Anxiety Disorders Nursing CE Course for RNs and LPNs

tability, agitation, restlessness, and an intense quest for safety. Affective symptoms include frustration, nervousness, jitteriness, and being on edge (Chand et al., 2022).                                            

Social Anxiety Disorder

Social anxiety disorder is an extreme, persistent fear that others are judging the individual and that everyone is always watching them. This fear is so intense and debilitating that it can affect going to school, work, or managing daily life. Symptoms associated with SAD include palpitations, diaphoresis, trembling, abdominal pain, body posture changes, decreased voice volume, and an inability to make eye contact (NIMH, 2022).

Panic Disorder

Panic disorders consist of frequent and unexpected panic attacks. Panic attacks are sudden episodes of extreme fear associated with losing control, even without clear danger or a trigger. During a panic attack, an individual may feel an impending doom, like they have no control. Patients with PD may experience shortness of breath, chest pain, palpitations, diaphoresis, trembling, and fear of going crazy or dying. These symptoms may occur unexpectedly in the absence of a trigger. Individuals who experience a panic attack may not develop a panic disorder (NIMH, 2022).

Agoraphobia

Agoraphobia is a distinct diagnosis based on intense fear and avoidance that often occurs in at least two of five everyday situations and lasts more than six months. The situations may involve using public transportation, being outside the home, in a crowd or standing in a line, being in open spaces, or being in enclosed spaces alone. Individuals with agoraphobia may experience panic-like symptoms as well as incontinence or falling (Chand et al., 2022).

Obsessive-Compulsive Disorder

OCD comprises a manifold of symptoms, including rituals, intrusive thoughts, preoccupations, and compulsions. Obsessions are intrusive and unwanted repetitive thoughts, urges, or impulses that can cause an increase in anxiety or distress. The onset of this chronic disorder usually occurs in early adulthood (late teens to early twenties) but can begin to manifest during the early teenage years as well (Gupta et al., 2019). People with a family history have a higher risk of having the disorder, and slightly more women are affected than men (Skapinakis et al., 2019). There is not as much known about this disorder as others, but it is widely believed that genetic and environmental factors are involved in its development (Yildirim & Boysan, 2019).

Posttraumatic Stress Disorder

PTSD is increased anxiety and stress after exposure to a traumatic or stressful event (Boland et al., 2021). PTSD is a psychological disorder caused by a traumatic event that includes flashbacks, sleep disturbances, depressed mood, and anxiety (Denke & Denham, 2019). Patients with PTSD may display irritability or have angry outbursts with little or no cause. They may also have an exaggerated startle response (Mann & Marwaha, 2022). Additional signs and symptoms of PTSD are flashbacks, fear, sleep disturbances, nightmares, depression, and social isolation (Scott, 2019).

Some public health and safety occupations are at a higher risk of developing panic disorders, especially PTSD. PTSD involves an emotional response (severe panic and worry) that can be triggered when reminded of past events. Individuals who are at increased risk of this disorder are victims who have been sexually assaulted or raped, victims of domestic violence or abuse, children who have witnessed domestic violence or abuse, war veterans, healthcare workers, and first responders (Guess et al., 2019). Something that should be taken into consideration when working with victims of domestic violence is that often when a victim decides to leave their abuser, the domestic relations court in many states does not recognize witnessing abuse as a form of abuse. Research shows the harmful impact witnessing abuse can have on children and their brain development. Family courts may force the victim to remain in contact with their abuser if they share children or allow them to maintain some form of parental rights, which can have devastating effects on victims attempting to get treatment for PTSD (Paul, 2018).

Diagnostic Criteria

Individuals with GAD may present with physical symptoms such as chest pain, shortness of breath, diaphoresis, and dizziness (Adwas et al., 2019). The diagnostic criteria include excessive concern and worry for at least 6 months with difficulty controlling these emotions, along with three or more of the following symptoms: restlessness, feeling keyed up or on edge, difficulty in concentrating or mind going blank, being easily fatigued, muscle tension, sleep disturbance, and irritability (Adwas et al., 2019; APA, 2022). The symptoms must substantially affect the patient’s ability to function professionally or socially. The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern, and the concern is not due to a more appropriate psychiatric condition such as panic attacks (i.e., panic disorder), past trauma (i.e., posttraumatic stress disorder), gaining weight (i.e., eating disorders), social interactions (i.e., social anxiety disorder), separation from a loved one (i.e., separation anxiety disorder), physical symptoms (i.e., somatic symptom disorder), a specific trigger (i.e., specific phobia), or a recurrent thought (i.e., obsessive-compulsive disorder; APA, 2022).

Social anxiety is terror or significant concern about a certain environment that exposes the patient to potential judgment by the public or individuals. The terror/concern or active evasion of the environment leads to dysfunction (academic, professional, social, or otherwise) or substantial anguish. The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern, and the concern is not due to a more appropriate psychiatric condition such as autism spectrum disorder, panic attacks (i.e., panic disorder), past trauma (i.e., posttraumatic stress disorder), separation from a loved one (i.e., separation anxiety disorder), a specific trigger (i.e., specific phobia), physical judgment (i.e., body dysmorphic disorder), or a recurrent thought (i.e., obsessive-compulsive disorder). In pediatric patients, the terror/concern must be present when interacting with peers (not only grown-ups) and may present as dependence, immobility, mutism, outbursts, or fits. The terror/concern is disproportionate or unconnected in those with a physical attribute that causes discomfort (e.g., significant scars, facial or other obvious physical differences). The diagnosis may specify performance only if applicable (APA, 2022).

Patients with panic disorder will exhibit panic attacks or unanticipated and sudden experiences characterized by an upwelling of terror that crests quickly (i.e., minutes) and is accompanied by more than three of the following sensations or physiologic reactions:

• perspiration
• difficulty breathing
• angina or chest tightness
• feeling unstable, fuzzy, woozy, or lightheaded
• tachycardia or a subjective feeling like your heart is pounding
• tremors or quivering
• globus sensation or dysphagia
• abdominal discomfort or feeling nauseous
• temperature dysregulation (feeling very hot or cold)
• concern that you may not survive/live
• concern that you are no longer in control or no longer sane
• a sense that the people and things around you are not real (derealization) or that you are not in your body (depersonalization)
• altered sensation (tingling) or a lack of feeling (numbness), especially in the extremities (APA, 2022).

Agoraphobia is defined as terror or significant concern about at least two of the following conditions:

• entering public places that are not confined (e.g., parks/fields, vacant lots, etc.)
• entering indoor spaces (e.g., conference rooms, stores, etc.)
• entering an area with lots of people, or waiting in a queue
• public transportation utilization
• leaving their house without anyone else, such as a companion or partner

If the patient also experiences panic attacks and meets the required characteristics of panic disorder, the patient may be diagnosed with both (APA, 2022).

Patients with OCD typically exhibit obsessions: repeated and consistent ideations, contemplations, or visions that are considered invasive, unpleasant, and/or not desired and lead to intense concern or anguish. The patient sometimes tries to avoid, subdue, or distract themselves from these contemplations or visions by carrying out a particular behavior. Compulsions are ritualistic physical or intellectual actions that the patient is compelled to complete due to a strict internal expectation or regulation, or related to an obsession, as defined above (APA, 2022, Boland et al., 2021).

PTSD symptoms are related to a prior experience of potential or genuine fatality, severe harm, or sexual assault. The patient may have been a participant, victim, or witness/bystander. The unpleasant symptoms may include:

• flashbacks, during which the patient temporarily mentally disconnects from their current environment and reality and has the sensation that the initial traumatizing experience is happening again
• repetitious nightmares associated with the initial traumatizing experience
• consistent and extreme negative opinions or outlooks regarding the world, people, and themselves (e.g., people are not to be trusted, the world is not safe, I am damaged permanently)
• consistent predominance of undesirable feelings (e.g., rage, terror, remorse, disgrace)
• unsafe or self-harming actions
• extreme edginess or precariously startled
• poor ability to initiate or maintain adequate sleep (APA, 2022)

Management

Nonpharmacological Treatment of Anxiety Disorders

Cognitive behavioral therapy (CBT) is an effective psychotherapy for individuals with anxiety disorders. CBT teaches individuals methods of rethinking, responding, and reacting to situations to feel less anxious and fearful. CBT is the gold standard for psychotherapy. Exposure therapy is a form of CBT utilized to treat certain anxiety disorders. Exposure therapy enhances individuals’ ability to confront the fears underlying their anxiety disorder and re-engages in activities they have been avoiding, as seen in phobias (NIMH, 2022). Virtual therapy uses computer programs to treat agoraphobia and social anxiety disorder. Patients are provided with a virtual environment, like the environment responsible for their phobia. They identify with the specific avatars during multiple sessions until they can cope with the anxiety while preparing for exposure in real life (Boland et al., 2021). Additional nonpharmacological treatments include lifestyle changes such as avoiding the consumption of excessive amounts of caffeine, reducing or avoiding alcohol consumption, smoking cessation, and incorporating stress management techniques, such as meditation, exercise, and mindfulness, which can help reduce anxiety symptoms and complement the effects of psychotherapy (NIMH, 2022).

Clinical guidelines suggest psychotherapy as a first-line treatment for OCD. Exposure and response prevention (ERP) is an effective therapy for patients with OCD. Medication is also recommended for patients with severe OCD as a first-line treatment. Evidence shows that the combination of psychotherapy and pharmacotherapy is very effective (Boland et al., 2021). Another treatment option that is exceptionally successful in patients with OCD is deep brain stimulation (DBS), which involves placing electrodes in targeted areas of the brain. Impulses are then sent through the electrodes to help regulate brain activity (NIMH, 2019). Encouraging patients to express and verbalize thoughts is essential when managing OCD, as well as developing a good rapport with the patient. Clinicians must work with the patient to reduce anxiety related to completing or not completing compulsions and increase coping mechanisms to interrupt or stop intrusive thoughts or compulsions (Skapinakis et al., 2019).

Several therapies have been shown to have positive results for patients with PTSD. Trauma-focused cognitive-behavioral therapy (TFCBT) involves prolonged exposure (PE) therapy. PE focuses on reexperiencing the traumatic event through repeatedly engaging with the memories and everyday reminders instead of avoiding triggers. Eye movement desensitization and reprocessing therapy (EMDR) involves repeatedly recalling distressing images while receiving sensory inputs. Cognitive processing therapy (CPT) emphasizes correcting faulty attributions and posttraumatic overgeneralizing the world as dangerous and uncontrollable. Present-centered therapy (PCT) focuses on the current relationship and work challenges rather than the trauma. Psychodynamic psychotherapy may also be useful in the treatment of many patients with PTSD (Boland et al., 2021). PTSD is a trauma-related disorder, so it is not always comfortable for patients to communicate and openly express their feelings. Therefore, it is imperative for clinicians, nurses, and other healthcare professionals to be knowledgeable about the signs and symptoms of PTSD. Studies have shown patients have a more favorable outcome with early detection and implementation of treatment (Mann & Marwaha, 2022).

The nurse must evaluate patients at risk who show signs of being abused, follow proper facility protocol, and make appropriate referrals to maintain the safety of the patient and their children (Paul, 2018). Particular attention should be given to the fact that these clients may have to maintain contact with their abuser if they have children together. The nurse should provide the patient with all the necessary resources and information to remain safe and continue to work towards recovering from the abuse and treating the resulting PTSD (Laing et al., 2018). Nurses should incorporate methods to develop a trusting relationship with the patient to communicate effectively (Paintain & Cassidy, 2018). Patients with PTSD require a calm and therapeutic environment that encourages the expression of feelings and fears and incorporates different therapies to benefit the patient. The nurse can assist the patient in identifying triggers or situations that may cause recurrent memories or flashbacks, developing coping mechanisms and methods to help reduce intrusive thoughts or memories, encouraging group participation and therapy, and discussing ways to desensitize the patient from the traumatic event.

Pharmacological Treatment for Anxiety Disorders

The first-line agent for generalized anxiety disorder, panic disorder, and social anxiety disorder is an SSRI that selectively inhibits serotonin reuptake and affects the GABA system. These medications are well tolerated and do not cause dependency. Commonly prescribed SSRIs are fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), paroxetine (Paxil), and escitalopram (Lexapro). Potential side effects of SSRIs include but are not limited to nausea, vomiting, diarrhea, headache, dizziness, dry mouth, drowsiness, insomnia, agitation, anxiety, sexual dysfunction, sweating, appetite/weight changes, and restlessness (see Table 1). Venlafaxine can also cause hypertension. It is essential to discuss with patients that many side effects are transient and will resolve within weeks. Patient education should include the importance of not abruptly stopping medications to prevent serotonin discontinuation syndrome. Patients should be aware of the effects of abruptly discontinuing an SSRI, such as disequilibrium, nausea, increased agitation, headache, flu-like symptoms, insomnia, diarrhea, and an increased feeling of being dissatisfied with life (Craske & Bystritsky, 2021; Hutchinson, 2015).

Table 1

Common Side Effects of SSRIs and SNRIs

 

	SSRIs	SNRIs
Possible Side Effects	Nausea, vomiting, diarrhea, headache, dry mouth, drowsiness, insomnia, nervousness, agitation, restlessness, sexual dysfunction, appetite change leading to weight loss or weight gain	Nausea, headache, dizziness, excessive sweating, dry mouth, tiredness, constipation, insomnia, sexual dysfunction, anorexia
Warnings and Monitoring	Serotonin syndrome; suicide risk; risk for withdrawal symptoms if stopped abruptly	Serotonin syndrome; suicide risk; risk for withdrawal symptoms if stopped abruptly

 (Mayo Clinic, 2019)

The nurse should assess for signs and symptoms of serotonin syndrome, excess serotonin in the brain that can be life-threatening. Symptoms of serotonin syndrome include restlessness, high fever, sweating, tremors, lack of coordination, delirium, rigidity, rapid changes in blood pressure, tachycardia, coma, and possible death (Mayo Clinic, 2019).

The SNRIs venlafaxine (Effexor) and duloxetine (Cymbalta) are also effective for anxiety (Gregory & Hardy, 2021). Hydroxyzine pamoate (Vistaril) is a sedating antihistamine that can be used as an alternative to benzodiazepines for the acute treatment of GAD. Buspirone (Buspar) is an azapirone that is also effective for treating GAD. Additional pharmacological treatments of GAD include benzodiazepines that are recommended for use as an adjunct to SSRIs during initial treatment or stabilization in an acute phase of anxiety and only for short-term use (Boland et al., 2021; Gregory & Hardy, 2021).

The recommended first-line treatments for SAD are SSRIs or SNRIs. β-blockers such as propranolol (Inderal) may be helpful for performance anxiety. (Boland et al., 2021; Gregory & Hardy, 2021).

PD is treated with SSRIs and SNRIs as the first-line drug choice; TCAs and monoamine oxidase inhibitors (MAOIs) are adequate but not favored for use (Boland et al., 2021).

Psychopharmacology treatments for agoraphobia involve SSRIs, which are generally first-line therapy. SNRIs, TCAs, or benzodiazepines may be considered as alternatives (Balaram & Marwaha, 2022).

In the past, the TCA clomipramine (Anafranil) was used as the first-line therapy for OCD; however, because of the significant side effects, the SSRIs fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) are now the first-line treatment for OCD (Brock & Hany, 2020).

Patients with PTSD may be prescribed SSRIs, particularly sertraline (Zoloft) and paroxetine (Paxil). Other medications that have been effective in treating PTSD are the SNRI venlafaxine (Effexor), the atypical antipsychotic risperidone (Risperdal), and the anticonvulsant topiramate (Topamax). Prazosin (Minipress) may help decrease or eliminate the nightmares associated with PTSD. A low dose of trazodone may also be prescribed to treat insomnia (Boland et al., 2021).

Nursing Considerations for Anxiety Disorders

Nurses should be able to apply the nursing process by understanding the symptoms, disease process, contributing factors, and treatment options for anxiety disorders. Nurses must identify ways to assist patients with coping skills to manage increased anxiety, nervousness, and panic levels. Nurses should remain nonjudgmental, be culturally sensitive and open-minded, and establish a good rapport with the patient (D'Errico et al., 2019). Nurses should be able to educate patients on coping mechanisms and ways to reduce anxiety, such as decreasing caffeine intake, incorporating physical exercise, and practicing deep breathing exercises. The nurse needs to ask the patient if they feel tense, nervous, fluttering in their abdomen, or any panic. The nurse needs to assess the autonomic nervous system by obtaining vital signs and observing for diaphoresis, tremors, or dry mouth (Munir et al., 2022).

Other essential factors in client-centered care include supporting patients, acknowledging their feelings, and communicating using simple language while calm. Providing a calm environment while actively listening to the patient is an effective nursing intervention. Incorporating nonpharmacological methods into the patient's plan of care, educating the patient on the specific techniques, and utilizing less invasive and restrictive methods to assist patients in the identification and care of their condition can dramatically reduce anxiety and facilitate successful coping mechanisms (Antoniadou et al., 2019).

The clinician and nurse must review all the patient's medications, including over-the-counter and herbal supplements. Effects of prescribed and over-the-counter medications, such as corticosteroids and herbal supplements, can mimic symptoms of GAD (DeMartini et al., 2019)

Patients with anxiety disorders may have co-existing depression. Nurses need to assess patient safety by asking about suicidal thoughts using open-ended and closed questions. Once safety is determined, nurses can educate patients on recognizing anxiety, including triggers. It is also essential for nurses to review coping strategies such as meditation skills and mindfulness. Resources for support groups, mobile applications, books, and YouTube videos that explain and demonstrate meditation skills and mindfulness techniques should be provided (Gregory & Hardy, 2021).

Future Research/Directions

GAD is a chronic disorder that can be debilitating. There are currently several nonpharmacological and pharmacological treatments recommended for GAD. Approximately half of the patients treated for GAD fail initial treatment, resulting in treatment-resistant (or refractory) GAD. Treatment–refractory GAD is characterized as failure to respond to at least one trial of a first-line pharmacological agent (Ansara, 2020). Studies are currently being conducted to examine the effectiveness of new medications that may result in additional options for treating anxiety. However, these newer medications may not replace current treatments but may be used as adjuncts. Researchers have noted the lack of efficient development of better biomarkers (Garakani et al., 2020).

Future research should incorporate more brain imaging, pharmacogenomic, and other neurobiochemical advances to further the advancement of treatment (Garakani et al., 2020). Research should also be directed to identifying the causes of anxiety and panic attacks and ways to reduce and treat symptoms related to anxiety disorders. The use of positive psychological interventions to reduce anxiety should be investigated; nonpharmacological methods can often dramatically improve patient outcomes more than certain medications, especially short-term medications (Brown et al., 2019). CBT remains the first-line psychological treatment for most anxiety disorders and is effective with short- and long-term treatment plans. Emerging treatments that have shown to be effective when augmented with CBT are exposure therapy with virtual reality, augmentation with mindfulness, and emotional regulation strategies (Reddy et al., 2020). There will continue to be a constant influx of new techniques for treating mental health illnesses. Clinicians, nurses, and healthcare professionals should remain open-minded about new treatments. When patients express interest in new treatments (whether FDA-approved or off-label), we are responsible for educating them about the risks, benefits, and limitations and openly evaluating the appropriateness of treatment as it relates specifically to the patient's symptoms (OR, 2019).

Conclusion

Anxiety disorders include GAD, SAD, PD, separation anxiety disorder, selective mutism, phobias, PTSD, and OCD; these are the 6^th leading cause of disability and the most common mental health disorder worldwide. Anxiety disorders are chronic and can impair an individual’s ability to function and overall quality of life (Zimmermann et al., 2020). Evidence-based practice has proven psychopharmacology and psychotherapy effective in treating anxiety disorders. The effectiveness of treatment may vary depending on the severity of the symptoms, leading to treatment-resistant anxiety (Penninx et al., 2021). Research has also shown additional therapies, such as meditation, mindfulness, and yoga, to treat anxiety effectively. It is crucial for clinicians and nursing staff to be familiar with the signs and symptoms of anxiety, as some can manifest physically. It is equally important to educate patients about the different treatment options, both pharmacologic and nonpharmacologic (Brahmbhatt et al., 2021). Psychiatric care is centered on developing a therapeutic relationship between the patient and the care provider. It is essential for nurses and other healthcare professionals to care for patients with GAD calmly and positively, promoting positive nurse-patient interactions (Kaçmaz & Çam, 2019).

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