7.8 Anxiety

Anxiety is a part of everyday life and can be experienced to varying degrees from helpful to harmful. Anxiety is a response to stress, whether the stressor is experienced as positive or negative. Positive stressors might be cleaning the house before family and friends arrive for a holiday gathering or studying for an exam whereas negative stressors can be losing car keys or getting into a fight with a loved one. Mild anxiety can provide energy and concentration needed to complete important tasks or provide motivation to make healthy behavioral changes. However, excessive anxiety can cause distress and impair an individual’s functioning in social, educational, occupational, or other areas of functioning.^[1]

Anxiety includes feelings of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat. Fear is a reaction to a specific danger, whereas anxiety is a vague sense of dread to a specific or unknown danger. The body reacts physiologically with the stress response to both anxiety and fear.

Signs and symptoms of mild anxiety may include restlessness, irritability, sleep disturbances, muscle tension, difficulty concentrating, or fatigue. Mild tension-relieving behaviors such as finger tapping, fidgeting, or nail biting may occur. As anxiety increases to a moderate level, the individual’s perceptual field narrows and ability to fully observe their surroundings decreases. The client experiences selective inattention where they only see or hear certain things in the environment unless they are pointed out. The ability to think clearly, learn, and problem solve is hampered but can still take place. The physiological stress response occurs with symptoms such as perspiration, elevated heart rate, and elevated respiratory rate. The individual may also experience headaches, gastric discomfort, urinary urgency, voice tremors, and shakiness but they may not be aware these symptoms are related to their level of stress and anxiety.^[2]

As anxiety increases to a severe level, the person’s perceptual field is greatly reduced. They may either focus on one particular detail or on many scattered details and often have difficulty noticing what is going on in their environment. They may appear dazed or confused. Learning, problem-solving, and critical thinking are not possible at this level. Symptoms of the stress response intensify and may include hyperventilation, a pounding heart, insomnia, and a sense of impending doom.

Panic attacks are an abrupt surge of intense fear or discomfort demonstrated by palpitations, sweating, tachycardia, shakiness, nausea, chest discomfort, lightheadedness, paresthesias, and feelings of a tightened throat. The individual is unable to process information from the environment and may experience depersonalization and lose touch with reality. Behaviors such as pacing, running, shouting, screaming, hallucinations, or withdrawal may occur. Acute panic can lead to exhaustion.^[3]

There are several types of anxiety disorders including the following^[4]:

• Phobias: Having extreme fear or anxiety about a specific object or situation, such as a dog, insect, snake, flying, or receiving an injection
• Social anxiety disorder: Extreme anxiety or fear related to social situations where they may be scrutinized by others
• Generalized anxiety disorder: Extreme anxiety or worry about a number of events or activities (such as work or school performance)
• Panic disorder: Having recurrent, unexpected panic attacks
• Separation anxiety disorder: Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached
• Substance/Medication-induced anxiety disorder: Anxiety or panic attacks after exposure or withdrawal from a medication or substance

Assessment (Recognizing Cues)

Nurses assess for signs and symptoms of anxiety, including the following:

• Restlessness
• Altered concentration, attention, or memory
• Diminished ability to learn or problem solve
• Hypervigilance
• Fear
• Irritability or nervousness
• Hand tremors
• Increased perspiration
• Quivering voice
• Increased respiratory rate, heart rate, and blood pressure
• Palpitations, chest pain, chest tightness
• Weakness
• Abdominal pain, nausea, or diarrhea
• Urinary urgency
• Altered sleep pattern

Screening Tool

The GAD-2 is a common screening tool to evaluate clients for anxiety. The US Preventive Services Task force recommends screening all adults under age 64 for anxiety, including pregnant and postpartum mothers, but they do not have enough information to recommend it for those older than 65.^[5] See the GAD-2 Scale in Table 7.8.

Table 7.8. Generalized Anxiety Disorder 2 (GAD-2) Scale

A score of three points is the preferred cut-off for needing further evaluation.

Some medical conditions (such as thyroid disorders, chronic obstructive pulmonary disease, and angina) or substances (such as caffeine, certain prescribed medications, or illicit drugs) can cause symptoms of anxiety. When a client is initially evaluated for anxiety by a health care provider, a physical health examination and diagnostic testing may be performed to rule out other potential causes of their anxiety symptoms.

Diagnostic and Lab Work

When initially assessing for anxiety disorders, the health care provider will typically order lab work to rule out common medical causes of anxiety, such as hyperthyroidism, hypoglycemia, hypercalcemia, hyperkalemia, hyponatremia, or hypoxia. Nurses review the results of these tests as part of the nursing assessment.

Anxiety in Children and Adolescents

All children experience some anxiety, and anxiety is expected at specific times of a child’s development. For example, from approximately age eight months through the preschool years, healthy children may show anxiety when separated from their parents or caregivers, called separation anxiety. Young children also commonly have fears, such as fear of the dark, storms, animals, or strangers. Anxiety is considered normal when situational. Consider the fear of dangerous situations such as approaching a rattlesnake or standing on a steep cliff; at crucial times such as these, anxiety is important because it provides safety. Anxiety can also be also motivational if it drives clients to accomplish goals.

When a child is overly worried or anxious, a nurse’s initial assessment should determine if conditions in the child’s environment are causing this feeling. For example, is the anxiety resulting from being bullied or from adverse childhood experiences (ACEs)? If so, protective interventions should be put into place. If no realistic threat exists and the anxiety causes significant life dysfunction, then the child should be referred to a mental health provider to determine if an anxiety disorder exists.

Children with anxiety disorders are overly tense or fearful and their worries interfere with daily activities. Some children may require significant amounts of reassurance. Because anxious children may also be quiet, compliant, and eager to please, their feelings of anxiety can be easily missed. When a child does not outgrow the typical fears and anxieties in childhood or when there are so many fears and worries, they interfere with school, home, or play activities, the child may be diagnosed with an anxiety disorder.

Anxiety can also make children irritable and angry and can include physical symptoms like fatigue, headaches, stomachaches, or trouble sleeping.

Early treatment of anxiety disorders in children and adolescents can enhance friendships, social and academic potential, and self-esteem.

Treatment of Anxiety Disorders

Anxiety disorders are generally treated by an interprofessional team with medications, psychotherapy, or a combination of both treatments. Nurses also teach clients about stress management and positive coping strategies.

Medications

Medications do not cure anxiety disorders but are used to help relieve symptoms of anxiety, panic attacks, extreme fear, and worry. The most common classes of medications used to treat anxiety disorders are antidepressants and antianxiety medications, such as benzodiazepines, buspirone, and beta-blockers. Review information about these medications in the “Psychotropic Medications” section of this chapter.

Psychotherapy

Cognitive behavioral therapy (CBT) is a type of psychotherapy that helps a person recognize distorted/negative thinking with the goal of changing thoughts and behaviors to respond to changes in a more positive manner.^[6]  Read more about CBT in the “Psychotherapy” section of this chapter.

Exposure therapy may be used alone or with CBT to treat some anxiety disorders such as phobias. Exposure therapy focuses on confronting the fears underlying an anxiety disorder by physically exposing the client to specifically feared objects or situations to help them engage in activities they have been avoiding.

Nursing Interventions

Acute Anxiety Reduction

Nurses implement several interventions if a client is experiencing acute anxiety. Clients experiencing extreme anxiety or panic attacks should not be left alone. See selected interventions for Anxiety Reduction from the Nursing Interventions Classification (NIC) for in the following box.

Stress Management and Coping Strategies

Nurses support the well-being of clients with anxiety disorders by teaching them to recognize symptoms of anxiety and using stress management and healthy coping strategies to manage the emotional responses.

Stress management techniques include engaging in regular physical exercise, selecting healthy food choices, setting personal and professional boundaries, and maintaining a healthy social support network. Additional stress management strategies include the techniques of grounding, unhooking, acting on our values, being kind, and making room. Emotion-focused coping refers to strategies used to manage one’s emotional responses, such as participating in mindfulness, meditation, or yoga; using humor and jokes; seeking spiritual or religious pursuits; breathing exercises; and seeking social support.^[9]

Individuals may use other complementary approaches to treat anxiety, such as acupuncture, massage therapy, or ingesting natural products like chamomile, kava, melatonin, or lavender. Research supporting complementary therapies is inconclusive; nurses can view current evidence at the National Center for Complementary and Integrative Health.

Health Teaching

Clients should be educated about symptoms of their diagnosed anxiety disorder and techniques to manage it. For some individuals, learning to become aware of symptoms of anxiety, naming them, and connecting their feelings to anxiety can help reduce the intensity of the anxiety. Certain substances such as caffeine, some over-the-counter cold medicines, illicit drugs, and herbal supplements may aggravate the symptoms of anxiety disorders or interact with prescribed medications. Clients should be advised to avoid these substances.^[10] Anxiety can suppress the appetite, so nurses can encourage clients to maintain healthy food intake.