Although some degree of anxiety is normal in life’s stresses, anxiety can be adaptive or maladaptive. Problems arise when the client has coping mechanisms that are inadequate to deal with the danger, which may be recognized or unrecognized. The essential feature of this inadequacy is unrealistic or excessive anxiety and worries about life circumstances. Anxiety disorders are the most common of all major groups of mental disorders in the United States, sharing comorbidity with major depression and substance abuse, increasing the client’s risk of suicide.
300.02 Generalized anxiety disorder
The Freudian view involves conflict between demands of the id and superego, with the ego serving as mediator. Anxiety occurs when the ego is not strong enough to resolve the conflict. Sullivanian theory states that fear of disapproval from the mothering figure is the basis for anxiety. Conditional love results in a fragile ego and lack of self-confidence. The individual with anxiety disorder has low self-esteem, fears failure, and is easily threatened.
Dollard and Miller (1950) believe anxiety is a learned response based on an innate drive to avoid pain. Anxiety results from being faced with two competing drives or goals.
Cognitive theory suggests that there is a disturbance in the central mechanism of cognition or information processing with the consequent disturbance in feeling and behavior. Anxiety is maintained by this distorted thinking with mistaken or dysfunctional appraisal of a situation. The individual feels vulnerable, and the distorted thinking results in a negative outcome.
Although biological and neurophysiological influences in the etiology of anxiety disorders have been investigated, no relationship has yet been established. However, there does seem to be a genetic influence with a high family incidence.
The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.
Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes, acute myocardial infarction, pheochromocytomas, substance intoxication and withdrawal, hypoglycemia, caffeine intoxication, mitral valve prolapse, and complex partial seizures.
The individual exhibiting dysfunctional behavior is seen as the representation of family system problems. The “identified patient” (IP) is carrying the problems of the other members of the family, which are seen as the result of the interrelationships (disequilibrium) between family members rather than as isolated individual problems.
It is recognized that multiple factors contribute to anxiety disorders.
1. Assist client to recognize own anxiety.
2. Promote insight into anxiety and related factors.
3. Provide opportunity for learning new, adaptive coping responses.
4. Involve client and family in educational/support activities.
1. Feelings of anxiety recognized and handled appropriately.
2. Coping skills developed to manage anxiety-provoking situations.
3. Resources identified and used effectively.
4. Client/family participating in ongoing therapy program.
5. Plan in place to meet needs after discharge.
Nursing diagnosis for generalized anxiety disorder: Severe Anxiety may be related to Real or perceived threat to physical integrity or self-concept (may or may not be able to identify the threat); Unconscious conflict about essential values (beliefs) and goals of life; unmet needs; Negative self-talk possibly evidenced by Persistent feelings of apprehension and uneasiness (related to unidentified stressor or stimulus) that client has difficulty alleviating; Sympathetic stimulation; restlessness; extraneous movements (foot shuffling, hand/arm fidgeting, rocking movements); Poor eye contact; focus on self; Impaired functioning; verbal expressions of having no control or influence over situation, outcome, or self-care; Free-floating anxiety; Nonparticipation in care or decision-making when opportunities are provided.
1. Verbalize awareness of feelings of anxiety.
2. Identify effective coping mechanisms to successfully deal with stress.
3. Report anxiety is reduced to a manageable level.
4. Demonstrate problem-solving skills/lifestyle changes as indicated for individual situation.
Nursing intervention with rationale:
1. Establish and maintain a trusting relationship through the use of warmth, empathy, and respect. Provide adequate time for response. Communicate support of the client’s self-expression.
Rationale: The client may perceive the nurse as a threat, which may increase the client’s anxiety. Attending behaviors can increase the degree of comfort the client experiences with the nurse.
2. Be aware of any negative or anxious feelings nurse may have because of client’s conscious or unconscious resistance of nurse’s helpful efforts.
Rationale: Negative reactions to the client will block future progress. Anxiety is “contagious,” and nurse needs to recognize and control own anxiety.
3. Identify behaviors of the client that produce anxiety in the nurse. Explore these behaviors with the client once relationship is established.
Rationale: Promotes growth and change and helps client realize how own behavior affects others.
4. Use supportive confrontation as indicated.
Rationale: Confrontation can be useful when client’s progress is blocked but may heighten anxiety to a level that is detrimental to the therapy process. Therefore, it should be used with caution.
5. Have client identify and describe the sensations of emotional and physical feelings. Assist the client to link behavior and feelings. Validate all inferences and assumptions with the client.
Rationale: To adopt new coping responses, the “5 R’s” of anxiety reduction are used. The client first needs to RECOGNIZE anxiety and be aware of feelings, how they link to certain maladaptive coping responses, and own responsibility in learning to control behavior.
6. Help to explore conflictual issues by beginning with nonthreatening topics and progressing to more conflict-laden ones.
Rationale: Anxious client does not think clearly, and beginning with simple topics promotes comfort level, increasing sense of success and progress.
7. Monitor the anxiety level of the nurse/client interaction on an ongoing basis.
Rationale: Moderate anxiety may be productive for/motivate client, but too high a level of anxiety can interfere with the interaction and ability to attend to information.
8. Assist the client to identify the situations and interactions that immediately precede the anxiety. Suggest that the client keep an “anxiety notebook” that focuses on feelings and what is going on in the environment when anxious feelings begin.
Rationale: After the client recognizes feelings of anxiety, examination of the development of the anxiety (e.g., what precipitates it, the strength of the stressor[s]) and what resources are available can help the client develop new coping skills. Therapeutic writing serves to decrease the anxiety while the client is learning about it, making it more tangible/controllable.
9. Encourage client to use relaxation techniques (e.g., meditation, massage, breathing techniques, exercises, guided imagery, and biofeedback).
Rationale: RELAXATION is the ultimate stress management technique because it brings about a decreased heart rate, lowers metabolism, and decreases respiration rate. The relaxation response is the physiological opposite of the anxiety response.
10. Administer medication as indicated, e.g., buspirone (BuSpar), benzodiazepines, e.g., alprazolam (Xanax), clonazepam (Klonopin), clorazepate (Tranxene), chloridiazepoxide (Librium), diazepam (Valium), oxazepam (Serax).
Rationale: Anxiolytics provide relief from the immobilizing effects of anxiety. BZDs have few side effects, are generally well tolerated, have a fairly rapid rate of onset, and do not impair sleep. Note: When anxiety is associated with depression, antidepressant agents alone may provide relief of symptoms. Unlike BZDs, BuSpar is nonaddicting, has a delayed onset of action (10 days–2 weeks), and must be taken on a regular basis (not PRN).