Download Anxiety Panic Disorder

Kristin Fahsel
Iris Gonzalo-Sowle
SUNYIT
NUR668
 Sense
of danger, apprehension, worry,
and dread in response to a trigger that is
not a truly threatening experience
(Fournier, 2013).
 Anxiety is a normal reaction to stressful
and uncertain situations. It’s your body
telling you to stay alert and protect
yourself (Anxiety and Depression
Association of America, 2010-2014).
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Generalized Anxiety Disorder (GAD) is
characterized by excessive anxiety and worry
lasting more than six months. GAD is diagnosed
when anxiety and worry are associated with at
least three of the following symptoms:
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Restlessness or feeling keyed-up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Suicide ideation or completed suicide
(Loomis, Griswold, Pastore, & Dunphy, 2011; Yates, 2012)
Anxiety disorders are common psychiatric disorders. The
Diagnostic and Statistical Manual of Mental Disorders (4th
edition), Text Revision (DSM-IV-R) classifies anxiety disorders
into the following categories:
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Anxiety due to a general medical disorder
Substance-induced anxiety disorder
Generalized anxiety disorder
Panic disorder
Acute stress disorder
Posttraumatic stress disorder (PTSD)
Adjustment disorder with anxious features
Obsessive-compulsive disorder (OCD)
Social phobia (aka Social anxiety disorder)
Specific phobia (aka Simple phobia). Examples include animal type,
environmental type, and injection/injury type.
(Yates, 2012)
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The body does not distinguish between a physical or
psychological threat.
The normal physiologic response to stress is commonly
known as “fight or flight.” This response is regulated
through cortisol, mediated by the hypothalamus-pituitaryadrenal (HPA) axis. This system operates on a negative
feedback loop.
In the CNS, the major neurotransmitters associated with
anxiety are norepinephrine, serotonin, dopamine, and
gamma-aminobutyric acid (GABA).
Other neurotransmitters such as corticotropin-releasing
factor may be involved.
Abnormalities in the transmission of these neurotransmitters
including poor regulation and increased metabolic activity
of different areas of the brain have been associated with
anxiety disorders.
(Fournier, 2013)
(http://img.medscape.com/fullsize/migr
ated/579/825/ga579825.fig1.gif)
(http://what-causes-anxiety.com)
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Female to male ratio is 3:2
Prevalence is 5-6% in the general population.
Most anxiety disorders begin in childhood, adolescence,
and early adulthood.
No difference in prevalence of anxiety disorders among
white, African-American, or Hispanic populations in the
Untied States.
Social phobia is the most common anxiety disorder; it has an
early onset (by age11, median age is 16 years) and is
considered a risk factor for depression and substance
abuse.
Specific anxiety disorders (panic disorder and OCD) appear
to vary between cultures and countries.
Those with GAD have a 60% of having a comorbid
psychiatric diagnosis, usually depression.
(Loomis et al., 2011; Yates, 2012)
 Being
female
 Childhood trauma
 Stress due to an illness
 Stress buildup
 Personality
 Family members with an anxiety disorder
 Drug or alcohol use
(Mayo Foundation for Medical Education and Research, 2013)
(http://anxietyadventures.files.wordpress.com/2013/07/anxiety.png?w=64)
http://www.gregdorter.com/toronto-therapist-blog/images/anxiety-cycle.png
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Acute Respiratory Distress Syndrome (ARDS)
Anorexia Nervosa
Asthma
Atrial Fibrillation
Body Dysmorphic Disorder
Cardiogenic Shock
Delirium
Depression
Diabetes, Type I
Encephalopathy
Fibromyalgia
Goiter
Irritable Bowel Syndrome
Sleep disorders (insomnia, sleep apnea)
Thyroiditis
Unstable Angina
(Yates, 2012)
Anxiety disorders are the most common mental
illness in the US (40 million people).
 North America has the highest rate of anxiety.
 A total of 28% of Americans will suffer anxiety in
their lifetime.
 Young people are growing up increasingly
anxious-20% of children report “worrying a lot.”
 People with anxiety disorders are 6x more likely
to be hospitalized.
 Anxiety disorders cost the US $42 billion a year
in treatments.
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(http://OnlinePsychologyDegree.net)
 Physical
examination
 Patient history
 Mental status exam
 CBC, BMP, TSH, EKG (usually normal)
 US, CT, MRI (to rule out medical conditions)
 Psychological questionnaires:
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http://www.phqscreeners.com/pdfs/02_PHQ9/English.pdf
https://pdbp.ninds.nih.gov/assets/crfs/Hamilton%
20Anxiety%20Rating%20Scale%20(HAM-A).pdf
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Patient education
Cognitive therapy
Behavioral therapy
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Relaxation techniques
Respiratory training
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Psychiatrist
Psychologist/Psychotherapy
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Diet
Physical activity
Sleep
Smoking cessation
Avoiding alcohol
Specialists
Lifestyle management/Health promotion
(Mayo Foundation for Medical Education and Research, 2013)
 SSRIs
 SNRIs
 Tricyclic
Antidepressants
 Azapirone
 Benzodiazepines
 Herbal supplements
 Other medications
(Mayo Foundation for Medical Education and Research, 2013)
 Chronic
disease
 Relapse is more likely with the
discontinuation of medications,
especially in the first year of treatment or
during periods of increased stress
 Severe impairments in all functional
areas
 Increase in unhealthy habits
 Suicidal ideation and increased risk for
suicide attempt
(Fournier, 2013; Flynn, 2014)
 Response
to treatment is evaluated after
4-6 weeks
 Many
patients will experience
improvement after 8-12 weeks
 Continued
treatment over 8 months or
longer is associated with a reduction in
the risk of relapse
(Davidson et al., 2008)
Patient education includes general information
about anxiety, symptom recognition, effective
interpretation of physical symptoms, decrease in
use of stimulants (nicotine and caffeine), and
relaxation training.
 Websites
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Anxiety and Depression Association of America
(www.adaa.org)
 National Alliance on Mental Illness (www.nami.org)
 National Institute of Mental Health
(www.nimh.nih.gov/health/topics/anxietydisorders/index.shtml)
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 Psychiatrist
 Psychologist
 Psychotherapist
 Social
worker
 Cardiology
 Neurology
 Endocrinology
 Massage therapist
 Chiropractor
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Definition:
• Multiple unexpected panic attacks
 Panic attack – brief period of sympathetic nervous system
hyperarousal accompanied by psychological terror
 Peak is typically about 10 minutes but can last up to an hour
 Symptoms include: palpitations, accelerated and pounding heart
rate, sweating, trembling/shaking, shortness of breath, choking
sensation, chest pain/discomfort, nausea, feeling
dizzy/unsteady/lightheaded/faint, depersonalization, fear of loosing
control, fear of dying, paresthesias, chills, or hot flashes
• Not associated with another psychiatric condition
• Not associated with alcohol or drug use
• Not associated with medical conditions
• Associated change in behavior (constant worry about another
panic attack)
(Katon & Ciechanowski, 2013; Domino, Baldor, Golding, Grimes, & Taylor, 2013)
Noradrenergic neurotransmission from the locus
coeruleus causes increased sympathetic stimulation
 Current research is being performed on abnormal
responses to anxiety producing stimuli in the
hippocampus, amygdala, and prefrontal cortex
 Peripheral and central nervous system dysregulation
 MRI have demonstrated pathologic involvement of
the temporal lobes, associated cerebral
vasoconstriction
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Cause unknown
System malfunction in dealing with anxiety stimuli
Defects in managing strong emotions like fear and
anger
(Dunphy, Winland-Brown, Porter, & Thomas, 2011; Domino et al., 2013)
 Incidence
• Seen in all age groups, but can be seen in ages
15-19 and a second peak in ages 35-50
• In school aged children, it can be confused with
conduct disorder or ways to avoid school
• Females (5%) more affected than males (2%)
 Prevalence
• About 8% of patients seen in primary care
clinics have panic disorder
• Of all patients who present to the ER with chest
pain, 25% is caused by panic disorder
(Katon & Ciechanowski, 2013; Domino et al., 2013)
 Any life stressors can precipitate an attack
 History of sexual or physical abuse
 Anxious and overprotective parents
 Substance abuse
 General temperament
 Bipolar disorder
 Major depression
 Obsessive compulsive disorder
 Phobia
 Family history (increases risk by 18-41%)
 Still doing research on neurobiology
(Katon & Ciechanowski, 2013; Domino et al., 2013)
 Psychiatric
Diagnosis:
 Other
Medical
Diagnosis:
• PTSD
• Hypertension
• Social phobias
• Mitral valve prolapse
• Depression
• Reflux esophagitis
• Bipolar disorder
• Interstitial cystitis
• Substance abuse
• Irritable bowel
• OCD
syndrome
• Fibromyalgia
• Nicotine dependence
• Separation anxiety
disorder
(Domino et al., 2013)
 No physical findings between attacks
 During attacks:
• Tachycardia (25%), chest pain (22%)
• Headaches (20%), dizziness (18%), hyperventilation,
sweating
• Epigastric pain (15%)
 Perform:
• Palpate thyroid – hyperthyroidism can cause anxiety
• Respiratory exam – rule out asthma or limited air
flow
• Cardiac exam – evaluate for murmurs or arrhythmia
(Katon & Ciechanowski, 2013; Domino et al., 2013)
Medication side effect (narcotics, beta blockers,
steroids, albuterol, fluoroquinolones, interferon, etc)
 Substance abuse and withdrawal
 Hyperthyroidism
 COPD
 Tachyarrhythmias
 Hypoglycemia
 Pulmonary embolism
 MI
 Celiac disease
 TIA
 Cushing syndrome
 Other psychiatric illnesses
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(Katon & Ciechanowski, 2013; Domino et al., 2013)
• A person with a panic disorder finds it difficult to
carry out normal activities, like going to the
grocery store or driving. Over one third of
patients become housebound.
• It can interfere with school or work
• Patients with repeated attacks may avoid
locations where they frequently occur, for
example an elevator or hospitals
(National Institute of Mental Health, n.d.)
 No
specific testing to indicate condition.
Testing is done to rule out other causes.
 Laboratory
tests
• CBC, Glucose, TSH, Electrolytes
 Diagnostics
• EKG, Pulse Oximetry, Holter monitoring, ECHO
(Katon & Ciechanowski, 2013; Domino et al., 2013)
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Cognitive behavioral therapy is key and first line
treatment!!
• Works best with individuals who are highly motivated and
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value problem solving
Provided education, relaxation and breathing techniques
Relapse prevention
Occasionally repeated exposure during counseling
Higher response rates (46% vs 27%) and longer remissions
(20% vs 12%) when used in combination with medications
Most require 10 – 20 weekly treatments that can last 60 – 120
minutes
Typically given homework assignments
Aerobic exercise reduces symptoms better than a
placebo
(Craske, 2013; Domino et al., 2013; Dunphy et al., 2011)
There is no evidence for superior efficacy in panic
disorder among the SSRIs
 The onset of therapeutic effect of SSRIs is somewhere
between 2 and 4 weeks, but clinical response can
take up to 8 to 12 weeks for some patients
 First line FDA approved:
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• Sertraline (Zoloft), Paroxetine (Paxil), Fluoxetine (Prozac),
Alprazolam (Xanax), and Clonazepam (Klonopin)
• Avoid Benzodiazepines in patients with history of substance
abuse
• All antidepressants except Bupropion (Wellbutrin) can treat
panic attacks, but fluoxetine can initial cause more nervousness
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Second line:
• Tricyclic antidepressants, specifically Imipramine (start at low
dose and slowly taper)
(Roy-Byrne, 2013; Domino et al., 2013)
 Medication
dependence
(benzodiazepines)
 Misdiagnosis of other medical or
psychiatric illnesses
(Domino et al., 2013)
 If
medication is started, patients should be
maintained on this until symptoms are
under control for at least 6 months to 1 year
 Follow up in office every 1 to 2 weeks when
starting medications, then every 2 to 4
weeks until therapeutic dose
 Appointments can be spaced out farther the
more stable the patient is
 If no improvement after 8 weeks, can refer
to psychiatrist
(Katon & Ciechanowski, 2013; Domino et al., 2013; Dunphy et al., 2011)
 Need
referral to psychiatrist if
accompanied by other psychiatric
disorder
• Bipolar disorder
• Borderline personality disorder
• Schizophrenia
• Suicidal ideation
• Substance abuse
(Domino et al., 2013)
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One patient’s quote about panic disorders:
“My friend saw how afraid I was and told me to call my
doctor for help. My doctor told me I was physically healthy
but that I have panic disorder. My doctor gave me medicine
that helps me feel less afraid. I've also been working with a
counselor learning ways to cope with my fear. I had to work
hard, but after a few months of medicine and therapy, I'm
starting to feel like myself again.”
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It’s important for patients to know that it is possible to have a
normal life again.
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Panic disorder is one of the most treatable anxiety
disorders.
(National Institute of Mental Health, n.d.)
1. A 24 year old woman has a new onset of panic disorder. You expect to find
the following except:
a. Symptoms worse about 10 minutes into the attack
b. Chest pain
c. Shortness of breath
d. A rash
2. Which of the following abnormal laboratory work would diagnosis panic
disorder?
a. Hct 40
b. CR 2.0
c. K 5.5
d. ESR 30
e. No blood work to diagnose
3. What is one of the key treatments for Panic Disorder?
a. Medications
b. Cognitive behavioral therapy
c. Aerobic exercise
4. What is considered a first-line medication treatment for generalized anxiety
disorders?
a. alprazolam
b. citalopram
c. duloxetine
d. amitriptyline
5. The most common anxiety disorder is
a. Obsessive-compulsive disorder (OCD)
b. Post-traumatic stress disorder (PTSD)
c. Social anxiety disorder
d. Panic disorder
6. Generalized anxiety disorder (GAD) is diagnosed when associated which of
the following three symptoms:
a. Restlessness, fatigue, and irritability
b.Weight loss, anorexia, and persistent nausea
c. Difficulty concentrating, muscle tension, and lack of interest
d. Sleep disturbance, depression, and suicidal ideation
7. Bobbie Jo is a 35 year old female is diagnosed with a Panic Disorder. She
admits to drinking a six pack a night. After establishing her with a counselor,
what would be the appropriate medication choice?
a. Xanax (Alprazolam)
b. Ativan (Lorazepam)
c. Wellbutrin (Bupropion)
d. Zoloft (Sertraline)
8. You prescribe Prozac for a patient with newly diagnosed Panic Disorder,
who is otherwise healthy. When will you bring her back in for a follow up in
the office?
a. 2 weeks
b. 1 month
c. 2 months
d. 6 months
9. The APN decides to do a workup for a patient with anxiety. What would be
expected with the results?
a. CBC shows an elevated WBC
b. BMP shows hyperkalemia or hypokalemia
c. TSH is elevated
d. The labs are within normal limits
10. Which is considered the best treatment for anxiety disorders?
a. Medications only
b. Medications with cognitive and behavioral therapy
c. Stress management
d. Cognitive and behavioral therapy only
1.
Answer D. Rash is not a typical symptoms of a panic attack/panic
disorder
2.
Answer E. Diagnostic testing is done to rule out other conditions, not to
diagnose panic disorder.
3.
Answer B. Medication is helpful, but cognitive behavioral therapy is a
key component of treatment.
4.
Answer: C. Duloxetine (Cymbalta) is a SNRI, which are considered firstline treatment for generalized anxiety disorders.
5.
Answer: C. Social anxiety disorder (aka social phobia) is considered the
most common anxiety disorder.
6.
Answer: A. Restlessness, fatigue, and irritability are all listed as
symptoms. GAD is diagnosed when anxiety and worry are associated
with these symptoms.
7.
Answer D. Should avoid the use of Benzodiazepines in patients with
substance abuse. Wellbutrin is not effective in treatment of panic
disorder.
8.
Answer A. She should be seen in 1-2 weeks to assess panic attacks or
medication side effects.
9.
Answer: D. Unless there is an underlying medical condition, the workup
for a patient with anxiety is usually within normal limits.
10.
Answer: B. Medication can be effective. But scientific research shows that
cognitive-behavioral therapy, or CBT, may be just as or more effective
than medication (or a combination of CBT and medication) for most
people, especially in the long run.
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