ANXIETY DISORDER

Anxiety disorders involve disorders that contain characteristics of excessive fear and anxiety and linked behavioral disturbances. There are several types of anxiety disorders including generalized anxiety disorder, agoraphobia, separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder or social phobia, panic disorder, substance/medication-induced anxiety disorder, and anxiety disorder due to another medical condition. Review this study guide and learn more about anxiety disorders, its nursing care management, interventions, and assessment.

CONTENTS:

Types of Anxiety Disorders

The characteristic features of this group of disorders are symptoms of anxiety and avoidance behavior. Anxiety disorders are categorized in the following manner:

Panic disorder (with or without agoraphobia). Panic disorder is characterized by by recurrent panic attacks, the onset of which are unpredictable, and manifested by intense apprehension, fear or terror, often associated with feelings of impending doom, and accompanied by intense physical discomfort.
Agoraphobia without history of panic disorder. The APA 2000 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) identifies the essential feature of this disorder as fear of being in places or situations from which escape might be difficult or in which help might not be available in the event of suddenly developing a symptoms(s) that could be incapacitating or extremely embarrassing.
Social phobia. Social phobia is characterized by a persistent fear of behaving or performing in the presence of others in a way that will be humiliating or embarrassing to the individual.
Specific phobia. Formerly called simple phobia, this disorder is characterized by persistent fears of specific objects or situations.
Obsessive-compulsive disorder. This disorder is characterized by involuntary recurring thoughts or images that the individual is unable to ignore and by recurring impulse to perform a seemingly purposeless activity.
Posttraumatic stress disorder. Posttraumatic stress disorder is characterized by the development of physiological and behavioral symptoms following a psychologically traumatic event that is generally outside the range of usual human experience.
Acute stress disorder. Acute stress disorder is characterized by the development of physiological and behavioral symptoms similar to those of PTSD; the major difference in the diagnosis lies in the length of time the symptoms exist; with acute stress disorder, the symptoms must subside within 4 weeks of occurrence of the stressor.
Anxiety disorder due to a general medical condition. The symptoms of this disorder are judged to be the direct physiological consequence of a general medical condition.
Substance-induced anxiety disorder. The DSM-IV-TR (APA, 2000) describes the essential features of this disorder as prominent anxiety symptoms that are judged to be caused by the direct physiological effects of a substance.

Obsessive-compulsive disorder (included in the obsessive-compulsive and related disorders), posttraumatic stress disorder (included in the trauma and stress-related disorders), and acute stress disorder, are no longer considered anxiety disorders as they were in the previous version of the DSM. Nonetheless, these disorders are closely linked to anxiety disorders and the sequential order of these chapters in the DSM-5 reflects this close connection.

Pathophysiology

The brain circuits and regions associated with anxiety disorders are beginning to be understood with the development of functional and structural imaging.

In the central nervous system (CNS) the major mediators of the symptoms of anxiety disorders appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA).
Other neurotrasmitters and peptides, such as corticotropin-releasing factor, may be involved.
Peripherally, the autonomic nervous system, especially the sympathetic nervous system, mediates many of the symptoms.

Statistics and Incidences

Anxiety disorders are the most common type of psychiatric disorders in the Unites States.

The lifetime prevalence of anxiety disorders among American adults is 28.8%.
Social anxiety disorder is the most common anxiety disorder; it has an early age of onset-by age 11 years in about 50%, and by age 20 years in about 80% of individuals that have the diagnosis- and it is a risk factor for subsequent depressive illness and substance abuse.
The prevalence of specific anxiety disorders appears to vary between countries and cultures.
The median prevalence of social anxiety disorder in Europe is 2.3%.
The female-to-male ratio for any lifetime anxiety disorder is 3:2.

Causes

Predisposing factors to anxiety disorder include the following:

Biochemical. Increased levels of norepinephrine have been noted in panic and generalized anxiety disorders; abnormal elevations of blood lactate have also been noted in patients with panic disorder.
Genetic. Studies suggest that anxiety disorders are prevalent within the general population; it has been shown that they are more common among first-degree biological relatives of people with the disorders than among the general population.
Medical or substance-induced. Anxiety disorders may be caused by a variety of medical conditions or the ingestion of various substances.
Psychodynamic theory. The psychodynamic view focuses on the inability of the ego to intervene when conflict occurs between the superego and the id, producing anxiety.
Cognitive theory. The main thesis of the cognitive view is that faulty, distorted, or counterproductive thinking patterns accompany or precede maladaptive behaviors and emotional disorders.

Clinical Manifestations

Signs and symptoms of anxiety disorders may include the following:

Pounding, rapid heart rate.
Feeling of choking or smothering.
Difficulty breathing.
Pain in the chest.
Feeling dizzy or faint.
Increased perspiration.
Feeling of numbness or tingling in the extremities.
Trembling.
Fear that one is dying or going crazy.
Sense of impending doom.
Feelings of unreality (derealization and/or depersonalization).

Assessment and Diagnostic Findings

For presentations with a higher index of suspicion for other medical causes of anxiety, more detailed evaluations may be indicated to identify or exclude underlying medical disorders.

EEG, lumbar puncture, and head/brain imaging. Rule out CNS disorder using EEG, lumbar puncture, brain computed tomography scan, as indicated by history and associated clinical findings.
Electrocardiography. Rule out cardiac disorders using electrocardiography or treadmill ECG.
Tests for infection. Rule out infectious causes using rapid plasma reagent test, lumbar puncture, or HIV testing.
Arterial blood gas analysis. Arterial blood gas analysis is useful in confirming hyperventilation and excluding hypoxemia or metabolic acidosis.
Chest radiography. Chest radiography is useful in excluding other causes of dyspnea with chest pain.
Thyroid function. Hyperthyroidism is one of the most common medical causes for anxiety related to a medical condition.

Medical Management

Treatment usually consists of a combination of pharmacotherapy and/or psychotherapy.

Cognitive therapy. Cognitive therapy helps patients understand how automatic thoughts and false beliefs/distortions lead to exaggerated emotional responses, such as anxiety, and can lead to secondary behavioral consequences.
Behavioral therapy. Behavioral therapy involves sequentially greater exposure of the patient to anxiety-provoking stimuli; over time, the patient becomes desensitized to the experience.
Diet. Caffeine containing products, such as coffee, tea, and colas, should be discontinued.

Pharmacologic Management

Antidepressant agents are the drugs of choice in the treatment of anxiety disorders, particularly the newer agents that have a safer adverse effect profile and higher ease of use than the older tricyclic antidepressants.

Selective serotonin reuptake inhibitors. The SSRIs are first-line agents for long-term management of anxiety disorders, with control gradually achieved over a 2-to 4-wk course, depending on required dosage increases.
Serotonin and norepinephrine reuptake inhibitors. Pharmacologic agents with reuptake inhibition of serotonin and norepinephrine may be helpful in a variety of mood and anxiety disorders.
Atypical antidepressants. Antidepressants that are not FDA-approved for the treatment of a given anxiety disorder still may be beneficial for the treatment of anxiety disorders; mirtazapine acts distinctly as an alpha-2 antagonist, consequently increasing synaptic norepinephrine and serotonin, while also blocking some postsynaptic serotonergic receptors that conceptually mediate excessive anxiety when stimulated with serotonin.
Tricyclic antidepressants. The tricyclic antidepressants are a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects.
Benzodiazepines. Benzodiazepines often are used with antidepressants as adjunct treatment; they are especially useful in the management of acute situational anxiety disorder and adjustment disorder where the duration of pharmacotherapy is anticipated to be 6 weeks or less and for the rapid control of anxiety attacks.
Antianxiety agents. Buspirone is a non-sedating antipsychotic drug unrelated to benzodiazepines, barbiturates, and other sedative hypnotics; it has fewer cognitive and psychomotor adverse effects, which makes its use preferable in elderly patients.
Anticonvulsant. The drug of choice in this category is the gamma-aminobutyric acid derivative pregabalin (Lyrica).
Antihypertensive agent. Agents in this class may have a positive effect on the physiological symptoms of anxiety; beta-blockers may be useful for the circumscribed treatment of situational/performance anxiety on an as-needed basis.
Monoamine oxidase inhibitor (MAOI). MAOIs are most commonly prescribed for patients with social phobia.
Antipsychotic agent. Atypical and typical antipsychotic medications are generally used more as augmentation strategies and are second-line treatment options in generalized anxiety disorder.

Nursing Management

Nursing management of a patient with anxiety disorder include the following:

Nursing Assessment

Nursing assessment of a patient with anxiety disorder include:

History. The client usually seeks treatment for panic disorder after he or she has experienced several panic attacks; usually, the client cannot identify any trigger for these events.
General appearance and motor behavior. The client may appear entirely “normal” or may have signs of anxiety if he or she is apprehensive about having a panic attack in the next few moments.
Mood and affect. Assessment of mood and affect may reveal that the client is anxious, worried, tense, depressed, serious, or sad.
Thought processes and content. During a panic attack, the client is overwhelmed, believing that he or she is dying, losing control, or “going insane”; the client may even consider suicide.
Sensorium and intellectual process. During a panic attack, the client may be confused and disoriented; he or she cannot take in environmental cues and respond appropriately.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnosis are:

Anxiety related to unconscious conflict about essential values and goals of life; situational or maturational crises.
Fear related to phobic stimulus.
Ineffective coping related to underdeveloped ego; punitive superego.
Powerlessness related to fear of disapproval from others.
Social isolation related to panic level of anxiety.

Nursing Care Planning and Goals

The major nursing care planning goals for patients with Anxiety Disorders are:

SEE ALSO: 7 Anxiety and Panic Disorders Nursing Care Plans

Client will verbalize ways to intervene in escalating anxiety within 1 week.
Client will be able to recognize symptoms of onset of anxiety and intervene before reaching the panic stage by time of discharge from treatment.

Nursing Interventions

The nursing interventions for anxiety disorders are:

Stay calm and be nonthreatening. Maintain a calm, nonthreatening manner while working with client; anxiety is contagious and may be transferred from staff to client or vice versa.
Assure client of safety. Reassure client of his or her safety and security; this can be conveyed by physical presence of the nurse; do not leave client alone at this time.
Be clear and concise with words. Use simple words and brief messages, speak calmly and clearly, to explain hospital experiences to client; in an intensely anxious situation, client is unable to comprehend anything but the most elementary communication.
Provide a non-stimulating environment. Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor); a stimulating environment may increase level of anxiety.
Administer medications as prescribed. Administer tranquilizing medication, as ordered by physician; assess medication for effectiveness and for adverse side effects.
Recognize precipitating factors. When level of anxiety has been reduced, explore with client possible reasons for occurrence; recognition of precipitating factors is the first step in teaching client to interrupt escalation of anxiety.
Encourage client to verbalize feelings. Encourage client to talk about traumatic experience under nonthreatening conditions; help client work through feelings of guilt related to the traumatic event; help client understand that this was an event to which most people would have responded in like manner.

Evaluation

The outcome criteria for Anxiety Disorders include:

Client is able to maintain anxiety at level in which problem solving can be accomplished.
Client is able to verbalize signs and symptoms of escalating anxiety.
Client is able to demonstrate techniques for interrupting the progression of anxiety to the panic level.

Documentation Guidelines

Documentation guidelines include the following:

Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
Cultural and religious beliefs, and expectations.
Plan of care.
Teaching plan.
Responses to interventions, teaching, and actions performed.
Attainment or progress toward the desired outcome.

Practice Quiz: Anxiety Disorders

Nursing practice questions for Anxiety Disorders. Please visit our nursing test bank page for more NCLEX practice questions.

1. After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby?

A. Allowing the client time to heal.
B. Recommending a high-protein, low-fat diet.
C. Exploring the meaning of the traumatic event with the client.
D. Giving sleep medication, as prescribed, to restore a normal sleep-wake cycle.

1. Answer: C Exploring the meaning of the traumatic event with the client.

Option C: The client with PTSD needs encouragement to examine and understand the meaning of the traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become depressed or engage in self-destructive behavior such as substance abuse.
Option B: A special diet isn’t indicated unless the client also has an eating disorder or a nutritional problem.
Option C: The client must explore the meaning of the event and won’t heal without this, no matter how much time passes. Behavioral techniques, such as relaxation therapy, may help decrease the client’s anxiety and induce sleep.
Option D: The physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence; sleep medication is rarely appropriate.

2. Alfred was newly diagnosed with anxiety disorder. The physician prescribed buspirone (BuSpar). The nurse is aware that the teaching instructions for newly prescribed buspirone should include which of the following?

A. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug.
B. A warning about the incidence of neuroleptic malignant syndrome (NMS).
C. A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days.
D. A warning that immediate sedation can occur with a resultant drop in pulse.

2. Answer: C. A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days.

Option C: The client should be informed that the drug’s therapeutic effect might not be reached for 14 to 30 days. The client must be instructed to continue taking the drug as directed.
Option A: Blood level checks aren’t necessary.
Options B and D: NMS hasn’t been reported with this drug, but tachycardia is frequently reported.

3. Patient Clint with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobias include:

A. Severe anxiety and fear
B. Withdrawal and failure to distinguish reality from fantasy
C. Insomnia and an inability to concentrate
D. Depression and weight loss

3. Answer: A. Severe anxiety and fear.

Option A: Phobias cause severe anxiety (such as a panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia, and elevated blood pressure.
Option B: Withdrawal and failure to distinguish reality from fantasy occur in schizophrenia.
Options C and D: Insomnia, an inability to concentrate, and weight loss are common in depression.

4. Which medications have been found to help reduce or eliminate panic attacks?

A. Anticholinergics
B. Mood stabilizers
C. Antipsychotics
D. Antidepressants

4. Answer: D. Antidepressants.

Option D: Tricyclic and monoamine oxidase (MAO) inhibitor antidepressants have been found to be effective in treating clients with panic attacks. Why these drugs help control panic attacks isn’t clearly understood.
Option A: Anticholinergic agents, which are smooth-muscle relaxants, relieve physical symptoms of anxiety but don’t relieve the anxiety itself.
Option B: Mood stabilizers aren’t indicated because panic attacks are rarely associated with mood changes.
Option C: Antipsychotic drugs are inappropriate because clients who experience panic attacks aren’t psychotic.

5. The nurse is assessing a client who has just been admitted to the emergency department. Which signs would suggest an overdose of an antianxiety agent?

A. Suspiciousness, dilated pupils, and increased blood pressure
B. Emotional lability, euphoria, and impaired memory
C. Agitation, hyperactivity, and grandiose ideation
D. Combativeness, sweating, and confusion

5. Answer: B. Emotional lability, euphoria, and impaired memory.

Option B: Signs of antianxiety agent overdose include emotional lability, euphoria, and impaired memory.
Option A: Hallucinogen overdose can produce suspiciousness, dilated pupils, and increased blood pressure.
Option C: Amphetamine overdose can result in agitation, hyperactivity, and grandiose ideation.
Option D: Phencyclidine overdose can cause combativeness, sweating, and confusion.