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Course: Mental Health Nursing�Topic: Anxiety

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Module Goals

Learners will be able to:

Describe anxiety and etiology of anxiety.
Outline the 4 stages of anxiety and their manifestations.
Describe the various defense mechanism for anxiety.
Describe the treatment and interventions for the client with anxiety.
Describe the nurse’s role in the care of client with anxiety.

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Anxiety

According to American Psychiatric Association (2021),

“Anxiety refers to anticipation of a future concern and is more associated with muscle tension and avoidance behavior.”

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Anxiety

One of the most common psychiatric disorders in the general population.
Not widely recognized as many people do not seek help or clinicians fail to make the diagnosis.
Has very high morbidity including substance abuse, alcoholism, and major depression.

Chand & Marwaha, 2021

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Anxiety

Constant anxiety also increases the risk of adverse cardiac events.
Anxiety impairs the ability to develop social relationships and worsens the quality of life. Severe anxiety has also been linked to high rates of suicide.
Anxiety disorders occur more frequently in females than in males with an approximate 2:1 ratio.

Chand & Marwaha, 2021

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Anxiety: Etiology

Bridley & Daffin, 2018

Biological:

Genetic influences: The interaction between genetics and stressful environmental influences accounts for more anxiety disorders than genetics alone.

Neurobiological: Several brain structures and pathways such as amygdala, hippocampus, and the prefrontal cortex are likely responsible for anxiety responses.

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Anxiety: Etiology

Bridley & Daffin, 2018

Psychological:

Cognitive: Negative appraisals, sensitivity to physiological arousal in combination with a biological predisposition to anxiety likely contribute to the development of anxiety symptoms.
Behavioral: Development of anxiety disorder is largely reserved for phobias- both specific and social phobia.
Modeling: An individual acquires a fear through observation and imitation.

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Anxiety: Etiology

Bridley & Daffin, 2018

Sociocultural

Living in poverty.
Experiencing significant daily stressors.
Increased exposure to traumatic events are all identified as major contributors to anxiety disorders.
Sociocultural influences such as gender and discrimination have received a great deal of attention.

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Anxiety: Etiology

Chand & Marwaha, 2021

Anxiety may be caused by the following conditions:

Medications
Herbal medications
Substance abuse
Trauma
Childhood experiences
Panic disorders

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Critical Thinking Exercise

Which of the following might contribute to anxiety?

A child witnesses their father beat his wife everyday
Was bullied in the school in childhood
Has only 4 friends who she can trust
Works with COVID-19 clients

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Characteristic Features of Clinical Anxiety

Chand & Marwaha, 2021

False Alarm: Presence of intense fear in absence of or in minimal threat cues.
Persistence: Anticipation of impending potential threats.
Impaired functioning: Interferes with effective and adaptive coping mechanisms and problem solving skills.
Stimulus hypersensitivity: Provoked by wider range of stimuli or situations.
Dysfunctional cognition and cognitive symptoms: Overestimation of threat or danger.

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Common Defense Mechanism for Anxiety

McLeod, 2020

Denial
Repression
Projection
Displacement
Regression
Sublimation
Rationalization
Reaction Formation
Introjection
Identification with the Aggressor

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Critical Thinking Exercise

Recall the moment where you experienced a maximum level of anxiety.

Identify the factors related to the anxiety.

Did you experience any physical symptoms?

Describe the coping mechanism you used or could have used to manage the anxiety.

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Types of Anxiety Disorders

Chand & Marwaha, 2021

Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder
Panic Disorder
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Other Medical Conditions

Note: These Disorders will be discussed in detail in another slide deck.

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Pathological Anxiety Characteristics

Chand & Marwaha, 2021

Cognitive Symptoms:

Fear: of losing control, physical injury, deaths, “going crazy”, negative evaluation by others, frightening thoughts.
Narrow attention, poor memory, difficulty speaking.
Hypervigilance for threats
Poor concentration
Distractible

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Pathological Anxiety Characteristics

(Chand & Marwaha, 2021)

Behavioral symptoms:

Avoidance of threat cues or situations; escape, flight; pursuit of safety
Restlessness, agitation, pacing; hyperventilation; freezing, motionless; and difficulty speaking

Affective symptoms:

Nervous, tense, wound up; frightened, fearful, terrified; edgy, jumpy, jittery; and impatient, frustrated

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Pathological Anxiety Characteristics

Chand & Marwaha, 2021

Physiological Symptoms:

Increase pulse, palpitation, shortness of breathing.
Chest pain/pressure, choking sensation.
Dizzy, lightheadedness, sweaty, hot flashes, chills.
Nausea, stomach upset, diarrhea.
Trembling, tingling/numbness sensation in arms or legs.
Weakness, faintness, rigidity of muscles, dry mouth.

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Characteristic Features Noted in Individuals with Clinical Anxiety

Chand & Marwaha (2021),

False alarms: The presence of intense fear in the absence of threat cues or very minimal threat provocation.
Persistence: There is a future-oriented perspective that involves the anticipation of threat or danger which causes the client to experience a heightened level of apprehension and thoughts about impending potential threat, regardless of whether it materializes.
Impaired functioning: Anxiety interferes with effective and adaptive coping in the face of a perceived threat and the person’s daily social or occupational life.
Stimulus hypersensitivity: In clinical states, fear is elicited by a wider range of stimuli or situations of relatively mild intensity that would be innocuous to a person who does not have clinical anxiety.
Dysfunctional cognition and cognitive symptoms: Thinking characterized by overestimation of threat or danger appraisal of a situation that is not confirmed in any way.

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Stages of Anxiety, Clinical Manifestations & Interventions

Mild Anxiety: (+1)

Psychomotor: Slight muscle tension, slight fidgeting, energetic, good eye contact.
Emotional: Slight irritability (occasional), feelings of being challenged, confident.
Cognitive: Alert, aware, attentive, logical reasoning and problem-solving skills, use of adaptive mechanism.
Interventions: Discuss the source of anxiety, solve problem, accept anxiety as natural phenomenon, aware that anxiety may be beneficial.

Keltner et al, 2007

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Stages of Anxiety, Clinical Manifestations & Interventions

Moderate Anxiety: (+2)

Psychomotor: Prepare body for constructive action, moderate muscle tension, increase in blood pressure, pulse, respiration, startle reflex, difficulty sitting still, increased pace of speech, sporadic eye contact, repeatedly fidgeting.
Emotional: Feeling uncomfortable, increased irritability, decreased confidence, use of palliative coping mechanism.
Cognitive: Difficulty concentrating, narrowed perceptions, tangentiality, misinterpretation of stimuli, need effort and assistance in solving problem.

Keltner et al, 2007

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Stages of Anxiety, Clinical Manifestations & Interventions

Keltner et al, 2007

Moderate Anxiety (+2)

Interventions:

Vent the anxiety: crying, perform light exercise, using relaxation techniques.
Refocus attention: relate feelings and behaviour to anxiety.
Use problem solving techniques
May need medic.

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Stages of Anxiety, Clinical Manifestations & Interventions

Severe Anxiety: (+3)

Psychomotor: Fight or flight, extreme muscle tension, increased perspiration, pacing, reflex responses, loud or rapid speech, poor eye contact, disturbed sleep.
Emotional: Extreme discomfort, feelings of dread, hypersensitivity, defensive with threats and demands, use of maladaptive coping mechanisms.
Cognitive: Distorted perception, difficulty focusing, flight of ideas, ineffective reasoning and problem solving skills, dellusional, may have suicidal/homicidal ideas.

Keltner et al, 2007

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Stages of Anxiety, Clinical Manifestations & Interventions

(Keltner et al, 2007)

Severe Anxiety: (+3)

Interventions:

Decrease the source of anxiety, stimuli or pressure
Use kind, firm, simple directions
Use time out techniques
Medications as per physician:

Anti anxiety medications like benzodiazepines, clonazepams

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Critical Thinking Exercise

A teenage girl walked in to the clinic and said she is having a very hard time as she recently broke up with her boyfriend. She is having difficulty concentrating on her studies, has been neglecting self care, and is using alcohol to lessen her pain.

She has taken this breakup so seriously that she frequently thinks of shooting her boyfriend (if she had a gun) and also has had urges to cut her own wrist. She bursts into the tears and says she doesn't want to live anymore.

What level of anxiety do you think the girl is in?

What is kind of assistance should the girl receive?

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Stages of Anxiety, Clinical Manifestations & Interventions

Panic: (+4)

Psychomotor: Actual flight or immobilization, suicide attempts or violence, body resources depletion, eyes fixed, hysterical or mute, incoherent.
Emotional: Feeling overwhelmed and out of control, rage, desperation, feeling totally drained, use of dysfunctional coping mechanisms.
Cognitive: Disorganized perceptions, disorganized or irrational reasoning and problem solving, neologisms, clang associations, word salad, out of control with reality, personality disorganization.

Keltner et al, 2007

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Stages of Anxiety, Clinical Manifestations & Interventions

Keltner et al, 2007

Panic: (+4)

Interventions:

Guide firmly, may need physical force to take control over the situation.
Might need medications.
Might need restraints (hospital settings).

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Critical Thinking Exercise

Marty is pacing and complains of racing thoughts. The nurse asks the client if something upsetting happened, and Marty’s response is vague and not focused on the question. The nurse assesses Marty’s level of anxiety as:

Mild
Moderate
Sever
Panic

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Treatment of Client with Anxiety

Psychotherapy

Cognitive Behavioral therapy: Focus on specific skills to improve the symptoms and gradually improve the quality of life.

Medications

Certain medications like anxiolytics or antidepressants

In special cases: Beta blockers, sedatives, or benzodiazepines might be needed.

Note: Psychopharmacology slide deck discusses in detail of all of these medications

Yamamoto-Mitani et al, 2016

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Nurse’s Role While Caring for Client with Anxiety

Yamamoto-Mitani et al, 2016

Reach out to the client with anxiety.
Know the client, identify the problem, listen carefully, validate their feelings, develop trust, present with non-judgemental attitude.
Don’t pressure them to open up, observe the cues (non verbal, facial expression, gesture).
Provide a professional environment i.e quiet, enough lighting.
Provide physical comfort.

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Nurse’s Role While Caring for Client with Anxiety

Yamamoto-Mitani et al, 2016

Help them to identify the support system around them.
Empower them by providing enough information, possible solution, teaching, including breathing exercises, support groups.
Help client to see an alternate outlook on the situation.

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Red Flags

Giving away personal and cherished possessions
Describes a plan to kill themselves
Insomnia
Showing violent attitude, using substance like alcohol, marijauna to cope with stress
Getting sick frequently
Unrealistic, catastrophic and pessimistic thoughts
Excessive avoidance: refusal to participate in expected activities, refusal to attend school, friend’s houses, religious activities, family gatherings, errands, vacations
Trembling and jitters from anxiety

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Cultural Considerations

According to Cuncis (2020),

Different cultural groups have various rates of social anxiety. In general, social anxiety is less common in East Asian countries.
In certain cultures, there are specific types of disorders that are similar to social anxiety disorder; in Japan and Korea, there is Taijin Kyofusho (TKS), which refers to worry about being observed or offending other people, khyâl attacks in the Cambodian population, and ataques de nervios of the Puerto Rican and Dominican cultures. Those with TKS generally avoid a wide range of social situations.

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Cultural Considerations

Asian Americans consistently show symptoms of anxiety disorders less frequently than any of the other racial groups, whereas White Americans consistently endorse more symptoms of social anxiety disorder, generalized anxiety disorder and panic disorder more frequently than African Americans, Hispanic Americans, and Asian Americans.

Hofmann & Hinton, 2014

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References:

American Psychiatric Association. (2021). Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Publishing.

Bridley, A., Daffin, L.W. (Eds.). (2018). Essentials of Abnormal Psychology. By Washington State University, licensed under CC BY 4.0. https://opentext.wsu.edu/abnormalpsychology/chapter/4-6-anxiety-disorders-etiology/

Chand SP, Marwaha R. Anxiety. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470361/

Cuncic, A. (2020). Social Anxiety Disorder: How do different culture experience social anxiety disorder?. https://www.verywellmind.com/cultural-social-anxiety-disorder-3024706

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References:

Hofmann, S. G., & Hinton, D. E. (2014). Cross-cultural aspects of anxiety disorders. Current psychiatry reports, 16(6), 450. https://doi.org/10.1007/s11920-014-0450-3

Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007). Psychiatric nursing (4th Eds). St. Louis, Mo: Mosby-Elsevier.

McLeod, S. A. (2019, April 10). Defense mechanisms. Simply Psychology. www.simplypsychology.org/defense-mechanisms.html

Yamamoto-Mitani, N., Noguchi-Watanabe, M., & Fukahori, H. (2016). Caring for Clients and Families With Anxiety: Home Care Nurses' Practice Narratives. Global qualitative nursing research, 3, 2333393616665503. https://doi.org/10.1177/2333393616665503

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