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Chapter 8
Anxiety and Anxiety Disorders
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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Concept of Anxiety and
Psychiatric Nursing
• Anxiety
– Universal human experience
– Dysfunctional behavior often defends against
anxiety
• Legacy of Hildegard Peplau (1909-1999)
– Operationally defined concept and levels of
anxiety
– Suggested specific nursing interventions
appropriate to each of four levels of anxiety
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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Anxiety and Fear
• Anxiety: feeling of apprehension,
uneasiness, uncertainty, or dread resulting
from real or perceived threat whose actual
source is unknown or unrecognized
• Fear: reaction to specific danger
• Similarity between anxiety and fear
– Physiological response to these experiences
is the same (fight-or-flight response)
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Types of Anxiety
• Normal
– Motivating force that provides energy to carry
out tasks of living
• Acute or state
– Anxiety that is precipitated by imminent loss
or change that threatens one’s security (crisis)
• Chronic or trait
– Anxiety that persists over time
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Levels of Anxiety: Mild and Moderate
• Mild
– Occurs in normal everyday living
– Increases perception, improves problem
solving
– Manifested by restlessness, irritability, mild
tension-relieving behaviors
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Levels of Anxiety: Mild and Moderate
• Moderate
– Escalation from normal experience
– Decreases productivity (selective inattention)
and learning
– Manifested by increased heart rate,
perspiration, mild somatic symptoms
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Levels of Anxiety: Severe and Panic
• Severe
– Greatly reduced perceptual field
– Learning and problem solving not possible
– Manifested by erratic, uncoordinated, and
impulsive behavior
• Panic
– Results in loss of reality focus
– Markedly disturbed behavior occurs
– Manifested by confusion, shouting,
screaming, withdrawal
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Nursing Interventions for Mild to
Moderate Anxiety
• Use of therapeutic communication and
listening
– Open-ended statements
– Broad openings
– Seeking clarification
– Exploration
• Importance of nurse remaining calm,
recognizing patient’s distress
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Nursing Interventions for
Severe to Panic Anxiety
• Reduce environmental stimuli
– Remove patient to quiet area
– Remain with patient
• Gross motor activity to drain tension
• Therapeutic communication techniques
– Firm, short, and simple statements
– Reinforce reality
• Medications and restraints
– Used only after least restrictive measures fail
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Defense Mechanisms
• Help protect people from painful
awareness of feelings and memories that
can cause overwhelming anxiety
– Operate all the time
– Adaptive (healthy) or maladaptive (unhealthy)
• First outlined and described by Sigmund
Freud and his daughter Anna Freud
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Properties of Defense Mechanisms
• Major means of managing conflict and
affect
• Relatively unconscious
• Discrete from one another
• Hallmarks of major psychiatric disorders
• Can be reversible
• Can be adaptive as well as pathological
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Healthy, Intermediate, and Immature
Defense Mechanisms
• Healthy
– Altruism, sublimation, humor, suppression
• Intermediate
– Repression, displacement, reaction formation,
undoing, rationalization
• Immature
– Passive aggression, acting-out behaviors,
dissociation, devaluation, idealization,
splitting, projection, denial
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Anxiety Disorders: General Information
• Prevalence
– Most prevalent lifetime psychiatric disorder
• Chief characteristic
– Use of rigid, repetitive, and ineffective
behaviors to try and control anxiety
• Comorbidity
– Often occur with other psychiatric disorders
as well as with medical illness
• Depression, substance abuse, eating disorders
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Biological Theories Related to
Anxiety Disorders
• Genetics
– Anxiety disorders cluster in families
• GABA benzodiazepine (BZA)
– BZA receptors are linked to a receptor that
inhibits GABA
– BZA medications that bind to BZA receptors
increase action of GABA and promote calm
(decreased anxiety)
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Biological Theories Related to
Anxiety Disorders
• Hypothalamus-pituitary-adrenal
dysfunction
– Stress response of patients with PTSD is
abnormal
• Brain anatomy can change as result of
repeated trauma (validated by
neuroimaging)
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Other Theories Related to
Anxiety Disorders
• Learning and behavioral theory
– Anxiety is a learned response from modeling
from parents and/or peers
• Cognitive theory
– Anxiety is caused by distortions in thinking
and perceiving
– Cognitive-behavioral therapy yields best
results in treatment of anxiety disorders
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Other Theories Related to
Anxiety Disorders
• Cultural considerations
– Sociocultural variation in symptoms of anxiety
disorders noted
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Panic Disorders: Panic Attack, Panic
Disorder with Agoraphobia
• Panic attack
– Sudden onset of extreme apprehension or fear
of impending doom
– Fear of losing one’s mind or having a heart
attack
• Panic disorder with agoraphobia
– Panic attacks combined with agoraphobia
• Agoraphobia is fear of being in places or situations
from which escape is difficult or help unavailable
– Feared places avoided, restricting one’s life
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Phobias
• Phobia: persistent, irrational fear of
specific objects, activities, or situations
• Types of phobias
– Specific: response to specific objects
– Social: result of exposure to social situations
or required performance
– Agoraphobia: fear of being in
places/situations from which escape is difficult
or help unavailable
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Obsessive-Compulsive Disorder
• Obsession
– Thoughts, impulses, or images that persist
and recur
• Ego-dystonic symptom: feels unacceptable to
individual
• Compulsion
– Ritualistic behaviors that individual feels
driven to perform
• Primary gain from compulsive behavior: anxiety
relief
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Generalized Anxiety Disorder (GAD)
• Excessive anxiety or worry about
numerous things lasting at least 6 months
• Common symptoms
– Restlessness
– Fatigue
– Poor concentration
– Irritability
– Tension
– Sleep disorders
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Posttraumatic Stress Disorder (PTSD)
• Reexperiencing highly traumatic event
• Characterized by:
– Recurrent dreams or flashbacks (dissociative
experiences in which event is relived)
– Avoidance of stimuli associated with trauma
– Numbing of responsiveness (feeling empty)
– Persistent symptoms of increased arousal
(irritability, difficulty sleeping/concentrating,
exaggerated startle response)
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Acute Stress Disorder
• Occurs within 1 month after exposure to
highly traumatic event
• Characterized by at least three
dissociative symptoms during/after event
– Subjective sense of numbing
– Reduction in awareness of surroundings
– Derealization
– Depersonalization
– Dissociative amnesia
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Anxiety Caused by Medical Conditions
• Direct physiological result of medical
conditions such as:
– Hyperthyroidism
– Pulmonary embolism
– Cardiac dysrhythmias
• Evidence must be present in history,
physical exam, or laboratory findings in
order to diagnose
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Nursing Process:
Assessment Guidelines
• Determine if anxiety is primary or
secondary (due to medical condition)
– Ensure sound physical/neurological exam
• Use of Hamilton Rating Scale
– Comprehensive data related to anxiety
• Determine potential for self-harm/suicide
• Perform psychosocial assessment
• Determine cultural beliefs and background
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Nursing Process: Diagnosis and
Outcomes Identification
• NANDA-International (NANDA-I)
– Nursing diagnoses useful for patient with
anxiety or anxiety disorder
• Nursing Outcomes Classification (NOC)
– Identifies desired outcomes for patients with
anxiety or anxiety disorders
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Considerations for Outcome Selection
for Patients with Anxiety Disorders
• Reflect patient values and ethical and
environmental situations
• Be culturally relevant
• Be documented as measurable goals
• Include a time estimate of expected
outcomes
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Nursing Process:
Planning and Implementation
• Planning
– Select interventions that can be implemented
in a community setting
– Include patient in process of planning
• Implementation
– Follow Psychiatric–Mental Health Nursing:
Scope and Standards of Practice (ANA, 2007)
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Nursing Interventions for Patients with
Anxiety Disorders
• Identify community resources offering
specialized treatments proven as effective
• Identify community support groups
• Use therapeutic communication, milieu
therapy, promotion of self-care activities,
and psychobiological and health teaching
and health promotion
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Nursing Interventions: Milieu Therapy
• Used as part of treatment approach for
patient with anxiety disorder who is
hospitalized
• Guiding principles
– Structure daily routine
– Provide daily activities to promote interaction
– Provide therapeutic interactions
– Include patient in decision making
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Treatment for Anxiety Disorder:
Cognitive-Behavioral Therapy (CBT)
• Therapist teaches patient to:
– Examine assumptions
– Redefine fears
– Restructure thinking
– Make changes
• Benefits of CBT
– Chemical changes can occur in brain that are
similar to changes occurring with medications
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Treatment for Anxiety Disorders:
Common Medications
• BZAs: short-term treatment only
– Causes dependence
• Buspirone: management of anxiety
disorders
• Selective serotonin reuptake inhibitors
(SSRIs): first-line treatment for all anxiety
disorders
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Treatment for Anxiety Disorders:
Common Medications
• Selective norepinephrine reuptake
inhibitors (SNRIs): venlafaxine approved
for panic disorder, GAD, and SAD
• Tricyclic antidepressants (TCAs): secondand third-line treatment
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Other Medications and
Complementary Therapy
• Other medications
– ß-blockers
– Antihistamines
– Anticonvulsants
• Complementary therapy (effectiveness
unproven)
– Kava kava
– Valerian root
– Gotu kola
– St. John’s wort
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Nursing Process: Evaluation
• Identified outcomes: basis for evaluation
– Is patient experiencing reduced anxiety?
– Does patient know symptoms are anxiety
related?
– Does patient still display symptoms?
– What newly learned behavior is displayed?
– Does patient perform self-care activities?
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Nursing Process: Evaluation
– Does patient maintain satisfactory
relationships?
– Can patient resume usual roles?
– Is patient compliant with medications?
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