Anxiety Disorder

Overview
Feelings of anxiety are so common in our society that they are almost considered
universal. Low levels of anxiety are adaptive and can provide the motivation required for
survival. The term anxiety is often used interchangeably with the word stress; however,
they are not the same (Townsend, 2008). Stress, or more properly, a stressor is an external
pressure that is brought to bear on the individual. Anxiety is the subjective emotional
response to stressor. Anxiety maybe distinguished from fear in that the former is an
emotional process, whereas fear is a cognitive one. It involves the intellectual appraisal of
a threatening stimulus; anxiety involves the emotional response to that appraisal
(Townsend, 2008).
Definition of Anxiety
An emotional response (e.g., apprehension, tension, uneasiness) to anticipation of
danger, the source of which is largely unknown or unrecognized (Townsend, 2008).
Etiology
Anxiety arises from the chaos and confusion that exists in the world today.
Fears of the unknown and conditions of ambiguity offer a perfect breeding ground for
anxiety to take root and grow. Anxiety becomes problematic when individual is unable
to prevent that anxiety from escalating to a level that interferes with the ability to meet
basic needs. (Townsend, 2008). Neuroanatomical- alterations in the limbic system,
diencephalon, temporal lobes and hippocampus can contribute to anxiety. Biochemicalelevations of blood lactate can be found in patients with panic disorders. NeurochemicalSerotonin and GABA are decreased in anxiety disorders. Medical Conditions- Acute MI,

Substance intoxication//withdrawal, hypoglycemia, caffeine intoxication, mitral valve

prolapsed and complex partial seizures. Some Predisposing Factors of anxiety are
Genetics Females; women are more likely than men Age, <45 years, Trauma, Stress
related to illness, Drugs or alcohol abuse Separated or divorced, Survivors of abuse Low
self-esteem.
Epidemiology
Anxiety disorders are the most common of all psychiatric illnesses and results in
considerable functional impairment and distress (Townsend, 2008). Anxiety disorders are
more common in women than in men, in a ratio of 2 to 1. Prevalence rate within the
general population have been given at 4 to 6 percent for generalized anxiety disorders and
panic disorders, 2 to 3 percent for obsessive compulsive disorder, 8 percent for
posttraumatic stress disorder, 13 percent for social anxiety disorder, and 22 percent for
phobias. Anxiety affects individuals at all ages (Townsend, 2008).
The Signs and Symptoms of anxiety are Shortness of breath, Dizziness,
Palpitations, Fidgeting, Trembling, Pacing, Sweating, Dry mouth, Nausea, Diarrhea,
Spasm. Affective Symptoms are; Fearful, Terrified, Apprehensive, Frightened, Scared,
Jittery, Jumpy, Uneasy, Impatient. Cognitive Symptoms are; Confusion, Difficulty
recalling, Difficulty focusing & concentrating, Distractibility, Blocking, Fear of: losing
control, not being able to cope, physical injury, death, mental disorder. Behavioral
Symptoms Inhibited, Flight, Avoidance, Speech dysfluency, Impaired coordination,
Restlessness, and Hyperventilation
Diagnostic Investigations
Health History

Physical exam to rule out other physical illness

Stages of Anxiety
In 1963, Peplau described four levels of anxiety:
I.

Mild anxiety: is associated with the tension experienced in response to the events

of day- to day living. Mild anxiety prepares people for action. It sharpens the senses,
increases motivation for productivity, increases perceptual field, and results in a
heightened awareness of the environment (Townsend, 2008). Learning is enhanced and
the individual is able to function at his or her optimal level. At this level, individuals use
any of a number of coping behaviors that satisfy their needs for comfort: Sleeping, Eating
Physical, exercise, Smoking, Yawning, Drinking, Daydreaming, Laughing, Cursing,
Pacing, Foot swinging, Fidgeting, Nail biting, &Finger tapping.
II.

Moderate anxiety: as the level of anxiety increases, the extend of the perceptual

field diminishes (Townsend, 2008). The moderately anxious individual is less alert to the
events occurring within the environment. The individuals attention span and ability to
concentrate decrease, although he or she may still attend to needs with directions.
Assistance with problem-solving may be required. Increased muscular tension and
restlessness are also included (Townsend, 2008).
III.

Severe anxiety: the perceptual field of the severely anxious individual is so

greatly diminished that concentration centers on one particular detail only or on many
extraneous details (Townsend, 2008). Attention span is extremely limited, and the
individual has much difficulty completing even the simplest task. Physical symptoms
(e.g., headaches, palpitations, insomnia) and emotional symptoms (e.g., confusion, dread,

horror) may be evident. Discomfort is experienced to the degree that virtually all overt
behavior is aimed at relieving that anxiety (Townsend, 2008).
IV.

Panic anxiety: in this most intense state of anxiety the individual is unable to

focus on even one detail within the environment (Townsend, 2008). Misperceptions are
common, and a loss of contact with reality may occur. The individual may experience
hallucinations or delusions. Behavior may be characterized by wild and desperate actions
or extreme withdrawal (Townsend, 2008). Human functioning and communication with
others are ineffective. Panic anxiety is associated with a feeling of terror, and individuals
may be convinced that they have a life-threatening illness or fear that they are going
crazy, are losing control, or are emotionally weak. Prolonged panic anxiety can lead to
physical and emotional exhaustion and can be life threatening (Townsend, 2008).
But, how much is too much? Anxiety is usually considered a normal reaction to a
realistic danger or threat to biological integrity or self-concept. It is difficult to draw a
precise line between normal and abnormal anxiety. Normality is determined by societal
standards therefore, what is considered normal in The Bahamas may not be so in The
United States. Anxiety can be considered abnormal or pathological if, it is out of
proportion to the situation that is creating it. Example: Mr. J.D witnessed a serious
automobile accident 4 weeks ago when he was out for a Sunday drive, and since that time
he refuses to drive even to the grocery store which is only a few miles from is house.
When she is available, his daughter must take him wherever he needs to go.
Five Categories of Anxiety Disorder
I.

Generalized Anxiety Disorder

According to Townsend (2008), generalized Anxiety Disorder is characterized by

chronic, unrealistic, and excessive anxiety and worry. The symptoms have existed for 6
months or longer and cannot be attributed to specific organic factors, such as caffeine
intoxication or hyperthyroidism.
Signs and Symptoms of Generalized Anxiety Disorder
According to Townsend (2008), the DSM-IV-TR identifies the following
symptoms associated with generalized anxiety disorder. Symptoms must have occurred
more days than not for at least 6 months and must cause clinically significant distress or
impairment areas of functioning (Townsend, 2008). Excessive anxiety and worry about a
number of events that the individual finds difficult to control, Restlessness or feelings
keyed up on edge, being easily fatigued, Difficulty concentration or mind: going blank
Irritability, Muscle tension, Sleep disturbance (difficulty falling or staying asleep, or
restless unsatisfying sleep).
Epidemiology
The onset of the disorder may begin in childhood or adolescence, but is not
uncommon after age 20 (Townsend, 2008). Depressive symptoms are common, and
numerous somatic complaints may also be a part of the clinical picture. Generalized
anxiety disorder tends to be chronic, with frequent stress-related exacerbations and
fluctuations in the course of the illness.
II.

Panic Disorder
According to Townsend (2008), panic is a sudden overwhelming feeling of terror or

impending doom. This most severe form of emotional anxiety is usually accompanied by
behavioral, cognitive, and physiological signs and symptoms considered to be outside the

expected range of normalcy. Panic disorder is characterized by recurrent panic attack, the
onset of which is unpredictable, and manifested by intense apprehension, fear, or terror,
often associated with feelings of impending doom and accompanied by intense physical
discomfort (Townsend, 2008).
Signs and Symptoms
According to Townsend (2008), symptoms come on unexpectedly; that is, they
do not occur immediately before or on exposure to a situation that usually causes anxiety
(as in specific phobia). They are not triggered by situations in which the person is the
focus of others attention (as in social phobia). At least four of the following must be
present to identify a panic attack: Palpations, Sweating, Trembling or shaking, Sensations
of shortness of breath Feeling of choking, Chest pain or discomfort, Nausea or abdominal
distress, Feeling of dizziness, unsteady, lightheaded, or faint Fear of losing control or
going crazy Fear of dying, De-realization (feelings of unreality) or depersonalization
(being detached from oneself) Chills or hot flashes
According to Townsend (2008), the attack usually last minutes, or more rarely hours. The
individual often experiences varying degrees of nervousness and apprehension between
attacks. Symptoms of depression are common.
Epidemiology
The average age of onset of panic disorder is the late 20s. Frequently and severity
of the panic attacks vary widely (Townsend, 2008). Some individuals may have attacks
or moderate severity weekly; others may have less severe or limited- symptom attacks
several times a week. Others, may experience panic attacks that are separated by weeks
or months or for a number of years. Sometimes the individual experiences periods of

remission and exacerbation. In time of remission, the person may have recurrent limitedsymptom attacks (Townsend, 2008).
III.

Obsessive Compulsive Disorder

Obsessive Compulsive Disorder is defined as recurrent obsessions or compulsions

that are serve enough to be time consuming or to cause marked distress or significant
impairment. The individual recognizes that the behavior is excessive or unreasonable but,
because of the feeling of relief from discomfort that it promotes is compel to continue the
act (Townsend 2008). According to Sarah Jacobs (2012), she adds that, These
individuals clean personal items and hands, or check lights, stove or locks repeatedly.
Anxious thoughts can influence our behavior, which is helpful at times. However, if that
thought becomes obsessive (recurring), it can influence unhealthy patterns of behavior
that can cause difficulties in daily functioning.
According to Jacobs (2012), some causes of OCD are, biological factors which had
been linked to several neurological factors and irregular levels of serotonin in particular;
and environmental / learned behaviors which may develop as a result of learned behavior,
either by direct conditioning or learning by watching the behavior of others, e.g. parents.
In addition, Jacobs (2012) states that, Issues that commonly concern people with OCD
and result in compulsive behavior include:
1. Cleanliness/order obsessive hand-washing or household cleaning to reduce an
exaggerated fear of contamination; obsession with order or symmetry, with an
overwhelming need to perform tasks or place objects, such as books or cutlery, in a
particular place and/or pattern

2. Counting/hoarding repeatedly counting items or objects, such as their clothes or

pavement blocks when they are walking; hoarding items such as junk mail and old
newspapers
3. Safety/checking obsessive fears about harm occurring to either themselves or others
which can result in compulsive behaviors such as repeatedly checking whether the stove
has been turned off or that windows and doors are locked
4. Sexual issues having an irrational sense of disgust concerning sexual activity
5. Religious/moral issues feeling a compulsion to pray a certain number of times a day
or to such an extent that it interferes with their work and/or relationships.

IV.

Post-Traumatic Stress Disorder

According to Tyler Nabar (2012) he states that, Post-traumatic stress disorder

(PTSD) is a particular set of reactions that can develop in people who have been through
a traumatic event which threatened their life or safety, or that of others around them. This
could be a car or other serious accident, physical or sexual assault, war or torture, or
disasters such as bushfires or floods. As a result, the person experiences feelings of
intense fear, helplessness or horror. Nabar (2012) notes that some symptoms of PostTraumatic Stress Disorder are:
1. Re-living the traumatic event The person relives the event through unwanted and
recurring memories, often in the form of vivid images and nightmares. There may be
intense emotional or physical reactions, such as sweating, heart palpitations or panic
when reminded of the event.

2. Being overly alert or wound up The person experiences sleeping difficulties,

irritability and lack of concentration, becoming easily startled and constantly on the
lookout for signs of danger.
3. Avoiding reminders of the event The person deliberately avoids activities, places,
people, thoughts or feelings associated with the event because they bring back painful
memories.
4. Feeling emotionally numb The person loses interest in day-to-day activities, feels cut
off and detached from friends and family, or feels emotionally flat and numb.

V.

Social Anxiety Disorder

According to Townsend (2008), social anxiety disorder is a type of anxiety

characterized by fear of being negatively judged by others or public embarrassment. This
includes stage fright, fear of intimacy or fear of humiliation. This disorder can cause
people to avoid public situations or human contact. For example, Jones (2012) states,
performance situations such as having to give a speech or being watched while doing
something at work or situations involving social interaction such as having a meal with
friends, or making small talk. Common symptoms of social anxiety disorder are
excessive perspiration, trembling, blushing or stammering when trying to speak and
nausea or diarrhea. Jones (2012) explains some of the causes of social anxiety are:
1. Temperament Adolescents who are shy or socially inhibited are particularly at risk. In
children, clingy behavior, shyness, crying easily and excessive timidity may indicate
temperaments that could possibly put them at risk of developing social phobia.

2. Family history Social phobia can run in the family, in part because of a possible
genetic predisposition.
3. Learned behavior/environment Some people with social phobia attribute the
development of the condition to being poorly treated, publicly embarrassed or humiliated
(e.g. being bullied at school)
VI.

Phobias
According to Andrea Wodele and Matthew Solan (2015), Phobia is an excessive and

irrational fear reaction. If you have a phobia, you may experience a deep sense of dread
or panic when you encounter the source of your fear. The fear can be of a certain place,
situation, or object. Unlike general anxiety disorders, a phobia is usually connected to
something specific. The impact of a phobia can range from annoying to severely
disabling. People with phobias often realize their fear is irrational, but theyre unable to
do anything about it. Such fears can interfere with your work, school, and personal
relationships.
There are many factors that cause phobias such ad genetic and environmental factors.
Children who have a close relative with an anxiety disorder are at risk for developing a
phobia. Distressing events such as nearly drowning can bring on a phobia. Exposure to
confined spaces, extreme heights, and animal or insect bites can all be sources of
phobias (Wodele & Solan 2015). According to The American Psychiatric Association,
there are more than 100 different kinds phobias, for example phobias such as:

Agoraphobia is a fear of places or situations that you cant escape from.

Gloss phobia: Performance anxiety, or the fear of speaking in front of an

audience.
Acrophobia: The fear of heights
Claustrophobia: The fear of enclosed or tight spaces.

Aviatophobia: The fear of flying.

Dentophobia: Fear of the dentist or dental procedures
Hemophobia: Fear of blood or injury
Arachnophobia: Fear of spiders.
Cynophobia: Fear of dogs.
Ophidiophobia: Fear of snakes.
Nyctophobia: Fear of the nighttime or darkness.

Treatment Modalities for Anxiety Disorders

Cognitive Behavioral Therapy
CBT involves working with a professional (therapist) to identify thought and behavior
patterns that are either making you more likely to become anxious, or stopping you from
getting better when youre experiencing anxiety professionals may use a range of
techniques in CBT. Examples include:
1.encouraging you to recognize the difference between productive and unproductive
worries
2.teaching you how to let go of worries and solve problems.
3.teaching relaxation and breathing techniques, particularly muscle relaxation, to control
anxiety and the physical symptoms of tension.

Behavioral Therapy
While behavior therapy is a major component of cognitive behavior therapy (CBT),
unlike CBT it doesnt attempt to change beliefs and attitudes. Instead it focuses on
encouraging activities that are rewarding, pleasant or give a sense of satisfaction, in an
effort to reverse the patterns of avoidance and worry that make anxiety worse.
Psychodynamic Theory

According to Townsend (2008), the psychodynamic view focuses on the inability of the
ego to intervene when conflict occurs between the id and the superego, producing
anxiety. For various reasons (unsatisfactory parent-child relationship; conditional
love).
E-Therapy
E-therapies, also known as online therapies or computer-aided psychological therapy, can
be just as effective as face-to-face services for people with mild to moderate anxiety.
Most e-therapies teach you to identify and change patterns of thinking and behavior that
might be preventing you from overcoming your anxiety. This can be via telephone, email,
text, or instant messaging, and helps you to successfully apply what youre learning to
your life.

Pharmacotherapy
Benzodiazepines (Cogentin)
sometimes called minor tranquillizers and sleeping pills are a class of drug commonly
prescribed in the short term to help people cope with anxiety conditions. Benzodiazepines
promote relaxation and reduce tension, but are not recommended for long-term use as
they can reduce alertness, affect coordination, and can be addictive. For example,
Alprazolam (Xanax)Lorazepam (Ativan)Clonazepam (Klonopin).

Antidepressant

antidepressant medication can help people to manage anxiety, even if they are not
experiencing symptoms of depression; for example, Clomipramine (Anafranil)
Imipramine (Tofranil).

Nursing Management/ Nursing Process

Nursing Diagnosis for Anxiety Disorders
1. Anxiety related to a subjective sense of uneasiness and tension.
2. Fear related to a specific object, for example, a phobis fear of heights.
3. Social isolation related to restriction of travel away from home or places felt to be
safe
4. Powerlessness related to feeling out of control of ones own thoughts and
behaviors.
5. Post-trauma syndrome related to anxiety felt following a significant, life
threatening event.
6. Complicated grieving related to inability to cope with grief following significant
losses associated with a significant life threatening event.
Patients Goals
At the end of therapy, patient will:
1. Express or verbalize a decrease in anxiety levels
2. Effectively employ learned relaxation techniques
3. Be able to describe early warning signs of anxiety
Interventions
1. Assess the level of anxiety to provide baseline data
2. Initiate supportive therapy to build trust
3. Teach skills of cognitive restructuring to assist client in controlling anxious
feelings.
4. Provide information on medications to aid compliance.
5. Encourage expression of thoughts and feelings to set the context for acceptance.
6. Teach problem solving techniques to assist the client find reasonable solutions

Reference

Townsend, C. Mary. (2008). Essentials of psychiatric mental health nursing: concepts of

care in evidence-based practice (4th ed). Philadelphia, PA: F.A. Davis Company.
Jacobs, S. Jones, M. & Nabar, T. (2012) Types of Anxiety. Retrieved from
https://www.beyondblue.org.au/the-facts/anxiety/types-of-anxiety