Anxiety Disorders Overview

Anxiety is a normal, adaptive response to perceived threat. Anxiety disorders are characterized by anxiety that is excessive, persistent, difficult to control, and causes significant functional impairment. The physiological basis involves activation of the sympathetic nervous system — the fight-or-flight response — beyond what the situation warrants.

Nurses must distinguish between normal situational anxiety (expected in hospitalized patients) and pathological anxiety requiring targeted intervention. Untreated anxiety disorders impair medication adherence, wound healing, and recovery from medical illness.

Anxiety Levels (Peplau's Model — NCLEX High-Yield):

• Mild: Heightened awareness, motivating — patient can learn and problem-solve
• Moderate: Narrowed perceptual field, decreased concentration — learning is possible with guidance
• Severe: Greatly reduced perceptual field, focused on details — unable to problem-solve; requires nursing intervention
• Panic: Disorganized, loss of rational thought, potential for harm — requires immediate intervention; do not leave patient alone

Generalized Anxiety Disorder (GAD)

Excessive, uncontrollable worry about multiple domains (work, health, family, finances) occurring more days than not for at least 6 months. GAD is the most common anxiety disorder in primary care settings.

• Core feature: pervasive, difficult-to-control worry
• Associated with muscle tension, restlessness, fatigue, concentration difficulty, irritability, and sleep disturbance
• Common in older adults; frequently co-occurs with depression
• Treatment: CBT, SSRIs, SNRIs, buspirone; benzodiazepines avoided for long-term use

Panic Disorder

Recurrent, unexpected panic attacks with persistent concern about future attacks and behavioral changes to avoid them. Panic attacks peak within 10 minutes and typically resolve within 20–30 minutes.

• Panic attack symptoms: palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, chills, paresthesias, derealization, fear of losing control or dying
• Medical causes must be ruled out — MI, pulmonary embolism, hyperthyroidism, hypoglycemia can mimic panic attacks
• Agoraphobia often develops — avoidance of situations where escape may be difficult
• Treatment: CBT with exposure therapy, SSRIs, SNRIs; short-term benzodiazepines for acute attacks

Other High-Yield Anxiety Disorders

• Social Anxiety Disorder: Intense fear of social situations with scrutiny; significant functional impairment
• Specific Phobia: Marked fear of a specific object or situation (needles, blood, heights); common in healthcare — needle phobia affects medication adherence
• PTSD: Classified separately — involves trauma re-experiencing, avoidance, negative cognitions, and hyperarousal after a traumatic event
• OCD: Also classified separately — obsessions (intrusive thoughts) drive compulsions (repetitive behaviors) to reduce distress

• Diaphragmatic breathing:

  Slow, deep belly breathing activates the parasympathetic nervous system and counters the fight-or-flight response. Teach before the patient is acutely anxious.

• Grounding (5-4-3-2-1):

  Identify 5 things you can see, 4 you can touch, 3 you can hear, 2 you can smell, 1 you can taste. Brings attention to the present moment and interrupts rumination.

• Progressive muscle relaxation (PMR):

  Systematically tensing and releasing muscle groups from feet to head. Reduces somatic tension and promotes body awareness.

• Cognitive reframing:

  Identifying and challenging distorted automatic thoughts ("What evidence supports vs. contradicts this fear?"). Core element of CBT.

• Activity pacing and scheduling:

  Alternating activity with rest; scheduling pleasant activities to counteract anxiety-driven avoidance and withdrawal.

Communication approach must match the patient's current anxiety level.

• Mild/Moderate anxiety: Use open-ended questions, encourage verbalization, explore coping history ("What has helped you in the past?")
• Severe anxiety: Use short, clear, directive statements; do not present complex options; reduce stimulation
• Panic level: Calm, low-stimulation environment; short simple directives; physical presence is critical — do not leave the patient
• Avoid: Telling the patient to "calm down" — this invalidates the experience and escalates anxiety
• Avoid: Providing excessive reassurance repeatedly — this reinforces anxiety-driven reassurance-seeking behavior

• Explain the fight-or-flight response — anxiety symptoms are the body's normal alarm system activating at the wrong time
• Medications (SSRIs, SNRIs, buspirone) take 2–6 weeks for full anxiolytic effect — do not stop abruptly
• Benzodiazepines are for short-term use only — risk of dependence, cognitive impairment in older adults, respiratory depression with CNS depressants
• CBT with exposure therapy is the most effective long-term treatment for most anxiety disorders
• Caffeine, alcohol, nicotine, and stimulants worsen anxiety — discuss lifestyle modifications
• Regular physical exercise reduces anxiety levels through neuroendocrine mechanisms