Notes: Panic Disorder and Generalized Anxiety Disorder

  PANIC DISORDER (EPISODIC PAROXYSMAL ANXIETY)

• It is characterized by spontaneous, unexpected occurrence of panic attacks. Panic attacks are relatively short lived period of anxiety or fear  which are accompanied by somatic symptoms like palpitations and tachycardia.

Features of panic disorder

• Not restricted to any particular situation
• Unpredictable
• Dominant symptoms vary from person to person.(but sudden onset of palpitations, chest pain, choking sensations, dizziness and feelings of unreality are common).
• A panic attack is followed by a persistent fear of having another attack.
• Panic disorder is differentiated from generalized anxiety disorder is by the sudden onset of distressing physical symptoms combined with thought of dread, impending doom, death and fear of being trapped.
• Women are two to three times more affected.

Etiology of panic disorder

• Biologic factors

Both central and peripheral nervous system deregulation. Cerebral vasoconstriction

• Genetic FACTORS

4 to 8 fold increase in panic disorder cases among first degree relatives of patients with other psychiatric disorders. Monozygotic twins get affected than dizygotic. Panic disorder with agoraphobia is more likely to be inherited.

• Psychosocial factors

Cognitive behavioral theory : anxiety is a learned response either by modeling or classical conditioning. Psychoanalytic theory : panic attacks are resulting from an unsuccessful defense against anxiety provoking impulses. Patients with panic disorder have a higher incidence of stressful life events. Clinical features of panic disorder

• Mental symptoms : Fear, sense of impending doom, confusion, lack of concentration, depersonalization
• Physical signs : tachycardia, palpitations, dyspnoea and  sweating
• GI symptoms : abdominal bloating, constipation or diarrhea, abdominal pain etc.
• MSE shows difficulty in speaking and impaired memory
• Panic attack generally last for 20-30 minutes

Diagnostic guidelines

• Several severe attacks of anxiety should have occurred within a period of about one month

1. In circumstances where there is no objective danger
2. Without being  confined to known or predictable situations
3. With comparative freedom from anxiety symptoms between attacks

Differential diagnosis

• Psychiatric

-social phobia, somatoform disorders, PTSD, schizophrenia

• Medical

-angina, HTN, MI, epilepsy, migraine, CVA, Addison's disease, Cushing's syndrome, alcohol withdrawal syndromes Management

• PHARMACOTHERAPY

1. Tricyclic antidepressants. Eg: Imipramine.
2. MAO inhibitors.  Eg: Phenelzine.
3. SSRIs.   Eg: Fluoxetine.
4. Benzodiazepines  : more effective . Onset of action within 1-2 hours.   E.g.: Alprazolam, Clonazepam, Lorazepam. 

5. Beta blockers

• PSYCHOLOGICAL THERAPIES

1. Relaxation techniques

• Deep breathing exercises
• Progressive relaxation
• Guided imagery
• Listening to calming music

1. Psychosocial therapies

• family therapy
• insight oriented psychotherapy

3. Cognitive therapy

• Teaches the patient to replace negative thoughts with more realistic, positive ways
• Helps to identify possible triggers

GENERALIZED ANXIETY DISORDER Meaning

• Anxiety which is generalized and persistent, but not restricted to , any particular environmental circumstances.(It is free-floating )
• Complaints of continuous feelings of nervousness, trembling, muscle tension, sweating, lightheadedness, palpitations, dizziness and epigastric discomfort  are common.
• Often expressed fear is that the sufferer or a relative will shortly become ill or have an accident along with other worries

Epidemiology

• It is the most common anxiety disorder.
• Ratio of women to men is 2:1

Etiology

• PSYCHOANALYTIC THEORY (Freud)

          -Anxiety is a symptom of an unresolved unconscious conflict

• COGNITIVE BEHAVIORAL THEORY.

         -It states that anxiety is a response to perceived danger

• BIOLOGICAL THEORY

            -Abnormalities  of  the  benzodiazepine  receptor  system in brain.

• GENETIC THEORY

            -Incidence of anxiety is  4  times  greater  in monozygotic twins than dizygotic . Diagnostic guidelines

• Sufferer must have primary symptoms of anxiety  most days usually for several months

1. Apprehension (worries about future misfortunes)
2. Motor tension (restlessness, tension headaches, trembling, inability to relax)
3. Autonomic  over activity (lightheadedness, sweating, tachycardia, tachypnoea, epigastric discomfort, dizziness, dry mouth  etc.)

Treatment

• Psychotherapy

    ( supportive therapy.focuses  on  maladaptive defenses  and  patients insight)

• Cognitive behavioral therapy

    ( includes psycho education, breathing training, flooding, exposure graded practice)

• Relaxation techniques

    ( jacobsons progressive muscle relaxation techniques, yoga, pranayama, meditation etc.) PHARMACOTHERAPY

1. Benzodiazepines (Diazepam)

1. Azapirones (Buspirone . It is less sedating than benzodiazepines and has no withdrawal symptoms)

1. Antidepressants  (Imipramine, Fluoxetine . Tricyclic antidepressants are more effective in GAD)

1. Beta blockers(Propranolol, atenolol. Help in anticipatory anxiety)

1. Combination treatment -of  psychotherapy and  pharmacotherapy

-of Benzodiazepines with antidepressants,  buspirone or beta blockers    may result in rapid symptom relief. Nursing Management (Refer anxiety disorder nursing management)