Anxiety

Anxiety: Key Concepts

  • Anxiety is a vague feeling of dread or apprehension; it is different from fear, which is a feeling of being afraid or threatened by an identifiable stimulus representing danger.

  • Anxiety disorders are characterized by excessive anxiety with behavioral, emotional, cognitive, and physiological responses.

  • Stress refers to the wear and tear that life causes on the body.

Anxiety as a Response to Stress

  • General Adaptation Syndrome (GAS) describes physiological aspects of stress identified by Selye:

    • Alarm reaction stage: preparation for defense

    • Resistance stage: blood shunted to areas needed for defense

    • Exhaustion stage: body stores depleted; emotional components unresolved

Levels of Anxiety

  • Mild: sensing something is different; increased sensory stimulation; motivational

  • Moderate: feeling something is definitely wrong; nervousness/agitation; difficulty concentrating; can be redirected

  • Severe: trouble thinking and reasoning; tightened muscles; increased vital signs; restless, irritable, angry

  • Panic: fight, flight, or freeze response; increased vital signs; enlarged pupils; cognitive processes focus on defense

Working With Anxious Clients

  • Maintain self-awareness of your own anxiety level

  • Assess the client’s anxiety level

  • Use short, simple, easy-to-understand sentences

  • Lower the client’s anxiety to moderate or mild before proceeding

  • Use a low, calm, soothing voice

  • In a panic, safety is the primary concern

  • Short-term use of anxiolytics (refer to Table 14.2)

True/False: Anxiety vs Fear

  • Statement: Are anxiety and fear considered two different things? True

  • Rationale: Anxiety is a vague feeling of dread; fear is a feeling of being afraid or threatened by an identifiable stimulus representing danger.

Anxiety Disorders I

  • Agoraphobia

  • Panic disorder

  • Specific phobia

  • Social anxiety disorder (social phobia)

  • Generalized anxiety disorder (GAD)

Anxiety Disorders II

  • Incidence: highest prevalence rates of all mental disorders in the United States

  • More prevalent in: women; people under 45 years

  • Onset and clinical course are extremely variable

  • Related disorders:

    • Selective mutism

    • Anxiety disorder due to another mental condition

    • Substance/medication-induced anxiety disorder

    • Separation anxiety disorder

Etiology of Anxiety

  • Biologic theories:

    • Genetic theories

    • Neurochemical theories (gamma-aminobutyric acid [GABA], serotonin)

  • Psychodynamic theories:

    • Intrapsychic/psychoanalytic theories (Freud and defense mechanisms)

    • Interpersonal theory (Sullivan, Peplau)

    • Behavioral theory

Cultural Considerations

  • Each culture has rules for expressing and dealing with anxiety.

  • Some cultures express anxiety through somatic symptoms (headaches, backaches, fatigue, dizziness, stomach problems).

  • Other cultures may view anxiety symptoms as caused by supernatural spirits or bad air.

  • Nurses should practice cultural humility: be aware of cultural differences but avoid stereotyping clients.

Treatment

  • Combination of medications and therapy

  • Antidepressants

  • Cognitive–behavioral therapy (CBT):

    • Positive reframing: turning negative messages into positive ones

    • Decatastrophizing: making a more realistic appraisal of the situation

    • Assertiveness training: learning to negotiate interpersonal situations

Question 2: Dopamine and Anxiety

  • Statement: Is the neurotransmitter dopamine associated with anxiety disorders? False

  • Rationale: The neurotransmitters GABA and serotonin are thought to play a role in anxiety disorders.

Age-Related Considerations

  • Conditions seen in children:

    • Selective mutism

    • Separation anxiety

    • Social anxiety disorder (can persist into adulthood)

  • Late-life anxiety disorders:

    • Phobias (agoraphobia, GAD) most common

    • Panic attacks are less common, often related to other illness

    • Ruminative thoughts

  • Treatment of choice: selective serotonin reuptake inhibitor (SSRI) antidepressants

Mental Health Promotion I

  • Anxiety as a warning of not dealing with stress effectively

  • Positive events can be stressful as well

  • Managing effects of stress and anxiety in life is important to health

  • Goal: effective management of stress and anxiety, not total elimination

  • Medication is important to relieve excessive anxiety but does not solve the problem entirely

Mental Health Promotion II

  • Tips for managing stress:

    • Positive attitude; belief in self; acceptance of lack of control over certain events

    • Assertive communication; expression of feelings: talking, laughing, crying

    • Learn to relax

    • Realistic goals; personally meaningful activity

    • Well-balanced diet, exercise, adequate rest/sleep

    • Limit intake of caffeine and alcohol

    • Use of stress management techniques

Panic Disorder I

  • Discrete episodes of panic attacks; no stimulus for a panic response

  • Disorder diagnosed when recurrent, unexpected attacks followed by at least 1 month of concern/worry about future attacks

    • rac12rac{1}{2} of people with panic disorder have agoraphobia

  • Increased risk of suicidality

  • Avoidance behavior

  • Primary and secondary gain

Panic Disorder II

  • Treatment:

    • CBT

    • Deep breathing, relaxation

    • Benzodiazepines, SSRIs, tricyclic antidepressants, antihypertensives (clonidine, propranolol)

Panic Disorder: Nursing Process Application I

  • Assessment: Hamilton Rating Scale for Anxiety (HAM-A) (see Box 14.1)

  • History

  • General appearance and motor behavior (automatisms)

  • Mood and affect (depersonalization, derealization)

  • Thought processes and content (disorganized thoughts, loss of rational thinking)

    • Sensorium and intellectual processes (confusion, disorientation)

    • Judgment and insight

    • Self-concept (self-blaming, consumed with worry)

    • Roles and relationships (avoidance of others)

    • Physiological and self-care concerns (sleeping, eating)

  • Data analysis and priorities: common problems

  • Outcome identification

  • Actions:

    • Promoting safety and comfort

    • Using therapeutic communication

    • Managing anxiety

    • Providing client and family education

  • Evaluation

Question 3

  • Question: Which finding would a nurse expect to assess in a client with a panic disorder?

    • A. Rational thinking

    • B. Blaming of others

    • C. Automatisms

    • D. Organized thoughts

  • Answer: C. Automatisms

  • Rationale: A client with panic disorder would demonstrate automatisms, irrational thinking, self-blame, and disorganized thoughts.

Phobias I

  • Intense, illogical, persistent fear of a specific object or situation

  • Response is out of proportion to the situation or circumstance

  • Categories:

    • Agoraphobia

    • Specific phobia

    • Social anxiety or social phobia

  • Categories of specific phobias:

    • Natural environment

    • Blood–injection

    • Situational

    • Animal

    • Other types

  • Treatment:

    • Behavioral therapy: positive reframing, assertiveness training, systematic desensitization, flooding

    • Medications (see Table 14.3)

Question 4

  • True/False: Phobias result from a past negative experience.

  • Answer: False

  • Rationale: Phobias usually do not result from past negative experiences; the person may never have had contact with the object of the phobia.

Self-Awareness Issues

  • Nurses need to understand what anxiety behaviors look like and how they work.

  • Nurses are vulnerable to stress and anxiety just as anyone else.

  • Everyone experiences stress and anxiety occasionally.

  • Avoid trying to “fix” the client’s problem; instead, use techniques to manage stress and anxiety in one’s own life.