Anxiety and Anxiety Disorders
INTRODUCTION
Anxiety is a vague feeling of dread or apprehension; it is a response to
external or internal stimuli that can have behavioral, emotional, cognitive, and
physical symptoms. Anxiety is distinguished from fear, which is feeling
afraid or threatened by a clearly identifiable external stimulus that represents
danger to the person. Anxiety is unavoidable in life and can serve many
positive functions such as motivating the person to take action to solve a
problem or to resolve a crisis. It is considered normal when it is appropriate to
the situation and dissipates when the situation has been resolved.
Anxiety disorders comprise a group of conditions that share a key feature
of excessive anxiety with ensuing behavioral, emotional, cognitive, and
physiological responses. Clients suffering from anxiety disorders can
demonstrate unusual behaviors such as panic without reason, unwarranted fear
of objects or life conditions, or unexplainable or overwhelming worry. They
experience significant distress over time, and the disorder significantly
impairs their daily routines, social lives, and occupational functioning.
This chapter discusses anxiety as an expected response to stress. It also
explores anxiety disorders, with particular emphasis on panic disorder. Other
disorders that include excessive anxiety are discussed in other chapters:
obsessive–compulsive disorder (OCD) is in Chapter 15, and posttraumatic
stress disorder (PTSD) is in Chapter 13.
ANXIETY AS A RESPONSE TO STRESS
Stress is the wear and tear that life causes on the body (Selye, 1956). It occurs
when a person has difficulty dealing with life situations, problems, and goals.
Each person handles stress differently; one person can thrive in a situation that
creates great distress for another. For example, many people view public
speaking as scary, but for teachers and actors, it is an everyday enjoyable
experience. Marriage, children, airplanes, snakes, a new job, a new school,
and leaving home are examples of stress-causing stimuli.
Hans Selye (1956, 1974), an endocrinologist, identified the physiological
aspects of stress, which he labeled general adaptation syndrome. He used
laboratory animals to assess biologic system changes; the stages of the body’s
physical responses to pain, heat, toxins, and restraint, and later the mind’s
emotional responses to real or perceived stressors. He identified three stages
of reaction to stress:
• In the alarm reaction stage, stress stimulates the body to send messages
from the hypothalamus to the glands (such as the adrenal gland, to send out
adrenaline and norepinephrine for fuel) and organs (such as the liver, to
reconvert glycogen stores to glucose for food) to prepare for potential
defense needs.
• In the resistance stage, the digestive system reduces function to shunt
blood to areas needed for defense. The lungs take in more air, and the heart
beats faster and harder so that it can circulate this highly oxygenated and
highly nourished blood to the muscles to defend the body by fight, flight,
or freeze behaviors. If the person adapts to the stress, the body responses
relax, and the gland, organ, and systemic responses abate.
• The exhaustion stage occurs when the person has responded negatively to
anxiety and stress; body stores are depleted or the emotional components
are not resolved, resulting in continual arousal of the physiological
responses and little reserve capacity.
Three reactions or stages of stress
Autonomic nervous system responses to fear and anxiety generate the
involuntary activities of the body that are involved in self-preservation.
Sympathetic nerve fibers “charge up” the vital signs at any hint of danger to
prepare the body’s defenses. The adrenal glands release adrenaline
(epinephrine), which causes the body to take in more oxygen, dilate the
pupils, and increase arterial pressure and heart rate while constricting the
peripheral vessels and shunting blood from the gastrointestinal (GI) and
reproductive systems and increasing glycogenolysis to free glucose for fuel
for the heart, muscles, and central nervous system. When the danger has
passed, parasympathetic nerve fibers reverse this process and return the body
to normal operating conditions until the next sign of threat reactivates the
sympathetic responses.
Physiological response
Anxiety causes uncomfortable cognitive, psychomotor, and physiological
responses, such as difficulty with logical thought, increasingly agitated motor
activity, and elevated vital signs. To reduce these uncomfortable feelings, the
person tries to reduce the level of discomfort by implementing new adaptive
behaviors or defense mechanisms. Adaptive behaviors can be positive and
help the person learn, for example, using imagery techniques to refocus
attention on a pleasant scene, practicing sequential relaxation of the body
from head to toe and breathing slowly and steadily to reduce muscle tension
and vital signs. Negative responses to anxiety can result in maladaptive
behaviors such as tension headaches, pain syndromes, and stress-related responses that reduce the efficiency of the immune system.
People can communicate anxiety to others both verbally and nonverbally. If
someone yells “fire,” others around him or her can become anxious as they
picture a fire and the possible threat that represents. Viewing a distraught
parent searching for a lost child in a shopping mall can cause anxiety in others
as they imagine the panic the parent is experiencing. They can experience
anxiety nonverbally through empathy, which is the sense of walking in
another person’s shoes for a moment in time (Sullivan, 1952). Examples of
nonverbal empathetic communication are when the family of a client
undergoing surgery can tell from the physician’s body language that their
loved one has died, when the nurse reads a plea for help in a client’s eyes, or
when a person feels the tension in a room where two people have been
arguing and are now not speaking to each other.
Levels of Anxiety
Anxiety has both healthy and harmful aspects, depending on its degree and
duration as well as on how well the person copes with it. Anxiety has four
levels: mild, moderate, severe, and panic (Table 14.1). Each level causes both
physiological and emotional changes in the person.
Mild anxiety is a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention
to learn, solve problems, think, act, feel, and protect him or herself. Mild
anxiety often motivates people to make changes or engage in goal-directed
activity. For example, it helps students focus on studying for an examination.
Moderate anxiety is the disturbing feeling that something is definitely
wrong; the person becomes nervous or agitated. In moderate anxiety, the
person can still process information, solve problems, and learn new things
with assistance from others. He or she has difficulty concentrating
independently but can be redirected to the topic. For example, the nurse might
be giving preoperative instructions to a client who is anxious about the
upcoming surgical procedure. As the nurse is teaching, the client’s attention
wanders, but the nurse can regain the client’s attention and direct him or her
back to the task at hand.
As the person progresses to severe anxiety and panic, more primitive
survival skills take over, defensive responses ensue, and cognitive skills
decrease significantly. A person with severe anxiety has trouble thinking and
reasoning. Muscles tighten, and vital signs increase. The person paces; is
restless, irritable, and angry; or uses other similar emotional–psychomotor
means to release tension. In panic, the emotional–psychomotor realm
predominates with accompanying fight, flight, or freeze responses. Adrenaline
surge greatly increases vital signs. Pupils enlarge to let in more light, and the
only cognitive process focuses on the person’s defense.
Working with Anxious Clients
Nurses encounter anxious clients and families in a wide variety of situations,
such as before surgery and in emergency departments, intensive care units
(ICUs), offices, and clinics. First and foremost, the nurse must assess the
person’s anxiety level because that determines what interventions are likely to
be effective.
Mild anxiety is an asset to the client and requires no direct intervention.
People with mild anxiety can learn and solve problems and are even eager for
information. Teaching can be effective when the client is mildly anxious.
With moderate anxiety, the nurse must be certain that the client is following
what the nurse is saying. The client’s attention can wander, and he or she may
have some difficulty concentrating over time. Speaking in short, simple, and
easy-to-understand sentences is effective; the nurse must stop to ensure that
the client is still taking in information correctly. The nurse may need to
redirect the client back to the topic if the client goes off on a tangent.
When anxiety becomes severe, the client can no longer pay attention or
take in information. The nurse’s goal must be to lower the person’s anxiety
level to moderate or mild before proceeding with anything else. It is also
essential to remain with the person because anxiety is likely to worsen if he or
she is left alone. Talking to the client in a low, calm, and soothing voice can
help. If the person cannot sit still, walking with him or her while talking can
be effective. What the nurse talks about matters less than how he or she says
the words. Helping the person take deep even breaths can help lower anxiety.
During panic anxiety, the person’s safety is the primary concern. He or she
cannot perceive potential harm and may have no capacity for rational thought.
The nurse must keep talking to the person in a comforting manner, even
though the client cannot process what the nurse is saying. Going to a small,
quiet, and nonstimulating environment may help reduce anxiety. The nurse
can reassure the person that this is anxiety, it will pass, and he or she is in a
safe place. The nurse should remain with the client until the panic recedes.
Panic-level anxiety is not indefinite, but it can last from 5 to 30 minutes.
When working with an anxious person, the nurse must be aware of his or
her own anxiety level. It is easy for the nurse to become increasingly anxious.
Remaining calm and in control is essential if the nurse is going to work
effectively with the client.
Short-term anxiety can be treated with anxiolytic medications (Table 14.2).
Most of these drugs are benzodiazepines, which are commonly prescribed for
anxiety. Benzodiazepines have a high potential for abuse and dependence,
however; so their use should be short term, ideally no longer than 4 to 6
weeks. These drugs are designed to relieve anxiety so that the person can deal
more effectively with whatever crisis or situation is causing stress.
Unfortunately, many people see these drugs as a “cure” for anxiety and
continue to use them instead of learning more effective coping skills or
making needed changes. Chapter 2 contains additional information about
anxiolytic drugs.
Stress-Related Illness
Stress-related illness is a broad term that covers a spectrum of illnesses that
result from or worsen because of chronic, long-term, or unresolved stress.
Chronic stress that is repressed can cause eating disorders, such as anorexia
nervosa and bulimia, which are discussed in depth in Chapter 20. Traumatic
stressors can cause a short, acute stress reaction or, if unresolved, may occur
later as PTSD, both discussed in Chapter 13. Stress that is ignored or
suppressed can cause physical symptoms with no actual organic disease called
somatic symptom disorders (see Chapter 21). Stress can also exacerbate the
symptoms of many medical illnesses, such as hypertension and ulcerative
colitis. Chronic or recurrent anxiety resulting from stress may also be
diagnosed as anxiety disorder.
OVERVIEW OF ANXIETY DISORDERS
Anxiety disorders are diagnosed when anxiety no longer functions as a signal
of danger or a motivation for needed change but becomes chronic and
permeates major portions of the person’s life, resulting in maladaptive
behaviors and emotional disability. Anxiety disorders have many
manifestations, but anxiety is the key feature of each. Types of anxiety disorders include the following:
• Agoraphobia
• Panic disorder
• Specific phobia
• Social anxiety disorder (social phobia)
• Generalized anxiety disorder (GAD)
Panic disorder is the most common of these and is the focus of this chapter.
Episodes of severe or panic-level anxiety can be seen under extreme stress in
many of the other anxiety disorders.
INCIDENCE
Anxiety disorders have the highest prevalence rates of all mental disorders in
the United States for both children and adults. Nearly one in four adults in the
United States is affected, and the magnitude of anxiety disorders in young
people is similar. Anxiety disorders are more prevalent in women, people
younger than 45 years of age, people who are divorced or separated, and
people of lower socioeconomic status (Merikangas & Eun, 2017).
ONSET AND CLINICAL COURSE
The onset and clinical course of anxiety disorders are extremely variable,
depending on the specific disorder. These aspects are discussed later in this
chapter within the context of each disorder.
RELATED DISORDERS
Selective mutism is diagnosed in children when they fail to speak in social
situations even though they are able to speak. They may speak freely at home
with parents but fail to interact at school or with extended family. Lack of
speech interferes with social communication and school performance. There is a high level of social anxiety in these situations.
Anxiety disorder due to another medical condition is diagnosed when the
prominent symptoms of anxiety are judged to result directly from a
physiological condition. The person may have panic attacks, generalized
anxiety, or obsessions or compulsions. Medical conditions causing this
disorder can include endocrine dysfunction, chronic obstructive pulmonary
disease, congestive heart failure, and neurologic conditions.
Substance/medication-induced anxiety disorder is anxiety directly caused
by drug abuse, a medication, or exposure to a toxin. Symptoms include
prominent anxiety, panic attacks, phobias, obsessions, or compulsions.
Treating anxiety disorder with medication is only part of the needed
approach. It is essential to teach people anxiety management techniques as
well as to make appropriate referrals for therapy. This approach is far more
effective than medication alone but takes time and work to yield desired
results.
Separation anxiety disorder is excessive anxiety concerning separation
from home or from persons, parents, or caregivers to whom the client is
attached. It occurs when it is no longer developmentally appropriate and
before 18 years of age.
ETIOLOGY
Biologic Theories
Genetic Theories
Anxiety may have an inherited component because first-degree relatives of
clients with increased anxiety have higher rates of developing anxiety.
Heritability refers to the proportion of a disorder that can be attributed to
genetic factors:
• High heritabilities are greater than 0.6 and indicate that genetic influences
dominate.
• Moderate heritabilities are 0.3 to 0.5 and suggest an even greater influence
of genetic and nongenetic factors.
• Heritabilities less than 0.3 mean that genetics are negligible as a primary
cause of the disorder.
Panic disorder, social anxiety disorder, and specific phobias, including
agoraphobia, have moderate heritability. GAD and OCD tend to be more
common in families, indicating a strong genetic component, but still require further in-depth study. Anxiety disorders aren’t inherited in any simple
Mendelian manner. At this point, current research indicates a clear genetic
susceptibility to or vulnerability for anxiety disorders; however, additional
factors are necessary for these disorders to actually develop (Hettemma &
Otowa, 2017).
Neurochemical Theories
Gamma-aminobutyric acid (GABA) is the amino acid neurotransmitter
believed to be dysfunctional in anxiety disorders. GABA, an inhibitory
neurotransmitter, functions as the body’s natural antianxiety agent by
reducing cell excitability, thus decreasing the rate of neuronal firing. It is
available in one-third of the nerve synapses, especially those in the limbic
system and in the locus coeruleus, the area where the neurotransmitter
norepinephrine, which excites cellular function, is produced. Because GABA
reduces anxiety and norepinephrine increases it, researchers believe that a
problem with the regulation of these neurotransmitters occurs in anxiety
disorders.
Serotonin, the indolamine neurotransmitter usually implicated in psychosis
and mood disorders, has many subtypes. 5-Hydroxytryptamine type 1a plays a
role in anxiety, and it also affects aggression and mood. Serotonin is believed
to play a distinct role in OCD, panic disorder, and GAD. An excess of
norepinephrine is suspected in panic disorder, GAD, and PTSD (Feder, Costi,
Iacoviello, Murrough, & Charney, 2017).
Psychodynamic Theories
Intrapsychic/Psychoanalytic Theories
Freud (1936) saw a person’s innate anxiety as the stimulus for behavior. He
described defense mechanisms as the human’s attempt to control awareness of
and to reduce anxiety (see Chapter 3). Defense mechanisms are cognitive
distortions that a person uses unconsciously to maintain a sense of being in
control of a situation, to lessen discomfort, and to deal with stress. Because
defense mechanisms arise from the unconscious, the person is unaware of
using them. Some people overuse defense mechanisms, which stops them
from learning a variety of appropriate methods to resolve anxiety-producing
situations. The dependence on one or two defense mechanisms also can
inhibit emotional growth, lead to poor problem-solving skills, and create
difficulty with relationships.
Interpersonal Theory
Harry Stack Sullivan (1952) viewed anxiety as being generated from
problems in interpersonal relationships. Caregivers can communicate anxiety
to infants or children through inadequate nurturing, agitation when holding or
handling the child, and distorted messages. Such communicated anxiety can
result in dysfunction, such as the failure to achieve age-appropriate
developmental tasks. In adults, anxiety arises from the person’s need to
conform to the norms and values of his or her cultural group. The higher the
level of anxiety, the lower the ability to communicate and to solve problems
and the greater the chance for anxiety disorders to develop.
Hildegard Peplau (1952) understood that humans exist in interpersonal and
physiological realms; thus, the nurse can better help the client achieve health
by attending to both areas. She identified the four levels of anxiety and
developed nursing interventions and interpersonal communication techniques
based on Sullivan’s interpersonal view of anxiety. Nurses today use Peplau’s
interpersonal therapeutic communication techniques to develop and to nurture
the nurse–client relationship and to apply the nursing process.
Behavioral Theory
Behavioral theorists view anxiety as being learned through experiences.
Conversely, people can change or “unlearn” behaviors through new
experiences. Behaviorists believe that people can modify maladaptive
behaviors without gaining insight into their causes. They contend that
disturbing behaviors that develop and interfere with a person’s life can be
extinguished or unlearned by repeated experiences guided by a trained
therapist.
CULTURAL CONSIDERATIONS
Each culture has rules governing the appropriate ways to express and deal
with anxiety. Culturally competent nurses should be aware of them while
being careful not to stereotype clients.
People from Asian cultures often express anxiety through somatic
symptoms such as headaches, backaches, fatigue, dizziness, and stomach
problems. One intense anxiety reaction is koro, or a man’s profound fear that
his penis will retract into the abdomen and he will then die. Accepted forms of
treatment include having the person firmly hold his penis until the fear passes,
often with assistance from family members or friends, and clamping the penis to a wooden box. In women, koro is the fear that the vulva and nipples will
disappear (Dan, Mondal, Chakraborty, Chaudhuri, & Biswas, 2017).
Susto is diagnosed in some Hispanic clients (Peruvians, Bolivians,
Colombians, and Central and South American Indians) during cases of high
anxiety, sadness, agitation, weight loss, weakness, and heart rate changes. The
symptoms are believed to occur because supernatural spirits or bad air from
dangerous places and cemeteries invades the body.
TREATMENT
Treatment for anxiety disorders usually involves medication and therapy. This
combination produces better results than either one alone (Huppert & Foa,
2017). Drugs used to treat anxiety disorders are listed in Table 14.3.
Antidepressants are discussed in detail in Chapter 17. Cognitive–behavioral
therapy (CBT) is used successfully to treat anxiety disorders. Positive
reframing means turning negative messages into positive messages. The
therapist teaches the client to create positive messages for use during panic
episodes. For example, instead of thinking, “My heart is pounding. I think I’m
going to die,” the client thinks, “I can stand this. This is just anxiety. It will go
away.” The client can write down these messages and keep them readily
accessible, such as in an address book, a calendar, or a wallet.
Decatastrophizing involves the therapist’s use of questions to more
realistically appraise the situation. The therapist may ask, “What is the worst
thing that could happen? Is that likely? Could you survive that? Is that as bad
as you imagine?” The client uses thought-stopping and distraction techniques
to jolt him or herself from focusing on negative thoughts. Splashing the face
with cold water, snapping a rubber band worn on the wrist, or shouting are all
techniques that can break the cycle of negative thoughts.
Assertiveness training helps the person take more control over life
situations. These techniques help the person negotiate interpersonal situations
and foster self-assurance. They involve using “I” statements to identify
feelings and to communicate concerns or needs to others. Examples include “I
feel angry when you turn your back while I’m talking,” “I want to have 5
minutes of your time for an uninterrupted conversation about something
important,” and “I would like to have about 30 minutes in the evening to relax
without interruption.”
ELDER CONSIDERATIONS
Anxiety that starts for the first time late in life is frequently associated with
another condition such as depression, dementia, physical illness, or
medication toxicity or withdrawal. Phobias, particularly agoraphobia, and
GAD are the most common late-life anxiety disorders. Most people with late-
onset agoraphobia attribute the start of the disorder to the abrupt onset of a
physical illness or as a response to a traumatic event such as a fall or
mugging. Late-onset GAD is usually associated with depression. Although
less common, panic attacks can occur in later life and are often related to
depression or a physical illness such as cardiovascular, GI, or chronic
pulmonary diseases. Ruminative thoughts are common in late-life depression
and can take the form of obsessions, such as contamination fears, pathologic doubt, or fear of harming others. The treatment of choice for anxiety disorders
in the elderly is selective serotonin reuptake inhibitor (SSRI) antidepressants.
Initial treatment involves doses lower than the usual starting doses for adults
to ensure that the elderly client can tolerate the medication; if started on too
high a dose, SSRIs can exacerbate anxiety symptoms in elderly clients.
Despite evidence of many potential risks of prescribing benzodiazepines to
older adults, the practice unfortunately continues (Gerlach, Wiechers, &
Maust, 2018).
COMMUNITY-BASED CARE
Nurses encounter many people with anxiety disorders in community settings
rather than in inpatient settings. Formal treatment for these clients usually
occurs in community mental health clinics and in the offices of physicians,
psychiatric clinical specialists, psychologists, or other mental health
counselors. Because the person with anxiety disorder often believes the
sporadic symptoms are related to medical problems, the family practitioner or
advanced practice nurse can be the first health care professional to evaluate
him or her.
Knowledge of community resources helps the nurse guide the client to
appropriate referrals for assessment, diagnosis, and treatment. The nurse can
refer the client to a psychiatrist or to an advanced practice psychiatric nurse
for diagnosis, therapy, and medication. Other community resources, such as
anxiety disorder groups or self-help groups, can provide support and help the
client feel less isolated and lonely.
MENTAL HEALTH PROMOTION
Too often, anxiety is viewed negatively as something to avoid at all costs.
Actually, for many people, anxiety is a warning that they are not dealing with
stress effectively. Learning to heed this warning and to make needed changes
is a healthy way to deal with the stress of daily events.
Stress and the resulting anxiety are not associated exclusively with life
problems. Events that are “positive” or desired, such as going away to college,
getting a first job, getting married, and having children, are stressful and cause
anxiety. Managing the effects of stress and anxiety in one’s life is important to
being healthy. Tips for managing stress include the following:
• Keep a positive attitude and believe in yourself.
• Accept there are events you cannot control.
Communicate assertively with others: Talk about your feelings to others,
and express your feelings through laughing, crying, and so forth.
• Learn to relax.
• Exercise regularly.
• Eat well-balanced meals.
• Limit intake of caffeine and alcohol.
• Get enough rest and sleep.
• Set realistic goals and expectations, and find an activity that is personally
meaningful.
• Learn stress management techniques, such as relaxation, guided imagery,
and meditation; practice them as part of your daily routine.
For people with anxiety disorders, it is important to emphasize that the goal
is effective management of stress and anxiety, not the total elimination of
anxiety. Although medication is important to relieve excessive anxiety, it does
not solve or eliminate the problem entirely. Learning anxiety management
techniques and effective methods for coping with life and its stresses is
essential for overall improvement in life quality.
PANIC DISORDER
Panic disorder is composed of discrete episodes of panic attacks, that is, 15
to 30 minutes of rapid, intense, escalating anxiety in which the person
experiences great emotional fear as well as physiological discomfort. During a
panic attack, the person has overwhelmingly intense anxiety and displays four
or more of the following symptoms: palpitations, sweating, tremors, shortness
of breath, sense of suffocation, chest pain, nausea, abdominal distress,
dizziness, paresthesias, chills, or hot flashes.
Panic attack
Panic disorder is diagnosed when the person has recurrent, unexpected
panic attacks followed by at least 1 month of persistent concern or worry
about future attacks or their meaning or a significant behavioral change
related to them. Slightly more than 75% of people with panic disorder have
spontaneous initial attacks with no environmental trigger. Half of those with
panic disorder have accompanying agoraphobia. Panic disorder is more
common in people who have not graduated from college and are not married.
There is an increased risk of suicidality in persons with panic disorder.
Studies show suicidal ideation prevalent in 17% to 32% of those with panic
disorder, while one-third had a history of suicide attempts (De La Vega,
Giner, & Courtet, 2018).
Clinical Course
The onset of panic disorder peaks in late adolescence and the mid-30s.
Although panic anxiety might be normal in someone experiencing a life-threatening situation, a person with panic disorder experiences these
emotional and physiological responses without this stimulus. The memory of
the panic attack, coupled with the fear of having more, can lead to avoidance
behavior. In some cases, the person becomes homebound or stays in a limited
area near home, such as on the block or within town limits. This behavior is
known as agoraphobia (“fear of the marketplace” or fear of being outside).
Some people with agoraphobia fear stepping outside the front door because a
panic attack may occur as soon as they leave the house. Others can leave the
house but feel safe from the anticipatory fear of having a panic attack only
within a limited area. Agoraphobia can also occur alone without panic attacks.
The behavior patterns of people with agoraphobia clearly demonstrate the
concepts of primary and secondary gain associated with many anxiety
disorders. Primary gain is the relief of anxiety achieved by performing the
specific anxiety-driven behavior, such as staying in the house to avoid the
anxiety of leaving a safe place. Secondary gain is the attention received from
others as a result of these behaviors. For instance, the person with
agoraphobia may receive attention and caring concern from family members
who also assume all the responsibilities of family life outside the home (e.g.,
work and shopping). Essentially, these compassionate significant others
become enablers of the self-imprisonment of the person with agoraphobia.
Treatment
Panic disorder is treated with CBTs, deep breathing and relaxation, and
medications such as benzodiazepines, SSRI antidepressants, tricyclic
antidepressants, and antihypertensives such as clonidine (Catapres) and
propranolol (Inderal).
History
The client usually seeks treatment for panic disorder after he or she has
experienced several panic attacks. The client may report, “I feel like I’m
going crazy. I thought I was having a heart attack, but the doctor says it’s
anxiety.” Usually, the client cannot identify any trigger for these events.
General Appearance and Motor Behavior
The nurse assesses the client’s general appearance and motor behavior.
The client may appear entirely “normal” or may have signs of anxiety if
he or she is apprehensive about having a panic attack in the next few
moments. If the client is anxious, speech may increase in rate, pitch, and
volume, and he or she may have difficulty sitting in a chair. Automatisms,
which are automatic, unconscious mannerisms, may be apparent.
Examples include tapping fingers, jingling keys, or twisting hair.
Automatisms are geared toward anxiety relief and increase in frequency
and intensity with the client’s anxiety level.
Mood and Affect
Assessment of mood and affect may reveal that the client is anxious,
worried, tense, depressed, serious, or sad. When discussing the panic
attacks, the client may be tearful. He or she may express anger at him or
herself for being “unable to control myself.” Most clients are distressed
about the intrusion of anxiety attacks in their lives. During a panic attack,
the client may describe feelings of being disconnected from him or herself
(depersonalization) or sensing that things are not real (derealization).
Thought Processes and Content
During a panic attack, the client is overwhelmed, believing that he or she
is dying, losing control, or “going insane.” The client may even consider
suicide. Thoughts are disorganized, and the client loses the ability to think
rationally. At other times, the client may be consumed with worry about when the next panic attack will occur or how to deal with it.
Sensorium and Intellectual Processes
During a panic attack, the client may become confused and disoriented.
He or she cannot take in environmental cues and respond appropriately.
These functions are restored to normal after the panic attack subsides.
Judgment and Insight
Judgment is suspended during panic attacks; in an effort to escape, the
person can run out of a building and into the street in front of a speeding
car before the ability to assess if safety has returned. Insight into panic
disorder occurs only after the client has been educated about the disorder.
Even then, clients initially believe they are helpless and have no control
over their anxiety attacks.
Self-Concept
It is important for the nurse to assess self-concept in clients with panic
disorder. These clients often make self-blaming statements such as, “I
can’t believe I’m so weak and out of control” or “I used to be a happy,
well-adjusted person.” They may evaluate themselves negatively in all
aspects of their lives. They may find themselves consumed with worry
about impending attacks and may be unable to do many things they did
before having panic attacks.
Roles and Relationships
Because of the intense anticipation of having another panic attack, the
person may report alterations in his or her social, occupational, or family
life. The person typically avoids people, places, and events associated with
previous panic attacks. For example, the person may no longer ride the bus
if he or she has had a panic attack on a bus. Although avoiding these
objects does not stop the panic attacks, the person’s sense of helplessness
is so great that he or she may take even more restrictive measures to avoid
them, such as quitting work and remaining at home.
Physiological and Self-Care Concerns
The client often reports problems with sleeping and eating. The anxiety of
apprehension between panic attacks may interfere with adequate, restful
sleep, even though the person may spend hours in bed. Clients may experience loss of appetite or eat constantly in an attempt to ease the
anxiety.
Promoting Safety and Comfort
During a panic attack, the nurse’s first concern is to provide a safe
environment and to ensure the client’s privacy. If the environment is
overstimulating, the client should move to a less stimulating place. A quiet
place reduces anxiety and provides privacy for the client.
The nurse remains with the client to help calm him or her down and to
assess client behaviors and concerns. After getting the client’s attention,
the nurse uses a soothing, calm voice and gives brief directions to assure
the client that he or she is safe.
Using Therapeutic Communication
Clients with anxiety disorders can collaborate with the nurse in the
assessment and planning of their care; thus, rapport between the nurse and
the client is important. Communication should be simple and calm
because the client with severe anxiety cannot pay attention to lengthy
messages and may pace to release energy. The nurse can walk with the
client who feels unable to sit and talk. The nurse should carefully evaluate
the use of touch because clients with high anxiety may interpret touch by a
stranger as a threat and pull away abruptly.
As the client’s anxiety diminishes, cognition begins to return.
Managing Anxiety
The nurse can teach the client relaxation techniques to use when he or she
is experiencing stress or anxiety. Deep breathing is simple; anyone can do
it. Guided imagery and progressive relaxation are methods to relax taut
muscles. Guided imagery involves imagining a safe, enjoyable place to
relax. In progressive relaxation, the person progressively tightens, holds,
and then relaxes muscle groups while letting tension flow from the body
through rhythmic breathing. Cognitive restructuring techniques (discussed
earlier in the text) may also help the client manage his or her anxiety
response.
For any of these techniques, it is important for the client to learn and
practice them when he or she is relatively calm. When adept at these
techniques, the client is more likely to use them successfully during panic attacks or periods of increased anxiety. Clients are likely to believe that
self-control is returning when using these techniques helps them manage
anxiety. When clients believe they can manage the panic attack, they
spend less time worrying about and anticipating the next one, which
reduces their overall anxiety level.
Providing Client and Family Education
Client and family education is of primary importance when working with
clients who have anxiety disorders. The client learns ways to manage stress and cope with reactions to stress and stress-provoking situations.
With education about the efficacy of combined psychotherapy and
medication and the effects of the prescribed medication, the client can
become the chief treatment manager of anxiety disorder. It is important for
the nurse to educate the client and family members about the physiology
of anxiety and the merits of using combined psychotherapy and drug
management. Such a combined treatment approach along with stress
reduction techniques can help the client manage these drastic reactions and
allow him or her to gain a sense of self-control. The nurse should help the
client understand that these therapies and drugs do not “cure” the disorder
but are methods to help him or her control and manage it. Client and
family education regarding medications should include the recommended
dosage and dosage regimen, expected effects, side effects and how to
handle them, and substances that have a synergistic or antagonistic effect
with the drug.
The nurse encourages the client to exercise regularly. Routine exercise
helps metabolize adrenaline, reduces panic reactions, and increases
production of endorphins; all these activities increase feelings of well-
being.
Evaluation
Evaluation of the plan of care must be individualized. Ongoing assessment
provides data to determine whether the client’s outcomes were achieved.
The client’s perception of the success of treatment also plays a part in
evaluation. Even if all outcomes are achieved, the nurse must ask whether
the client is comfortable or satisfied with the quality of life.
Evaluation of the treatment of panic disorder is based on:
• Does the client understand the prescribed medication regimen, and is he
or she committed to adhering to it?
• Have the client’s episodes of anxiety decreased in frequency or
intensity?
• Does the client understand various coping methods and when to use
them?
• Does the client believe his or her quality of life is satisfactory?
PHOBIAS
A phobia is an illogical, intense, and persistent fear of a specific object or a
social situation that causes extreme distress and interferes with normal
functioning. Phobias usually do not result from past negative experiences. In
fact, the person may never have had contact with the object of the phobia.
People with phobias have a reaction that is out of proportion to the situation or
circumstance. Some individuals may even recognize that their fear is unusual
and irrational but still feel powerless to stop it (Kimmel & Roy-Byrne, 2017).
People with phobias develop anticipatory anxiety even when thinking about
possibly encountering the dreaded phobic object or situation. They engage in
avoidance behavior that often severely limits their lives. Such avoidance
behavior usually does not relieve the anticipatory anxiety for long.
There are three categories of phobias:
• Agoraphobia (discussed earlier in text)
• Specific phobia, which is an irrational fear of a particular object or a
situation
• Social anxiety or phobia, which is anxiety provoked by certain social or
performance situations
Many people express “phobias” about snakes, spiders, rats, or similar
objects. These fears are specific, easy to avoid, and cause no anxiety or worry.
The diagnosis of a phobic disorder is made only when the phobic behavior
significantly interferes with the person’s life by creating marked distress or
difficulty in interpersonal or occupational functioning.
Specific phobias are subdivided into the following categories:
• Natural environmental phobias: fear of storms, water, heights, or other
natural phenomena
• Blood–injection phobias: fear of seeing one’s own or others’ blood,
traumatic injury, or an invasive medical procedure such as an injection
• Situational phobias: fear of being in a specific situation such as on a bridge
or in a tunnel, elevator, small room, hospital, or airplane
• Animal phobia: fear of animals or insects (usually a specific type; often,
this fear develops in childhood and can continue through adulthood in both
men and women; cats and dogs are the most common phobic objects)
• Other types of specific phobias: for example, fear of getting lost while
driving if not able to make all right (and no left) turns to get to one’s
destination.
In social phobia, also known as social anxiety disorder, the person
becomes severely anxious to the point of panic or incapacitation when
confronting situations involving people. Examples include making a speech,
attending a social engagement alone, interacting with the opposite sex or with
strangers, and making complaints. The fear is rooted in low self-esteem and concern about others’ judgments. The person fears looking socially inept,
appearing anxious, or doing something embarrassing such as burping or
spilling food. Other social phobias include fear of eating in public, using
public bathrooms, writing in public, or becoming the center of attention. A
person may have one or several social phobias; the latter is known as
generalized social phobia.
Specific phobias
Onset and Clinical Course
Specific phobias usually occur in childhood or adolescence. In some cases, merely thinking about or handling a plastic model of the dreaded object can
create fear. Specific phobias that persist into adulthood are lifelong 80% of
the time.
The peak age of onset for social phobia is middle adolescence; it sometimes
emerges in a person who was shy as a child. The course of social phobia is
often continuous, though the disorder may become less severe during
adulthood. Severity of impairment fluctuates with life stress and demands.
Treatment
Behavioral therapy works well. Behavioral therapists initially focus on
teaching what anxiety is, helping the client identify anxiety responses,
teaching relaxation techniques, setting goals, discussing methods to achieve
those goals, and helping the client visualize phobic situations. Therapies that
help the client develop self-esteem and self-control are common and include
positive reframing and assertiveness training (explained earlier).
One behavioral therapy often used to treat phobias is systematic (serial)
desensitization, in which the therapist progressively exposes the client to the
threatening object in a safe setting until the client’s anxiety decreases. During each exposure, the complexity and intensity of exposure gradually increase,
but the client’s anxiety decreases. The reduced anxiety serves as a positive
reinforcement until the anxiety is ultimately eliminated. For example, for the
client who fears flying, the therapist would encourage the client to hold a
small model airplane while talking about his or her experiences; later, the
client would hold a larger model airplane and talk about flying. Even later,
exposures might include walking past an airport, sitting in a parked airplane,
and, finally, taking a short ride in a plane. Each session’s challenge is based
on the success achieved in previous sessions (Huppert & Foa, 2017).
Flooding is a form of rapid desensitization in which a behavioral therapist
confronts the client with the phobic object (either a picture or the actual
object) until it no longer produces anxiety. Because the client’s worst fear has
been realized and the client did not die, there is little reason to fear the
situation anymore. The goal is to rid the client of the phobia in one or two
sessions. This method is highly anxiety producing and should be conducted
only by a trained psychotherapist under controlled circumstances and with the
client’s consent.
GENERALIZED ANXIETY DISORDER
A person with GAD worries excessively and feels highly anxious at least 50%
of the time for 6 months or more. Unable to control this focus on worry, the
person has three or more of the following symptoms: uneasiness, irritability,
muscle tension, fatigue, difficulty thinking, and sleep alterations. More people
with this chronic disorder are seen by family physicians than by psychiatrists.
The quality of life is diminished greatly in older adults with GAD. Buspirone
(BuSpar) and SSRI or serotonin–norepinephrine reuptake inhibitor
antidepressants are the most effective treatments (Ravindran & Stein, 2017).
SELF-AWARENESS ISSUES
Working with people who have anxiety disorders is a different kind of
challenge for the nurse. These clients are usually average people in other
respects who know that their symptoms are unusual but feel unable to stop
them. They experience much frustration and feelings of helplessness and
failure. Their lives are out of their control, and they live in fear of the next
episode. They go to extreme measures to try to prevent episodes by avoiding people and places where previous events occurred.
It may be difficult for nurses and others to understand why the person
cannot simply stop being anxious and “calm down.” Nurses must understand
what and how anxiety behaviors work, not just for client care but to help
understand the role anxiety plays in performing nursing responsibilities.
Nurses are expected to function at a high level and to avoid allowing their
own feelings and needs to hinder the care of their clients. But as emotional
beings, nurses are just as vulnerable to stress and anxiety as others, and they
have needs of their own.
Points to Consider When Working with Clients with
Anxiety and Anxiety Disorders
• Remember that everyone occasionally suffers from stress and anxiety that
can interfere with daily life and work.
• Avoid falling into the pitfall of trying to “fix” the client’s problems.
• Discuss any uncomfortable feelings with a more experienced nurse for
suggestions on how to deal with your feelings toward these clients.
• Remember to practice techniques to manage stress and anxiety in your own
life.