Anxiety Disorders: (PTSD, Anxiety, Panic Attack)

Definition/Etiology:

Anxiety is a person’s response to an impending threat, real or imagined. Fear is a natural response to an actual or potential threat. Anxiety usually involves a faceless, non-specific threat.

Anxiety disorders include:

• Panic disorders
• Obsessive-Compulsive Disorder
• PTSD
• Generalized Anxiety Disorder
• Phobias

Pathophysiology:

Anxiety mediators in the CNS are thought to be nor-epi, serotonin, dopamine and gamma-aminobutryic acid (GABA). Most of the symptoms are mediated by the sympathetic nervous system.

The amygdala plays an important role in tempering fear and anxiety. Patients with anxiety disorders have been found to show heightened amygdala response to anxiety cues. Abnormalities here may be reversed with psychological or pharmacologic interventions.

Clinical Presentation:

Panic disorders or acute anxiety attacks can occur without any warning. These patients may have feelings of impending danger, death, or “going crazy” Physically, they can be tachycardic, have palpitations, hyperventilation, paresthesia, diaphoresis, tremors, hyperactivity, and want to leave the location immediately. They can also have contractures of the hands and fingers, kind of like a claw.

OCD presents with recurrent thoughts, images, or impulses that invade the mind and cause increased anxiety. They will be resigned to perform repetitive behaviors to reduce their own discomfort. These can include:

• Hand washing
• Cleaning the house
• Excessive ordering and arranging
• Incessant checking and rechecking
• Repetitive counting, touching, and activity rituals
• Excessive slowness in activities

PTSD forms after exposure to a traumatic event in which severe physical harm occurred or was threatened. We see this often in returning veterans and victims of sexual assault. Sufferers of PTSD often relive the event in their mind over and over again. They often feel stress, anxiety or fear even when they are no longer in danger. The disorder can manifest in flashbacks causing hyperarousal. They will try to stay away from people or places that remind them of the event.

They can become emotionally numb, have strong feelings of guilt, a loss of interest in activities they used to enjoy, and difficulty remembering the event.

I myself have worked with PTSD victims for several years. I work with several veteran organizations whose primary purpose is to get these men and women out and about and around people. We do it mostly through athletic events like obstacle course racing and skydiving and hiking and such. Just getting them around their peers again and showing them that they can enjoy things helps to ease some of their symptoms.

Collaborative Management:

When it comes to diagnostic testing, we always want to rule out physiologic causes of symptoms so some basic blood work and tox screens aren’t out of the question. From a nursing standpoint, we want to provide a safe, non-threatening environment. Treat their medical symptoms such as hyperventilation, but many times, fixing their symptoms like tachycardia and tachypnea will only require talking with them. Reassuring them they are safe in a calm and quiet tone. Listening to their concerns and not providing false reassurances.

Therapeutic management may involve some medications such as benzos. Assess if they actually use anything like this at home.

Evaluation | Patient Monitoring | Education:

The simplest evaluation is whether the acute symptoms subside. We need to assess suicide risk in these patients, especially the PTSD sufferers. Asses for potential violence continuously. Always allow the patients to verbalize what they are feeling. Most of these patients will be discharged. If needed, we can always include a psych consult, but I myself like to ask the patient if they would like to speak to someone before we actually make that call.

Linchpins: (Key Points)

• Stay Calm
• Stay Safe
• Listen