A nurse in an outpatient clinic interviews a young woman who is unable to go grocery shopping for fear of having an attack of shortness of breath, chest pain, sweaty palms, and a racing heart. At a student health service, a college student admits that he has been late for class because he feels he must check his car ignition repeatedly to be sure that it is really off before he can get out of his vehicle. In a hospital medical unit, a woman with terminal lung cancer has problems with shortness of breath and such extreme nervousness that she can’t sleep well, feeling frightened “all the time.” An occupational health nurse speaks with a middle-aged salesman who has altered his driving routes because he has become extremely fearful when driving over bridges and down steep hills. Although these symptoms are quite varied, moderate to severe levels of anxiety can cause them all.

What is anxiety?

Anxiety is a feeling of alertness and concern that readies an individual to take some sort of action.¹ A part of life, it involves heightened awareness or worry. Anxiety about passing an exam may motivate us to study. Anxiety can compel us to take action to protect ourselves from a threat. Anxiety is different than fear in that fear involves the intellectual evaluation of something that may be threatening, while anxiety is the emotional component to that appraisal. All major positive or negative events or changes in our lives can cause some degree of anxiety.¹

Anxiety is a sensation that permeates our reaction to stress. The “fight or flight” response is the immediate physiological response of the body to stress, shunting blood away from digestive organs toward the muscles and mobilizing the body to meet the challenge of a stressor. Physical signs of the stress response include shortness of breath, palpitations, sweating, clammy hands, dry mouth, dizziness, nausea, diarrhea, flushes or chills, frequent urination, and sometimes a feeling of having a “lump in the throat.” All of us have felt some of these symptoms, particularly after a frightening experience, such as a traffic accident. Anxiety can impact the quality of life, precipitate social withdrawal, interfere with self-care, and exacerbate health problems.² Patients with anxiety are more likely to report unexplained fatigue.¹

Anxiety can be mild, moderate, or severe and even escalate to panic.¹ Mild anxiety is part of the tension of everyday life, and a person may actually see, hear, and comprehend more effectively when slightly anxious. Moderate anxiety causes an individual to focus on immediate concerns, selectively blocking out tangential information. A severely anxious person is so focused on specific details that he or she can’t think of anything else, and behavior becomes directed toward relieving the anxiety. Panic is associated with loss of control and a sense of dread, with increased motor activity, reduced ability to relate to others, and distorted perceptions.¹

What causes anxiety?

Prolonged or severe symptoms of anxiety may be evidence of an anxiety disorder. Severe anxiety can arise under persistent stress or extreme change. For example, a person recovering from a heart attack may have a level of anxiety that prevents successful rehabilitation if he or she is too fearful to begin exercise and to resume normal activities. However, research seems to indicate that symptoms of anxiety may have a genetic or biochemical basis, and that it can even arise without the presence of a major stressor. Recent research has focused on the amygdala, a part of the brain where a “harm avoidance” response may be etched.^3,4 A disruption of neurotransmitters — norepinephrine, serotonin, and gamma-aminobutyric acid (GABA), an inhibitor neurotransmitter — is thought to play a role in anxiety.^4,5 Neuropeptide substance P (SP) and neurokinins, proteins, and receptors that function as cotransmitters for serotonin and GABA also contribute to anxiety.⁶

Abnormalities in brain function or structure in such areas as the limbic system, the temporal lobe, and the brain stem have also been implicated in anxiety disorders.⁷ Magnetic resonance imaging (MRI) scans of the brain suggest a genetic susceptibility to anxiety as individuals with anxiety have been found to have less gray matter and weaker mood-regulating circuit connections.⁴ When anxiety symptoms appear suddenly and inexplicably, these patients can become extremely distressed.

Anxiety disorders are among the most prevalent and disabling psychiatric disorders, affecting more than 25 million Americans.⁸ Young and middle-age adults are significantly impacted by anxiety, with 13.3% of Americans ages 18 to 54 affected.⁹

Productivity can be significantly impacted. In one study of more than 27,000 people, those with anxiety disorders were more likely to experience absenteeism from work (30%) — more so than those with substance abuse disorders (20%) — and when individuals have both disorders, the likelihood of absenteeism increased to 34%.¹⁰

Another two-year study of 2,646 working men and women identified that poor working conditions, especially those that are psychologically demanding or limit individual decision-making abilities, are a source of stress that can contribute to the development of anxiety disorders. The study also showed that development of anxiety disorders was not mediated by a sense of job security or the presence of an adequate social support system in the workplace.¹¹

Anxiety disorders are among the most common psychiatric illnesses of the elderly, though the symptoms tend to be milder if the disorder appears for the first time late in life.¹² Recent studies suggest that these illnesses are even more prevalent in the elderly than previously thought. Anxiety symptoms are common in depressed and nondepressed older people.¹² Nurses in all settings, from hospital to community, should be able to identify anxiety symptoms and provide immediate support to extremely anxious patients. Surveys of nursing diagnoses indicate that anxiety is one of the most common problems for patients.¹

The symptoms of anxiety can be closely associated with medical problems and often coexist with other psychiatric disorders. Anxious and depressed patients tended to have higher healthcare costs because of higher utilization of medical, rather than psychiatric, care. Effective recognition and treatment of anxiety, however, have been associated with improvement in management of medical conditions and a decreased economic burden — for example, reduced A1c levels in individuals with diabetes.¹³ Conversely, medical problems, substance abuse or withdrawal, and medications can cause anxiety symptoms.

Anxiety disorders are common in many critical care settings and seem to interfere with healing and recovery, especially for patients who require prolonged mechanical ventilation. Adequate sedation, analgesia, and strategies to maximize comfort are crucial to enhance recovery and reduce the incidence of anxiety postextubation.¹⁴

Psychiatric disorders involving anxiety and depression are also present in a significant number of cancer patients. One study of women receiving treatment for breast cancer revealed a 39.6% prevalence of anxiety.¹⁵

Anxiety disorders also frequently occur in individuals who have chronic medical illnesses, including infections and irritable bowel syndrome.^1,15,16 Up to one-forth of children may experience anxiety after infection with B-hemolytic streptococcus infections.¹⁷

HIV-positive individuals with anxiety disorders receiving antiretroviral therapy are less likely to achieve the desired therapeutic viral suppression response as their nonanxious counterparts.¹⁶ To view an evidenced-based clinical guideline on mental health care and HIV, go to http://guideline.gov/summary/summary.aspx?doc_id=9029&nbr=004888&string=anxiety+AND+disorders.

One National Institute of Mental Health-sponsored study revealed that nearly half of adults with anxiety disorders also had psychiatric disorders in their childhood. The researchers discovered links between specific anxiety disorders in adulthood and childhood. For example, adults with posttraumatic stress disorder (PTSD) are more likely to have histories of extreme defiance and conduct disorders in childhood, and adults with obsessive-compulsive disorder are likely to have experienced delusional beliefs and hallucinations as children. Phobias diagnosed in adulthood tended to be linked to specific phobias that occurred during childhood.¹⁸ 

Anxiety disorders are a complex of symptoms as well as behaviors patients exhibit in response to those symptoms. The most common anxiety disorders are generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, phobias, and posttraumatic stress disorder.

Generalized anxiety disorder

Generalized anxiety disorder (GAD) is excessive and unreasonable anxiety and worry that lasts at least six months. It is more common in women than in men, and may begin at any time during life, although it is more common in younger individuals.¹⁹ Symptoms of GAD may include restlessness, being easily fatigued, difficulty with concentration, irritability, muscle tension, and sleeping problems.²⁰ These symptoms are extremely distressing, and patients feel unable to control them. Patients often recognize that the worry is far out of proportion to their actual situation.²¹ Persons suffering from GAD may still be able to function socially and at work, but if severe, these symptoms can be very disabling. GAD often begins in late childhood leading to disability in the prime of life. Later in life, GAD is more likely to occur along with major depression.²²

Panic disorder

Panic disorder affects about 1.7% of the population and is twice as common in women as in men.⁹ This disorder is characterized by recurrent attacks that can produce dizziness, faintness, palpitations, trembling, sweating, nausea, numbness, flushes or chills, and chest pain. The patient may think that he or she is dying. These feelings usually come on suddenly and usually last several minutes. Panic disorder may be accompanied by substance abuse, depression, or suicidal impulses.^2,7 At the same time, similar symptoms may be caused by many medical conditions, including hyperthyroidism, hypoglycemia, pheochromocytoma, mitral valve prolapse, heavy use of caffeine, or substance abuse.^1,21

Patients may alter their lives to avoid anything that they fear might set off a panic attack; for example, the young woman who avoided going to the grocery store because she feared that the trip could trigger an attack. About one-third of the people with panic disorder also develop agoraphobia — a fear of being in places or situations from which escape might be difficult, or where help may not be available if an attack occurs.²¹

Someone who also has agoraphobia may find it difficult to ever leave home at all.

Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder is equally present in men and women. It occurs in about 2.3% of all people, and usually first appears in teens or young adults.⁹ Prevalence of OCD in children may be higher than previously thought, and some cases of OCD in young people may be linked to a prior streptococcal infection.⁵ Obsessions are recurrent and persistent thoughts, impulses, or images that are regarded as unwanted and inappropriate. For example, a person might have obsessive thoughts about germs and dirt.

While handwashing and avoiding physical contact with obviously soiled areas are reasonable, individuals with this type of obsession cannot stop thinking that their hands are contaminated, in spite of taking normal precautions.

Compulsions are repetitive behaviors, such as excessive handwashing, or mental acts, such as counting or repeating words silently, that the person feels driven to do in response to an obsession. These individuals may repeatedly wash or scrub their hands, to the degree that their hands will become raw. Obsessions and compulsions go far beyond what is logical and reasonable, and these thoughts and behaviors are often very disturbing and disruptive to daily routines and social relationships.⁸ People usually recognize that their behavior is senseless, but sometimes they do not.

Phobias

Phobias are classified as either social or specific. A social phobia, also diagnosed as social anxiety disorder (SAD), is a fear of being terribly humiliated or embarrassed in a social setting, such as a fear of public speaking. The prevalence of SAD is estimated as high as 13.1%, occurring equally among men and women; however, it is often undetected and undertreated.^9,23 Specific phobias are intense, irrational fears of certain things or situations, such as cats, snakes, elevators, flying, or driving. Specific phobias are more common than social phobias, occurring in more than 4.4% of Americans.⁹ Although some fears may seem fairly common, a phobia is present when the fear interferes with the person’s ability to function. Phobic individuals make every effort to avoid the situation or thing that causes such dread.

Posttraumatic Stress Disorder

Posttraumatic Stress Disorder (PTSD) occurs from 20% to 25% of the time when a person is exposed to a traumatic event in which the person experienced or witnessed serious injury, death, or a grave threat to himself or herself or others.²⁴ The person’s response involves intense fear, horror, or helplessness. Natural disasters, wars, terrible accidents, and crimes can all cause long lasting emotional trauma in both witnesses and victims. While PTSD is difficult to predict, some factors appear to increase the risk.

Factors found to increase the likelihood of developing PTSD within a year after a traumatic event include high levels of symptomatic distress during the year following the event, prior trauma, history of stimulant intoxication, and female gender.^9,24 Sexual assault is the most likely trigger event for PTSD.⁹ Sleep-related complaints, evident as early as one month after the traumatic event, are also an early predictor of the development of chronic PTSD.²⁴

This disorder involves recurring intrusive memories of the event, troubling nightmares, and even flashbacks where the person feels that he or she is actually reliving the event. Certain cues may set off intense distress, and the person tends to become hyperalert and hypervigilant. For example, a veteran of combat might react to a sudden loud noise by dropping to the ground and trying to take cover. The actual event could have occurred a week to many years ago. Individuals also talk about feeling emotionally numb, and some have difficulty with outbursts of anger. Flashbacks can be prolonged and the individual can seem quite agitated for some time after. Symptoms tend to become worse when the individual is under stress.

Nurses and other healthcare personnel are sometimes the victims of posttraumatic stress disorder, as we are often some of the first people on the scene after accidents and natural disasters, not to mention the daily stresses of dealing with acutely ill patients. Nurses on psychiatric and medical units are likely to have experienced traumatic incidents, such as a patient suicide or repeated traumatic deaths of patients. Nursing management should encourage assessment of patients and staff for reactions to these traumatic incidents and include periodic assessments after such incidents to detect delayed reactions.

Assessment of the anxious patient

If you suspect that a patient has an anxiety disorder, what should you do first? As with any other disorder, a good history is extremely important, and a nurse needs to assess the quantity and quality of the anxiety symptoms.¹ For example, when did these symptoms first appear? Can the patient recall ever feeling this way before? What is happening in the patient’s life? Have there been recent changes or stressors? How does the patient feel about these changes, and how is he or she coping?¹ What has been done to try to relieve these symptoms? Also ask about social support and personal relationships. One study of 4,688 adults revealed stressful relationships and lack of social support increase anxious episodes.²⁵ Investigate the use of current prescription or over-the-counter medications, as side effects of medications can cause symptoms of anxiety.

You will need to find out whether any of the patient’s symptoms could be caused by a physical condition or medication. Blood chemistry screening, especially for blood glucose, thyroid levels, and electrolytes, as well as a urinalysis and an ECG, are appropriate tests. The possibility of substance abuse must be explored, because individuals may try to cope by abusing drugs or alcohol. Does the patient ever feel depressed? Although this is a difficult subject to approach, does your patient think that life is not worth living, or think about suicide? Significant numbers of individuals with severe anxiety and panic disorders consider or attempt suicide to escape the sometimes unbearable symptoms.²¹

Sometimes, medical tests or treatments can produce anxiety, either temporarily or long-term, especially if they are confining or constricting, producing claustrophobia — an abnormal fear or dread of closed spaces.¹⁹ Continuous positive airway pressure therapy, prescribed to treat sleep apnea is especially anxiety-producing, as are MRIs and CT scans, and hyperbaric oxygenation chambers.²⁶ Even devices that are not confining can promote anxiety — up to 37% of patients implanted with cardioverter-defibrillators have anxiety.²⁷

Does the patient seem very distressed by these symptoms? The level of distress is usually high in anxiety disorders, and patients may cry, shake, wring their hands, pace, perspire, and appear frightened.¹ Their voices may even shake as they talk, and their respirations and heart rate may be elevated.¹ Muscle tension may be obvious in their posture and movements. If family members are present, determine whether they appear exasperated, supportive, or unaware of the degree of the symptoms. Be sure to ask about the patients’ sleep habits.²⁴

Think young and screen often! Anxiety disorders, like many other mental health disorders are quite likely to appear at an early age. Research supported by the National Institute of Mental Health found that half of all lifetime cases of mental illness begin by age 14 and that delays in diagnosis are common.²² Anxiety affects American children significantly, especially in adverse family environments where there is a low socioeconomic status and maltreatment. Children most often manifest anxiety as OCD, GAD, and phobias. They also tend to internalize their problems and have inhibited temperaments.²⁸ An evidenced-based clinical guideline for the assessment and treatment of anxiety disorders among children can be reviewed at http://guideline.gov/summary/summary.aspx?doc_id=10549&nbr=005512&string=anxiety+AND+disorders.

Controlling anxiety

The goal of intervention for very anxious patients is to lower their anxiety level.¹ They should not be left alone, and a nurse should be available to listen to their fears and provide support. Sometimes a quieter, less stimulating environment is helpful. For ongoing anxiety problems, goals should focus on helping patients learn how to tolerate a certain level of anxiety, as the expectation that patients can become completely free from anxiety may be unrealistic. Patients can learn to relax through relaxation training and progressive relaxation.¹ They might think about a peaceful image, such as a secluded beach, or can be taught to consciously relax each muscle group, usually starting at the toes and progressing up toward the head. Nurses should caution these individuals against the use of caffeine and other stimulants.

Patients who appear to have a high level of anxiety need to be referred to a mental health professional for further evaluation. Some of the treatments used for anxiety disorders include biofeedback, cognitive behavioral therapy, medications, psychotherapy, or a combination of therapies.¹ In therapy, patients discover that their symptoms are due to anxiety, and learn methods to control and manage the anxiety. The therapist may be a nurse, social worker, psychologist, or psychiatrist. Cognitive-behavioral therapy teaches patients to react differently to the symptoms of anxiety, for instance, telling themselves, “This is a panic attack symptom. I am not really having a heart attack.” For some phobics and panic disorder sufferers, therapists may go out with the patient to practice managing the anxiety in situations they dread. Group therapy or support groups are also very helpful.¹

While help is available, up to 70% of people with anxiety disorders go untreated each year. Some may shun traditional modalities for treatment interventions, lacking access or fearing stigma. Technological advances that may expand treatment access include Internet-based therapy, computer-guided and virtual reality programs, and self-help programs.²⁹ Not surprisingly, therapeutic interventions delivered through these new methods have been especially well-received by young adults.³⁰ The National Institute for Health and Clinical Excellence has published a clinical guideline on the use of computerized cognitive behavior therapy for depression and anxiety at http://guideline.gov/summary/summary.aspx?doc_id=9087&nbr=004901&string=anxiety+AND+disorders.

The good news is that treatment of anxiety disorders is usually very successful. Medications can be useful, but research has also indicated that behavioral or cognitive-behavioral therapy alone or in combination with medication can be equally if not more effective.²² Short-acting benzodiazepines, such as alprazolam (Xanax), are often prescribed to alleviate symptoms of anxiety. However, the side effect profile of these medications and their potential for addiction makes them a poor choice for long-term therapy, especially because of the impaired ability to drive.² A nonbenzodiazepine, such as buspirone (BuSpar), is often helpful for long-term use for anxiety, especially with elderly patients, because it does not depress the central nervous system.²⁰ Another non-addictive option for treatment, especially effective for GAD is hydroxyzine (Vistaril).²⁰

Antidepressants, such as imipramine (Tofranil), and MAO inhibitors, such as phenelzine (Nardil), have some efficacy for anxiety disorders, especially if some depression is also present — however side effects including dry mouth, tachycardia, and diaphoresis can be problematic, especially with imipramine use.²⁰ The antidepressant clomipramine (Anafranil) has been effective in treating OCD.²⁰ Beta blockers, such as propranolol (Inderal), are used for certain types of social phobias, such as a musician who might take a beta-blocker on the day of a concert to reduce performance anxiety symptoms.²²

Selective serotonin reuptake inhibitors (SSRIs), especially sertraline (Zoloft) and paroxetine (Paxil), are becoming a first choice in treating panic disorders.²⁰ Once very difficult to treat to remission, GAD responds quite well to venlafaxine (Effexor).²⁰

While many of the antidepressant drugs can be highly effective in management of anxiety disorders, the U.S. Food and Drug Administration (FDA) has issued an alert and required many of them to contain updated black-box warnings regarding increased risks of suicidal thinking and behavior, especially among young adults ages 18 to 24 during initial treatment (generally the first one to two months of drug use). To access the FDA news releases, question and answer sheets, and a complete list of all medications included in the warnings, visit www.fda.gov/cder/drug/antidepressants/default.htm.

Getting Help

If your patients oppose the idea of psychiatric care, help them to obtain information about their disorder and provide information about treatment. Let them know that their symptoms, as varied and unrelated as they may seem, may be associated with anxiety, and that with help, they can learn to control them. Nurses can act as patient advocates and assist them to receive appropriate help. They need to know that medication and therapy can both be very useful. If the patients’ families and friends are involved and interested, their support will help their loved ones succeed in finding treatment and relief.

Some psychiatric facilities and mental health outpatient clinics specialize in the treatment of anxiety disorders and can suggest methods to help a person obtain treatment. There are even treatment options for homebound patients. Many home health agencies now have psychiatric nurses who are available to make in-home evaluations, and Medicare and other third-party payers will now pay for these visits, at least for a limited time.

Mild to moderate levels of anxiety can help us prepare to meet life’s challenges. However, more severe levels of anxiety should be recognized as potentially significant problems. Anxiety disorders are serious, painful, but most important, treatable. Whether a nurse practices in a hospital or in the community, the ability to recognize severe anxiety, provide immediate support and encouragement, and make appropriate referrals for evaluation of a possible anxiety disorder can make a huge impact on the course of that patient’s recovery. Severe anxiety can drastically affect a patient’s ability to live a productive life and to function socially, and even reduce a patient’s ability to recover from medical conditions or surgery. Treatment can provide relief from many of these symptoms, and can give patients the ability to control symptoms that persist so that an active lifestyle can be resumed.