According to the American Psychiatric Association (APA), anxiety disorders are the most common type of psychiatric disorder. However, despite the high prevalence rates of these anxiety disorders, they often are underrecognized and undertreated clinical problems. The Diagnostic and Statistical Manual (DSM-5) specifically describes anxiety as excessive worry and apprehensive expectations, occurring more days than not for at least six months, about a number of events or activities, such as work or school performance.
Anxiety is a normal and necessary basic emotion without which individual survival would be impossible. Pathologically increased anxiety can arise not only in anxiety disorders but also in most other types of mental illness. Anxiety can also be a warning signal of potential harm in somatic illnesses. Anxiety is a disease requiring treatment when it arises in the absence of any threat, or in disproportionate relation to a threat, and keeps the affected individual from leading a normal life.
Anxiety disorders are among the so-called complex genetic diseases characterized by a complex pathogenetic interaction of environmental factors with multiple genetic variants. They appear to be caused by an interaction of biopsychosocial factors, including genetic vulnerability, which interact with situations, stress, or trauma to produce clinically significant syndromes.
- Genetic factors. The heritability of anxiety disorders lies within the range of 30 to 67%, with the remainder of the variation accounting for individual negative environmental factors. Family studies have shown that first-degree relatives of clients with panic disorders have a three- to five-fold elevation of the risk of developing such a disorder themselves compared to the general population.
- Environmental factors. Environmental factors such as early childhood trauma can also contribute to the risk of later anxiety disorders. Negative life events that predispose the client to anxiety include abuse and neglect (physical or emotional), sexual violence, chronic illness, traumatic injuries, deaths of significant others, separation and divorce, or financial difficulties.
There is persuasive evidence that anxiety disorders are the most frequent psychiatric disorders in childhood, adolescence, and adulthood. Up to 12% of children and up to 32% of adolescents and adults in the community are estimated to have been diagnosed with any anxiety disorders. In addition to being highly prevalent, anxiety disorders tend to co-occur frequently both among themselves and with numerous other psychiatric disorders such as depression and substance use disorders. Studies have also reported that more females than males meet the diagnosis of anxiety disorders.
According to DSM-5. Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances. These include the following:
- Generalized anxiety disorder (GAD). This involves persistent and excessive worry that interferes with daily activities. This ongoing worry may be accompanied by physical symptoms.
- Panic disorder. The core symptom of panic disorder is recurrent panic attacks, an overwhelming combination of physical and psychological distress. Panic attacks may be expected, such as a response to a feared object, or unexpected, apparently occurring for no reason.
- Specific phobias. A specific phobia is an excessive and persistent fear of a specific object, situation, or activity that is generally not harmful. The client knows their fear is excessive, but they cannot overcome it.
- Agoraphobia. The fear of being in situations where escape may be difficult or embarrassing, or help might not be available in the event of panic symptoms. This includes situations such as using public transportation, being in open spaces, being in enclosed spaces, standing in line or being in a crowd, or being outside the home alone.
- Social anxiety disorder. A client with a social anxiety disorder has significant anxiety and discomfort about being embarrassed, humiliated, rejected, or looked down on in social interactions. People with this disorder will try to avoid or endure the situation with great anxiety.
- Separation anxiety disorder. A client with a separation anxiety disorder is excessively fearful or anxious about separation from those with whom they are attached. The feeling is beyond appropriate for the client’s age, persists for at least four weeks in children and six months in adults, and causes problems with functioning.
- Selective mutism. Children with selective mutism do not speak in some social situations where they are expected to speak, such as school, even though they speak in other situations. The lack of speech may interfere with social communication. Although children with this disorder sometimes use nonverbal means of communicating.
- Substance/medication-induced anxiety disorder. This disorder is characterized by anxiety or fear, sometimes accompanied by physical symptoms caused by the effects of a medication or psychoactive substance. These symptoms may occur while under the influence of the drug (intoxication) or after the use of the drug has stopped (withdrawal).
- Anxiety disorder due to a medical condition. When a client suffers from anxiety disorders due to a medical condition, the presence of that medical condition leads directly to the anxiety experienced. Anxiety is a predominant feature and may take the form of panic attacks, obsessive-compulsive behavior, or generalized anxiety.
Treatment usually consists of a combination of pharmacotherapy and/or psychotherapy. Decisions about treatment should be made in light of the severity of the disorder; the preference of the informed client, the expected latency and durability of the treatment effect, the expected side effects, and the availability of the treatment in question.
- Relieve the client’s fear and anxiety.
- Prevent the client from any risks of injury or to their safety.
- Restore the client’s quality of life into a functioning one.
- Adhere to all therapeutic regimens.
- Ensure timely follow-up of the client’s mental health once discharged.
The exact mechanism is not entirely known. Anxiety symptoms and the resulting disorders are thought to be due to disrupted modulation within the central nervous system. Physical and emotional manifestations of this dysregulation are the result of heightened sympathetic arousal of varying degrees.
Several neurotransmitter systems have been implicated to have a role in one or several of the modulatory steps involved. Many believe that low serotonin system activity and elevated nonadrenergic system activity are responsible for the development of this condition. Disruption of the gamma-aminobutyric acid (GABA) system has also been implicated because of the response of many anxiety spectrum disorders to treatment with benzodiazepines.
Epidemiology of Anxiety
The lifetime prevalence of anxiety disorders among American adults is 28.8%. Social anxiety disorder is the most common anxiety disorder.; it has an early age of onset- by 11 years of age in about 50% and by age 20 years in about 80% of individuals that have the diagnosis- and it is a risk factor for subsequent depressive illness and substance abuse.
The prevalence of specific anxiety disorders appears to vary between countries and cultures. The median prevalence of social anxiety disorder in Europe is 2.3%. In some Far East cultures, individuals with a social anxiety disorder may develop fears of being offensive to others rather than fears of being embarrassed.
The Epidemiological Catchment Area study found no difference in rates of panic disorder among white, African American, or Hispanic populations in the United States. The female-to-male ratio for any lifetime anxiety disorder is 3:2. For the age distribution for anxiety disorders, most begin in childhood, adolescence, and early adulthood.
Signs and Symptoms
The DSM-5 criteria for panic disorder include the experiencing of recurrent panic attacks, with one or more attacks followed by at least one month of fear of another panic attack or significant maladaptive behavior related to the attacks. A panic attack is an abrupt period of intense fear or discomfort accompanied by four or more of the following 13 systemic symptoms:
Common signs and symptoms
- Palpitations, pounding heart, or accelerated heart rate
- Trembling and 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
Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of events and activities. Worrying is difficult to control. Anxiety and worry are associated with at least three of the following six symptoms occurring more days not for at least six months:
- Restlessness or feeling keyed-up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Muscle tension
- Sleep disturbance
Although evidence-based treatments for anxiety disorders are available, large numbers of people do not seek treatment, do not respond to treatment, or experience a new episode over time. Therefore, it is increasingly being argued that treatment alone is not sufficient to alleviate the individual and societal burden associated with these disorders, but that this needs to be complemented by prevention.
- Learn relaxation techniques. Relaxation strategies, such as deep breathing, can reduce anxiety by lowering blood pressure and heart rate and reducing tension. Guided imagery can help reduce overwhelming anxiety through mental visualization to evoke relaxation.
- Participate in exercise programs. Exercise has been shown to decrease stress hormones that influence anxiety and also improve overall mood.
- Consume a healthy, balanced diet. A healthy diet is also important to reduce and prevent anxiety and help the client feel more at ease on a regular basis, despite stressors.
- Get enough rest and sleep. Taking some time to wind down can reduce stress and anxiety. Not getting enough sleep can trigger anxiety.
- Be aware of triggers for anxiety. A key component in the prevention of anxiety is awareness. Learning to recognize anxious thinking patterns when they arise can help the client with anxiety manage and reduce them quickly.
- Universal intervention programs. Preventive interventions are offered to all clients with anxiety without pre-selection.
- Reduce repetitive negative thinking (RNT). RNT, which involves rumination and worry, appears to be a promising target for prevention because it predicts future levels of anxiety, the onset of major depressive disorders, and substance abuse symptoms.
- School-based prevention programs. The effect of anxiety prevention programs is maintained at 6 to 12 months after the program is delivered and highlights the need for long-term follow-up assessments to establish whether gains remain at and beyond this point.
Anxiety disorders are manageable and treatable, and the vast majority of clients with anxiety disorders can be helped with professional care.
- Antidepressants. Antidepressant agents are the drugs of choice in the treatment of anxiety disorders, particularly the newer agents, which have a safer adverse effect profile and higher ease of use than the older tricyclic antidepressants (TCAs).
- Benzodiazepines. Intravenous or acute oral sedation with benzodiazepines may be used. Alprazolam has been widely used for panic disorder, but it is currently discouraged because of its higher dependence potential. Clonazepam has become a favored replacement because it has a longer half-life and elicits fewer withdrawal reactions upon discontinuation.
- Selective serotonin reuptake inhibitors (SSRIs). SSRIs relieve symptoms of anxiety by blocking reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which improves mood.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs). SNRIs are notable for a dual-mechanism of action: increasing the levels of the neurotransmitters serotonin and norepinephrine by inhibiting their reabsorption into cells in the brain. These agents are as effective as SSRIs, therefore they are considered a first-line treatment for anxiety disorders.
- Cognitive behavioral therapy (CBT). Behavioral therapy and CBT have demonstrated efficacy through controlled studies. Computerized CBT has been recommended for panic disorder and phobia by the National Institute for Health and Clinical Excellence guidelines (NICE).
- Exposure therapy. A form of CBT, exposure therapy is a process for reducing anxiety and fear responses. In therapy, the client is gradually exposed to a feared situation or object, learning to become less sensitive over time.
- Acceptance and commitment therapy. This type of therapy uses strategies of acceptance and mindfulness (living in the moment and experiencing things without judgment), along with commitment and behavior change, as a way to cope with unwanted thoughts, feelings, and sensations.
- Dialectical behavioral therapy (DBT). Integrating cognitive-behavioral techniques with concepts from Eastern meditation, DBT combines acceptance and change. DBT involves individual and group therapy to learn mindfulness, as well as skills for interpersonal effectiveness, tolerating distress, and regulating emotions.
- Cranial electrotherapy stimulator (CES). In 2019, the FDA approved a cranial electrotherapy stimulator (CES) for the treatment of anxiety, depression, and insomnia. The prescription device delivers micro pulses of electrical current across the brain, which in clinical trials led to a reduction in anxiety levels, insomnia, and depressed mood.
- Transcranial magnetic stimulation (TMS). this may be a safe, effective, and noninvasive option for people who have depression that has not improved with medications. TMS creates a magnetic field to induce a small electric current in a specific part of the brain; the current comes from the magnetic field created by an electromagnetic coil that delivers pulses through the scalp (Anxiety & Depression Association of America.
Assessment and Diagnosis
Nursing assessments for anxiety and diagnosis play a vital role in the comprehensive care of a client with anxiety disorder. The assessment begins with a thorough examination of the client’s physical and psychological health, taking into account their medical history, current symptoms, and any potential triggers. The nurse may also conduct a mental status examination to assess cognitive functioning and evaluate the client’s overall mental well-being.
Mental Health Assessment
Anxiety is a nonspecific syndrome and can be due to a variety of medical or psychiatric syndromes. For a client who presents for a repeat visit with similar complaints, after medical contributors have been ruled out, a careful mental status examination might be better suited.
- Assess suicidal ideation. Ask the client about passive thoughts of death, desires to be dead, thoughts of harming self, or plans or acts to harm self.
- Assess the client’s cognition. Cognition is typically intact with no impairment in memory, language, or speech.
- Assess for GAD. Two main elements of the mental status examination should be assessed in GAD. The first involves asking about suicidal/homicidal ideation or plan and the second involves formal testing of orientation or recall.
- Assess the client’s mood. The client’s mood may be described as similar to “anxious”, with congruent affect. Incongruent affect should raise consideration for other diagnostic possibilities.
- Assess thought process and content. Thought processes should be logical, linear, and goal-directed. Though content is particularly important to specifically assess in order to ensure the client has no suicidal or homicidal thoughts.
Because symptoms of anxiety manifest with a number of physical symptoms, any client who presents with a de novo complaint of physical symptoms suggesting an anxiety disorder should have a physical assessment and basic laboratory workup to rule out medical conditions that might present with anxiety-like symptoms. In panic disorder, no signs on physical examination are specific. The diagnosis is primarily made by history. Findings during the physical assessment for a client diagnosed with anxiety or panic disorder include the following:
- Anxious appearance. The client may have an anxious appearance. A client manifesting in an acute state of panic can physically manifest any anticipated sign of an increased sympathetic state.
- Alterations in vital signs. Tachycardia and tachypnea are common; blood pressure and temperature may be within the reference range, though hypertension may occur as well.
- Hyperventilation. Hyperventilation may be difficult to detect by observing breathing because the respiratory rate and tidal volume may appear normal.
Common physical signs of a generalized anxiety disorder include:
- Sweaty palms
- Stomach cramping
- A feeling of a lump in the throat or inability to swallow
- Frequent need to urinate
- Dry mouth
- Cold/clammy hands
- Neck or backaches
There are no specific laboratory or diagnostic tests for a client with anxiety disorder. However, initial laboratory testing may be done to rule out the possibility of other medical conditions.
- Complete blood count
- Chemistry profile
- Thyroid function tests
- Urine drug screen
Prior to medication treatment, testing for drugs of abuse, pregnancy, and screening tests for diabetes mellitus must be done. Anxiety disorders are typically diagnosed through a comprehensive evaluation that involves various components. The diagnostic criteria outlined in DSM-5 are used as a standard guideline for diagnosing anxiety disorders. The nurse may compare the client’s reported symptoms and experiences with the specific criteria for various anxiety disorders. Structured or semi-structured clinical interviews may be employed to gather additional information about the client’s anxiety symptoms, their frequency, intensity, duration, and the impact on daily functioning. Screening tools and questionnaires, such as the Generalized Anxiety Disorder 7-item scale (GAD-7) or the Hamilton Anxiety Rating Scale, may be utilized to assess the severity of the symptoms of anxiety and track changes over time.
The nursing management of a client with anxiety disorder involves a holistic approach that focuses on providing comprehensive care, support, and education to help alleviate the symptoms and improve the client’s overall well-being. Establishing nursing care plans together with the client or family members is essential for active participation and adherence to the therapeutic regimen.
Conduct a thorough nursing assessment to gather detailed information about the client’s anxiety symptoms, triggers, coping strategies, and their impact on daily functioning. Standardized assessment tools, observation of behavioral cues, and communication can effectively identify the severity of anxiety.
- Disturbed sleep patterns
- Feelings of hyperactivity
- Feeling cold even when the room is warm
- Feeling a lack of sense of control
- Stress factors-family move, divorce, the onset of puberty
- Generalized vague complaints
- Feelings of choking
- Chest pain or discomfort
- Fear of losing control or dying
- Cold hands and feet
- Emotional states of depression or anxiety
- Weight loss
- Frequent sighs or difficulty with breath holding
Nursing diagnoses applicable for a client diagnosed with anxiety include:
- Anxiety related to a real or perceived threat to physical integrity or self-concept, unconscious conflict about essential valuers/beliefs and goals in life, unmet needs, negative self-talk
- Ineffective coping related to the level of anxiety experienced, personal vulnerability
- Disturbed sleep patterns related to psychological stress, repetitive thoughts
- Risk for compromised family coping related to temporary family disorganization and role changes
- Impaired social interaction related to low self-concept, inadequate personal resources, hypervigilance
- Risk for ineffective health management related to complexity of therapeutic regimen, decisional conflicts, family conflict
- Imbalanced nutrition: less than body requirements related to lack of appetite
- Disturbed thought process related to perceived lack of control
Nursing Care Planning and Goals
The goals appropriate for the care of a client diagnosed with anxiety are:
- The client will acknowledge and discuss feelings.
- The client will display an appropriate range of feelings and lessened fear.
- The client will appear relaxed and report anxiety is reduced to a manageable level.
- The client will demonstrate the use of effective coping mechanisms and active participation in the treatment regimen.
- The client will demonstrate the ability to problem solve appropriately for the individual situation.
- The client will use resources and support systems effectively.
Nursing Interventions for Anxiety
- Determine the degree of anxiety or fear present.
- Determine the presence of physical symptoms such as numbness headache, tightness in the chest, nausea, and pounding heart.
- Develop a trusting relationship with the client.
- Discuss with the client the perception of what is causing anxiety or panic.
- Assist the client to correct any distortions being experienced. Share perceptions with the client.
- Assist the client in identifying appropriate short- and long-term goals.
- Assist the client to solve problems in a constructive manner.
- Provide factual information concerning the diagnosis, treatment, and prognosis.
- Encourage an attitude of realistic hope as a way of dealing with feelings of anxiety.
- Acknowledge the client’s spiritual/cultural background, and encourage the use of spiritual resources as appropriate.
- Appraise the needs and desires for social support, and assist the client to identify available support systems.
- Assist the client to identify positive strategies to deal with limitations, manage needed lifestyle or role changes, and work through the losses of chronic illness and/or disability as appropriate.
- Encourage the client to perform relaxation techniques, such as progressive muscle relaxation, the Benson relaxation response, and relaxation with guided imagery.
- Progressive muscle relaxation involves tensing and releasing the muscles of the body in sequence and sensing the difference in feeling.
- The Benson relaxation response combines meditation with relaxation. Along with the repeated word or phrase, a passive demeanor is essential. The exercise works best on an empty stomach, regardless of the time of the day.
- In guided imagery, the nurse can help the client select a pleasant scene or experience, such as watching the ocean r dabbling the feet in a cool stream. The image serves as the mental device in this technique. As the client sits comfortably and quietly, the nurse guides the person to review the scene, trying to feel and relive the imagery with all of the senses.
- Provide education about stress management through sensory information and procedural information to reduce stress and improve the client’s coping ability.
- Encourage the family and friends to provide emotional support to give a sense of sharing the burden. Being able to talk with someone and express feelings openly may help the client gain mastery of the situation.
- Provide recommendations to support and therapy groups. Many find that being a member of a group with similar problems or goals has a releasing effect that promotes freedom of expression and the exchange of ideas.
- Help the family support the client emotionally by being available and through active listening.
After the implementation of nursing interventions, the nurse evaluates if the desired goals and outcomes were achieved. The nurse needs to ensure that:
- The client and the family deal with the situation realistically.
- Anxiety and fear are manageable.
- A safe environment is maintained.
- The nursing care plan is in place to meet needs after discharge.
Discharge and Home Care Guidelines
For clients discharged to their homes, monitoring should be performed on a continual basis based on the following parameters, which help in the overall management of the disease.
- Education and self-care practices. Provide comprehensive education to the client and their family members about anxiety disorder, including its symptoms, triggers, and management strategies. Teach relaxation techniques, stress management techniques, and coping skills.
- Medication instructions. If the client is prescribed medications for anxiety, ensure that they understand the dosage, timing, and potential side effects. Emphasize the importance of adhering to the prescribed medication regimen. Encourage the client to keep track of their medication schedule and refill prescriptions in a timely manner.
- Safety precautions. Assess the client’s home environment for potential safety concerns. Discuss strategies to create a calm and supportive environment at home, such as minimizing noise, creating a comfortable sleep space, and reducing clutter that may contribute to anxiety.
- Self-monitoring. Teach the client to recognize and track their anxiety symptoms. Encourage them to maintain a journal or use an anxiety-tracking app to record triggers, symptoms, and their effectiveness in managing anxiety.
- Follow-up schedule. Schedule and emphasize the importance of follow-up appointments with the healthcare provider to monitor the client’s progress, adjust the treatment plan if needed, and provide ongoing support.
- Encourage healthy lifestyle habits. Reinforce the importance of maintaining a healthy lifestyle. Encourage the client to engage in regular physical activities, practice relaxation techniques, and maintain a balanced diet.
The focus of documentation on a client diagnosed with anxiety should include the following:
- Level of anxiety and precipitating/aggravating factors
- Description of feelings
- Awareness or ability to recognize and express feelings
- Related substance abuse if applicable
- Treatment plan and individual responsibility for specific activities
- Teaching plan
- Client involvement and response to interventions/teaching and actions performed
- Attainment/progress toward desired outcomes
- Modifications to plan of care
- Referrals and follow-up plan
- Specific referrals made
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