Care of the Patient with Anxiety

Anxiety is a normal, daily experience. It can be described as a short-term, mild to moderate feeling of uneasiness or worry that is a response to a particular stressor.

Anxiety becomes abnormal or to a level of a disorder when the person feels intense and excessive worry and fear, the anxiety level causes impaired function of daily activities, and the response is greater than the actual risk or situation justifies (World Health Organization [WHO], 2023).

According to the World Health Organization (WHO), anxiety disorders are the most diagnosed mental health disorder (WHO, 2023). In fact, anxiety disorders affect over 300 million people worldwide (WHO, 2023). It is estimated that over 40 million adults, aged 18 years and older, in the United States experience any one of the anxiety disorders at some time in their lives (Anxiety & Depression Association of America [ADAA], 2022). Even though anxiety disorders are quite treatable, only about 1 in 4 people who require it actually end up receiving any form of treatment (WHO, 2023). Why do you think that is? Some common barriers to accessing and receiving care include a general lack of awareness, a shortage of mental health professionals, and a very real negative social stigma (WHO, 2023).

Just as anxiety disorders are the most diagnosed mental health disorders in the world in general, they are also the most common mental health issues specifically in the pediatric population. Some levels of worry and anxiety are essential for proper growth and development. However, too much can be harmful. Children and adolescents who suffer with anxiety disorders experience anxiety that interferes with and impacts their daily functioning, generally both at home and at school.

Disorders of anxiety are also particularly present in the older population. It is estimated that 10-20% of older adults suffer with anxiety, although it is often undiagnosed (American Association for Geriatric Psychiatry [AAGP], 2022). The symptoms are often masked by physical complaints that tend to be focused on more. In fact, older adults are often misdiagnosed with physical diseases and psychological causes are less often considered first.

It is not known exactly what causes anxiety disorders. However, a complex mix of factors have been associated with playing a role in causing anxiety disorders (Bhandari, 2023). Research indicates that there are several factors involved in anxiety, including genetics, environment, development, and psychological states. It is believed that genetics play a role, as anxiety disorders commonly run in families (Bhandari, 2023). Environmental stressors, such as witnessing violence or being a victim or a life-threatening event, can have a cumulative impact over time, increasing one’s risk of an anxiety disorder (Bhandari, 2023). In addition, some lung, heart, and thyroid conditions can cause symptoms that are very similar to those of anxiety or can simply make symptoms of the individual’s anxiety even worse (Bhandari, 2023). It is also believed that psychological states or personality/temperament factors like certain personality traits, low self-esteem, and behavioral differences might make someone more at risk for having an anxiety disorder (Bhandari, 2023).

The main symptom of anxiety disorders is excessive worry or fear. Common general symptoms include (American Psychological Association [APA], 2022):

• Feelings of doom or danger
• Sleep difficulty
• Not being able to stay calm
• Not being able to be still
• Cold, sweaty, or numb hands or feet
• Hyperventilation
• Heart palpitations
• Dry mouth
• Dizziness
• Tense muscles
• Gastrointestinal distress (pain, diarrhea, nausea)
• Rumination of a problem (thinking about it repeatedly)
• Inability to focus
• Intensely avoiding something or some place that is feared

The specific symptoms that are shown by a person suffering with an anxiety disorder are dependent on the type of anxiety disorder they have.

It is important to be able to identify the signs of anxiety, worry, and stress in children and adolescents. Often, when anxiety is severe, children and adolescents can demonstrate regressive behaviors. Regressive behavior is when children demonstrate signs of an earlier stage of development, one of which they have already mastered (APA, 2022; Melnyk & Lusk, 2022). For example, a preschool-aged child might go back to sucking their thumb again when they have not done so in a while. The action of regression takes place because these behaviors are a source of comfort and security that has worked for them in the past to calm themselves (APA, 2022; Melnyk & Lusk, 2022).

Several types of anxiety exist in the American Psychological Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision (DSM-5-TR), which is used to diagnose mental health disorders. This section will cover an overview of the different anxiety disorders including (American Psychological Association [APA], 2022):

1. Separation anxiety disorder
2. Selective mutism
3. Specific phobia
4. Social anxiety disorder
5. Panic disorder
6. Generalized anxiety disorder (GAD)

The following disorders are purposefully ordered developmentally, meaning that those that are present at younger ages will appear first (APA, 2022).

Defense mechanisms are automatic, unconscious reactions that block unpleasant, threatening feelings (Grande, 2023). Defense mechanisms are normal to protect people from anxiety, maintain self-image, and block feelings, conflicts, and memories. Using defense mechanisms can help people adjust to the environment or be adaptive (Grande, 2023). However, these mechanisms become problematic or maladaptive when they keep people from facing reality.

The individual using them does not always acknowledge their own defense mechanisms (Grande, 2023). Most people use several defense mechanisms, but not always at the same level or at the same time. In order to evaluate whether a defense mechanism is adaptive or maladaptive, it will be important to observe frequency, intensity, and duration.

Some common examples of defense mechanisms are as follows (Grande, 2023):

Compensation: This is used to cover up shortcomings related to perceived deficiencies and protect the mind from recognizing them. For example, an adaptive use of compensation is a person becoming assertive and dressing themselves even though they feel they make poor clothing choices. An example of a maladaptive use of compensation is when a person with low self-esteem throws objects to relieve their discomfort.

Denial: This is a refusal to accept facts or an uncomfortable event in order to make thoughts and feelings not exist. The person will refuse to talk about the problem and accept their reality. For example, an alcoholic will deny they have a problem with alcohol even though they have been arrested several times for driving drunk.

Displacement: This is the transfer of one emotion toward a particular person, object, or situation onto something else. For example, a patient may be angry with his wife when she failed to visit but take that anger out on the nursing assistant instead.

Projection: This is when unpleasant or unacceptable characteristics of one’s own self are unconsciously given to another person, situation, or object. For example, a student might blame their teacher for the reason why they did not pass a test, when it was the student who did not study.

Dissociation: This is a separation of emotions and thoughts. Typically, this person will lose track of time and can lose their self-image. An example is an adult who was abused during childhood, disconnected from reality, and mentally goes to a different place when stressed.

Regression: As mentioned above when reviewing signs and symptoms of anxiety in pediatric patients, this is reverting back to an earlier phase of psychological development. Another possible example of regression, this time for adults, could be a man who is having a stressful time at work who all of a sudden refuses to leave the house. In childhood, staying home likely brought him the comfort and attention of his parents, allowing him to feel safe, secure, and valued. The overwhelmed adult ego might feel like just not going will allow them to avoid facing their work anxiety.

There are several other defense mechanisms that people use to decrease or avoid their feelings of anxiety. Understanding how and why defense mechanisms are used will help the caregiver assist the patient in coping with anxiety.

Helping a person who is upset, anxious, or agitated may include the following (Acello & Hegner, 2022; Welby, 2020):

• Attempt to identify and eliminate the stressor.
• Do not argue or confront the person.
• Make sure the environment is safe for them.
• Assign the patient a brief task or activity to distract them.
• Watch for injuries.
• Prevent the patient from becoming exhausted.
• Get the nurse if panic or severe anxiety is present.

If the patient is becoming anxious, try to help them gain control by using distraction or giving them something else to do. Help them to identify coping strategies that they have used in the past to calm down (Acello & Hegner, 2022; Welby, 2020). Use communication techniques such as asking open-ended questions, giving broad opening statements, and exploring and seeking clarification of the situation (Acello & Hegner, 2022; Welby, 2020). It is important to remain calm and recognize that the person is in distress and is not doing this on purpose. The ability to listen is also important!

For severe or panic-level anxiety, the nurse should be involved as the patient may not know what is happening and may be unable to follow directions well (Acello & Hegner, 2022; Welby, 2020). The patient experiencing severe or panic level of anxiety is out of their own control, and they need to know they are safe. Use short, simple sentences and remain with the person when possible (Acello & Hegner, 2022; Welby, 2020). It is also important to maintain their physical needs, such as fluid and rest, to prevent exhaustion when they are calm again. The person should be moved to a quieter environment with minimal stimulation. The nurse may also give medications to help lessen the current state of anxiety.

Certain behaviors need to be reported immediately to the nurse for everyone's safety. Anytime the patient is in an unsafe environment or at risk for injury, it should be reported immediately.

If the patient is unable to focus on the environment, appears paralyzed with fear, is not able to communicate, begins to hallucinate or have delusions, or is blocking out the environment or events around them, the nurse should be notified immediately (Acello & Hegner, 2022; Welby, 2020). It is, however, important that someone stays with the patient or keeps an eye on the patient until the nurse or additional help arrives.

If the patient can describe a feeling of dread, confusion, a sense of impending doom, physical complaints, hyperventilation, rapid heartbeat, loud, rapid speech, or if they begin to threaten or make demands upon anyone, the nurse should also be notified (Acello & Hegner, 2022; Welby, 2020; APA, 2022). The patient may also be observed to be hyperactive or in flight mode, have dilated pupils, jumbled words, severe shakiness, sleeplessness, or agitation (APA, 2022). Be sure to stay clear of the patient unless they appear to be at risk of falling or injuring themselves. Do not allow yourself to be in harm's way.

Watch for signs that the patient is becoming agitated. Express your willingness to help and listen to their feelings and concerns. Approach the patient calmly and non-threateningly; however, maintain your personal space for your own safety.

Your eyes should be on the same level as the patient to decrease intimidation. Avoid allowing the patient to stand between you and the exit from the room. It is important to always leave yourself an escape route if the patient becomes out of control.

If the patient becomes verbally abusive, do not take the verbal abuse personally. Use open-ended statements and questions rather than challenging statements such as “what's wrong with you?” Avoid threatening, accusatory, or challenging statements. Instead, try to find out what is going on behind the aggressive behavior.

Ask the patient if they want to go to a quieter place. Pay close attention to the environment. For example, is there a lot of activity around the patient that might be agitating them and causing or worsening their anxiety? If the patient becomes agitated, which may be obvious by the use of inappropriate words or activity or even disorientation, the nurse should intervene (Acello & Hegner, 2022; Welby, 2020).

One of the most important interventions when working with anxious patients is for you to remain calm (Acello & Hegner, 2022). If the patient can see how calm the caregiver is, they may become calmer. It is also important to stay with the patient and speak slowly and calmly, as this conveys calmness and promotes security.

If the patient is given medication for anxiety, be sure to watch for side effects. Side effects of medications that are commonly given for anxiety can include drowsiness, lack of energy, slow reflexes, slurred speech, confusion, disorientation, and depression (Melnyk & Lusk, 2022). If any of these signs are noticed, report them to the nurse immediately.

Sally is a patient of yours today. The report you received from the nurse says she is a little upset today. Her family visited her last night, and now she cannot stop talking about when she eats. As you enter the room, you notice that she is looking around the room, wringing her hands, mumbling to herself, and appearing upset. You enter her room smiling and asking how you can help her today. “You seem upset,” you state. Sally continues to wring her hands and looks even more upset.

“I have to leave. I have to get dinner ready. They will be here soon,” Sally tells you. Her face appears tense and stressed, and she begins to get up to pace.

“Ok, Sally, let’s go into the other room and talk,” you say.

Before you can finish, Sally picks up a hairbrush and throws it at you. She starts yelling that she has to leave now, and that you cannot keep her prisoner here anymore.

What do you do?

First, make sure you are near the door, or at least do not allow the patient in between you and the exit. Remember that anxiety can lead to agitation quickly, such as this case you are starting to see with Sally. Talk slowly and calmly. Although it may be difficult to stay calm in such a situation, Sally must see you calm and collected. Remaining quiet and not making sudden moves will help Sally calm down too. Never argue or tell her she is wrong. If you can reach for the call light, do so and get someone into the room with you. If you must leave the room to get help, make sure Sally is safe. Notify the nurse how you found Sally and what happened.

If this is happening in Sally’s home rather than in a hospital setting, get another family member to stand close by to help calm Sally or use distraction until you can get a hold of the nurse. Make sure Sally is not hurting herself and that her environment is free from objects she can hurt herself or others with. Also, remember that she had visitors last night. Perhaps that is a trigger. Consider all of the following:

• What is the current level of anxiety? Did it change when you talked to Sally? If so, do you know why?
• What does the environment look like?
• What does Sally look like? Does it look like she has not slept? Is she eating?
• What is she doing physically?
• What is she saying? Is she talking to you, herself, or someone else?
• Did something happen previously to trigger this episode?

You should mentally ask yourself these questions as you are in the room with Sally. The answers will give you and the nurse ideas of how to help Sally calm down.

Once Sally is calm, suggest a distraction such as folding clothes or walking the halls. You may suggest she wash up or get dressed or even get something to eat. Sally may prefer to stay in a quiet location rather than being around others. Be sure to check on her frequently to make sure she does not begin to get anxious again. Develop a plan and strategy with the nurse to anticipate Sally’s anxiety and calm her to avoid or prevent further escalation.

Working with a patient who suffers from anxiety can be difficult. You may experience feelings of frustration or even anger. Understanding and using empathy is important, as well as having patience. If you feel yourself getting frustrated or angry, remember not to transfer those feelings to the patient (Acello & Hegner, 2022; Welby, 2020). Instead, find another healthcare professional to talk to and try to come up with alternative ways of working with the patient. One way is to keep things simple. Small, reachable goals will help you and the patient feel less overwhelmed.

Remember that everyone gets anxious at one time or another. It is when the anxiety does not allow the person to continue with their normal daily activities that it becomes a chronic problem and a disorder. It is important to remember to stay calm and have a plan to get help when needed. Try to recall the events that take place during the anxious episode as well as what might have occurred right before. There might be triggers to report to the nurse and adjustments that can be made in the patient’s environment and overall care.

In the case of a panic attack, which often does not have a trigger, it is important to stay with the patient until they calm down. These patients often explain that they literally feel like they are dying. They are normally terrified and, often, in pain. Talk slowly and calmly. Try to get the patient to focus on you or their own breathing until the nurse arrives or you get further instructions.

Using all of the tips and tricks we talked about in this course, you can both identify anxiety and then help your patient overcome their moments of heightened anxiety.

• Acello, B., & Hegner, B. (2022). Nursing assistant: A nursing process approach. (12th Ed.). Cengage Learning. Visit Source.
• American Association for Geriatric Psychiatry. (AAGP). (2022). Anxiety and older adults: Overcoming worry and fear. American Association for Geriatric Psychiatry (AAGP). Visit Source.
• American Psychological Association. (APA). (2022). Diagnostic and statistical manual of mental disorders (5th Ed. Text Revision). (DSM-5-TR). American Psychological Association Publishing: Washington, D.C. Visit Source.
• Anxiety & Depression Association of America. (ADAA). (2022). Anxiety disorders: Facts & statistics. Anxiety & Depression Association of America (ADAA). Visit Source.
• Bhandari, S. (2023). Anxiety disorders. WebMD. Visit Source.
• Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan and Sadock’s synopsis of psychiatry. (12th Ed.). Lippincott Williams & Wilkins (LWW). Visit Source.
• Grande, D. (2023). Defense mechanisms: Definition, types, & examples. Choosing Therapy. Visit Source.
• Melnyk, B., & Lusk, P. (2022). A practical guide to child and adolescent mental health screening, evidence-based assessment, intervention, and health promotion. (3rd Ed.) Springer Publishing Company: New York, NY. Visit Source.
• Welby, M. (2020). The anxious patient: How to calm a patient down to improve care. Wolters Kluwer. Visit Source.
• World Health Organization. (WHO). (2023). Anxiety disorders. World Health Organization (WHO). Visit Source.