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Chapter 14: Anxiety & Anxiety Disorders

Key terms:

Agoraphobia: fear of being outside

Anxiety: a vague feeling of dread or apprehension; it is a response to external or internal stimuli that
can have behavioral, emotional, cognitive, and physical symptoms
Anxiety disorders: Group of conditions that share a key feature of excessive anxiety, with ensuing
behavioral, emotional, cognitive, physiologic changes
Assertiveness training: the Ability to express positive and negative ideas and feelings in an open,
honest, and direct way
Avoidance behavior: behaviors designed to avoid unpleasant consequences or potentially threatening
Decatastrophizing: a technique that involves learning to assess situations realistically rather than
always assuming catastrophe will happen
Defense mechanisms: cognitive distortions that a person uses unconsciously to maintain a sense of
being in control of the situation, to lessen discomfort, and to deal with stress; also called ego defense
Depersonalization: feelings of being disconnected from himself or herself; the client feels detached
from his or her behavior
Derealization: client senses that events are not real, when, in fact, they are
Fear: feeling afraid or threatened by a clearly identifiable, external stimulus that represents danger to
the person
Flooding: a form of rapid desensitization in which a behavioral therapist confronted the client with the
focus object (either a picture of the actual object) until it no longer produces the anxiety
Mild anxiety: a sensation that something is different and warrants special attention
Moderate anxiety: the disturbing feeling that something is definitely wrong; the person becomes
nervous or agitated
Panic anxiety: intense anxiety, may be a response to a life-threatening situation
Panic attacks: between 15 and 30 minutes of rapid, intense, escalating anxiety in which the person
experiences great emotional fear as well as physiologic discomfort
Panic disorder: composed of discrete episodes of panic attacks, that is, 15-30 minutes of rapid, intense,
escalating anxiety in which the person experiences great emotional fear as well as physiologic
Phobia: an illogical, intense, and persistent fear of a specific object or social situation that causes
extreme distress and interferes with normal functioning
Positive reframing: a cognitive-behavioral technique involving turning negative messages into positive
Primary gain: the relief of anxiety achieved by performing the specific anxiety-driven behavior; the
direct external benefits that being sick provides, such as relief of anxiety, conflict, or distress
Secondary gain: the internal or personal benefits received from others because one is sick, such as
attention from family members, comfort measures, and being excused from usual responsibilities or
Selective mutism:
Severe anxiety: an increased level of anxiety when more primitive survival skills take over, defensive
responses ensure, and cognitive skills decreased significantly; person with severe anxiety has trouble
thinking and reasoning
Stress: the wear and tear that life causes on the body
Chapter 14: Anxiety & Anxiety Disorders
Systematic desensitization: behavioral technique used to help overcome irrational fears and anxiety
associated with a phobia

Learning Objectives:

1. Describe anxiety as a response to stress.

a. Alarm stage: stress stimulates the body to send messages from the hypothalamus to the glands
and organs to prepare for potential defense needs
b. Resistance stage: the digestive system reduces function to shunt blood to areas needed for
defense. The lungs take in more air, the heart beats faster and harder so it can circulate this
highly oxygenated and highly nourished blood to the muscles to defend the body by fight,
flight, or freeze behaviors.
c. Exhaustion stage: occurs when the person has responded negatively to anxiety and stress: body
stores are depleted, or the emotional components are not resolved, resulting in continual
arousal of the physiologic responses and little reserve capacity.
2. Describe the levels of anxiety with behavioral changes related to each level.
a. Mild: sensory stimulation increases and helps the person focus attention to learn, solve
problems, think, act, feel, and protect himself or herself. It motivates people to make changes
or to engage in goal-directed anxiety.
b. Moderate: In moderate anxiety, the person can still process information, solve problems, and
learn new things with assistance from others. He or she has difficulty concentrating
independently but can be redirected to the topic.
c. Severe: Trouble thinking and reasoning; muscles tighten and vital signs increase; the person
paces, is restless, irritable, and angry; or uses other similar emotion-psychomotor means to
release tension.
d. Panic: the emotional=psychomotor realm predominates with accompanying fight, flight, or
freeze responses. Adrenaline surge greatly increases vital signs. Pupils enlarge to let in more
light, and the only cognitive process focuses on the persons defense.
3. Discuss the use of defense mechanisms by people with anxiety disorders.
a. Freud described defense mechanisms as the human's attempt to control awareness of and to
reduce anxiety. Defense mechanisms are cognitive distortions that a person uses unconsciously
to maintain a sense of being in control of a situation, to lessen discomfort, and to deal with
stress. Because defense mechanisms arise from the unconscious, the person is unaware of
using them. Some people overuse defense mechanisms, which stops them from learning a
variety of appropriate methods to resolve anxiety-producing situations. The dependence on
one or two defense mechanisms also can inhibit emotional growth, lead to poor problem-
solving skills, and create difficulty with relationships.
b. Defense mechanisms can help a person to reduce anxiety. This is the only positive outcome of
using defense mechanisms. The dependence on defense mechanisms can inhibit emotional
growth, lead to poor problem-solving skills, and create difficulty with relationships. These are
all negative outcomes of using defense mechanisms.
Chapter 14: Anxiety & Anxiety Disorders
4. Describe the current theories regarding the etiologies of major anxiety disorders.
a. Biologic Theories
i. Genetic theories
1. Anxiety may have an inherited component because first-degree relatives of
clients with increased anxiety have higher rates of developing anxiety
ii. Neurochemical theories
1. Gamma-aminobutyric acid (GABA) is the amino acid neurotransmitter believed
to be dysfunctional in anxiety disorders. GABA reduces anxiety, and
norepinephrine increases it; researchers believe that a problem with the
regulation of these neurotransmitters occurs in anxiety disordersPsychodynamic
iii. Intrapsychic/Psychoanalytic Theories
1. Freud's intrapsychic theory views a person's innate anxiety as the stimulus for
iv. Interpersonal theory
1. Interpersonal theories include Sullivan's theory that anxiety is generated from
problems in interpersonal relationships and Peplau's belief that humans exist in
interpersonal and physiologic realms.
v. Behavioral theory
1. Behavioral theorists view anxiety as being learned through experiences.
5. Evaluate the effectiveness of treatment including medications for clients with anxiety disorders.
a. Anxiolytics are designed for short-term use to relieve anxiety. These drugs are designed to
relieve anxiety so that the person can deal more effectively with whatever crisis or situation is
causing stress. Benzodiazepines tend to cause dependence. Clients need to know that
antianxiety agents are aimed at relieving symptoms such as anxiety but do not treat the
underlying problems that cause the anxiety. See Table 14.2 Anxiolytics Drugs
6. Apply the nursing process to the care of clients with anxiety and anxiety disorders.
a. Assessment
i. History: clients seeks treatment for panic disorder after theyve experienced several
panic attacks. Usually, they cant identify any trigger for these events
ii. General Appearance and Motor Behavior: client may appear normal or may have signs
of anxiety if they are apprehensive about having a panic attack in the next few
moments. If they are anxious, speech may increase in rate, pitch, and volume, and they
may have difficulty sitting in a chair. Automatisms may be apparent, such as tapping
fingers, jingling keys, or twisting hair. Automatisms are geared toward anxiety relief and
increase in frequency and intensity with the clients anxiety level.
iii. Mood and Affect: may reveal that the client is anxious, worried, tense, depressed,
serious, or sad. May be tearful, angry.
iv. Thought processes and content: during a panic attack, the client is overwhelmed,
believing they are dying, losing control, or going insane.
v. Sensorium and intellectual processes: the client may become confused and disoriented.
They cannot take in environmental cues and respond appropriately.
vi. Judgment and insight: judgment is suspended during panic attacks. Insight into panic
disorder occurs only after the client has been educated about the disorder.
vii. Self-concept: Nurse must assess self-concept in clients with panic disorder.
viii. Roles and relationships: Client may report alterations in his or her social, occupational,
or family life. Avoiding these objects does not stop the panic attacks, but the persons
Chapter 14: Anxiety & Anxiety Disorders
sense of helplessness is so great that he or she may take even more restrictive measures
to avoid them.
ix. Physiologic and self-care concerns: reports of problems sleeping and eating; they may
eat constantly or experience loss of appetite in an attempt to ease the anxiety
b. Data analysis
i. Common diagnoses
1. Risk for injury
2. Anxiety
3. Situational low self-esteem (panic attacks)
4. Ineffective coping
5. Powerlessness
6. Ineffective role performance
7. Disturbed sleep pattern
c. Intervention
i. Provide a safe environment and ensure the clients privacy during a panic attack
ii. Remain with the client during a panic attack
iii. Help the client to focus on deep breathing
iv. Talk to the client in a calm, reassuring voice
v. Teach the client to use relaxation techniques
1. The nurse can teach the client relaxation techniques to use when he or she is
experiencing stress or anxiety, including deep breathing, guided imagery and
progressive relaxation, and cognitive restructuring techniques. For any of these
techniques, it is important for the client to learn and to practice them when he
or she is relatively calm.
vi. Help the client to use cognitive restructuring techniques
vii. Engage the client to explore how to decrease stressors and anxiety-provoking situations
7. Provide teaching to clients, families, caregivers, and communities to increase understanding of
anxiety and stress-related disorders.
a. Client/family education for panic disorder includes reviewing breathing control and relaxation
techniques, discussing positive coping strategies, encouraging regular exercise, emphasizing the
importance of maintaining prescribed medication regimen and regular follow-up, describing
time management techniques such as creating to do lists with realistic estimated deadlines
for each activity, crossing off completed items for a sense of accomplishment, saying no, and
stressing the importance of maintaining contact with community and participating in
supportive organizations. Medication should be adhered to as prescribed. Daily responsibilities
cannot be avoided, rather should be successfully accomplished.
8. Examine your feelings, beliefs, and attitudes regarding clients with anxiety disorders.
a. Nurses must understand why and how anxiety behaviors work, not just for client care but to
help understand the role anxiety plays in performing nursing responsibilities. Nurses are
expected to function at a high level and to avoid allowing their own feelings and needs to
hinder the care of their clients, but as emotional beings, nurses are just as vulnerable to stress
and anxiety as others, and they have needs of their own.