Anxiety, Fear, and Fatigue: Comprehensive Clinical Nursing Notes

Learning Competencies

• Differentiate between the concepts of stress, anxiety, and fear.

• Discuss nursing interventions utilized in the care of patients experiencing anxiety across the human life span.

• Describe specific interventions designed to eliminate or reduce levels of anxiety and fear in patients.

• Formulate nursing diagnoses and outcome criteria for patients diagnosed with anxiety, obsessive-compulsive (OCD), and related disorders.

• Discuss various treatment modalities relevant to the management of anxiety, obsessive-compulsive, and related disorders.

• Describe the pharmacotherapeutic agents utilized in the treatment of anxiety.

The Nature of Stress, Anxiety, and Fear

• Stress: The body's response to external triggers.

  • Involves the release of stress hormones by the hypothalamus.

  • Encompasses physiological and emotional reactions.

  • Can be acute or chronic.

  • Potential consequences include anxiety, depression, and changes in eating habits.

• Anxiety: A heightened state of arousal characterized by feelings of fear, dread, or uneasiness.

  • The cause is not always apparent.

  • May present as a general sense of apprehension.

  • Severity can range from mild to severe.

• Shared Manifestations (Stress and Anxiety):

  • Increased heart rate and blood pressure.

  • Increased respirations.

  • Excessive worry.

  • Gastrointestinal symptoms.

  • Sleep disturbances and irritability.

The Anxiety Cycle and Responses to Stressors

• The Cycle Factors:

  • Stress: Questions like "What will happen next?"

  • Fear: Thoughts such as "I can't do this" and "Only bad will come of this."

  • Anxiety/Worry: Physical symptoms including dizziness, elevated heart rate, GI distress, fast/shallow breathing, dry throat, sweating, and disrupted concentration.

• Behavioral Responses (The Four Fs):

  • Fight: Characterized by anger, frustration, and aggression.

  • Flight: Characterized by avoidance and behaviors like drinking alcohol.

  • Freeze: The individual is unable to respond.

  • Fawn: Trying to please others to avoid underlying anxiety or stress.

Levels and Physiological Effects of Anxiety

• Differentiated Levels:

  • Mild: Characterized by restlessness and trouble sleeping.

  • Moderate: Feeling overwhelmed and unsure what to do.

  • Severe: Results in acting out.

  • Panic: Feelings of terror, exhaustion, and a state where the individual is no longer responding to stimuli.

• Short-term Stress Symptoms:

  • Increased alertness and respiratory rate.

  • Dry mouth and pale skin.

  • Increased heart rate and a pounding heart.

  • Elevated blood pressure.

  • Muscle tension and sweaty palms.

• Long-term Stress Symptoms:

  • Fatigue and general malaise.

  • Insomnia.

  • Headaches and backaches.

  • Chronic illness and hypertension.

Impact of Childhood Experiences (ACEs and PCEs)

• Framework: Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs) both play significant roles in the development of anxiety and OCD.

• Interaction: PCEs do not cancel out ACEs, but they may serve as a protective factor.

• Nursing Role: Nurses must assess for both types of experiences.

• Comparison of Risks and Protective Factors:

  • ACE Risk: Children who do not feel close to parents/caregivers or cannot talk to them about feelings vs. PCE: Families that create safe, stable, nurturing relationships where children are supported.

  • ACE Risk: Children with few or no friends vs. PCE: Children with positive friendships and peer networks.

  • ACE Risk: Families with inconsistent discipline or low parental monitoring vs. PCE: Families where caregivers engage in monitoring, supervision, and consistent rule enforcement.

Epidemiological and General Risk Factors

• Prevalence and Demographics:

  • Anxiety disorders are the most common mental illness among adults in the United States.

  • More than $25\%$ of the population between the ages of $13$ and $18$ years old are affected.

  • Persons assigned female at birth are twice as likely to develop an anxiety-related disorder compared to persons assigned male at birth.

  • Run in families, suggesting a mix of heredity and learned responses.

• Identification of a Disorder: Anxiety reaches the level of a disorder when:

  • Feelings occur at inappropriate times or situations.

  • Frequency and intensity increase.

  • Ability to function is affected.

  • Duration becomes increasingly prolonged.

  • Daily life and relationships are interfered with.

• Specific Risk Factors:

  • Trauma or negative life experiences (ACEs).

  • Personality traits/temperament, such as shyness or avoidance.

  • Family history of mental health disorders.

  • History of medical illness (e.g., thyroid or cardiac conditions).

  • Genetic predisposition.

  • Lifestyle factors (poor diet, lack of exercise, alcohol or substance use).

Signs and Symptoms of Anxiety

• Physical Manifestations:

  • Palpitations: A feeling that the heart is racing or pounding.

  • Tremors/Shaking: Particularly noticeable in the hands.

  • Sweating: Excessive perspiration even in cool environments.

  • Shortness of Breath: Feeling unable to take a deep breath.

  • Gastrointestinal: Nausea, stomach cramps, or diarrhea.

  • Fatigue: Feeling unusually tired/drained.

  • Sleep: Nightmares or difficulty falling/staying asleep.

• Cognitive Manifestations:

  • Excessive Worry: Constant concern regarding grades, performance, etc.

  • Difficulty Concentrating: Struggling to focus on lectures or tasks.

  • Indecisiveness: Difficulty making decisions.

  • Memory Issues: Forgetting learned material or misplacing items.

• Behavioral Manifestations:

  • Avoidance: Evading situations due to fear of failure/judgment.

  • Procrastination: Continually postponing tasks.

  • Restlessness: Fidgeting or inability to sit still.

  • Isolation: Pulling away from social networks.

• Emotional Manifestations:

  • Feeling Overwhelmed: Sensation that everything is "too much."

  • Mood Swings: Rapid shifts from high to low moods.

  • Irritability: Easily angered or annoyed.

  • Sense of Impending Doom: Constant feeling that something terrible will happen.

Comorbidities of Anxiety

• Anxiety is transdiagnostic and connects to multiple conditions:

  • Psychiatric: Panic disorders, Depressive disorders, Trauma-related disorders, Substance use, Sleep-wake disorders, Eating disorders, ADHD (common in children), Oppositional defiant disorder, Schizophrenic spectrum disorders, and Tic disorders.

  • Psychosomatic/Personality: Somatic manifestations and Obsessive-compulsive personality disorder.

  • Medical Conditions: Pulmonary embolism, asthma, emphysema, stroke, Myocardial infarction, cancer, sepsis, chronic pain, Irritable bowel syndrome (IBS), and delirium.

Generalized Anxiety Disorder (GAD)

• DSM-5 Diagnostic Criteria:

  • Excessive anxiety and worry occurring more days than not for at least $6\,\text{months}$ regarding number of events (work/school).

  • The individual finds it difficult to control the worry.

  • Associated with $3$ or more of the following $6$ symptoms (present for more days than not for the past $6\,\text{months}$):

    1. Restlessness or feeling keyed up/on edge.

    2. Being easily fatigued.

    3. Difficulty concentrating or mind going blank.

    4. Irritability.

    5. Muscle tension.

    6. Sleep disturbance.

  • Symptoms cause clinically significant distress or impairment.

  • Disturbance is not attributable to substances (drugs of abuse/medication) or medical conditions (e.g., hyperthyroidism).

• Diagnosis and Treatment:

  • Diagnostic Process: Multidisciplinary assessment focusing on nature, duration, and triggers; comprehensive medical workup to rule out organic causes.

  • Treatment: Psychotherapy (specifically CBT) and Psychopharmacology.

Obsessive-Compulsive Disorder (OCD)

• Definitions:

  • Obsessions: Recurrent, persistent, intrusive, and unwanted thoughts, urges, or impulses causing marked anxiety. The individual attempts to ignore or neutralize them through compulsions.

  • Compulsions: Repetitive behaviors (hand washing, ordering) or mental acts (praying, counting) the individual feels driven to perform to reduce anxiety or prevent a dreaded event. These are not realistically connected to the threat.

• Epidemiology:

  • Prevalence: Approximately $1.2\%$ in the US.

  • Gender: More common in persons assigned female at birth, but symptoms appear earlier in those assigned male at birth.

  • Severity: $50\%$ of diagnosed adults have severe impairment.

• DSM-5 Specifics:

  • Symptoms must be time-consuming (taking more than $1\,\text{hour}$ per day).

  • Insight Specifiers:

    • Good/Fair: Recognizes beliefs are probably not true.

    • Poor: Thinks beliefs are probably true.

    • Absent/Delusional: Completely convinced beliefs are true.

  • Tic-related: Indicates a history of tic disorder.

• Examples of Obsessions: Fears of harming others, safety concerns, cleanliness/germs, offending a deity, forgetting items, or needing items neatly arranged.

• Examples of Compulsions: Checking locks, ritualistic handwashing, repeating phrases, self-harm (hair pulling), counting objects, or repeating activities specific numbers of times.

Related Obsessive-Compulsive Disorders

• Body Dysmorphic Disorder: Persistent preoccupation with perceived flaws in appearance (often face/head).

  • Ratio: $3:2$ female to male.

  • Behaviors: Mirror checking, excessive grooming, skin picking, and seeking reassurance.

  • Men typically see muscle dysmorphia.

  • $25\%$ may compulsively tan to hide defects.

• Hoarding: Persistent difficulty discarding possessions regardless of value, leading to clutter that overwhelms living areas.

• Trichotillomania: Ritualized pattern of serially and intentionally pulling out hair. Often triggered by boredom or anxiety; provides a sense of relief or gratification.

• Excoriation Disorder: Recurrent picking at skin resulting in lesions, commonly on face, hands, or arms.

Phobias and Panic Disorder

• Common Phobias:

  • Arachnophobia (spiders).

  • Acrophobia (heights).

  • Agoraphobia (open/crowded spaces where escape is difficult).

  • Claustrophobia (enclosed spaces).

  • Social phobia (performance/social embarrassment).

  • Aerophobia (flying).

  • Trypanophobia (needles).

  • Ophidiophobia (snakes).

  • Xenophobia (strangers).

  • Murophobia (mice).

• Panic Disorder: Characterized by recurrent unexpected panic attacks involving an abrupt surge of fear.

  • Symptoms ($4$ or more required): Palpitations, sweating, trembling, shortness of breath, choking feelings, chest pain, nausea, dizziness, chills/heat sensations, paresthesia, derealization/depersonalization, fear of losing control, and fear of dying.

  • Diagnosis Support: At least one attack followed by $1\,\text{month}$ of persistent concern about more attacks or significant maladaptive behavior changes.

• Anxiety vs. Panic:

  • Anxiety: Gradual onset, can be long-duration, typically mild symptoms (irritability, muscle tension).

  • Panic: Sudden onset, short-duration, intense symptoms (nausea, numbness, rapid heart rate).

Trauma and Stressor-Related Disorders

• Trauma Types:

  • Physical: From accidents, violence, or self-inflicted damage.

  • Psychological: Emotional injury from an overwhelmingly stressful event threatening survival.

• Resilience: The capacity to withstand stress and catastrophe, developed over time via internal and external factors.

• Specific Disorders:

  • Posttraumatic Stress Disorder (PTSD): Follows exposure to actual/threatened trauma (directly, witnessed, or learned).

    • Onset: Within days of event, must persist for at least $30\,\text{days}$.

    • Criteria: Flashbacks (intrusion), avoidance, mood/cognition changes, hyperarousal/hypervigilance.

    • Epidemiology: $6.1\%$ to $9.2\%$ prevalence; higher in veterans ($0$-$48\%$ males; $2$-$68\%$ females).

  • Acute Stress Disorder (ASD): Similar to PTSD but resolves within $1\,\text{month}$ of the event.

  • Attachment Disorders: Reactive Attachment (withdrawn behavior toward caregivers) and Disinhibited Social Engagement (overly familiar with strangers).

  • Adjustment Disorder.

  • Separation Anxiety: Inappropriate fear of separation from attachment figures, often involving nightmares and physical distress.

Pharmacological Treatments

• Benzodiazepines (Commonly used for short-term relief; risk of dependence):

  • diazepam (Valium): Long acting; used for anxiety, muscle relaxation, alcohol withdrawal, and seizures.

  • alprazolam (Xanax): Intermediate acting; used for anxiety and panic disorder.

  • lorazepam (Ativan): Intermediate acting; used for anxiety, insomnia, status epilepticus, and alcohol withdrawal.

  • clonazepam (Klonopin): Long acting; used for panic disorder and seizures.

  • chlordiazeperoxide (Librium): Long acting; used for alcohol withdrawal and anxiety.

  • oxazepam (Serax): Short to intermediate acting; used for anxiety and alcohol withdrawal.

• Antidepressants (SSRIs and SNRIs):

  • fluoxetine (Prozac): SSRI; used for GAD, Panic, OCD, and depression.

  • sertraline (Zoloft): SSRI; used for GAD, Panic, OCD, Social anxiety, and PTSD.

  • paroxetine (Paxil): SSRI; used for GAD, Panic, Social anxiety, OCD, and PTSD.

  • citalopram (Celexa) & escitalopram (Lexapro): SSRIs; used for GAD and depression.

  • venlafaxine (Effexor XR): SNRI; used for GAD, Panic, and Social anxiety.

  • duloxetine (Cymbalta): SNRI; used for GAD, depression, and neuropathic pain.

• Other Medications:

  • buspirone (Buspar): Azapirone; non-benzodiazepine for chronic anxiety.

  • clomipramine (Anafranil): Tricyclic antidepressant; FDA approved for OCD.

  • fluvoxamine (Luvox): SSRI used for OCD.

Nursing Management and Non-Pharmacological Interventions

• Psychotherapy Modalities:

  • Cognitive Behavioral Therapy (CBT): Focuses on how thoughts and behaviors react to causes of anxiety.

  • Exposure Therapy: Gradual exposure to the underlying cause of anxiety (e.g., driving in traffic) to increase comfort.

  • Exposure and Response Prevention (ERP): Standard for OCD.

  • EMDR (Eye Movement Desensitization and Reprocessing): Used for PTSD restoration.

• Integrative/Complementary Approaches:

  • Relaxation techniques: Deep breathing, progressive muscle relaxation, guided imagery, mindfulness, and meditation.

  • Other: Hypnosis, massage therapy, and music therapy.

• Lifestyle Management: Nutritional strategies (healthy diet), exercise, and avoidance of excessive caffeine/substances.

• Nursing Interventions (General):

  • Active listening and support.

  • Identification/challenging of negative thought patterns.

  • Developing individualized treatment plans with the team.

  • Monitoring medication effectiveness and side effects.

  • Maintaining a calm, supportive demeanor (especially during panic attacks).

  • Grounding techniques.

• Nursing Interventions (OCD): Stress time management skills, self-care practices, and goal setting.

The Nursing Process: Clinical Judgment and Screening

• Recognize Cues (Assessments):

  • Look for manifestations, duration, intensity, and triggering variables.

  • Rule out physiological causes using: Thyroid function tests, Blood glucose levels, Echocardiography, and Toxicology screening.

• Screening Tools:

  • GAD-7: Generalized Anxiety Disorder 7.

  • HAM-A: Hamilton Anxiety Rating Scale.

  • SCARED: Screen for Child Anxiety Related Disorders.

  • LSAS: Leibowitz Social Anxiety Scale.

  • HADS: Hospital Anxiety and Depression Scale.

  • PSWQ: Penn State Worry Questionnaire.

  • Y-BOCS: Yale-Brown Obsessive Compulsive Scale.

  • BOCS: Brief Obsessive-Compulsive Scale.

• Analyze Cues/Prioritize Hypotheses:

  • Priority is always Safety (risk for suicide/harm).

  • Secondary focus: Coping, problem solving, and recovery.

• Generate Solutions/Planning: Goals must be SMART (Specific, Measurable, Achievable, Relevant, Time-bound).

  • Example Goal: "The client will report a reduction in anxiety and acclimatize to therapeutic milieu within $8\,\text{hours}$ of nursing intervention."

• Evaluation (Outcomes):

  • Has the client remained free from injury?

  • Has manifestation reduced after re-assessment?

  • Was the client able to use strategies (like deep breathing) effectively?