References:
- Psychiatric-Mental Health Nursing, 8th Edition, 978-1-975116-37-8, by Sheila L. Videbeck
- Lecturers (Jimenez)
Anxiety is a vague, unpleasant feeling of apprehension; it is a response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms. It normally motivates a person to take action for resolving a problem or crisis, but it can become abnormal when excessive, chronic, and results in impairment of major functioning e.g. panic without reason, phobias, and uncontrollable repetitive actions. Underlying causes of anxiety include:
- Interpersonal Factors: fear of interpersonal rejection; traumatic or dysfunctional relationships.
- Behavioral Factors: exposure to early negative life circumstances and learned responses to frustration.
- Psychoanalytic Factor: anxiety is produced by conflicts between the id and the superego.
Anxiety causes uncomfortable cognitive, psychomotor, and physiological responses, such as difficulty with logical thought, increasingly agitated motor activity, and elevated vital signs. Anxiety can be categorized into four types based on the presenting behaviors and the level of distress experienced by the individual. Hildegard Peplau outlined four levels of anxiety: mild, moderate, severe, and panic.
- Mild anxiety is a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect him or herself. Mild anxiety often motivates people to make changes or engage in goal-directed activity. For example, it helps students focus on studying for an examination.
- Mild anxiety is an asset to the client and requires no direct intervention. People with mild anxiety can learn and solve problems and are even eager for information. Teaching can be effective when the client is mildly anxious.
- Moderate anxiety is the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated. In moderate anxiety, the person can still process information, solve problems, and learn new things with assistance from others. He or she has difficulty concentrating independently but can be redirected to the topic. For example, the nurse might be giving preoperative instructions to a client who is anxious about the upcoming surgical procedure. As the nurse is teaching, the client’s attention wanders, but the nurse can regain the client’s attention and direct him or her back to the task at hand.
- With moderate anxiety, the nurse must be certain that the client is following what the nurse is saying. The client’s attention can wander, and he or she may have some difficulty concentrating over time. Speaking in short, simple, and easy-to-understand sentences is effective; the nurse must stop to ensure that the client is still taking in information correctly. The nurse may need to redirect the client back to the topic if the client goes off on a tangent.
- As the person progresses to severe anxiety and panic, more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantly. A person with severe anxiety has trouble thinking and reasoning. Muscles tighten, and vital signs increase. The person paces; is restless, irritable, and angry; or uses other similar emotional–psychomotor means to release tension.
- With moderate anxiety, the nurse must be certain that the client is following what the nurse is saying. The client’s attention can wander, and he or she may have some difficulty concentrating over time. Speaking in short, simple, and easy-to-understand sentences is effective; the nurse must stop to ensure that the client is still taking in information correctly. The nurse may need to redirect the client back to the topic if the client goes off on a tangent.
- In panic, the emotional–psychomotor realm predominates with accompanying fight, flight, or freeze responses. Adrenaline surge greatly increases vital signs. Pupils enlarge to let in more light, and the only cognitive process focuses on the person’s defense.
- During panic anxiety, the person’s safety is the primary concern. He or she cannot perceive potential harm and may have no capacity for rational thought. The nurse must keep talking to the person in a comforting manner, even though the client cannot process what the nurse is saying. Going to a small, quiet, and nonstimulating environment may help reduce anxiety. The nurse can reassure the person that this is anxiety, it will pass, and he or she is in a safe place. The nurse should remain with the client until the panic recedes. Panic-level anxiety is not indefinite, but it can last from 5 to 30 minutes.
| Type | Perception | Behavioral | Coping | Nursing Management | Medical Management |
|---|---|---|---|---|---|
| Mild | Widened | Alert, Energetic, Attentive | Adaptive | Encourage verbalization | N/A |
| Moderate | Narrowed | Distracted, Pacing | Palliative | Refocus (grounding techniques), Supervision, KISS | PO Anxiolytic |
| Severe | Distorted | Impaired thinking, Confusion, Disorientation | Excessive, Maladaptive | Relaxation, Less Stimuli, Presence, Listening | IM Anxiolytic |
| Panic | Disorganized | Immobilization, Mute/Hysterical, Irrational, Overwhelmed (Suicidal), Potential Hallucination/Delusion | Dysfunctional | Safety, Less Stimuli, Presence (judicious touch) | N/A |
Anxiety Medications
Gamma aminobutyric acid (GABA) is a neurotransmitter that reduces the activity of nerve cells in the brain, promoting relaxation and reducing anxiety. A deficiency in GABA is associated with anxiety. Benzodiazepines enhance GABA’s inhibitory effects by binding to specific receptors, which results in a calming and sedative effect.
- Benzodiazepines: Valium (diazepam) and Librium (chlordiazepoxide) are examples of benzodiazepines used to treat anxiety disorders. Other commonly prescribed benzodiazepines include Xanax (alprazolam), Ativan (lorazepam), and Klonopin (clonazepam).
- Side Effects: drowsiness, dizziness, impaired coordination, memory problems, and a risk of dependency and addiction when used for an extended period.
- Alcohol and caffeine can interact with these medications and increase their sedative effects, leading to dangerous drowsiness and impairment.
- Signs of Withdrawal: Prolonged use of benzodiazepines can lead to physical dependence, and abrupt discontinuation can result in withdrawal symptoms (e.g., anxiety, insomnia, irritability, tremors, sweating, seizures). It’s crucial to taper off benzodiazepines under the supervision of a healthcare provider to minimize these withdrawal symptoms.
- Treatment for Withdrawal: If someone is experiencing benzodiazepine withdrawal, they should seek medical help immediately. Treatment may involve gradually reducing the dosage (tapering) to minimize withdrawal symptoms. In severe cases, healthcare providers may prescribe medications like diazepam or phenobarbital to manage withdrawal symptoms and prevent seizures.
Seizures
Seizures are the target of prevention for patients with withdrawal from benzodiazepines. The nurse helps with tapering medication, maintaining fluid and electrolyte balance, reducing stimuli and seizure triggers, and instituting an emergency plan in the even of a seizure.
Anxiety Disorders
Anxiety disorders comprise a group of conditions that share a key feature of excessive anxiety with ensuing behavioral, emotional, cognitive, and physiological responses. Unusual behaviors can appear, such as panic without reason, unwarranted fear of objects or life conditions, or unexplainable or overwhelming worry. They experience significant distress over time, and the disorder significantly impairs their daily routines, social lives, and occupational functioning.
- Agoraphobia
- Panic Disorder (most common)
- Specific phobia
- Social anxiety disorder (social phobia)
- Generalized anxiety disorder (GAD)
Treatment
Treatment for anxiety disorders usually involves medication and therapy. This combination produces better results than either one alone. Cognitive-behavioral therapy (CBT) is used successfully to treat anxiety disorders.
- Positive reframing means turning negative messages into positive messages. The therapist teaches the client to create positive messages for use during panic episodes. For example, instead of thinking, “My heart is pounding. I think I’m going to die,” the client things, “I can stand this. This is just anxiety. It will go away.” The client can write down these messages and keep them readily accessible, such as in an address book, a calendar, or a wallet.
- Decatastrophizing involves the therapist’s use of questions to more realistically appraise the situation. The therapist may ask, “What is the worst thing that could happen? Is that likely? Could you survive that? Is that as bad as you imagine?” The client uses thought-stopping and distraction techniques to jolt him or herself from focusing on negative thoughts. Splashing the face with cold water, snapping a rubber band worn on the wrist, or shouting are all techniques that can break the cycle of negative thoughts.
- Assertiveness training helps the person take more control over life situations. These techniques help the person negotiate interpersonal situations and foster self-assurance. They involve using “I” statements to identify feelings and to communicate concerns or needs to others. Examples include “I feel angry when you turn your back while I’m talking,” “I want to have 5 minutes of your time for an uninterrupted conversation about something important,” and “I would like to have about 30 minutes in the evening to relax without interruption.”