Chapter14: Anxiety and Anxiety Disorders Study Notes

Anxiety and Anxiety Disorders

Key Terms

• Agoraphobia: Fear of open or public places.
• Anxiety: A vague feeling of dread or apprehension in response to internal or external stimuli.
• Anxiety Disorders: Conditions sharing excessive anxiety with behavioral, emotional, cognitive, and physiological responses.
• Assertiveness Training: Techniques to help individuals take control of life situations.
• Avoidance Behavior: Actions taken to evade feared objects or situations.
• Decatastrophizing: A therapeutic technique to assess situations more realistically.
• Defense Mechanisms: Unconscious cognitive distortions used to reduce anxiety.
• Fear: Feeling afraid or threatened by a clearly identifiable external stimulus.
• Flooding: A rapid desensitization technique involving exposure to the phobic object.
• Mild Anxiety: Heightened sensory stimulation, increased motivation, and effective problem-solving.
• Moderate Anxiety: Narrowed perceptual field, selective attention, and increased use of automatisms.
• Panic Anxiety: Overwhelmingly intense anxiety with distorted perceptions and loss of rational thought.
• Panic Attacks: Discrete episodes of intense, escalating anxiety with great emotional fear and physiological discomfort.
• Panic Disorder: Recurrent, unexpected panic attacks followed by persistent worry about future attacks.
• Phobia: Illogical, intense, and persistent fear of a specific object or situation.
• Positive Reframing: Turning negative messages into positive ones.
• Primary Gain: Relief of anxiety achieved by performing anxiety-driven behavior.
• Secondary Gain: Attention received from others as a result of anxiety-driven behaviors.
• Selective Mutism: Failure to speak in social situations despite the ability to speak.
• Severe Anxiety: Reduced perceptual field, ineffective problem-solving, and behavior geared toward anxiety relief.
• Stress: The wear and tear that life causes on the body.

Learning Objectives

1. Describe anxiety as a response to stress.
2. Describe the levels of anxiety with behavioral changes related to each level.
3. Describe the current theories regarding the etiologies of major anxiety disorders.
4. Discuss the use of defense mechanisms by people with anxiety disorders.
5. Evaluate the effectiveness of treatment, including medications, for clients with anxiety disorders.
6. Develop a plan of care for clients with anxiety and anxiety disorders.
7. Provide teaching to clients, families, caregivers, and communities to increase understanding of anxiety and stress-related disorders.
8. Examine your feelings, beliefs, and attitudes regarding clients with anxiety disorders.

Nursing Concepts

• Anxiety
• Stress & Coping

Introduction

• Anxiety: A vague feeling of dread or apprehension; a response to stimuli with behavioral, emotional, cognitive, and physical symptoms.
• Fear: Feeling afraid or threatened by an identifiable external stimulus representing danger.
• Anxiety is unavoidable and can be positive, motivating action to solve problems.
• Anxiety disorders involve excessive anxiety with behavioral, emotional, cognitive, and physiological responses.
• Symptoms include panic without reason, unwarranted fear, or overwhelming worry.
• These disorders impair daily routines, social lives, and occupational functioning.
• Other disorders involving excessive anxiety include obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).

Anxiety as a Response to Stress

• Stress: The wear and tear that life causes on the body (Selye, 1956).
• Occurs when a person struggles to deal with life situations, problems, and goals.
• Stress response varies individually.
• Examples of stress-causing stimuli: marriage, children, airplanes, snakes, new job, new school, leaving home.
• Hans Selye identified the physiological aspects of stress as general adaptation syndrome (GAS) assessing biologic system changes in the body.

Stages of Reaction to Stress

1. Alarm Reaction Stage:
   • Stress stimulates the hypothalamus to send messages to glands (e.g., adrenal gland) and organs (e.g., liver) to prepare for potential defense needs.
   • Adrenaline and norepinephrine are released.
   • Glycogen stores are converted to glucose.
2. Resistance Stage:
   • Digestive system reduces function to shunt blood to areas needed for defense.
   • Lungs take in more air.
   • Heart beats faster and harder.
   • Blood circulates to muscles for fight, flight, or freeze behaviors.
   • If the person adapts, body responses relax.
3. Exhaustion Stage:
   • Occurs when the person responds negatively to anxiety and stress.
   • Body stores are depleted or emotional components are not resolved.
   • Results in continual arousal of physiological responses and little reserve capacity.

Autonomic Nervous System Responses to Fear and Anxiety

• Involuntary activities involved in self-preservation are generated.
• Sympathetic Nerve Fibers:
  • "Charge up" vital signs at any hint of danger.
  • Adrenal glands release adrenaline (epinephrine).
  • Body takes in more oxygen, dilates pupils, increases arterial pressure and heart rate.
  • Peripheral vessels constrict, shunting blood from the GI and reproductive systems.
  • Glycogenolysis increases to free glucose for fuel.
• Parasympathetic Nerve Fibers:
  • Reverse the process when the danger has passed.
  • Return the body to normal operating conditions.

Physiological Response

• Anxiety causes uncomfortable cognitive, psychomotor, and physiological responses.
  • Difficulty with logical thought.
  • Increasingly agitated motor activity.
  • Elevated vital signs.
• The person tries to reduce discomfort using new adaptive behaviors or defense mechanisms.
• Adaptive Behaviors:
  Positive: Using imagery techniques, practicing sequential relaxation.
  Negative: Maladaptive behaviors like tension headaches, pain syndromes, and reduced immune system efficiency.

Communication of Anxiety

• People communicate anxiety verbally and nonverbally.
• Example: Yelling "fire" can cause anxiety in others.
• Watching a distraught parent searching for a lost child can cause anxiety nonverbally.
• Empathy: Experiencing anxiety nonverbally by "walking in another person’s shoes."
• Examples: Family knowing a loved one has died from a physician’s body language, a nurse reading a plea for help in a client’s eyes, feeling tension in a room after an argument.

Levels of Anxiety

• Anxiety has both healthy and harmful aspects, depending on its degree and duration.
• Four levels: mild, moderate, severe, and panic.
• Each level causes physiological and emotional changes.

Table 14.1: Levels of Anxiety

Description of Each Level

• Mild Anxiety:
  • Sensation that something is different and warrants special attention.
  • Sensory stimulation increases, helping the person focus attention to learn, solve problems, think, act, feel, and protect themself.
  • Often motivates people to make changes or engage in goal-directed activity.
  • Example: Helps students focus on studying for an examination.
• Moderate Anxiety:
  • Disturbing feeling that something is definitely wrong; the person becomes nervous or agitated.
  • The person can still process information, solve problems, and learn new things with assistance from others.
  • Difficulty concentrating independently but can be redirected to the topic.
  • Example: A nurse redirecting a client's attention during preoperative instructions.
• Severe Anxiety:
  • 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.
• Panic:
  • Emotional–psychomotor realm predominates with accompanying fight, flight, or freeze responses.
  • Adrenaline surge greatly increases vital signs.
  • Pupils enlarge to let in more light.
  • Cognitive process focuses on the person’s defense.
• Concept Mastery Alert: Anxiety is a warning sign that the person needs to assess and evaluate both self and situation.

Working With Anxious Clients

• Nurses encounter anxious clients and families in various settings.
• The nurse must assess the person’s anxiety level to determine effective actions.
• Mild Anxiety:
  • An asset to the client.
  • Requires no direct intervention.
  • People can learn and solve problems and are eager for information.
  • Teaching can be effective.
• Moderate Anxiety:
  • The nurse must be certain that the client is following what the nurse is saying.
  • The client's attention can wander, and they may have some difficulty concentrating over time.
  • Speaking in short, simple, and easy-to-understand sentences is effective.
  • The nurse may need to redirect the client back to the topic.
• Severe Anxiety:
  • 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 the client is left alone.
  • Talking to the client in a low, calm, and soothing voice can help.
  • Helping the person take deep even breaths can help lower anxiety.
• Panic Anxiety:
  • The person’s safety is the primary concern.
  • They cannot perceive potential harm and may have no capacity for rational thought.
  • The nurse must keep talking to the person in a comforting manner.
  • Going to a small, quiet, and nonstimulating environment may help reduce anxiety.
  • The nurse can reassure the person that it will pass and that they are 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.

Nurse's Self-Awareness

• The nurse must be aware of their own anxiety level.
• Remaining calm and in control is essential if the nurse is going to work effectively with the client.

Anxiolytic Medications

• Short-term anxiety can be treated with anxiolytic medications (Table 14.2).
• Most of these drugs are benzodiazepines.
• Benzodiazepines have a high potential for abuse and dependence.
• Their use should be short term, ideally no longer than 4 to 6 weeks.
• Designed to relieve anxiety so that the person can deal more effectively with whatever crisis or situation is causing stress.
• 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.

Stress-Related Illness

• 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.
• Traumatic stressors can cause a short, acute stress reaction or PTSD.
• Stress that is ignored or suppressed can cause physical symptoms with no actual organic disease called somatic symptom disorders.
• Stress can 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 an anxiety disorder.

Overview of Anxiety Disorders

• Diagnosed when anxiety no longer functions as a signal of danger or motivation for change but becomes chronic.
• Results in maladaptive behaviors and emotional disability.
• Anxiety is the key feature of each.
• Types of anxiety disorders include:
  • Agoraphobia
  • Panic disorder
  • Specific phobia
  • Social anxiety disorder (social phobia)
  • Generalized anxiety disorder (GAD)
• Panic disorder is the most common.
• Episodes of severe or panic-level anxiety can be seen under extreme stress in many of the other anxiety disorders.

Plan of Care for a Client with Anxious Behavior

• Problem: Anxiety
• Assessment Data:
  • Decreased attention span
  • Restlessness, irritability
  • Poor impulse control
  • Hyperactivity, pacing
  • Wringing hands
  • Feelings of discomfort, apprehension, or helplessness
  • Perceptual field deficits
  • Decreased ability to communicate verbally
• Expected Outcomes
  • Immediate
    • The client will be free from injury throughout hospitalization.
    • Discuss feelings of dread, anxiety, and so forth within 24 to 48 hours.
    • Respond to relaxation techniques with staff assistance and demonstrate a decreased anxiety level within 2 to 3 days.
  • Stabilization
    • The client will demonstrate the ability to perform relaxation techniques.
    • Reduce own anxiety level without staff assistance.
  • Community
    • The client will be free from anxiety attacks.
    • Manage the anxiety response to stress effectively.
• Implementation
  • Nursing Actions
    • Remain with the client at all times when levels of anxiety are high (severe or panic).
    • Move the client to a quiet area with minimal or decreased stimuli such as a small room or seclusion area.
    • PRN medications may be indicated for high levels of anxiety, delusions, disorganized thoughts, and so forth.
    • Remain calm in your approach to the client.
    • Use short, simple, and clear statements.
    • Avoid asking or forcing the client to make choices.
    • Be aware of your own feelings and level of discomfort.
    • Encourage the client’s participation in relaxation exercises such as deep breathing, progressive muscle relaxation, meditation, and imagining being in a quiet, peaceful place.
    • Teach the client to use relaxation techniques independently.
    • Help the client see that mild anxiety can be a positive catalyst for change and does not need to be avoided.
    • Encourage the client to identify and pursue relationships, personal interests, hobbies, or recreational activities that may appeal to the client.
    • Encourage the client to identify supportive resources in the community or on the internet.

Incidence

• Anxiety disorders have the highest prevalence rates of all mental disorders in the United States for both children and adults.
• Nearly 30% of people will experience an anxiety disorder during their lifetime.
• They are more prevalent in women and people under 45 years of age.

Onset and Clinical Course

• Extremely variable, depending on the specific disorder.

Related Disorders

• Selective Mutism:
  • Diagnosed in children when they fail to speak in social situations even though they are able to speak.
  • High level of social anxiety.
• Anxiety Disorder Due to Another Medical Condition:
  • Symptoms result directly from a physiological condition.
  • Medical conditions include endocrine dysfunction, COPD, CHF, and neurologic conditions.
• Substance/Medication-Induced Anxiety Disorder:
  • Anxiety caused directly by drug abuse, medication, or toxin exposure.
• Separation Anxiety Disorder:
  • Excessive anxiety concerning separation from home or attached individuals.
  • 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.
  • Panic disorder, social anxiety disorder, and specific phobias, including agoraphobia, have moderate heritability (0.3 to 0.5).
  • GAD and OCD tend to be more common in families, indicating a strong genetic component, but still require further in-depth study.
• Neurochemical Theories:
  • Gamma-aminobutyric acid (GABA) is dysfunctional in anxiety disorders.
    • GABA reduces cell excitability.
  • Serotonin (5-Hydroxytryptamine type 1a)
    • Plays a role in anxiety.
    • Also affects aggression and mood.
    • Suspected in OCD, panic disorder, and GAD.
  • Excess of norepinephrine is suspected in panic disorder, GAD, and PTSD.

Psychodynamic Theories

• Intrapsychic/Psychoanalytic Theories:
  • Freud saw anxiety as the stimulus for behavior.
  • Defense mechanisms control awareness and reduce anxiety.
• Interpersonal Theory:
  • Harry Stack Sullivan viewed anxiety as being generated from problems in interpersonal relationships.
  • Hildegard Peplau understood that humans exist in interpersonal and physiological realms.

Behavioral Theory

• Behavioral theorists view anxiety as being learned through experiences.
• People can change or “unlearn” behaviors through new experiences.
• Behaviorists believe that people can modify maladaptive behaviors without gaining insight into their causes.

Cultural Considerations

• Each culture has rules governing the appropriate ways to express and deal with anxiety.
• Cultural humility means nurses should be aware that differences exist while being careful not to stereotype clients.

Treatment

• Usually involves medication and therapy.
• Cognitive–Behavioral Therapy (CBT):
  • Positive Reframing: Turning negative messages into positive messages.
  • Decatastrophizing: Realistically appraising the situation.
  • Assertiveness Training
    • Helps the person take more control over life situations.
    • Involve using “I” statements to identify feelings and to communicate concerns or needs to others.

Age-Related Considerations

• Selective mutism and separation anxiety disorder are seen in children.
• The anxiety disorders as a group have one of the earliest onsets of all psychiatric diagnoses, with a median age of onset of 12 years.
• Late-onset anxiety is frequently associated with another condition such as depression, dementia, physical illness, or medication toxicity or withdrawal.
• The treatment of choice for anxiety disorders in older adults is selective serotonin reuptake inhibitor (SSRI) antidepressants.
• A significantly increased risk for hip fracture is associated with long-term use of benzodiazepines by older persons.

Community-Based Care

• Nurses encounter many people with anxiety disorders in community settings rather than in inpatient settings.
• Knowledge of community resources helps the nurse guide the client to appropriate referrals for assessment, diagnosis, and treatment.

Mental Health Promotion

• Anxiety is a warning that they are not dealing with stress effectively.
• Managing the effects of stress and anxiety in one’s life is important to being healthy.
  • Keep a positive attitude and believe in yourself.
  • Accept that there are events you cannot control.
  • Communicate assertively with others
  • Learn to relax.
  • Exercise regularly.
  • Eat well-balanced meals.
  • Limit intake of caffeine and alcohol.
  • Get enough rest and sleep.

Panic Disorder

• Composed of discrete episodes of panic attacks.
• 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.
• Diagnosed when the person has recurrent, unexpected panic attacks.

Clinical Course

• The onset of panic disorder peaks in late adolescence and the mid-30s.
• The memory of the panic attack, coupled with the fear of having more, can lead to avoidance behavior.

Primary and Secondary Gain

• Primary Gain: The relief of anxiety achieved by performing the specific anxiety-driven behavior.
• Secondary Gain: The attention received from others as a result of these behaviors.

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 and propranolol.

Care of Clients with Panic Disorder

Assessment Data

• The Hamilton Rating Scale for Anxiety helps evaluate the patient's degree of anxiety.

History

• The client usually seeks treatment for panic disorder after they have experienced several panic attacks.

General Appearance and Motor Behavior

• The client may appear "normal" or may have signs of anxiety.
• Automatisms may be apparent.

Mood and Affect

• Assessment may reveal that the client is anxious, worried, tense, depressed, serious, or sad.
• May describe feelings of depersonalization or derealization.

Thought Processes and Content

• During a panic attack, the client is overwhelmed, believing that they are dying, losing control, or “going insane."

Sensorium and Intellectual Processes

• During a panic attack, the client may become confused and disoriented.

Judgment and Insight

• Judgment is suspended during panic attacks.
• Insight into panic disorder occurs only after the client has been educated about the disorder.

Self-Concept

• Clients often make self-blaming statements.

Roles and Relationships

• The person may report alterations in their social, occupational, or family life.

Physiological and Self-Care Concerns

• The client often reports problems with sleeping and eating.

Data Analysis and Priorities

• Risk of injury, anxiety, situational low self-esteem, ineffective coping, powerlessness, ineffective role performance, and disturbed sleep pattern.
• The priority is correctly determining the client’s anxiety level.

Outcome Identification

• The client will be free from injury.
• The client will verbalize feelings.
• The client will demonstrate use of effective coping mechanisms.
• The client will verbalize a sense of personal control.
• The client will reestablish adequate nutritional intake.

Actions 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.
• The nurse remains with the client to help calm them 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 they are 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.
• The nurse can teach the client relaxation techniques to use when they are experiencing stress or anxiety.

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.

Evaluation

• Evaluation of the plan of care must be individualized.

CLIENT AND FAMILY EDUCATION For Panic Disorder

• Review breathing control and relaxation techniques.
• Discuss positive coping strategies.
• Encourage regular exercise.
• Emphasize the importance of maintaining prescribed medication regimen and regular follow-up.
• Describe time management techniques.
• Stress the importance of maintaining contact with community and participating in supportive organizations.

Phobias

• An illogical, intense, and persistent fear of a specific object or a social situation that causes extreme distress and interferes with normal functioning.
• There are three categories of phobias:
  • Agoraphobia
  • Specific Phobia
  • Social Anxiety or Phobia
    Specific Phobias Subdivided into The Following Categories: Natural Environmental Phobias, Blood-injection Phobias, Situational Phobias, Animal Phobias And Other Types of Specific Phobias

Social Phobia

• The person becomes severely anxious to the point of panic or incapacitation when confronting situations involving people.

Onset and Clinical Course

• Specific phobias usually occur in childhood or adolescence.
• Specific phobias that persist into adulthood are lifelong 80% of the time.
• Cognitive Therapy Competence Scale

Treatment

• Behavioral therapy works well.
• Therapies that help the client develop self-esteem and self-control are common and include positive reframing and assertiveness training.
• One behavioral therapy often used to treat phobias is systematic (serial) desensitization.
• Flooding is a form of rapid desensitization.

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.
• Buspirone (BuSpar) and SSRI or serotonin–norepinephrine reuptake inhibitor antidepressants are the most effective treatments

Self-Awareness Issues

• Working with people who have anxiety disorders is a different kind of challenge for the nurse.
• Points to Consider When Working With Clients With Anxiety and Anxiety Disorders
• Critical Thinking Questions

Key Points

• Anxiety is a vague feeling of dread or apprehension.
• Anxiety has positive and negative side effects.
• The four levels of anxiety are mild anxiety, moderate anxiety, severe anxiety, and panic.
• Defense mechanisms are intrapsychic distortions that a person uses to feel more in control.
• Treatment for anxiety disorders involves medication (anxiolytics, SSRI and tricyclic antidepressants, and clonidine and propranolol) and therapy.
• CBTs used to treat clients with anxiety disorders include positive reframing, decatastrophizing, thought-stopping, and distraction.
• In a panic attack, the person feels as if they are dying.
• Phobias are excessive anxiety about being in public or open places (agoraphobia), a specific object, or social situations.