam (Ativan), clonazepam (Klonopin); anxiety and promotes participation in ADLs and
therapy program. Drug effects may be noted
shortly after beginning therapy but problems
with
dependence/withdrawal symptoms may occur.
Antidepressants, e.g., imipramine (Tofranil), May be used in conjunction with other drugs as
desipramine (Norpramin); or selective antidepressants may require several weeks
before
serotonin reuptake inhibitors (SSRIs), e.g., positive effects are noted, and still may not alter
fluoxetine (Prozac), sertraline (Zoloft); client’s fear of panic attacks. SSRIs have fewer/
milder side effects and may be better tolerated
by
client. Note: Upwards of 50% of client’s with
panic
disorder also have an episode of major
depression.
Monoamine-oxidase inhibitors (MAOIs), e.g., These drugs have also been found to be effective
in
phenelzine sulfate (Nardil); treating panic attacks. Side effects may be
temporary, and caution needs to be exercised
about food that should not be consumed while
receiving these drugs.
Propranolol (Inderal); Several antihypertensive agents such as this
beta
blocker have potent effects on the somatic
manifestations of anxiety (e.g., palpitations,
tremors, etc.), although they have less dramatic
effects on the psychological component of
anxiety.
Anticonvulsants, e.g., valproate (Depakene), These drugs have a sedative effect on the CNS
and
carbamazepine (Tegretol). are used to stabilize mood in some clients,
especially when other drugs are ineffective.
Refer client/family to counseling, psychotherapy, May need additional assistance/long-term
support
or groups, as indicated. to make lifestyle changes necessary to achieve
maximum recovery.