Anxiety Disorders & Nursing Practice – Comprehensive Study Notes

Anxiety as an Adaptive Signal
- Heightens awareness, keeps clinicians “on their toes.”
- Mild, situational anxiety before clinical practice or public speaking is normal and beneficial.
Red-Flag Transition to Maladaptive Anxiety
- Performance becomes impaired (paralysis, freezing, clouded thinking).
- Out-of-proportion response to the trigger.
- Interference with social, occupational, or other key areas of functioning → pathological.
Behavioral Guidance for Nurses & Students
- A little worry about IV dose, medication accuracy, etc., is protective.
- If routine care consistently produces debilitating fear, consider slower-paced units.

Cognitive / Affective
- Excessive fear, rumination, sense of impending doom.
- Difficulty making decisions, irritability.
Autonomic / Somatic
- Heart palpitations, chest tightness.
- Sweating, tremors, chills.
- GI upset: nausea, diarrhea; urinary urgency (fight-or-flight rebound).
- Insomnia → chronic fatigue.
- Note: Patients who verbalize “I’m going to die” = high-priority assessment.

Panic Attack – DSM-5 Definition
- Sudden surge of intense fear/discomfort, peaks in $10\text{–}20$ min.
- Must include $\ge 4$ of 13 symptoms: pounding heart, chest pain, sweating, tremor, SOB, choking, nausea, dizziness, chills/heat, paresthesias, derealization/depersonalization, fear of losing control, fear of dying.
Panic Disorder Criteria
- $\ge 2$ unexpected (uncued) panic attacks.
- Persistent worry or maladaptive behavior change (e.g., avoidance) ≥ 1 month.
- Not due to substances, medical illness, or other mental disorder.
Clinical Course
- Attacks can occur in safe places → unpredictability increases anxiety.
- Anticipatory anxiety and avoidance (parks, elevators, driving) → functional restriction, may evolve into agoraphobia.
Epidemiology & Etiology
- $\text{Female}:\text{Male} = 2:1$ .
- Familial/genetic loading; multifactorial neurobiology.
Management
- Cognitive-Behavioral Therapy (CBT) – 5 core steps: education, monitoring diary, breathing/relaxation, cognitive reframing, graded exposure.
- Medications: SSRIs (first-line), benzodiazepines (short-term), anticonvulsants in severe cases.
- Goal = prevent avoidance & restore function.

Key Features
- Excessive, persistent, and unreasonable worry about multiple domains (finances, family, work).
- Often no specific trigger; “free-floating” anxiety.
DSM-5 Diagnostic Thresholds
- Duration: anxiety present “more days than not” for $\ge 6$ months (≈ $\ge 90$ of $180$ days).
- Difficulty controlling the worry.
- Adults: $\ge 3$ associated symptoms; children: $\ge 1$ .
- Causes clinically significant distress/impairment.
- Not due to substances, medical condition, or another mental disorder.
Associated Symptoms
- Restlessness/edginess, easy fatigue, poor concentration, irritability, muscle tension, sleep disturbance.
Epidemiology
- Lifetime prevalence ≈ $3\%$ .
- $2:1$ female predominance.
- Runs in families; gene–environment interplay.
Treatment
- CBT – long-term superiority over meds for relapse prevention.
- Pharmacologic options: SSRIs, SNRIs, benzodiazepines (short-term), buspirone.
- Combined therapy often most effective.
Continuum Concept
- Anxiety exists on a spectrum; many “functional worriers” never meet full DSM criteria.
- Personal anecdote: effective SSRI use can markedly improve quality of life; meds need not be lifelong.

Core Fear
- Being negatively evaluated, embarrassed, or humiliated in social or performance situations.
DSM-5 Points
- Persistent (≥ $6$ months).
- Causes significant distress/impairment.
- Not attributable to substances/medical or other mental disorder.
Subtypes & Presentations
- Generalized social interactions (e.g., meeting new people, small talk).
- Performance-only (public speaking, toasts).
- Ego-dystonic: sufferers know fear is irrational, which may worsen anxiety.
Physiological & Behavioral Expressions
- Blushing, trembling, sweating → worsen fear of scrutiny.
- Severe cases: derealization, reliance on alcohol (“liquid courage”) → addiction risk.
Differential Highlights
- Versus GAD: social judgment focus vs. broad worry.
- Versus agoraphobia: fear of entrapment/escape, not judgment.
- Versus PD: spontaneous uncued attacks vs. situation-bound fear of scrutiny.
Management
- CBT (social-skills training, exposure, cognitive restructuring).
- Pharmacology: SSRIs, SNRIs, benzodiazepines, beta blockers for performance anxiety.
- Long-term: psychotherapy preferred to avoid medication side effects.

Multifactorial model:
- Genetic susceptibility.
- Neurochemical differences (serotonin, norepinephrine, GABA).
- Environmental precipitants (stress, trauma, neglect).
- Psychodynamic theories (id/ego/superego conflicts) acknowledged but less emphasized clinically.

Assessment
- Screen for severity, functional impact, substance use, suicidal ideation.
- Recognize red-flag somatic complaints (chest pain, “sense of doom”).
Intervention Hierarchy
- Safety → grounding techniques → engage resources (colleagues, rapid response).
- Provide patient education on anxiety continuum and treatment options.
Self-Care for Nurses
- Normalization of mild anticipatory anxiety.
- Seek CBT or pharmacologic support if worry becomes persistent or sleep-impairing.
- Avoid reliance on maladaptive coping (e.g., alcohol).

$\text{Panic Disorder: Female}:\text{Male} = 2:1$ .
$\text{GAD prevalence} \approx 3\%$ .
Duration cutoffs:
- PD behavior change ≥ $1$ month after attack(s).
- GAD worry ≥ $6$ months.
- Social Anxiety ≥ $6$ months.
GAD frequency guide: $\ge 90$ of $180$ days exhibit excessive worry.

Panic Attack – “STUDENTS Fear The 13 Cs”
- Sweating, Trembling, Unsteadiness (dizzy), Derealization, Excessive heart rate, Nausea, Tingling (paresthesia), Shortness of breath
- Fear of dying/losing control, Chills/heat, Chest pain, Choking.

Stigma reduction: normalize discussion of medications & therapy.
Avoid unit assignment mismatching; ensure safe practice environments for nurses prone to high anxiety.
Promote CBT literacy among healthcare teams; it recurs across behavioral-health curricula.