University of Baghdad/ College of Nursing

Psychiatric Mental Health Nursing Department

Master Programme/ Specialty
2018-2019/ First Semester/ 7th Lecture

7. Anxiety

Definition
Anxiety is a vague feeling of dread or apprehension; it is a response to external or internal stimuli
that can have behavioral, emotional, cognitive, and physical symptoms. Anxiety is distinguished
from fear, which is feeling afraid or threatened by a clearly identifiable external stimulus that
represents danger to the person. Anxiety is unavoidable in life and can serve many positive
functions such as motivating the person to take action to solve a problem or to resolve a crisis. It is
considered normal when it is appropriate to the situation and dissolves when the situation has been
resolved.
Anxiety disorders include a group of conditions that share a key feature of excessive anxiety with
following behavioral, emotional, cognitive, and physiologic responses. Clients suffering from
anxiety disorders can demonstrate unusual behaviors such as:
- Panic without reason,
- Unjustified fear of objects or life conditions,
- Uncontrollable repetitive actions,
- Re-experiencing of traumatic events, or
- Unexplainable or overwhelming worry.
They experience significant distress over time, and the disorder significantly impairs their
daily routines, social lives, and occupational functioning.

Etiology (Causes)
1. Biologic Theories
A. Genetic Theories
- Anxiety may have an inherited component because first-degree relatives of clients with increased
anxiety have higher rates of developing anxiety. Heritability refers to the proportion of a disorder
that can be attributed to genetic factors:
- High heritability is greater than 0.6 and indicate that genetic influences dominate.
- Moderate heritability is 0.3 to 0.5 and suggests an even greater influence of genetic and non-
genetic factors.
- Heritability less than 0.3 means that genetics are small as a primary cause of the disorder.
- Panic disorder and social and specific phobias, including agoraphobia, have moderate heritability.
- GAD and OCD tend to be more common in families, indicating a strong genetic component, but
still require further in depth study.

B. Neurochemical Theories
- Gamma-aminobutyric acid (GABA) is the amino acid neurotransmitter believed to be
dysfunctional in anxiety disorders. GABA, an inhibitory neurotransmitter, functions as the body’s
natural antianxiety agent by reducing cell excitability, thus decreasing the rate of neuronal firing.
Because GABA reduces anxiety and norepinephrine increases it, researchers believe that a problem
with the regulation of these neurotransmitters occurs in anxiety disorders.
- Serotonin, the indolamine (monoamine) neurotransmitter usually implicated in psychosis and
mood disorders, has many subtypes. 5-Hydroxytryptamine type 1a plays a role in anxiety, and it
also affects aggression and mood. Serotonin is believed to play a distinct role in OCD, panic
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disorder, and GAD. An excess of norepinephrine is suspected in panic disorder, GAD, and
posttraumatic stress disorder.

2. Psychodynamic Theories
A. Intrapsychic / Psychoanalytic Theories
- Freud (1936) saw a person’s distinctive anxiety as the stimulus for behavior. He described defense
mechanisms as the human’s attempt to control awareness of and to reduce anxiety.
Defense mechanisms are cognitive distortions that a person uses unconsciously to maintain a sense
of being in control of a situation, to lessen discomfort, and to deal with stress. Because defense
mechanisms arise from the unconscious, the person is unaware of using them. Some people overuse
defense mechanisms, which stops them from learning a variety of appropriate methods to resolve
anxiety-producing situations. The dependence on one or two defense mechanisms also can inhibit
emotional growth, lead to poor problem-solving skills, and create difficulty with relationships.

B. Interpersonal Theory
- Harry Stack Sullivan (1952) viewed anxiety as being generated from problems in interpersonal
relationships. Caregivers can communicate anxiety to infants or children through inadequate
development, agitation when holding or handling the child, and distorted messages. Such
communicated anxiety can result in dysfunction such as failure to achieve age-appropriate
developmental tasks. In adults, anxiety arises from the person’s need to conform to the norms and
values of his or her cultural group. The higher the level of anxiety, the lower the ability to
communicate and to solve problems and the greater the chance for anxiety disorders to develop.
- Hildegard Peplau (1952) understood that humans exist in interpersonal and physiologic realms;
thus, the nurse can better help the client to achieve health by attending to both areas. She identified
the four levels of anxiety and developed nursing interventions and interpersonal communication
techniques based on Sullivan’s interpersonal view of anxiety. Nurses today use Peplau’s
interpersonal therapeutic communication techniques to develop and to nurture the nurse–client
relationship and to apply the nursing process.

C. Behavioral Theory
Behavioral theorists view anxiety as being learned through experiences. Conversely, people can
change or “unlearn” behaviors through new experiences. Behaviorists believe that people can
modify maladaptive behaviors without gaining insight into their causes. They struggle that
disturbing behaviors that develop and interfere with a person’s life can

Cultural Considerations
Each Culture Has Rules Governing the Appropriate ways to express and deal with anxiety.
Culturally competent nurses should be aware of them while being careful not to stereotype clients.
People from Asian cultures often express anxiety through somatic symptoms such as headaches,
backaches, fatigue, dizziness, and stomach problems. In some Hispanics during cases of high
anxiety, sadness, agitation, weight loss, weakness, and heart rate changes. The symptoms are
believed to occur because supernatural spirits or bad air from dangerous places and cemeteries
invades the body.

Anxiety as a Response to Stress

- Stress is the wear and tear that life causes on the body. It occurs when a person has difficulty
dealing with life situations, problems, and goals.
- Each person handles stress differently: One person can thrive in a situation that creates great
distress for another.

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 - For example, many people view public speaking as scary, but for teachers and actors, it is an
everyday, enjoyable experience. Marriage, children, airplanes, snakes, a new job, a new school, and
leaving home are examples of stress-causing events.
- Three stages of reaction to stress:
• In the alarm reaction stage, stress stimulates the body to send messages from the hypothalamus to
the glands (such as the adrenal gland, to send out adrenaline and to reconvert glycogen stores to
glucose for food) to prepare for potential defense needs.
• In the resistance stage, the digestive system reduces function to shunt blood to areas needed for
defense. The lungs take in more air, and the heart beats faster and harder so it can circulate this
highly oxygenated and highly nourished blood to the muscles to defend the body by fight, flight, or
freeze behaviors. If the person adapts to the stress, the body responses relax, and the gland, organ,
and systemic responses decrease.
• The exhaustion stage occurs when the person has responded negatively to anxiety and stress: body
stores are exhausted or the emotional components are not resolved, resulting in continual arousal of
the physiologic responses and little reserve capacity.

 Autonomic nervous system responses to fear and anxiety generate the involuntary activities
of the body that are involved in self-preservation. Sympathetic nerve fibers “charge up” the vital
signs at any hint of danger to prepare the body’s defenses. The adrenal glands release adrenalin
(epinephrine), which causes the body to take in more oxygen, dilate the pupils, and increase arterial
pressure and heart rate while constricting the peripheral vessels and shunting blood from the
gastrointestinal and reproductive systems and increasing glycogenolysis to free glucose for fuel for
the heart, muscles, and central nervous system. When the danger has passed, parasympathetic nerve
fibers reverse this process and return the body to normal operating conditions until the next sign of
threat reactivates the sympathetic responses.
 Anxiety causes uncomfortable cognitive, psychomotor, and physiologic responses, such as
difficulty with logical thought, increasingly agitated motor activity, and elevated vital signs. To
reduce these uncomfortable feelings, the person tries to reduce the level of discomfort by
implementing new adaptive behaviors or defense mechanisms. Adaptive behaviors can be positive
and help the person to learn, for example, using imagery techniques to refocus attention on a
pleasant scene, practicing sequential relaxation of the body from head to toe, and breathing slowly
and steadily to reduce muscle tension and vital signs. Negative responses to anxiety can result in
maladaptive behaviors such as tension headaches, pain syndromes, and stress-related responses that
reduce the efficiency of the immune system.
 People can communicate anxiety to others both verbally and nonverbally. If someone
screams “fire,” others around them can become anxious as they picture a fire and the possible threat
that represents. Viewing a worried mother searching for her lost child in a shopping mall can cause
anxiety in others as they imagine the panic she is experiencing. They can convey anxiety
nonverbally through empathy, which is the sense of walking in another person’s shoes for a moment
in time.
Examples of nonverbal empathetic communication are when the family of a client
undergoing surgery can tell from the physician’s body language that their loved one has died,
when the nurse reads a plea for help in a client’s eyes, or when a person feels the tension in a
room where two people have been arguing and are now not speaking to each other.
* Working with Anxious Clients
- Nurses encounter anxious clients and families in a wide variety of situations such as before
surgery and in emergency departments, intensive care units, offices, and clinics. First and foremost,

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 the nurse must assess the person’s anxiety level because that determines what interventions are
likely to be effective.
- Mild anxiety is an asset (Benefit) 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 very
effective when the client is mildly anxious.
- In 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 an unrelated line.
- When anxiety becomes severe, the client no longer can pay attention or take in information. The
nurse’s goal must be to lower the person’s anxiety level to moderate or mild before proceeding with
anything else. It is also essential to remain with the person because anxiety is likely to worsen if he
or she is left alone. Talking to the client in a low, calm, and soothing voice can help. If the person
cannot sit still, walking with him or her while talking can be effective.
What the nurse talks about matters less than how he or she says the words. Helping the person to
take deep even breaths can help lower anxiety.
- During panic-level 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 non-stimulating environment may help to reduce anxiety. The nurse can
reassure the person that this is anxiety, that it will pass, and that he or she is in a safe place. The
nurse should remain with the client until the panic recedes. Panic-level anxiety is not continued
indefinitely but can last from 5-30 minutes.

Levels of Anxiety
Psychological Responses Physiologic Responses
- Wide perceptual field - Restlessness
- Sharpened senses - Fidgeting
Mild

- Increased motivation - GI “butterflies”

- Effective problem-solving - Difficulty sleeping
- Increased learning ability - Irritability - Hypersensitivity to noise
- Muscle tension - Diaphoresis
Moderate

- Perceptual field narrowed to immediate task

- Pounding pulse
- Selectively attentive
- Headache - Dry mouth - GI upset
- Cannot connect thoughts or events independently
- High voice pitch - Frequent urination
- Increased use of automatisms
- Faster rate of speech
- Perceptual field reduced to one detail or scattered details - Severe headache
- Cannot complete tasks - Nausea, vomiting, and diarrhea
Severe

- Cannot solve problems or learn effectively - Trembling

- Behavior geared toward anxiety relief and is usually ineffective - Rigid stance
- Doesn’t respond to redirection - Vertigo - Pale
- Feels awe, dread, or horror Cries - Tachycardia
- Ritualistic behaviour - Chest pain
- Perceptual field reduced to focus on self
- May bolt and run
- Cannot process any environmental stimuli
OR
- Distorted perceptions
Panic

- Totally immobile and mute

- Loss of rational thought
- Dilated pupils
- Doesn’t recognize potential danger
- Increased blood pressure and pulse
- Can’t communicate verbally
- Flight, fight, or freeze
- Possible delusions and hallucination - May be suicidal

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 Treatment
Treatment for anxiety disorders usually involves medication and therapy. This combination
produces better results than either one alone. Cognitive-behavioral therapy is used successfully to
treat anxiety disorders.
- Positive reframing means turning negative messages into positive messages. The therapist
teaches the person 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 thinks, “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.
- De-catastrophizing 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 himself 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. 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.”
Anxiolytics
Half-
Generic (trade) Speed of
life Side Effects Nursing Implications
Name Onset
(Hours)
Benzodiazepines
Diazepam (Valium) Fast 20-100 - Avoid other CNS depressants, such as
Alprazolam Intermediat antihistamines and alcohol.
6-12
(Xanax) e - Avoid caffeine.
Chlordiazepoxide Intermediat Dizziness, clumsiness, sedation, - Take care with potentially hazardous
5-30
(Librium) e headache, fatigue, sexual activities such as driving.
Intermediat dysfunction, blurred vision, - Rise slowly from lying or sitting
Lorazepam (Ativan) 10-20 dry throat and mouth, position.
e
Clonazepam constipation, high potential for - Use sugar-free beverages or hard
Slow 18-50 abuse and dependence candy.
(Klonopin)
Oxazepam (Serax) Slow 4-15 - Drink adequate fluids.
- Take only as prescribed.
- Do not stop taking the drug abruptly.
Non-benzodiazepines
Buspirone (BuSpar) Very slow
- Rise slowly from sitting position.
Meprobamate
Rapid - Dizziness, restlessness, agitation,- Take care with potentially hazardous
(Miltown, Equanil)
drowsiness, headache, weakness, activities such as driving.
nausea, vomiting, paradoxical - Take with food.
excitement or euphoria - Report persistent restlessness,
agitation, excitement, or euphoria to
physician.

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  Drugs used to treat Anxiety Disorders

Generic (Trade) Drug Name Classification Used to Treat

Alprazolam (Xanax) Benzodiazepine Anxiety, panic disorder, OCD, social
phobia, agoraphobia
Buspirone (BuSpar) Non-benzodiazepine anxiolytic Anxiety, OCD, social phobia, GAD
Chlorazepate (Tranxene) Benzodiazepine Anxiety
Chlordiazepoxide (Librium) Benzodiazepine Anxiety
Clomipramine (Anafranil) Tricyclic antidepressant OCD
Clonazepam (Klonopin) Benzodiazepine Anxiety, panic disorder, OCD
Clonidine (Catapres) Beta-blocker Anxiety, panic disorder
Diazepam (Valium) Benzodiazepine Anxiety, panic disorder
Fluoxetine (Prozac) SSRI antidepressant Panic disorder, OCD, GAD
Fluvoxamine (Luvox) SSRI antidepressant OCD
Hydroxyzine (Vistaril, Atarax) Antihistamine Anxiety
Imipramine (Tofranil) Tricyclic antidepressant Anxiety, panic disorder, agoraphobia
Meprobamate (Miltown, Equanil) Non-benzodiazepine anxiolytic Anxiety
Oxazepam (Serax) Benzodiazepine Anxiety
Paroxetine (Paxil) SSRI antidepressant Social phobia, GAD
Propranolol (Inderal) Alpha-adrenergic agonist Anxiety, panic disorder, GAD
Sertraline (Zoloft) SSRI antidepressant Panic disorder, OCD, social phobia, GAD

Elder Considerations
Anxiety that starts for the first time in late life is frequently associated with another condition such
as depression, dementia, physical illness, or medication toxicity or withdrawal. Phobias, particularly
agoraphobia, and GAD are the most common late-life anxiety disorders. Most people with late-
onset agoraphobia attribute the start of the disorder to the sudden onset of a physical illness or as a
response to a traumatic event such as a fall or assault.
* Community-Based Care
- Nurses encounter many people with anxiety disorders in community settings rather than in
inpatient settings. Formal treatment for these clients usually occurs in community mental health
clinics and in the offices of physicians, psychiatric clinical specialists, psychologists, or other
mental health counselors. Because the person with an anxiety disorder often believes the irregular
symptoms are related to medical problems, the family practitioner or advanced practice nurse can
be the first health-care professional to evaluate him or her.
- Knowledge of community resources helps the nurse guide the client to appropriate referrals for
assessment, diagnosis, and treatment. The nurse can refer the client to a psychiatrist or to an
advanced practice psychiatric nurse for diagnosis, therapy, and medication. Other community
resources such as anxiety disorder groups or self-help groups can provide support and help the
client feel

Mental Health Promotion

- Too often, anxiety is viewed negatively as something to avoid at all costs. Actually, for many
people, anxiety is a warning they are not dealing with stress effectively. Learning to notice this
warning and to make needed changes is a healthy way to deal with the stress of daily events.
- Stress and resulting anxiety are not associated exclusively with life problems. Events that are
“positive” or desired, such as going away to college, getting a first job, getting married, and having
children, are stressful and cause anxiety. Managing the effects of stress and anxiety in one’s life is
important to being healthy. Tips for managing stress include the following:

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  Keep a positive attitude and believe in yourself.
 Accept there are events you cannot control.
 Communicate assertively with others: talk about your feelings to others and express your
feelings through laughing, crying, and so forth.
 Learn to relax.
 Exercise regularly.
 Eat well-balanced meals.
 Limit intake of caffeine and alcohol.
 Get enough rest and sleep.
 Set realistic goals and expectations and find an activity that is personally meaningful.
 Learn stress management techniques, such as relaxation, guided imagery, and meditation;
practice them as part of your daily routine.

- For people with anxiety disorders, it is important to emphasize that the goal is effective
management of stress and anxiety, not the total elimination of anxiety. Although medication is
important to relieve excessive anxiety, it does not solve or eliminate the problem entirely. Learning
anxiety management techniques and effective methods for coping with life and its stresses is
essential for overall improvement in life quality.

* Panic Disorder
- Panic disorder is composed of separate episodes of panic attacks, that is, 15 to 30 minutes of
rapid, intense, escalating anxiety in which the person experiences great emotional fear as well as
physiologic discomfort.
- During a panic attack, the person has overwhelmingly intense anxiety and displays four or more
of the following symptoms: palpitations, sweating, tremors, shortness of breath, sense of
suffocation, chest pain, nausea, abdominal distress, dizziness, paresthesia, chills, or hot flashes.
- Panic disorder is diagnosed when the person has recurrent, unexpected panic attacks followed by
at least 1 month of persistent concern or worry about future attacks or their meaning or a significant
behavioral change related to them.
- Slightly more than 75% of people with panic disorder have spontaneous initial attacks with no
environmental trigger. Half of those with panic disorder have accompanying agoraphobia.
- Panic disorder is more common in people who have not graduated from college and are not
married. The risk increases by 18% in people with depression.

* Generalized Anxiety Disorder

- A person with GAD worries excessively and feels highly anxious at least 50% of the time for 6
months or more. Unable to control this focus on worry, the person has three or more of the
following symptoms: uneasiness, irritability, muscle tension, fatigue, difficulty thinking, and sleep
alterations.
- More people with this chronic disorder are seen by family physicians than by psychiatrists. The
quality of life is diminished greatly in older adults with GAD. Buspirone (BuSpar) and SSRI
antidepressants are the most effective treatments.

Nursing Care Plan/ Anxious Behavior

Nursing Diagnosis
Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often
nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an
alerting signal that warns of approaching danger and enables the individual to take measures to deal with the
threat.

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• Assessment Data Expected Outcomes
• - Decreased attention span Immediate
• - Restlessness, irritability The client will
• - Poor impulse control - Be free from injury
• - Feelings of discomfort, apprehension, or helplessness - Discuss feelings of dread, anxiety, and so forth
• - Hyperactivity, pacing - Respond to relaxation techniques with a decreased anxiety
• - Wringing hands level
• - Perceptual field deficits
• - Decreased ability to communicate verbally Stabilization
The client will
• In addition, in panic anxiety - Demonstrate the ability to perform relaxation techniques
• - Inability to discriminate harmful stimuli or situations - Reduce own anxiety level
• - Disorganized thought processes
• - Delusions Community
• The client will
- Be free from anxiety attacks
- Manage the anxiety response to stress effectively
Implementation
Nursing Interventions Rationale
- Remain with the client at all times when levels of - The client’s safety is a priority. A highly anxious client
anxiety are high (severe or panic). should not be left alone-his or her anxiety will escalate.
- Move the client to a quiet area with minimal or decreased - Anxious behavior can be escalated by external stimuli. In a
stimuli such as a small room or seclusion area. large area, the client can feel lost and panicked, but a smaller
room can enhance a sense of security.
- PRN (Pro re nata) medications may be indicated for high - Medication may be necessary to decrease anxiety to a level
levels of anxiety, delusions, disorganized thoughts, and so at which the client can feel safe.
forth
- Remain calm in your approach to the client. - The client will feel more secure if you are calm and if the
client feels you are in control of the situation
- Use short, simple, and clear statements. - The client’s ability to deal with abstractions or complexity
is impaired.
- Avoid asking or forcing the client to make choices. - The client may not make sound decisions or may be unable
to make decisions or solve problems.
- Be aware of your own feelings and level of discomfort. - Anxiety is communicated interpersonally. - Being with an
anxious client can raise your own anxiety level.
- Encourage the client’s participation in relaxation - Relaxation exercises are effective, nonchemical ways to
exercises such as deep breathing, progressive muscle reduce anxiety.
relaxation, meditation, and imagining being in a quiet,
peaceful place.
- Teach the client to use relaxation techniques - Using relaxation techniques can give the client confidence
independently. in having control over anxiety.
- Help the client see that mild anxiety can be a positive - The client may feel that all anxiety is bad and not useful.
promoter for change and does not need to be avoided.

Assist. Professor
Dr. Maan Hameed Ibrahim
2018-2019