ANXIETY DISORDERS

Anxiety disorders affect 19% of the population, and because the majority of individuals with anxiety disorders will access medical care at some point in their lives, anxiety disorders are likely the most common psychiatric illnesses to be encountered by healthcare professionals (NAMI, 2022).

Anxiety disorders include:

  • Generalized anxiety disorder
  • Panic disorder
  • Social anxiety disorder
  • Phobia-related disorders
  • Agoraphobia
  • Separation anxiety
  • Selective mutism
  • Posttraumatic stress disorder (PTSD)

Anxiety is an uncomfortable feeling of apprehension or dread in response to internal or external stimuli. Anxiety involves physiologic arousal (fight-or-flight) and alterations in cognitive processes (decision-making), requiring implementation of coping strategies.

Signs and Symptoms of an Anxiety Disorder

Anxiety disorders have one of the longest differential diagnosis lists of all psychiatric disorders and can be due to a wide variety of medical or psychiatric syndromes. Symptoms can also be the result of certain medications.

A patient with generalized anxiety disorder can present with:

  • Complaints of feeling restless, wound-up, or on edge
  • Being easily fatigued
  • Having difficulty concentrating
  • Being irritable
  • Having headaches, muscle aches, stomachaches, or unexplained pains
  • Difficulty controlling feelings of worry
  • Having sleep problems

Patients experiencing panic disorder have periods of intense fear, discomfort, or sense of losing control even without clear danger or trigger. Patients with panic disorder frequently present to the emergency department with the complaint of chest pain, dyspnea, and the fear that they are experiencing a heart attack.

Others with an anxiety disorder may exhibit physical signs of anxiety such as tremor, sweaty palms, restlessness, and distractibility. Patients may also complain of other physical symptoms including:

  • Tachycardia
  • Tachypnea
  • Dyspnea
  • Diaphoresis
  • Stomach cramping
  • A lump in the throat or inability to swallow
  • Urinary frequency
  • Dry mouth
  • Nausea
  • Diarrhea
  • Headache, neck or backaches

It is common for patients with these symptoms to present to health professionals repeatedly, with pressing but long-standing concerns that prove to be medically unexplained (Bhatt, 2019).

SCREENING FOR ANXIETY

Patients who present with signs and symptoms of an anxiety disorder without already having been diagnosed should be screened. A tool that is easy to perform as an initial screening is the Generalized Anxiety Disorder 7-item (GAD-7). Although designed as a screening tool for generalized anxiety, the GAD-7 also performs well as a screening tool for three other common anxiety disorders: panic disorder, social anxiety disorder, and posttraumatic stress disorder (NHIVC, 2022).

Treatment for Anxiety Disorders

Anxiety disorders are generally treated with psychotherapy, medication, or both. The most common medications used for treatment are antidepressants, anti-anxiety medications, mild tranquilizers, and beta-blockers.

  • Antidepressants (SSRIs and SNRIs) are the drugs of choice. Tricyclics are used but may cause significant adverse effects. Examples include:
    • SSRIs: citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)
    • SNRIs: duloxetine (Cymbalta), venlafaxine (Effexor), desvenlafaxine (Pristiq)
    • Tricyclics: amitriptyline, amoxapine, doxepin, imipramine (Tofranil), nortriptyline (Pamelor)
  • Anxiolytics include benzodiazepines and the milder tranquilizer buspirone. Benzodiazepines are used for short-term acute management. Benzodiazepines are controlled substances and have the potential for abuse, addiction, and diversion. Examples include diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Rivotril).
  • Beta-blockers are used to tamp down the fight-or-flight response to control the physical symptoms of anxiety, including tachycardia and shakiness. Examples include: propranolol (Inderal), atenolol (Tenormin), and metoprolol (Lopressor).
    (Chand, 2022)

How to Respond to and Care for a Patient with Signs and Symptoms of Anxiety Disorder

It can be easy to discount someone’s anxiety when it is obviously out of proportion to the situation or circumstances. This can lead to minimizing or disregarding the patient’s symptoms. Providers can also experience feelings of frustration when they are unable to get the panicked person to calm down. It is important to recognize that anxiety is contagious and may be transferred from healthcare provider to patient or vice versa.

These are effective strategies when responding to a patient with anxiety disorders:

  • Remain calm, present a calm demeanor, and speak in a soothing voice.
  • If possible, move to a quiet place with minimal stimuli.
  • Acknowledge what patients are experiencing but remind them that they are not in danger, they will be okay, and you are there to help.
  • Speak in short, simple sentences and encourage the patient.
  • Remind patients to breathe; if they are hyperventilating, have them breathe into their hands cupped over the mouth and nose or a small paper bag.
  • Guide the patient through a simple, distracting physical task, such as raising the arms over the head.
  • Offer PRN medications and watch for adverse side effects.
  • Encourage participation in relaxation exercises such as deep breathing.
  • Offer a distraction:
    • Ask the person to list five things they can see, four things they can touch, three things they can hear, two things they can smell, and one thing they can taste.
    • Talk about mundane things.

The following are actions to be avoided in interactions with such patients:

  • Touching patients. Patients experiencing a panic attack are concerned about survival, experience serious threat to self, and usually distort intentions of those who invade their personal space.
  • Telling patients experiencing a panic attack to calm down. This suggests that they have control over their symptoms and can result in increased anxiety.
  • Telling patients that they have nothing to fear or be nervous about. This implies that their fear is unfounded. These patients usually already understand there is no reason to be so anxious but are unable to prevent the attack from finishing its course.
  • Telling patients that their behavior is embarrassing. This can increase anxiety and feelings of shame.
  • Telling patients they are overreacting. Minimizing can be discouraging, increase the patient’s discomfort, and make it even harder for them to calm down.

When the level of anxiety has been reduced, it can be useful to explore with patients the possible reasons the anxiety occurred so that they can learn to interrupt escalating anxiety in the future (Townsend, 2018; Vera, 2022).

CASE

A Patient Having a Panic Attack

Andrew is a visiting nurse caring for Rhiddhi’s grandmother, who is recovering from a surgical procedure. Andrew arrives at her home to change her dressings. When he has finished, Rhiddhi, who is 31 years old, enters the room. Andrew notices that Rhiddhi is quite short of breath and appears pale and frightened. He asks her how she is feeling, and she says she is feeling dizzy, her heart is pounding, and she can’t breathe. She says she is having a panic attack and that she’s had them before. Andrew walks with her to the sofa.

Andrew says to her, “Rhiddhi, come sit down on the sofa with me. You’re having a panic attack, and it will be over soon. You’re safe here. You’ll get through this.”

Andrew continues, speaking slowly and in a soothing voice: “You are doing a great job, Rhiddhi. You’ll be okay. I’m here to help you. I’ll stay with you. I’m okay staying here with you.”

Andrew begins to model slow breathing. He breathes in through his nose for a count of 4 seconds and out through his mouth for 8 seconds and says, “Rhiddhi, look at me. I’m breathing slowly. Follow my breathing.”

When Rhiddhi’s breathing has begun to slow down, Andrew asks her to focus on a physical task: “Good, Rhiddhi. Now raise your arms over your head like this.”

Rhiddhi raises her arms. Andrew then says, “Okay, now put them in your lap.” They both lower their arms.

Andrew asks her to repeat the movement. “Let’s do that again.” Rhiddhi responds by following along with Andrew. Andrew says, “Good, Rhiddhi. Now raise both arms over your head. Like this.”

As they raise and lower their arms, Andrew asks, “Have you been to the new supermarket yet?” Rhiddhi, becoming calmer, replies, “No, not yet.”

“Well, it’s really quite beautiful,” replies Andrew.

Discussion

Andrew recognizes that Rhiddhi is experiencing serious physical symptoms, but when she tells him she is experiencing a panic attack, which she has had before, it allows him to change his initial reaction from her physical symptoms to focus instead on her psychological symptoms. He begins by staying calm and speaking quietly while guiding her to a comfortable place. Andrew verbally encourages Rhiddi and reassures her that she is safe and that he will remain with her.

Andrew asks her to focus on performing slow breathing, and when she makes an effort to do so, he instructs her to perform a physical task in order to distract her from her symptoms. As she follows along, he attempts to distract her further by discussing a mundane matter (the supermarket).

At no point during his intervention does Andrew tell Rhiddi there are no grounds for her fear (accepting). He does not minimize her symptoms, shame her in any way, or tell her to calm down.