Anxiety is a normal reaction to stress. It can be beneficial in some situations as it can alert us to dangers and help us prepare and pay attention. Anxiety may be regarded as pathological when the level of anxiety becomes so excessive and out of proportion to the situation that it interferes with social and occupational functioning, achievement of desired goals, or emotional comfort.
Anxiety disorders are the most common of mental disorders, affecting nearly 30 percent of adults at some point in their lives. But anxiety disorders are treatable and there are several effective treatments available. This article focuses on anxiety disorders in general and their nursing management.
Anxiety disorders are the most common mental health disorders. Despite the high prevalence rates of these anxiety disorders, they often are under recognized and undertreated. It is important to diagnose and treat an anxiety disorder that develops or worsens during the childhood and early adulthood to help prevent the problem from becoming chronic and continuing into later life.
Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances. (DSM-5) *.
These disorders include:
Obsessive-compulsive disorder (OCD), acute stress disorder, and posttraumatic stress (PTSD) are no longer considered as anxiety disorders as in the previous version of the DSM. However, these disorders are closely related to anxiety disorders.
Fear is an emotional response to an immediate threat and is more associated with a fight or flight reaction – either staying to fight or leaving to escape danger.
*Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
In general, for a patient to be diagnosed with an anxiety disorder, the fear or anxiety must:
- Be out of proportion to the situation or age inappropriate
- Hinder the ability to function normally
Type of Anxiety Disorders and Clinical Presentation
Generalized Anxiety Disorder
The symptoms can cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The anxiety and worry may be accompanied by physical symptoms, such as restlessness, feeling on edge or easily fatigued, difficulty in concentrating, muscle tension or trouble sleeping.
Panic disorder is characterized by recurrent, unexpected panic attacks, the onset of which are sudden, unpredictable, and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom, and accompanied by intense physical discomfort.
A panic attack is an abrupt period of intense fear or discomfort accompanied by 4 or more of the following symptoms:
- Palpitations, pounding heart, or accelerated heart rate
- Trembling or shaking
- Shortness of breath or feeling of smothering
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, lightheaded, or faint
- Chills or heat sensations
- Paresthesias (numbness or tingling sensations)
- Derealization (feeling of unreality) or depersonalization (being detached from oneself)
- Fear of losing control or going crazy
- Fear of dying
DSM 5 criteria for panic disorder: recurrent panic attacks, with 1 or more attacks followed by at least 1 month of fear of another panic attack or significant maladaptive behavior related to the attacks.
Other symptoms may include headache, cold hands, diarrhea, insomnia, fatigue, intrusive thoughts, and ruminations.
The attacks usually last for minutes, or more rarely, hours.
The individual often experiences varying degrees of nervousness and apprehension between attacks. Symptoms of depression are common.
Phobias, Specific Phobia
A specific phobia is marked and persistent fear of a specific object, situation or activity that is generally not harmful (e.g., flying, heights, animals, receiving an injection, seeing blood). The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation. The fear cause significant distress and people go extreme lengths to avoid what they fear. This can result in impairment in social, occupational, or other important areas of functioning
Agoraphobia is the fear of being in places or situations from which escape might be difficult or in which help might not be available in the event that panic symptoms should occur. A person with agoraphobia experiences marked fear or anxiety in two or more of the following situations:
- using public transportation
- being in open spaces
- being in enclosed places
- standing in line or being in a crowd
- being outside the home alone
The individuals may have experienced the symptoms in the past and is preoccupied with fears of their recurrence. The fear is out of proportion to the actual danger posed by the situation and typically lasts six months or more. The fear can cause significant impairment in social, occupational, or other important areas of functioning. In severe cases, the individual is unable to leave his or her home without being accompanied by a friend or relative whom he trusts.
Social Anxiety Disorder (social phobia)
A person with social phobia will typically report a marked and persistent fear of social or performance situations in which the individual is exposed to possible judgment and scrutiny by others, to the extent that his or her ability to function is impaired.
The social situations are avoided or endurd with great anxiety. Examples are social interactions, speaking or performing in front of others. The fear, anxiety and avoidance typically last at least six months and causes problems with daily functioning.
Separation Anxiety Disorder
Separation anxiety disorder is characterized by excessive fear or anxiety about separation from those with whom he or she is attached. The feeling is beyond what is appropriate for the person’s age, persists (at least four weeks in children and six months in adults) and causes problem with functioning.
A rare disorder associated with anxiety is selective mutism. Selective mutism is characterized by failure to speak in specific social situations despite having normal language skills. Usually occurs before the age of 5 and is often associated with extreme shyness, fear of social embarrassment, withdrawal, compulsive traits, clinging behavior, and temper tantrums.
Anxiety Disorder Due to Another Medical Condition
The symptoms of this disorder are considered to be the direct physiological consequence of another medical condition. Symptoms may include prominent generalized anxiety symptoms, panic attacks, or obsessions or compulsions. Medical conditions known to cause anxiety disorders include endocrine, cardiovascular, respiratory, metabolic, and neurological disorders.
Substance/Medication-Induced Anxiety Disorder
The essential features of this disorder is prominent anxiety symptoms that are considered to be caused by the direct physiological effects of a substance (substance intoxication or withdrawal from alcohol, amphetamines, cocaine, hallucinogens, sedatives, hypnotics, anxiolytics, caffeine, cannabis, or other substances)
- Genetic factors: Anxiety disorders are common among first-degree biological relatives of people with the disorders than among the general population.
- Biochemical: Researches shows link between anxiety disorders with the regulation of certain neurotransmitters, including serotonin, norepinephrine and gamma-aminobutyric acid.
- Neuroanatomical: Brain imaging studies in patients with anxiety disorder have shown abnormalities in cerebral blood flow and metabolism, as well as structural abnormalities.
- Medical or Substance-Induced: Anxiety can be due to a known or unrecognized medical condition. Substance use, particularly stimulants such as caffeine, cocaine and Ritalin may induce anxiety symptoms.
- Environmental factors such as early childhood trauma can also contribute to risk for later anxiety disorders.
- Psychodynamic Theory: The inability of the ego to intervene when conflict occurs between the id and the superego, producing anxiety. Due to various reasons (unsatisfactory parent-child relationship, conditional love, or provisional gratification), ego development is delayed. This can compromise the capacity to modulate anxiety and the individual resorts to unconscious mechanisms to resolve the conflict. Excessive or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety.
- Cognitive Theory: If there is a disturbance in cognition, there is a consequent disturbance in feeling, thought and behavior. Distorted thinking results in an irrationalor erroneous appraisal of a situation resulting in anxiety. There is a loss of ability to reason regarding the problem, the individual feels vulnerable in a given situation.
- Learning Theory: Certain anxiety disorders like Phobias may be acquired by direct learning or imitation (modeling). For example a mother who exhibits fear toward an object will provide a model for the child, who may also develop a phobia of the same object.
- Life Experiences: Certain early experiences may set the stage for phobic reactions later in life.
Related Anatomy and Pathophysiology
The brain amygdala seems key to modulating fear and anxiety. Patients with anxiety disorders often show increased amygdala response to anxiety cues. The amygdala and other structures of the limbic system are connected to the regions of the prefrontal cortex. Hyper responsiveness of the amygdala may be associated with low activation thresholds in responding to perceived social threat. Abnormalities in prefrontal-limbic activation have been shown to reverse with clinical response to psychologic or pharmacologic interventions.
In the central nervous system, the major mediators of the anxiety disorders symptoms appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Other neurotransmitters and peptides, such as corticotropin-releasing factor, may be involved. Peripherally, the autonomic nervous system, especially the sympathetic nervous system, mediates many of the symptoms.
Positron emission tomography (PET) scanning has demonstrated increased flow in the right Para hippocampal region and reduced serotonin type 1A receptor binding in the anterior and posterior cingulate and raphe of patients with panic disorder.
Magnetic resonance imaging has shown a smaller temporal lobe volume despite normal hippocampal volume in these patients.
The CSF studies in humans shows elevated levels of hypocretin, which is believed to play an important role in the pathogenesis of panic episodes.
United States statistics
- Anxiety disorders are the most common type of psychiatric disorder in U.S. The lifetime prevalence among American adults is 28.8%.
- In any given year the estimated percent of U.S. adults with various anxiety disorders are: specific phobia (7-9%), social anxiety disorder (7%), panic disorder (2-3%), agoraphobia (2%), generalized anxiety disorder (2%), separation anxiety disorder (1-2%).
The prevalence of specific anxiety disorders seems to vary between countries and cultures. An international study of the prevalence of panic disorder found lifetime prevalence rates ranging from 0.4% in Taiwan to 2.9% in Italy. The average prevalence of social anxiety disorder in Europe is 2.3%.
Women are more affected than men (female-to-male ratio for any lifetime anxiety disorder is 3:2).
New-onset symptoms in older adults may be due to general medical condition, a substance abuse disorder, or major depression with secondary anxiety symptoms.
- Early identification and management are key to recovery and can prevent secondary disorders such as depression and substance use problems.
- Anxiety disorders have high comorbidity with major depression and alcohol and substance abuse.
- Chronic anxiety may be associated with increased risk for cardiovascular morbidity and mortality.
- Social phobia results in significant functional impairment and decreased quality of life.
- Severe anxiety disorders (panic disorder, comorbid phobias, acute stress due to adverse life events such as divorce or financial disaster) can lead to suicidal thoughts and attempts.
- Anxiety disorders can be managed well in the primary care setting with access to experts in cognitive-behavioural therapy.
- A detailed history and review of symptoms is essential to rule out anxiety disorders secondary to general medical or substance abuse conditions,.
- Ask about concurrent depressive symptoms that are common in all of the anxiety disorders.
- Severe anxiety disorders can cause significant distress and agitation. Assess about suicidal ideation or suicidal intent.
Physical Examination: Patients with new onset anxiety symptoms should have a physical examination and basic laboratory workup to rule out medical conditions that might present with anxiety like symptoms
- Patients may show physical signs of anxiety such as sweaty palms, restlessness, and distractibility.
- Mood may be normal or depressed.
- Affect is often preserved.
- Psychotic symptoms not typical of uncomplicated anxiety disorders.
- Assess for suicidal ideation by asking about passive thoughts of death, desires to be dead, thoughts of harming self, or plans or acts to harm self. Homicidal ideation is uncommon.
- Cognition: typically intact with no impairment in memory, language, or speech.
- Insight and judgment: typically intact.
When anxiety is thought to be not due to an underlying medical disorder (lack of physical findings, younger age, typical anxiety disorder presentation), initial laboratory studies might be limited to the following:
- Complete blood cell count
- Chemistry profile
- Thyroid function tests
- Urine drug screen
Studies to Exclude Medical Disorders
For patients with a higher index of suspicion for other medical causes of anxiety (ie, atypical anxiety disorder presentation, older age, specific physical examination abnormalities), more detailed evaluations to be done to identify or exclude underlying medical disorders.
- Electroencephalography, lumbar puncture, and head/brain imaging to rule out CNS disorders.
- Electrocardiography to rule out cardiac disorders
- Tests for infection: Infectious causes should be ruled out using rapid plasma reagent test, lumbar puncture (CNS infections), or HIV testing.
- Arterial blood gas analysis: Arterial blood gas analysis is useful in confirming hyperventilation (respiratory alkalosis) and excluding hypoxemia or metabolic acidosis.
- Electrolyte analysis: Electrolyte analysis is unnecessary, although several abnormalities may be present in the setting of hyperventilation.
- Chest radiography: Useful in excluding other causes of dyspnea with chest pain (eg, pulmonary embolism).
- Thyroid function: One of the most common medical causes for anxiety related to a medical condition is Hyperthyroidism. Serum TSH and T4 levels should be considered for excluding a primary thyroid abnormality.
Treatment usually consists of a combination of pharmacotherapy and/or psychotherapy.
- Psychotherapy: including cognitive behavioral therapy
- Pharmacotherapy: antianxiety medications and antidepressants.
- Complementary health approaches: such as stress and relaxation techniques, yoga, meditation.
The outcome of treatment is determined by several factors, including the following:
- Cognitive Behavioral Therapy (CBT): Cognitive behavioral therapy (CBT) is the first-line psychotherapy for anxiety disorders. CBT focuses on finding the counterproductive thinking patterns that contribute to anxiety. CBT uses many constructive strategies to reduce the beliefs and behaviors that lead to anxiety.
- Exposure Response Prevention is a psychotherapy method for specific anxiety disorders like phobias and social anxiety. Its aims to help the person develop a more constructive response to a fear.
The goal is for patient to “expose” themselves to that which they fear, in an attempt to experience less anxiety over time and develop effective coping tools.
- Anti-anxiety medications: to reduce the emotional and physical symptoms of anxiety. Benzodiazepines can be effective for short-term reduction of symptoms, but can create the risk of dependence when used for a long time.
- Antidepressants: Antidepressant drugs are the drugs of choice in the treatment of anxiety disorders. Newer agents, such as selective serotonin reuptake inhibitors (SSRIs), have a safer adverse effect profile and higher ease of use than the older tricyclic antidepressants (TCAs). These can also be useful if anxiety has a co-occurring depression. Older antidepressants (TCAs and monoamine oxidase inhibitors) also are effective in the treatment of some anxiety disorders.
Complementary Health Approaches
Complementary and alternative treatments can be used along with conventional treatment to help with recovery. These include:
- Self-management strategies, such as allowing for specific periods of time for worrying. Persons become an expert on their condition and its triggers gains more control over their day.
- Stress and Relaxation Techniques often combine breathing exercises and focused attention to calm the mind and body. These techniques can be an important component in treating phobias or panic disorder.
- Yoga: combination of physical postures, breathing exercises and meditation found in yoga have helped many people improve the management of their anxiety disorder.
- Aerobic exercise can have a positive effect on your stress and anxiety.
- Assess the patient’s level of anxiety. Anxiety can be assessed using tools (diagnostic questionnaires) like GAD-7, State-Trait Anxiety Inventory (STAI)
- Collect full history and conduct mental status examination. Assess familial, physiological and psychosocial factors for the development of the disease. Assess organic causes of anxiety, such as stimulant use, endocrine disorders, asthma or congestive heart failure.
- Monitor vital signs and other physical signs of anxiety/panic attacks.
- Assess for functional, interpersonal and social difficulties the person is experiencing.
- Assess regularly the person’s safety and risk because suicidal ideation may be present, particularly if the person also has depression.
- Anxiety related to real or perceived threat to biological integrity or self-concept
- Fear related to phobic stimulus, being in place or situation from which escape might be difficult
- Disturbed sleep pattern related to heightened anxiety and apprehension
- Impaired communication related to fear of social situations
- Ineffective coping related to situational crises, inadequate support systems, fear of failure
- Powerlessness related to impaired cognition
- Social isolation related to panic level of anxiety, past experiences of difficulty in interactions with others, repressed fears
- Self-care deficit related to withdrawal, isolation from others, disabling anxiety, irrational fears
- Reduce anxiety and fear
- Improve sleep pattern
- Improve coping with stressful life situations
- Promote socialization
- Encourage self-care activities
Planning and Goals
- Reduce anxiety and fear
- Improve sleep pattern
- Improve coping with stressful life situations
- Promote socialization
- Encourage self-care activitie
Nursing care plan of Anxiety
1Nursing diagnosis: Anxiety
- Real or perceived threat to biological integrity or self-concept
As evidenced by
- Any or all of the physical symptoms identified by the DSM-IV as being descriptive of panic or generalized anxiety disorder.
Goal: The client will experience a reduction with anxiety and fear and can be evidenced by verbalization concerning the feeling of being less anxious, regaining usual sleep pattern, relaxed facial expressions and stable vital signs.
- Establish a therapeutic relationship.
- Be available to client.
- Acknowledge anxiety and fear. Stay with the client and reassure the client of his/her safety and security.
- Adopt a calm, reassuring, nonthreatening, friendly approach.
- Use simple words and brief messages; spoke calmly and clearly, to explain hospital experiences.
- Keep the immediate surroundings low in stimuli (dim lighting, few people).
- Administer tranquilizing medication, as ordered by physician. Monitor for effectiveness.
- Educate the client about the signs and symptoms of escalating anxiety, and ways to interrupt its progression (relaxation techniques, deep-breathing exercises, and meditation, or physical exercise, brisk walks, and jogging).
2Nursing diagnosis: Fear
- Phobic stimulus
- Being in place or situation from which escape might be difficult
As evidenced by
- Refusing to leave own home alone
- Refusing to speak or perform in public
- Refusing to expose self to (specify phobic object or situation)
Goal: Client will be able to function in the presence of the phobic object or situation without experiencing panic anxiety.
- Be available to the client and reassure client of his/her safety and security.
- Explore the person’s perception of threat to physical integrity or threat to self-concept.
- Explain the reality of the situation with client.
- Include the client in making decisions related to the selection of alternative coping strategies.
- If the client elects to work on elimination of the fear, the techniques of desensitization may be employed.
- Explore the underlying feelings that may be contributing to irrational fears and help the client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities.
- Encourage verbalization of feelings that contribute to fear in a nonthreatening environment as it may help client come to terms with unresolved issues.
3Nursing diagnosis: Disturbed sleep pattern
- Heightened anxiety and apprehension
As evidenced by
- Reduced sleeping hours
- Patient looking fatigued and exhausted
Goal: Client will have adequate sleep hours, feel less exhausted
- Reassure the patient.
- Provide a comfortable environment, low in stimuli (dim light, less visitors).
- Encourage the family members or the person whom the client trusts the most to stay with the client.
- Encourage the client to sleep for at least six to eight hours.
- Encourage afternoon naps.
4Nursing diagnosis: Impaired communication
- Fear of social situations
As evidenced by
- Lack of communication
- Withdrawal from society
Goal: client will overcome fear and will communicate freely.
- Provide support and reassurance to the patient.
- Environment should be calm. Talk to the patent slowly with pause.
- Help him to convey the message slowly.
- Use communication techniques of reflecting, pinpointing, clarifying, restating and summarizing.
- Help the patient to identify clarity in his/her talk.
5Nursing diagnosis: Ineffective coping
- Situational crises
- Inadequate support systems
- Fear of failure
As evidenced by
- Inability to meet basic needs
- Inability to meet role expectations
- Inadequate problem-solving
- Alteration in societal participation
Goal: Client will demonstrate ability to cope effectively and will be able to manage a stressful situation in future without an anxiety episode.
- Assess client’s level of anxiety.
- Educate the client regarding the signs and symptoms of escalating anxiety. Teach methods like deep breathing and relaxation techniques etc to interrupt its progression.
- Encourage independent behaviors.
- Provide positive reinforcement for independent behaviors. This enhances self-esteem and encourages repetition of desired behaviors.
- Educate the client to use the successful coping strategy in future also to overcome stress.
6Nursing diagnosis: Powerlessness
- Impaired cognition
As evidenced by
- Verbal expressions of no control over life situation
- Nonparticipation in decision-making related to own care or life situation.
Goal: Client will be able to effectively problem solve ways to take control of life situation, thereby decreasing feelings of powerlessness and anxiety
- Allow client to take responsibility for self-care practices. Examples include:
- Encourage the client to establish own schedule for self-care activities.
- Provide client with privacy as needed.
- Assist with self care if needed.
- Provide positive feedback for actions/decisions made.
- Respect client’s right to make decisions independently, and refrain from attempting to influence him/her toward those that may seem more logical.
- Assist client to set realistic goals.
- Help the client identify areas of life situation that he/she can control.
- Help the client identify areas of life situation that they cannot control. Encourage verbalization of feelings related to this inability.
7Nursing diagnosis: Social isolation
- Panic level of anxiety
- Past experiences of difficulty in interactions with others
- Repressed fears
As evidenced by
- Social withdrawal
- Staying alone in room
- Lack of eye contact and proper communication.
Short-term Goal: Client will attend therapy activities accompanied by trusted support person.
Long-term Goal: Client will voluntarily spend time with other clients and staff members in group activities by time of discharge from treatment.
- Accept the patient with his symptoms and make brief, frequent contacts. An accepting attitude increases feelings of self-worth and facilitates trust.
- Show unconditional positive regard. This conveys to the client that he/she as a worthwhile human being.
- Be with the client and offer support during group activities that may be frightening or difficult for him/her.
- Be honest and keep all promises. Honesty and dependability promote a trusting relationship.
- Be cautious with touch. A person in panic anxiety may perceive touch as a threatening gesture.
- Encourage relatives to support his/her appropriate behavior. Discuss with client the signs of increasing anxiety and techniques for interrupting the response (e.g., relaxation exercises, thought stopping).
- Give recognition and positive reinforcement for the clients voluntary interactions with others as it enhances self-esteem and encourages repetition of acceptable behaviors.
- Administer tranquilizing medications as ordered by physician and monitor for effectiveness.
8Nursing diagnosis: Self-care deficit
- Isolation from others
- Disabling anxiety
- Irrational fears
As evidenced by
- Lack of interest in diet, personal hygiene and grooming
- Disheveled appearance.
Goals: Client will be able to take care of own ADLs and demonstrate a willingness to do so.
- Encourage client to perform ADLs to his/her ability.
- Give recognition and positive reinforcement for independent accomplishments as it enhances self-esteem.
- Provide simple, concrete demonstrations of activities that would be performed without difficulty under normal conditions.
- Assess food and fluid intake. Offer nutritious snacks and fluids between meals. Client may be unable to tolerate large amounts of food at mealtimes and may therefore require additional nourishment at other times during the day to receive adequate nutrition.
- If client is incontinent, establish routine schedule for toileting needs. Assist client to bathroom as need is determined, until he or she is able to fulfill this need without assistance.
- Experiences a reduction in anxiety and fear
- Demonstrate the ability to function in stressful situations/in the presence of the phobic object without experiencing panic anxiety
- Gets adequate sleep
- Communicates freely and effectively
- Demonstrate improved coping in life situations and shows decreased feeling of powerlessness
- Voluntarily spends time with others
- Shows the ability to take care of own ADLs
- Mary C. Townsend, Psychiatric Nursing: Assessment, Care Plans, and Medications. 2015. F. A. Davis Philadelphia. Page no 169-184.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA Press; 2013.
- American psychiatric association. Anxiety disorders, Available at https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety disorders. Accessed July 5, 2020
- National Institute of Mental Health (2018). Anxiety Disorders. Retrieved on July 8, 2020, from https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
- National alliance on Mental Illness (2018). Anxiety disorders. Retrieved on July 8, 2010 from http://www.nami.org/Learn-More/Mental-Health-Conditions/Anxiety-Disorders