Mild anxiety

Mild anxiety occurs in the normal experience of everyday living and allows an individual to perceive reality in sharp focus. A person experiencing a mild level of anxiety sees, hears, and grasps more information, and problem solving becomes more effective. Physical symptoms may include slight discomfort, restlessness, irritability, or mild tension-relieving behaviors (e.g., nail biting, foot or finger tapping, fidgeting).

Moderate anxiety

As anxiety increases, the perceptual field narrows, and some details are excluded from observation. The person experiencing moderate anxiety sees, hears, and grasps less information and may demonstrate selective inattention, in which only certain things in the environment are seen or heard unless they are pointed out. The ability to think clearly is hampered, but learning and problem solving can still take place although not at an optimal level. Sympathetic nervous system symptoms begin to kick in. The individual may experience tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (e.g., gastric discomfort, headache, urinary urgency). Voice tremors and shaking may be noticed. Mild or moderate anxiety levels can be constructive because anxiety may be a signal that something in the person’s life needs attention or is dangerous (see the Case Study and Nursing Care Plan for moderate anxiety on the Evolve website).

Severe anxiety

The perceptual field of a person experiencing severe anxiety is greatly reduced. A person with severe anxiety may focus on one particular detail or many scattered details and have difficulty noticing what is going on in the environment, even when another points it out. Learning and problem solving are not possible at this level, and the person may be dazed and confused. Behavior is automatic and aimed at reducing or relieving anxiety. Somatic symptoms (e.g., headache, nausea, dizziness, insomnia) often increase; trembling and a pounding heart are common, and the person may experience hyperventilation and a sense of impending doom or dread (see Case Study and Nursing Care Plan 15-1).

Panic

Panic is the most extreme level of anxiety and results in markedly disturbed behavior. Someone in a state of panic is unable to process what is going on in the environment and may lose touch with reality. The behavior that results may be manifested as pacing, running, shouting, screaming, or withdrawal. Hallucinations, or false sensory perceptions (e.g., seeing people or objects not really there), may be experienced. Physical behavior may become erratic, uncoordinated, and impulsive. Automatic behaviors are used to reduce and relieve anxiety although such efforts may be ineffective. Acute panic may lead to exhaustion.

Review Table 15-1, which distinguishes among the levels of anxiety in regard to their (1) effects on perceptual field, (2) effects on problem solving, and (3) physical and other defining characteristics.

Separation anxiety disorder

Separation anxiety is a normal part of infant development; it begins around 8 months of age, peaks around 18 months, and begins to decline after that. People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other (Bostic & Prince, 2010). There may also be fear that something horrible will happen to the other person and that it will result in permanent separation. The anxiety is so intense that it distracts sufferers from their normal activities, causes sleep disruptions and nightmares without the significant other close by, and is often manifested in physical symptoms such as gastrointestinal disturbances and headaches.

This problem is typically diagnosed prior to the age of 18 after about a month of symptoms. Separation anxiety may develop after a significant stress, such as the death of a relative or pet, an illness, a move or change in schools, or a physical or sexual assault (Ursano et al., 2011).

Recently, clinicians have begun to recognize an adult form of separation anxiety disorder that may begin either in childhood or in adulthood. Those who are the subject of the attachment—a parent, a spouse, a child, or a friend—may grow weary of the constant neediness and clinginess. In fact, adults with this disorder often have extreme difficulties in romantic relationships and are more likely to be unmarried (Nichols, 2009). Characteristics of adult separation anxiety disorder include harm avoidance, worry, shyness, uncertainty, fatigability, and a lack of self-direction (Mertol & Alkin, 2012). It is accompanied by a significant level of discomfort and disability that impairs social and occupational functioning and does not respond well to the most popular type of psychotherapy, cognitive-behavioral therapy.

Panic disorders

Panic attacks are the key feature of panic disorder. A panic attack is the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom. The feelings of terror present during a panic attack are so severe that normal functioning is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur. People experiencing panic attacks may believe they are losing their minds or having a heart attack. Uncomfortable physical symptoms such as palpitations, chest pain, breathing difficulties, nausea, and feelings of choking, chills, and hot flashes may occur. Typically, panic attacks come “out of the blue” (i.e., suddenly and not necessarily in response to stress), are extremely intense, last a matter of minutes, and then subside.

Unpredictability is a key aspect of panic disorder in children and adolescents. The attacks of panic seem to come out of nowhere, last about 10 minutes, and then subside. During the attack the young person has much the same symptoms as adults, but is often less able to articulate the psychological aspects, such as fear. They may become avoidant of situations where help is not available, may develop feelings of hopelessness in controlling these attacks, and may become depressed. Alcohol or substance abuse is not uncommon in adolescents with this disorder.

People who experience these attacks begin to “fear the fear” and become so preoccupied about future episodes of panic that they avoid what could be pleasurable and adaptive activities, experiences, and obligations. Table 15-3 outlines a generic nursing care plan for panic disorder, and the Evidence-Based Practice box provides additional information.

Agoraphobia

Agoraphobia is intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available. The feared places are avoided in an effort to control anxiety. Examples of situations that are commonly avoided by patients with agoraphobia are being alone outside; being alone at home; traveling in a car, bus, or airplane; being on a bridge; and riding in an elevator. These situations may be made more tolerable with the addition of a friend. Avoidance behaviors can be debilitating and life constricting. Consider the effect on a father whose agoraphobia renders him unable to leave home and prevents him from seeing his child’s high school graduation or the businesswoman whose avoidance of flying prevents her from attending distant business conferences.

Specific phobias

A specific phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance, or actual avoidance of the object, activity, or situation. Specific phobias are characterized by the experience of high levels of anxiety or fear in response to specific objects or situations, such as dogs, spiders, heights, storms, water, blood, closed spaces, tunnels, and bridges.

Characteristically, phobic individuals experience overwhelming and crippling anxiety when faced with the object or situation provoking the phobic response. Daily functioning is compromised, and phobic people go to great lengths to avoid the feared object or situation. A phobic person may not be able to think about or visualize the object or situation without becoming severely anxious. The life of a phobic person becomes more restricted as activities are given up so that the phobic object can be avoided. All too frequently, complications ensue when sufferers try to decrease anxiety through self-medication with alcohol or drugs.

Consider the case of Daniel, who developed a profound fear of elevators after being trapped in one for 3 hours during a power outage. As his fear and anxiety intensified, it became necessary for him to use only stairs or escalators. He obsesses about the possibility that he will be forced to use an elevator in social situations and avoids attending events where this may occur. It has reached a point where even going inside closets or small storage rooms is unbearable. This fear of enclosed spaces is called claustrophobia. Other common phobias are listed in Table 15-4.

Social anxiety disorder

Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that could be evaluated negatively by others. Situations that trigger this distress include fear of saying something that sounds foolish in public, not being able to answer questions in a classroom, looking awkward while eating or drinking in public, and performing badly on stage. Whenever possible, people with social anxiety disorder avoid these social situations; if they are unable to avoid them, they endure the situation with intense anxiety and emotional distress.

Small children with this disorder may be mute, nervous, and hide behind their parents. Older children and adolescents may be paralyzed by fear of speaking in class or interacting with other children; the worry over saying the wrong thing or being criticized immobilizes them. Conversely, younger people may act out to compensate for this fear making an accurate diagnosis more difficult. This anxiety often results in physical complaints to avoid social situations, particularly school.

Fear of public speaking is the most common manifestation of social anxiety disorder. Interestingly, this disorder has afflicted famous singers and actors such as Barbra Streisand and Sir Laurence Olivier, both of whom were terrified that they might forget the words to songs and scripts.

Generalized anxiety disorder

The key pathological feature of generalized anxiety disorder is excessive worry (Newman & Llera, 2011). Children, teens, and adults may experience this worry, which is out of proportion to the true impact of events or situations. Persons with generalized anxiety disorder anticipate disaster and are restless, irritable, and experience muscle tension. Decision making is difficult due to poor concentration and dread of making a mistake.

Common worries in generalized anxiety disorder are inadequacy in interpersonal relationships, job responsibilities, finances, and health of family members. Because of this worry, huge amounts of time are spent in preparing for activities. Putting things off and avoidance are key symptoms and may result in lateness or absence from school or employment, and overall social isolation. Family members and friends are overtaxed as the person with this disorder seeks continual reassurance and perseverates about meaningless details.

Sleep disturbance is common because the individual worries about the day’s events and real or imagined mistakes, reviews past problems, and anticipates future difficulties. Fatigue is a noticeable side effect of this sleep deprivation. Refer to Table 15-5 for a generic care plan for generalized anxiety disorder.

TABLE 15-5   

GENERIC CARE PLAN FOR GENERALIZED ANXIETY DISORDER

Nursing diagnosis: Ineffective coping related to persistent anxiety, fatigue, difficulty concentrating
Outcome criteria: Patient will maintain role performance.
SHORT-TERM GOAL	INTERVENTION	RATIONALE
1. Patient will state that immediate distress is relieved by end of session.	1a. Stay with patient. 1b. Speak slowly and calmly. 1c. Use short, simple sentences. 1d. Assure patient that you are in control and can assist him or her. 1e. Give brief directions. 1f. Decrease excessive stimuli; provide quiet environment. 1g. After assessing level of anxiety, administer appropriate dose of antianxiety agent if warranted. 1h. Monitor and control own feelings.	1a. Conveys acceptance and ability to give help. 1b. Conveys calm and promotes security. 1c. Promotes comprehension. 1d. Counters feeling of loss of control that accompanies severe anxiety. 1e. Reduces indecision. Conveys belief that patient can respond in a healthy manner. 1f. Reduces need to focus on diverse stimuli. Promotes ability to concentrate. 1g. Reduces anxiety and allows patient to use coping skills. 1h. Anxiety is transmissible. Displays of negative emotion can cause patient anxiety.
2. Patient will be able to identify source of anxiety by (date).	2a. Encourage patient to discuss preceding events. 2b. Link patient’s behavior to feelings. 2c. Teach a cognitive therapy principle: Anxiety is the result of automatic thinking with a dysfunctional appraisal of a situation. 2d. Ask questions that clarify and dispute illogical thinking: “What evidence do you have?” “Explain the logic in that.” “Are you basing that conclusion on fact or feeling?” “What’s the worst thing that could happen?” 2e. Have patient give an alternative interpretation.	2a. Promotes future change through identification of stressors. 2b. Promotes self-awareness. 2c. Provides a basis for behavioral change. 2d. Helps promote accurate cognition. 2e. Broadens perspective. Helps patient think in a new way about problem or symptom.
3. Patient will identify strengths and coping skills by (date). Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: The nursing process and standards of care for psychiatric mental health nursing Cultural implications for psychiatric mental health nursing Sleep-wake disorders Biological basis for understanding psychiatric disorders and treatments Stay updated, free articles. Join our Telegram channel Join Tags: Varcarolis Foundations of Psychiatric Mental Health Nursing Feb 3, 2017 | Posted by admin in NURSING | Comments Off on Anxiety and obsessive-compulsive related disorders Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access