Anxiety disorders are a group of mental health conditions characterized by persistent feelings of fear, worry, and apprehension that go beyond normal levels of stress. These disorders can significantly impact a person’s thoughts, emotions, and daily life.
While it’s natural to experience occasional anxiety in response to challenging situations, anxiety disorders involve excessive and irrational fear that can become overwhelming and disruptive. They encompass a range of specific disorders, each with unique symptoms and triggers, such as generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias.
This nursing note provides a glimpse into the world of anxiety disorders, discussing their types, symptoms, causes, nursing interventions, and the importance of seeking appropriate treatment and support.
Table of Contents
- What are Anxiety Disorders?
- Types of Anxiety Disorders
- Statistics and Incidences
- Clinical Manifestations
- Assessment and Diagnostic Findings
- Medical Management
- Nursing Management
What are Anxiety Disorders?
Anxiety disorders involve disorders that contain characteristics of excessive fear and anxiety and linked behavioral disturbances. It manifests as a prolonged and dysfunctional reaction to stress, influenced by variations in one’s genetic predisposition, developmental factors, and life experiences.
Types of Anxiety Disorders
The characteristic features of this group of disorders are symptoms of anxiety and avoidance behavior. Anxiety disorders are categorized in the following manner:
- Panic disorder (with or without agoraphobia). Panic disorder is characterized by by recurrent panic attacks, the onset of which are unpredictable, and manifested by intense apprehension, fear or terror, often associated with feelings of impending doom, and accompanied by intense physical discomfort.
- Agoraphobia without history of panic disorder. The APA 2000 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) identifies the essential feature of this disorder as fear of being in places or situations from which escape might be difficult or in which help might not be available in the event of suddenly developing a symptoms(s) that could be incapacitating or extremely embarrassing.
- Social phobia. Social phobia is characterized by a persistent fear of behaving or performing in the presence of others in a way that will be humiliating or embarrassing to the individual.
- Specific phobia. Formerly called simple phobia, this disorder is characterized by persistent fears of specific objects or situations.
- Obsessive-compulsive disorder. This disorder is characterized by involuntary recurring thoughts or images that the individual is unable to ignore and by recurring impulse to perform a seemingly purposeless activity.
- Posttraumatic stress disorder. Posttraumatic stress disorder is characterized by the development of physiological and behavioral symptoms following a psychologically traumatic event that is generally outside the range of usual human experience.
- Acute stress disorder. Acute stress disorder is characterized by the development of physiological and behavioral symptoms similar to those of PTSD; the major difference in the diagnosis lies in the length of time the symptoms exist; with acute stress disorder, the symptoms must subside within 4 weeks of occurrence of the stressor.
- Anxiety disorder due to a general medical condition. The symptoms of this disorder are judged to be the direct physiological consequence of a general medical condition.
- Substance-induced anxiety disorder. The DSM-IV-TR (APA, 2000) describes the essential features of this disorder as prominent anxiety symptoms that are judged to be caused by the direct physiological effects of a substance.
Obsessive-compulsive disorder (included in the obsessive-compulsive and related disorders), posttraumatic stress disorder (included in the trauma and stress-related disorders), and acute stress disorder, are no longer considered anxiety disorders as they were in the previous version of the DSM. Nonetheless, these disorders are closely linked to anxiety disorders and the sequential order of these chapters in the DSM-5 reflects this close connection.
The brain circuits and regions associated with anxiety disorders are beginning to be understood with the development of functional and structural imaging.
- In the central nervous system (CNS) the major mediators of the symptoms of anxiety disorders 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.
Statistics and Incidences
Anxiety disorders are the most common type of psychiatric disorder in the United States.
- 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 age 11 years 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%.
- The female-to-male ratio for any lifetime anxiety disorder is 3:2.
Predisposing factors for anxiety disorder include the following:
- Biochemical. Increased levels of norepinephrine have been noted in panic and generalized anxiety disorders; abnormal elevations of blood lactate have also been noted in patients with panic disorder.
- Genetic. Studies suggest that anxiety disorders are prevalent within the general population; it has been shown that they are more common among first-degree biological relatives of people with the disorders than among the general population.
- Medical or substance-induced. Anxiety disorders may be caused by a variety of medical conditions or the ingestion of various substances.
- Psychodynamic theory. The psychodynamic view focuses on the inability of the ego to intervene when conflict occurs between the superego and the id, producing anxiety.
- Cognitive theory. The main thesis of the cognitive view is that faulty, distorted, or counterproductive thinking patterns accompany or precede maladaptive behaviors and emotional disorders.
Signs and symptoms of anxiety disorders may include the following:
- Pounding, rapid heart rate.
- Feeling of choking or smothering.
- Difficulty breathing.
- Pain in the chest.
- Feeling dizzy or faint.
- Increased perspiration.
- Feeling of numbness or tingling in the extremities.
- Fear that one is dying or going crazy.
- Sense of impending doom.
- Feelings of unreality (derealization and/or depersonalization).
Assessment and Diagnostic Findings
For presentations with a higher index of suspicion for other medical causes of anxiety, more detailed evaluations may be indicated to identify or exclude underlying medical disorders.
- EEG, lumbar puncture, and head/brain imaging. Rule out CNS disorder using EEG, lumbar puncture, and brain computed tomography scan, as indicated by history and associated clinical findings.
- Electrocardiography. Rule out cardiac disorders using electrocardiography or treadmill ECG.
- Tests for infection. Rule out infectious causes using rapid plasma reagent test, lumbar puncture, or HIV testing.
- Arterial blood gas analysis. Arterial blood gas analysis is useful in confirming hyperventilation and excluding hypoxemia or metabolic acidosis.
- Chest radiography. Chest radiography is useful in excluding other causes of dyspnea with chest pain.
- Thyroid function. Hyperthyroidism is one of the most common medical causes of anxiety related to a medical condition.
Treatment usually consists of a combination of pharmacotherapy and/or psychotherapy.
- Cognitive therapy. Cognitive therapy helps patients understand how automatic thoughts and false beliefs/distortions lead to exaggerated emotional responses, such as anxiety, and can lead to secondary behavioral consequences.
- Behavioral therapy. Behavioral therapy involves sequentially greater exposure of the patient to anxiety-provoking stimuli; over time, the patient becomes desensitized to the experience.
- Diet. Caffeine-containing products, such as coffee, tea, and colas, should be discontinued.
Antidepressant agents are the drugs of choice in the treatment of anxiety disorders, particularly the newer agents that have a safer adverse effect profile and higher ease of use than the older tricyclic antidepressants.
- Selective serotonin reuptake inhibitors. The SSRIs are first-line agents for the long-term management of anxiety disorders, with control gradually achieved over a 2-to 4-wk course, depending on required dosage increases.
- Serotonin and norepinephrine reuptake inhibitors. Pharmacologic agents with reuptake inhibition of serotonin and norepinephrine may be helpful in a variety of mood and anxiety disorders.
- Atypical antidepressants. Antidepressants that are not FDA-approved for the treatment of a given anxiety disorder still may be beneficial for the treatment of anxiety disorders; mirtazapine acts distinctly as an alpha-2 antagonist, consequently increasing synaptic norepinephrine and serotonin, while also blocking some postsynaptic serotonergic receptors that conceptually mediate excessive anxiety when stimulated with serotonin.
- Tricyclic antidepressants. Tricyclic antidepressants are a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects.
- Benzodiazepines. Benzodiazepines often are used with antidepressants as adjunct treatment; they are especially useful in the management of acute situational anxiety disorder and adjustment disorder where the duration of pharmacotherapy is anticipated to be 6 weeks or less and for the rapid control of anxiety attacks.
- Antianxiety agents. Buspirone is a non-sedating antipsychotic drug unrelated to benzodiazepines, barbiturates, and other sedative-hypnotics; it has fewer cognitive and psychomotor adverse effects, which makes its use preferable in elderly patients.
- Anticonvulsant. The drug of choice in this category is the gamma-aminobutyric acid derivative pregabalin (Lyrica).
- Antihypertensive agent. Agents in this class may have a positive effect on the physiological symptoms of anxiety; beta-blockers may be useful for the circumscribed treatment of situational/performance anxiety on an as-needed basis.
- Monoamine oxidase inhibitor (MAOI). MAOIs are most commonly prescribed for patients with social phobia.
- Antipsychotic agent. Atypical and typical antipsychotic medications are generally used more as augmentation strategies and are second-line treatment options in generalized anxiety disorder.
Nursing management of a patient with anxiety disorder includes the following:
Nursing assessment of a patient with anxiety disorder includes:
- History. The client usually seeks treatment for panic disorder after he or she has experienced several panic attacks; usually, the client cannot identify any trigger for these events.
- General appearance and motor behavior. The client may appear entirely “normal” or may have signs of anxiety if he or she is apprehensive about having a panic attack in the next few moments.
- Mood and affect. Assessment of mood and affect may reveal that the client is anxious, worried, tense, depressed, serious, or sad.
- Thought processes and content. During a panic attack, the client is overwhelmed, believing that he or she is dying, losing control, or “going insane”; the client may even consider suicide.
- Sensorium and intellectual process. During a panic attack, the client may be confused and disoriented; he or she cannot take in environmental cues and respond appropriately.
- Anxiety related to unconscious conflict about essential values and goals of life; situational or maturational crises.
- Fear related to phobic stimulus.
- Ineffective coping related to underdeveloped ego; punitive superego.
- Powerlessness related to fear of disapproval from others.
- Social isolation related to panic level of anxiety.
Nursing Care Planning and Goals
The major nursing care planning goals for patients with Anxiety Disorders are:
- The client will verbalize ways to intervene in escalating anxiety within 1 week.
- The client will be able to recognize symptoms of the onset of anxiety and intervene before reaching the panic stage by the time of discharge from treatment.
The nursing interventions for anxiety disorders are:
- Stay calm and be non-threatening. Maintain a calm, nonthreatening manner while working with clients; anxiety is contagious and may be transferred from staff to client or vice versa.
- Assure the client of safety. Reassure the client of his or her safety and security; this can be conveyed by the physical presence of the nurse; do not leave the client alone at this time.
- Be clear and concise with words. Use simple words and brief messages, and speak calmly and clearly, to explain hospital experiences to the client; in an intensely anxious situation, the client is unable to comprehend anything but the most elementary communication.
- Provide a non-stimulating environment. Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor); a stimulating environment may increase the level of anxiety.
- Administer medications as prescribed. Administer tranquilizing medication, as ordered by physician; assess medication for effectiveness and for adverse side effects.
- Recognize precipitating factors. When level of anxiety has been reduced, explore with client possible reasons for occurrence; recognition of precipitating factors is the first step in teaching client to interrupt escalation of anxiety.
- Encourage client to verbalize feelings. Encourage client to talk about traumatic experience under nonthreatening conditions; help client work through feelings of guilt related to the traumatic event; help client understand that this was an event to which most people would have responded in like manner.
The outcome criteria for Anxiety Disorders include:
- Client is able to maintain anxiety at level in which problem solving can be accomplished.
- Client is able to verbalize signs and symptoms of escalating anxiety.
- Client is able to demonstrate techniques for interrupting the progression of anxiety to the panic level.
Documentation guidelines include the following:
- Individual findings include factors affecting, interactions, the nature of social exchanges, and specifics of individual behavior.
- Cultural and religious beliefs, and expectations.
- Plan of care.
- Teaching plan.
- Responses to interventions, teaching, and actions performed.
- Attainment or progress toward the desired outcome.