PANIC DISORDER AND

GENERALIZED ANXIETY DISORDER PREPARED BY KANKANA CHAKRABORTY COLLEGE OF NURSING AIIMS PATNA

PANIC DISORDER

DEFINITION• This disorder is characterized by recurrent panic attacks, the onset of

which is unpredictable, and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort.

PANIC ATTACK Panic attack is an episode of intense fear or apprehension with a sudden onset. Such symptoms

develop abruptly and usually reach its peak within 10 - 15 minutes.

At least four of the following symptoms must be present to identify the presence of a panic attack. ● Palpitations, pounding heart, or accelerated heart rate ● Sweating ● Trembling or shaking ● Sensations of shortness of breath or smothering ● Feeling of choking ● Chest pain or discomfort ● Nausea or abdominal distress ● Feeling dizzy, unsteady, lightheaded, or faint ● Derealization or depersonalization ● Fear of losing control or going crazy ● Fear of dying ● Paresthesias (numbness or tingling sensations) ● Chills or hot flash

EPIDEMIOLOGY• 3% to 5% of the population. • More common in women.• The age of onset is usually between 15 and 24.

ETIOLOGY OF PANIC DISORDER AND GAD

• Biological Aspects• Psychological Aspects

BIOLOGICAL ASPECTSGenetics :The concordance rate for identical twins is 30 percent, and

the risk for the disorder in a close relative is 10 to 20 percent. Neuroanatomical : Structural brain imaging studies in patients with

panic disorder have implicated pathological involvement in the temporal lobes, particularly the hippocampus and the amygdala.

Biochemical : Abnormal elevations of blood lactate have been noted in clients with panic disorder.

Neurochemical : Stronger evidence exists for the involvement of the neurotransmitter norepinephrine in the etiology of panic disorder (Daniels & Yerkes, 2006). Norepinephrine is known to mediate arousal, and it causes hyper arousal and anxiety.

Alteration in GABA level may lead to production of anxiety.

CONTD….Medical conditions :● Abnormalities in the hypothalamic–pituitary–adrenal and hypothalamic–pituitary thyroid axes● Acute myocardial infarction● Pheochromocytomas● Substance intoxication and withdrawal (cocaine, alcohol, marijuana, opioids)● Hypoglycemia● Caffeine intoxication● Mitral valve prolapse● Complex partial seizures

PSYCHOLOGICAL ASPECTSPsychodynamic theory : The psychodynamic view focuses on the

inability of the ego to intervene when conflict occurs between the id and the superego, producing anxiety.

Learning factor : The learning theorists have tried to explain panic attacks as learnt phenomena – specifically as responses to conditioned stimuli.

Cognitive theory : According to this theory , anxiety is related to cognitive distortions and negative automatic thoughts

DIAGNOSIS• Tests to rule out organic or pharmacologic basis for symptoms• Serum glucose measurements to rule out hypoglycemia• TFT to rule out hyperthyroidism• Urine and serum toxicology tests to rule out presence of psychoactive

substances such as barbiturates , caffeine, and amphetamines.• Based on ICD 10 criteria

TREATMENT MODALITIESPharmacotherapy: Benzodiazepines — alprazolam , clonazepam Antidepressants Betablockers -- propranolol Behavioural therapy: Relaxation techniques Deep breathing exercise Positive verbalization or guided imagery Listening calm musicCognitive therapy: Replacing negative thoughts with more realistic ,positive ways Helping to identify possible triggers of panic attacks Identify and evaluate thoughts that precede anxiety and restructures

them

GENERALIZED ANXIETY DISORDER

GENERALIZED ANXIETY DISORDER

• GAD is characterized by chronic , unrealistic, and excessive anxiety and worry.

• Symptoms have existed for 6 months or longer and can not be attributed to specific organic factors ,such as caffeine intoxication and hyperthyroidism.

COURSE AND PREVALENCE• Onset occurring after age 20 years• 1 year prevalence rate for GAD is 3 % and life time rate 5%

SYMPTOMS OF GAD• The DSM IV TR identifies the following symptoms associated with GADExcessive anxiety and worry about a number of events that the individual

finds difficult to controlRestlessness or feeling keyed up Being easily fatigued Difficulty concentrating or mind “going back”IrritabilityMuscle tensionSleep disturbances(difficulty falling asleep)• Depressive symptoms are common

PSYCHOLOGICAL SYMPTOMS

• Fearful anticipation• Irritability• Sensitivity to noise• Restlessness• Poor concentration• Worrying thoughts • Apprehension

PHYSICAL SYMPTOMSGastrointestinal:• Dry mouth• Difficulty swallowing• Epigastric discomfort• Frequent or loose motionsRespiratory: • Constriction in the chest• Difficulty inhalingCardiovascular:• Palpitation• Discomfort in chestGenitourinary:• Frequency or urgent micturition• Failure of erection• Menstrual discomfort

Neuromuscular:• Tremor• Tinnitus• Dizziness• Headache Sleeping disturbances:• Insomnia• Night terrorOther symptoms:• Depression• Obsessions• Depersonalization• Derealization

TREATMENT OF GADBehavioural therapy : Biofeedback Relaxation techniques – Jacobson’s progressive muscle relaxation

technique, yoga, pranayama, meditation. Supportive psychotherapyCognitive therapy : by restructuring thoughts.Pharmacotherapy : Antianxiety agents – Benzodiazepines (alprazolam, clonazepam) Beta blockers – propranolol

NURSING DIAGNOSIS• Panic Anxiety• Powerlessness• Fear• Social Isolation• Ineffective Coping• Ineffective Role Performance