Panic disorders and phobias are expound to be a disabling condition which presents a profound impact in life to a point that it can impair the social, family, and working lives of the individual suffering from it. These commonly transpire among young adult, and such conditions should not be marginalized because a simple manifestation of panic or fear could be a start of a more dreadful experience. Below are detailed explanation of panic disorders and phobias that can help us better understand their discrepancies.
Diagnostic and Statistical Manual of Mental Disorders DSM-IV
Panic Disorder and 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
Threshold definition IN DSM-IV
|– Retain the DSM-III-R thresholds of the 4 panic attacks in 4 weeks with no requirement of an incurrent anxiety or even on unexpected attack, with at least a month of worry regarding panic recurrence.|
|– Require recurrent unexpected panic attacks and a month of obstinate worry regarding the next panic, which would follow the liberal threshold from the DSM-III-R.|
|– Require an unexpected panic attack and a month of persistent worry regarding the following panic, which would follow the liberal threshold from DSM-III-R.|
|– Require one unforeseen attack and a month of persistent worry about the next panic or its complications with regards to loss of control and health worries. A broadened definition of worry is:
– Between episodes of panic, there is a development of persistent anxiety or worry. This usually concerns recurrence of panic attacks, worry that the anxiety manifestations reflect underlying medical or psychiatric illnesses, or fear of episodes of loss control.
– Require recurrent unexpected pain attacks and a month of worry regarding the next panic or implications.
– Simply necessitates recurrent unexpected panic attacks.
Source: Wolfe, B. (1994). Treatment of panic disorder: A consensus development conference. Washington, D.C.: American Psychiatric Press
Panic Disorder without Agoraphobia
Agoraphobia is a condition which is often associated with panic disorder. In DSM-IV, this is demarcated as an anxiety about being in places or circumstances from which escape might be difficult or in which help may be not available, in event if having a panic attack or encountering panic-like manifestations. This fears includes anxiety about being outside home alone, being on a bridge, being in a crowd, standing in a line, travelling in any transportation, visiting establishments such as malls or grocery stores.
Panic disorder without agoraphobia is the most common among the group of anxiety disorder. In fact, this is present among 2 percent of the population, while Panic with agoraphobia is less than 1.5 percent of the population. The diagnosis for this type of panic disorder entails at least four panic attacks within the last month, ongoing concern of having additional attacks or worry regarding the implications of having additional attacks. The diagnostic criteria for this condition are recurrent unexpected panic attacks and at least one of the attacks has been followed after a month; absence of agoraphobia, occurrence of panic attacks which are not brought about by the direct physiological effects of substance, and attacks which are not accounted for by another mental disorder.
Panic Disorder with Agoraphobia
The diagnostic criteria for panic disorder with acrophobia condition are recurrent unexpected panic attacks and at least one of the attacks has been followed after a month or more such as (one or more of the following) persistent concern regarding possibility of having an attack, a profound change in behavior which is related to the attacks, or worrying about the implications of the attack or its possible consequences; absence of agoraphobia, occurrence of panic attacks which are not brought about by the direct physiological effects of substance, and attacks which are not accounted for by another mental disorder such as social phobia, specific phobia, obsessive- compulsive disorder, posttraumatic stress disorder, or separation anxiety disorder.
Agoraphobia without history of panic disorder
The diagnostic criteria for this condition are based on the fear of sudden incapacitating or an embarrassing symptom. The differential diagnosis for agoraphobia without history of panic disorder entails all the medical disorders which can cause depression or anxiety. The psychiatric differential diagnosis includes paranoid personality disorder, major depressive disorder, avoidance personality disorder, dependent personality disorder, and schizophrenia.
Social & Specific phobia
Patients who experience a single panic attack in a specific setting may go on to have a long –lasting avoidance of the specific setting, regardless of whether they ever have another panic attack. These are the patient who are considered to meet the diagnostic criteria for specific phobia. On the other hand, a person who experiences one or more panic attacks may then fear speaking in public. Although this situation manifest an identical picture with the clinical picture of social phobia, a diagnosis of social phobia is excluded because the avoidance of the public situation is based on fear of having a panic attack; instead of fear of the public speaking per se.
Specific phobia was expound to be more common as compared to social phobia, particularly among women, and among those who are affected with substance related disorder. Social phobia on the other hand, the epidemiological studies would state that females are often affected more by this condition than males, however, clinical studies frequently manifested the reverse. The peak age of onset of social phobia is in teens, but this can appear as young as 5 years old.
- SSRIs: Paroxetine, Paroxetine CR, Fluoxetine, Sertraline, Fluvoxamine, Citalopram, Escitalopram
- Tricyclic Antidepressants: Clomipramine, Imipramine, Desipramine
- Benzodiazepines: Alprazolam, Clonazepam, Diazepam, Lorazepam
- MAOIs: Phenelzine, Tranylcypromine
- RIMAs: MOclobemide, Brofaromine
- Atypical Antidepressants: Venlafaxine, Venlafaxine XR
- Other Agents: Valproic acid, Inositol
Cognitive and Behavior Therapies
- Cognitive therapy – for panic disorder, there are two major focus of this therapy. First is the instruction about a patient’s false beliefs which underscore on their tendency to misinterpret mild bodily sensation, and informing the patient about panic attacks which entails explanation when panic attacks transpire.
- Applied Relaxation – the goal of this intervention is to instill a sense of control over the patient’s level of anxiety and relaxation.
- Respiratory Training – hyperventilation is commonly associated with panic attack, therefore, it would be helpful to train patient how to control the urge to hyperventilate.
- In Vivo Exposure – this was used to be the primary behavior treatment for panic disorder. This entails a great exposure of the patient to the feared stimulus, in sequential manner. Then over time, the patient would become desensitized to the experience.
Other Psychosocial Therapies
- Family Therapy – this is directed toward education and support for the whole family of the patient.
- Insight-Oriented Psychotherapy – focuses on helping the patient understand the hypothesized unconscious meaning of the anxiety.
Nursing Care Plans for Panic Disorder and Phobias (Based on NANDA)
Nursing diagnosis: Fear
May be related to
- Unfounded morbid dread of a seemingly harmless object/situation (fear of being alone in public places, snakes, spiders, dark, heights, stormy weather (virtually any object/situation)
Possibly evidenced by
- Physiological symptoms, mental/cognitive behaviors indicative of panic
Desired outcomes/evaluation criteria—patient will:
- Acknowledge and discuss fears.
- Demonstrate understanding through use of effective coping behaviors and active participation in treatment regimen.
- Resume normal life activities.
|Encourage discussion of the phobia. Investigate sexual concerns, noting problems expressed (e.g sex is a duty/obligation that is not enjoyed by the client).||Only when a difficulty is acknowledged can it be dealt with. Note: Phobic reaction to sex may indicate a problem of incest/sexual abuse.|
|Provide for client’s safety (e.g. a secure environment,staying with the client, letting the client know the nurse will provide for safety).||In severe anxiety, client fears total disintegration and loss of control.|
|Suggest that the client substitute positive thoughts for negative ones.||Emotion connected to thought, and changing to a more positive thought can decrease the level of anxiety experienced. This also gives the client an alternative way of looking at the problem.|
|Discuss the process of thinking about the feared object/situation before it occurs.||Anticipation of a future phobic reaction allows client to deal with the physical manifestations of fear.|
|Encourage client to share the seemingly unnatural fears and feelings with others, especially the nurse therapist.||Clients are often reluctant to share feelings for fear of ridicule and may have repeatedly been told to ignore feelings. Once the client begins to acknowledge and talk about these fears, it becomes apparent that the feelings are manageable.|
|Share own experience with client as indicated after relationship has been established.||If nurse therapist has dealt successfully with phobia in own life, client may be encouraged by the fact that someone has overcome a similar problem. Use judiciously to avoid meeting own needs rather than focusing on the client’s needs.|
|Encourage to stop, wait, and not rush out of feared situation as soon as experienced. Support use of relaxation exercises (e.g breath control, muscle relaxation, self-hypnosis).||Client fears disorganization and loss of control of body and mind when exposed to the fear producing stimulus.This fear leads to an avoidance response, and reality is never tested. If client waits out the beginnings of anxiety and decreases it with relaxation exercises, then she or he may be ready to continue confronting the fear.|
|Explore things that may lower fear level and keep it manageable (e.g. use of singing while dressing,practicing positive self-talk while in a fearful situation).||Provides the client with a sense of control over the fear. Distracts the client so that fear is not totally focused on and allowed to escalate.|
|Use desensitization approach, e.g.:||Systematic desensitization (gradual systematic exposure of the client to the feared situation under controlled conditions) allows the client to begin to overcome the fear, become desensitized to the fear. Note: Implosion or flooding (continuous, rapid presentation of the phobic stimulus) may show quicker results than systematic desensitization, but relapse is more common or client may become terrified and withdraw from therapy.|
|Expose client to a predetermined list of anxiety-provoking stimuli rated in hierarchy from the least frightening to the most frightening.||Experiencing fear in progressively more challenging but attainable steps allows client to realize that dangerous consequences will not occur. Helps extinguish conditioned avoidance response.|
|Pair each anxiety-producing stimulus (e.g. standing in an elevator) with arousal of another affect of an opposite quality (e.g. relaxation, exercise,biofeedback) strong enough to suppress anxiety.||Helps client to achieve physical and mental relaxation as the anxiety becomes less uncomfortable.|
|Help client to learn how to use these techniques when confronting an actual anxiety-provoking situation. Provide for practice sessions (e.g.role-play), deal with phobic reactions in real- life situations.||Client needs continued confrontation to gain control over fear. Practice helps the body become accustomed to the feeling of relaxation, enabling the individual to handle feared object/situation.|
|Encourage client to set increasingly more difficult goals.||Develops confidence and movement toward improved functioning and independence.|
Administer antianxiety medications as indicated:Benzodiazepines, e.g.Alprazolam (Xanax),Clonazepam (Klonopin) diazepam (Valium),lorazepam (Ativan) chlordiazepoxide (Librium),oxazepam (Serax).
|Biological factors may be involved in phobic/panic reactions, and these medications (particularly Xanax) produce a rapid calming effect and may help client change behavior by 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 appropriate, with client holding breath,hyperventilating and inhaling CO2, or receiving sodium lactate injections as indicated.||Alters client’s response to internal sensations as client learns that the feelings associated with panic do not indicate impending disaster.|
Nursing diagnosis: Anxiety [severe to panic]
May be related to
- Unidentified stressor(s)
- Contact with feared object/situation
- Limitations placed on ritualistic behavior
Possibly evidenced by
- Attacks of immobilizing apprehension
- Physical, mental, and cognitive behaviors indicative of panic
- Expressed feelings of terror and inability to cope
Desired outcomes/evaluation criteria—patient will:
- Verbalize a reduction in anxiety to a manageable
- Use individually appropriate techniques to interrupt progression of anxiety to panic level.
- Demonstrate increasing tolerance to phobic object/situation.
Identify and use resources effectively.
Establish and maintain a trusting relationship by listening to the client; displaying warmth, answering questions directly, offering unconditional acceptance; being available and respecting the client’s use of personal space.
|Therapeutic skills need to be directed toward putting the client at ease, because the nurse who is a stranger may pose a threat to the highly anxious client.|
|Be aware and in control of own feelings; explore the cause of own anxiety and use this understanding therapeutically||The nurse’s anxiety can be communicated to the client, which only adds to the client’s sense of 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 client’s present coping mechanism (panic) without focusing on the symptoms that are being expressed.||The symptoms that the client is experiencing relieve some of the intolerable anxiety felt by the 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 coping responses. Validate what you observe with the client.||Sets groundwork for dealing with anxiety when
client is calmer. Includes client in plan of care, providing sense of control/self-worth.
|Emphasize relationship between physical andemotional health, and reinforce that this is an area to be explored when client feels better.||Client needs to be aware of mind-body relationship and the physiological changes that cause discomfort.|
|Observe for increasing anxiety. Assume a calm manner, decrease environmental stimulation, and provide temporary isolation as indicated.||Early detection and intervention facilitate modifying client’s behavior by changing the environment and the client’s interaction with it, to minimize the spread of anxiety.|
|Assist client/family to recognize and modify situations that cause anxiety when precipitating factor can be identified. (Note: Simple phobias are usually specific and object-centered; this is not so
with all phobic disorders.)
|Recognition of causes/relationships provides opportunity to intervene before anxiety escalates or loss of control occurs.|
|Determine/discuss use of alcohol and other drugs.||May be used to reduce anxiety/avoid panic attacks and can lead to abuse.|
- Dunphy, L., Winland-Brown, J., Porter, B. & Thomas, D. (2015). Primary Care: Art and Science of Advanced Practice Nursing. Philadelphia, PA: F.A. Davis Company.
- Sadock, B., Kaplan, H. & Sadock, V. (2007). Kaplan & Sadock’s Synopsis of psychiatry: Behavioral sciences/clinical psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins
- Thyer, B. & Wodarski, J. (2007). Social work in mental health: An evidence-based approach. Hoboken, NJ: John Wiley & Sons.
- Wolfe, B. (1994). Treatment of panic disorder: A consensus development conference. Washington, D.C.: American Psychiatric Press