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
Panic attack is a discrete period of intense fear or discomfort with onset spontaneous/unpredictable or situationally bound, peaking within 10 minutes.
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 CO2 levels and a sensitivity to lactate associated with the panic attack.
Family Dynamics
(Refer to CP: Generalized Anxiety Disorder.)
CLIENT ASSESSMENT DATA BASE
Circulation
Palpitations or tachycardia
Sweating, hot flashes, or chills
Ego Integrity
A persistent fear of some object/situation that poses no actual danger or in which the danger is magnified out of proportion to its seriousness; tries to avoid or escape contact with the feared object or situation
Degree of discomfort may vary from mild anxiety to incapacitation; may be unable to move, speak, or identify ways of decreasing anxiety or may begin running about aimlessly and shouting
May express a sensation of dread and a certain knowledge that death is at hand or may fear dying, going crazy, or doing something uncontrolled
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.)
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
Panic attack is a discrete period of intense fear or discomfort with onset spontaneous/unpredictable or situationally bound, peaking within 10 minutes.
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 CO2 levels and a sensitivity to lactate associated with the panic attack.
Family Dynamics
(Refer to CP: Generalized Anxiety Disorder.)
CLIENT ASSESSMENT DATA BASE
Circulation
Palpitations or tachycardia
Sweating, hot flashes, or chills
Ego Integrity
A persistent fear of some object/situation that poses no actual danger or in which the danger is magnified out of proportion to its seriousness; tries to avoid or escape contact with the feared object or situation
Degree of discomfort may vary from mild anxiety to incapacitation; may be unable to move, speak, or identify ways of decreasing anxiety or may begin running about aimlessly and shouting
May express a sensation of dread and a certain knowledge that death is at hand or may fear dying, going crazy, or doing something uncontrolled
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.)
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