Anxiety, Fear, and Anxiety Disorders: Strategies for Care - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

OVERVIEW

Anxiety and fear are interconnected (e.g., one can trigger the other) and share certain characteristics. For example, both are essential for survival, are manifestations of reactions to a threat or pressure, and play important roles with the process of restoring homeostasis to the body.

Although they have shared characteristics, anxiety and fear are distinct responses differentiated by their association with autonomic arousal and behaviors (Box 1) (Table 1).^{undefined#ref3">3,5,10} Fear involves the involuntary or reflexive activation of the limbic system (i.e., the emotional brain) as a reaction to an immediate and identifiable trigger or perceived threat (i.e., the fight, flight, freeze, or fawn response).^5,14 Anxiety is a generalized emotional response involving feelings of apprehension, uneasiness, uncertainty, or dread that lead to behaviors aimed at preparing an individual for self-defense from a potential real or perceived threat or trigger.⁵ The symptoms and associated behaviors occur on a spectrum, ranging from mild to extreme (i.e., a panic) (Table 2).⁵

In contrast to other anxiety states or reactions, anxiety disorders involve a disturbance in the regulatory system of neural networks, leading to excessive or prolonged anxiety or fear.⁸ This excessive or prolonged anxiety or fear leads to behavioral disturbances (e.g., rigid, repetitive, and ineffective behaviors)⁵ that last for 6 months or more in adults (may be less than 6 months in children).^3,9 Anxiety disorders also affect personal, occupational, and social functioning.⁵ The key feature of each anxiety disorder is based on the specific object or situation that triggers the anxiety or fear, which ultimately results in a particular behavioral response.³ Risk for anxiety disorders includes temperamental, environmental, genetic, and physiologic factors (Box 2).^3,9

Although each anxiety disorder has unique diagnostic features (Table 3), symptoms generally include excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances (Table 4).^3,9 However, diagnosis can be difficult because typical signs and symptoms are also common to, or may be caused by, other conditions (Box 3) (Table 5).³ For example, panic attacks and states of panic are not limited to anxiety disorders and can occur with other mental health and medical conditions.^1,3,9 Furthermore, some differential diagnoses are also common comorbidities of anxiety disorders (Table 6).³ Therefore, positive screening results for an anxiety disorder should be followed by a confirmatory diagnostic assessment to ensure accurate diagnosis and appropriate treatment.¹²

Symptoms of anxiety are often experienced during stressful situations for patients with or without an anxiety disorder diagnosis.¹¹ Interventions for acute exacerbations of anxiety symptoms should be patient and situation specific, with a focus on decreasing feelings of anxiety and fear along with other psychiatric and physical symptoms of any potential underlying etiologies and comorbid conditions (Table 7). This includes assessing for and monitoring the risk for suicide and self-harm because the patient may have an increased risk for suicide (e.g., when both an anxiety disorder and depression are present).¹¹

For long-term treatment of anxiety disorders, cognitive behavioral therapy (CBT) is generally recommended as the first-line psychotherapy, and first-line pharmacotherapeutic options typically include selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) (Table 8).¹¹ Support groups, stress management techniques, and complementary and alternative medicine (CAM) techniques, such as exercise, mindfulness, and meditation, can also help to reduce anxiety symptoms and enhance the effects of psychotherapy for anxiety disorders.^9,11

Whether or not a patient has an anxiety disorder diagnosis, using a comprehensive care approach for a patient experiencing anxiety or fear promotes the likelihood that the patient will receive the appropriate care and support needed to manage symptoms and improve quality of life.^3,4,6,9,12

EDUCATION

• Give developmentally and culturally appropriate education based on desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Give information regarding the patient’s rights and responsibilities while receiving care in the current setting.
• Discuss common measures that may be utilized in the current care setting to promote, achieve, and maintain a safe environment (e.g., frequent safety rounds, searches of belongings).
• Discuss signs and symptoms of anxiety, fear, and anxiety disorders (Box 1) (Table 4), including levels of anxiety severity and the associated risk for the patient to self-harm or harm others (Table 2).
• Explain the importance of being open and honest with health care team members about mental health symptoms. Advise the patient to tell health care team members if symptoms are worsening or not improving.
• Provide information about the nature of anxiety and anxiety disorders (e.g., risk factors [Box 2], common comorbidities [Table 6]), treatment methods and options (Table 8), and the importance of adherence to prescribed treatment(s).⁹
• Discuss the importance of finding a therapist with whom the patient feels comfortable. Explain that the patient may have to try different therapists, and it is not the patient’s fault if the patient-therapist relationship is not a good fit.
• Give information about local, regional, and national support resources.⁹ Discuss steps to take if symptoms worsen or do not improve with self-help strategies when in the community.⁹
• Give education about the benefits of having others (e.g., family) involved in treatment.

Promotion of Optimal and Appropriate Care

• Promote open communication and formation of a therapeutic alliance by employing a trauma-informed care (TIC) approach and therapeutic communication techniques (e.g., maintain an open, engaging, and nonjudgmental demeanor).
• Maintain awareness of any patient-specific factors (i.e., triggers) that may contribute to the patient's emotional, affective, or physiologic dysregulation, which may cause the patient to experience increased anxiety, suicidal ideation, or urges to self-harm.
• Foster an environment in which action is taken to reduce stigma, discrimination, and barriers for a patient seeking help for mental health concerns.
  • Maintain an awareness that experienced or perceived stigma and discrimination associated with mental health conditions can make it difficult for a patient to disclose mental health symptoms, access mental health services, or accept treatment.
  • Provide information on the etiology of mental health conditions (e.g., related to a combination of multifactorial, gene–environment interactions) and explain that having mental health concerns should not be viewed as a personal weakness or choice.

Promotion of Safety

• Assess, identify, and mitigate safety risks throughout the patient’s admission (e.g., remove items that could be used for self-harm, search items brought upon admission or received from others outside the facility after admission for contraband or potential safety hazards [e.g., belts, charging cords for cell phones or computers]), as applicable and per the organization’s practice.
• Ensure that health care team members who may be involved in caring for the patient are aware of the patient’s relevant medical or mental health conditions, including history of anxiety, trauma, behavioral issues, and any related triggers.
• Initiate and adjust precautions (e.g., suicide, fall) based on the patient’s presentation and other applicable factors, per the organization’s practice.
• Continuously assess, observe, and monitor for indicators of emotional, affective, and physiologic dysregulation to promote the opportunity for early recognition and intervention.
• Do not assume that a patient who denies suicidal ideation is not at risk for suicide or suicidal gestures, particularly if presentation (e.g., behaviors, affect) is incongruent with the patient’s reports.
• Be aware of the potential for minimization of symptoms, which can be influenced by psychological, environmental, and contextual factors.
• If an unsafe or crisis situation occurs, respond in a calm, therapeutic, and nonthreatening manner. Use the least restrictive interventions to prevent harm to patients or staff.

Promotion of Privacy

• Prior to discussing patient information with, or in front of, others (e.g., non–health care team members, family), locate and verify release of information documentation.
  • Confirm documents or permission has not expired or been revoked.
  • Maintain awareness of situations in which the patient’s expressed consent or refusal for others to be aware of or involved in the patient’s care may be overridden (e.g., the patient is under civil commitment or has a legal guardian).
• Provide clear communication about mandatory reporting obligations of health care team members and how they could relate to or affect the patient’s expectation of privacy.

ASSESSMENT AND INTERVENTIONS

1. Prior to interacting with the patient:
   1. Use available resources (e.g., the electronic health record, other health care team members) to gather information about the patient that can be used to assist with patient interactions and provide optimal care (Box 4).
   2. Through observation, evaluate the patient’s current presentation to assess the risk for the patient to self-harm or harm others (e.g., showing signs of increased agitation), using a standardized tool if available. Ensure that an adequate number of appropriately trained health care team members or other support staff (e.g., security) are aware of the current situation and available to assist, if needed.

      In a potentially unsafe or dangerous situation, never approach the patient alone or attempt to stop aggressive or violent behavior without assistance. Always ensure there is a clear path to quickly exit the area.

   3. Anticipate and be prepared to manage, and optimally prevent, symptom exacerbation based on the patient’s presentation, diagnoses, and other relevant history.
2. Be prepared to perform assessments privately with the patient (i.e., away from non-health care team members, such as family or caregivers) and in a designated area where it is possible to speak in confidence without being overheard.

   Rationale: Performing assessments privately promotes patient confidentiality and increases the likelihood of the patient sharing in a more open and honest manner about mental health symptoms and disclosing abuse or maltreatment, including human trafficking.

3. Whenever non–health care team members (e.g., family, friends, significant others) are present:
   1. Verify the identity of the individuals and their relationship to the patient.
   2. Observe interactions and monitor the patient’s behavior for clues of potential abuse or maltreatment (e.g., patient shows signs of anxiety or makes poor eye contact).

      Rationale: This can help with recognition and identification of potentially abusive situations (including human trafficking).

4. If the patient is (or becomes) unwilling or unable to participate in assessments or to be interviewed privately, or if there are concerns about the patient’s capacity to make decisions, be prepared to:
   1. Perform interventions to address immediate physical and psychological needs as indicated.
   2. Consider placing the patient under continuous observation by an appropriately trained health care team member to monitor mental status and behaviors, per the licensed practitioner (LP)’s orders and the organization’s practice.
   3. Complete assessments as thoroughly as possible (e.g., valuable information can be obtained through observation).
   4. Notify the LP of the situation to determine a plan for further clinical evaluation and management.
5. Be prepared to perform interventions during assessments based on the patient’s symptoms or presentation (e.g., level of anxiety), particularly if there is an increased risk for the patient to self-harm or harm others (Table 2).
6. Determine if the patient has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety or privacy.
7. Evaluate the patient’s mental status.
   1. Assess the level of orientation, mood, affect, cognitive function, presence of hallucinations, and the patient’s insight into the situation and ability to respond rationally to others in the context of the current presentation and symptoms.
   2. Assess current symptoms of fear or anxiety and the level of anxiety (mild, moderate, severe, or panic) (Box 1) (Table 2) (Table 4), using a validated, standardized scale when possible (e.g., Fear Questionnaire [for phobias], Panic Disorder Severity Scale [for panic symptoms], Severity Measure for Generalized Anxiety Disorder–Adult) (Box 1) (Table 2) (Table 4).⁵
   3. Assess the methods the patient uses to cope with anxiety and other symptoms, including both adaptive strategies (e.g., cognitive reappraisal, problem solving, acceptance) and maladaptive strategies (e.g., hypervigilance, checking behaviors, avoidance), and the patient’s ability to use adaptive (safe) strategies in the current care setting.¹
   4. Use validated screening and assessment tools to screen and assess suicidal ideation, thoughts of self-harm, and thoughts of harming others.⁷ If the patient screens positive for suicide risk, complete a comprehensive suicide risk assessment. Listen carefully for a patient’s expressions of helplessness and hopelessness.¹⁰
8. Determine whether the patient is experiencing fear or a typical anxiety response to a given situation, fear or anxiety associated with a psychiatric or medical condition (other than an anxiety disorder), or fear or anxiety caused by the use of or withdrawal from medications or other substances.³
   1. Evaluate for situations and conditions known to increase the risk for, or have similar presentations to, anxiety, fear, or anxiety disorders, including experiencing trauma or maltreatment (e.g., bullying, abuse, neglect, human trafficking) (Box 2) (Box 3) (Table 5). Maintain awareness that the patient may have a condition that has not been diagnosed yet, has not been disclosed, or is not noted in the medical record.
   2. Determine if there is a specific source or stressor contributing to the patient’s current symptoms (e.g., anxiety provoked by admission to an acute care setting, patient’s anxiety or fear about certain procedures, personal stressors).
   3. Assess physical and neurologic symptoms. Use standardized tools if available and as appropriate (e.g., the Abnormal Involuntary Movement Scale).
   4. Obtain a comprehensive medication and substance use history, including prescribed and over-the-counter medications.^9,13
      1. Assess the patient’s use of caffeine and over-the-counter cold medications.^9,13

         Rationale: Caffeine and certain cold medications can cause anxiety symptoms.⁹

      2. Assess if the patient is taking medications as prescribed or has had any recent medication changes.

         Rationale: Abruptly stopping certain medications (e.g., antidepressants and anti-anxiolytics) can cause withdrawal symptoms, including anxiety.⁹ Starting a new medication, taking a recently increased medication dose, or taking more than one medication can increase the chances of an adverse reaction (e.g., serotonin syndrome).¹³

      3. Review the patient’s substance use history, particularly details about recent substance use. Perform interventions to address any immediate needs associated with substance use or withdrawal as appropriate and per the organization’s practice.

         Rationale: Symptoms of anxiety, panic attacks, obsessions, and compulsions may develop due to the effects of using or withdrawing from various substances (e.g., alcohol, cocaine, heroin, hallucinogens).⁵ Also, it is imperative to know if the patient could be experiencing withdrawal from substances so that appropriate treatment can be provided.

   5. Review the results of laboratory and diagnostic tests. Look for findings outside of the defined reference range and perform additional interventions (e.g., additional testing, practitioner notification) as indicated, per the LP’s orders or the organization’s practice. For example, in neuroleptic malignant syndrome (NMS), laboratory results generally include elevated creatine phosphokinase (CPK), leukocytosis, and elevated liver enzymes; in serotonin syndrome, results include elevated white blood cell count, elevated CPK, and decreased serum bicarbonate.
   6. Determine if the patient has other psychiatric and medical conditions that commonly co-occur with anxiety disorders (Table 5).
9. Notify the designated LP of assessment findings and diagnostic test results, per the organization’s practice.
10. If possible and applicable, consult collateral informants (e.g., family members, community social workers) to gather information that could be helpful in the patient’s care. Adhere to Health Insurance Portability and Accountability Act (HIPAA) standards, privacy and confidentiality laws, and the organization’s privacy and confidentiality practices.

    Rationale: Collateral information can be helpful when determining suicide risk because a patient may minimize symptoms. Information can be received from outside sources without revealing confidential information about the patient.

11. Use a validated screening tool to screen for anxiety disorders. Consider risk factors associated with anxiety disorders (Box 2).^3,9 (Defer screening, if needed, depending on the patient’s current presentation and level of anxiety.)
12. Seek specialist consults (e.g., psychiatric practitioner, nutritionist, neurologist, endocrinologist), as indicated. If the screening for an anxiety disorder has a positive result, perform a confirmatory diagnostic assessment to ensure an accurate diagnosis.
13. Implement the most supportive and least restrictive interventions required to promote stabilization of physical and mental health symptoms (including anxiety) while maintaining safety.
    1. Take steps to address current, potentially acute symptoms of anxiety, fear, and anxiety disorder(s) (Table 7). This may include giving as-needed medications or placing the patient in seclusion.
    2. Use various interventions on an ongoing basis to help prevent future exacerbations of anxiety and anxiety disorder symptoms (including fear) (Table 8).
       1. Discuss coping skills, medications, and other interventions that have previously been effective or ineffective for managing anxiety, fear, or anxiety disorder symptoms.
       2. Identify accessible and realistic resources and strategies the patient may use to manage anxiety, fear, or anxiety disorder symptoms while in the current care setting (e.g., ask the patient what health care team members can do to decrease anxiety or fear and prevent exacerbations).
    3. Perform ongoing cycles of assessment and monitoring of psychiatric and physical conditions and the patient’s response to pharmacologic and nonpharmacologic interventions, including reassessing suicide risk, behavioral symptoms, or emotional dysregulation. The time span, frequency, type, and total number of times interventions are attempted or utilized can vary significantly.
       1. Administer scheduled and as-needed medications as ordered. Perform mouth checks per the organization’s or the unit’s practice.
       2. Encourage the patient’s participation in therapy sessions and provide any additional support as needed.
       3. Respond to a crisis in a calm, supportive, and therapeutic manner.
14. In collaboration with the patient and the health care team, adjust the patient’s plan of care as warranted, including details regarding reassessment, monitoring, interventions, treatments (e.g., additional diagnostic testing, transfer to another care setting), and the discharge plan.

MONITORING AND CARE

1. Monitor for side effects and adverse reactions associated with medications commonly used to treat anxiety and anxiety disorders, including:¹³
   1. Attempts or increased thoughts to self-harm or harm others
   2. Serious, potentially life-threatening, adverse reactions associated with SSRIs (e.g., serotonin syndrome) and antipsychotics (e.g., NMS, tardive dyskinesia [TD])
   3. SSRI common side effects (e.g., nausea, diarrhea, constipation, headache, tremors, agitation, dizziness, sweating, sexual dysfunction, sleep disturbance, memory loss, cognitive function)
   4. First-generation (typical) antipsychotic side effects (e.g., stiffness, akathisia, tremors, sleepiness, weight gain, sexual dysfunction, constipation, dry mouth, blurred vision)
   5. Second-generation (atypical) antipsychotic side effects (e.g., metabolic syndrome, weight gain, decreased sex drive, sun sensitivity, seizures, drowsiness)

EXPECTED OUTCOMES

• Patient’s health status improves or stabilizes.
• Patient’s privacy and confidentiality are maintained.
• Based on the patient’s desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state:
  • Patient verbalizes a clear understanding of patient rights and responsibilities.
  • Patient is able to identify how to access assistance while in the current care setting and after discharge.
  • Patient is able to identify goals for treatment.
  • Patient and health care team members collaborate to develop a treatment plan.
• Patient, health care team members, other patients, or visitors do not sustain injury.

UNEXPECTED OUTCOMES

• Patient’s health status worsens or does not improve.
• Patient’s privacy or confidentiality is breached.
• Based on the patient’s desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state:
  • Patient is not able to verbalize a clear understanding of patient rights and responsibilities.
  • Patient is not able to identify how to access assistance while in the current care setting and after discharge.
  • Patient is not able to identify goals for treatment.
  • Patient and health care team members do not collaborate to develop a treatment plan.
• Patient, health care team members, other patients, or visitors sustain injury.

DOCUMENTATION

• Details of assessments (e.g., neurologic, mental, and physical status), including objective descriptions of observations and patient reports, results of assessments using standardized assessment tools, and frequency of reassessments
• Patient’s views and preferences regarding treatment and treatment goals, including details related to releases of information
• Results of laboratory or other diagnostic tests, as applicable
• Strategies and interventions utilized and their associated effectiveness
• Consultation requests and referrals
• Family’s or support person’s involvement in the patient’s care, as applicable
• Details provided by or obtained from collateral resources or informants relevant to the patient’s care
• Notifications of the practitioner per the organization’s practice
• Notifications of the patient’s guardians per the organization’s practice
• Location of the patient’s belongings, as applicable
• Education
• Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

• Anxiety disorders in children and adolescent patients often co-occur with other disorders, such as attention-deficit/hyperactivity disorder (ADHD), learning disabilities, and behavioral disorders, which can complicate diagnosis and treatment.^3,4 Understanding and addressing these comorbidities are crucial for effective treatment.⁴
• Caregiver and family involvement in the diagnostic process can provide valuable insights into the pediatric patient’s behavior and emotional state.⁹
• Adolescents are particularly susceptible to psychosocial stressors, such as academic pressure, peer relationships, and family dynamics. These factors can contribute to the development or exacerbation of anxiety disorders.³
• The treatments for anxiety disorders in adolescent patients are similar to those for adult patients but should be tailored to the developmental stage of the patient.
• Pharmacotherapy should be closely monitored because of developmental considerations, the differing side effect profiles, and potential for serious, potentially life-threatening, adverse reactions (e.g., serotonin syndrome associated with SSRIs).
• Educating families about anxiety disorders can improve treatment adherence and outcomes.⁹
• Pediatric patients may demonstrate anxiety through a change in behaviors (e.g., becoming restless, withdrawn, or uncooperative), physical complaints, or developmental regression.

OLDER ADULT CONSIDERATIONS

• Older adults should be monitored closely for adverse reactions or toxicity if given certain medications for anxiety (e.g., first-generation antihistamines, tertiary tetracycline antidepressants [TCAs], SSRIs, benzodiazepines).²
• Tools such as the Geriatric Anxiety Scale (GAS) and the Geriatric Anxiety Inventory (GAI) can be used to screen for anxiety in older adults.¹²

SPECIAL CONSIDERATIONS

• Screening for anxiety disorders in pregnant and postpartum patients is important because of the high prevalence and often unrecognized nature of these conditions.¹²

REFERENCES

1. Amaral, R.I. and others. (2022). Effectiveness and efficacy of therapeutic interventions performed by nurses for anxiety disorders: A systematic review. Journal of the American Psychiatric Nurses Association, 28(4), 283-294. doi:10.1177/10783903211068105
2. American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. doi:10.1111/jgs.18372
3. American Psychiatric Association (APA). (2013, revised 2022). Anxiety disorders. In DSM-5-TR: Diagnostic and statistical manual of mental disorders (5th ed., text rev., pp. 215-262). Washington, DC: Author.
4. Davies, M.R. and others. (2023). Factors associated with anxiety disorder comorbidity. Journal of Affective Disorders, 323, 280-291. doi:10.1016/j.jad.2022.11.051
5. Halter, M.J. (2022). Chapter 15: Anxiety and obsessive-compulsive disorders. In M.J. Halter (Ed.), Varcarolis’ foundations of psychiatric-mental health nursing: A clinical approach (9th ed., pp. 268-292). St. Louis: Elsevier.
6. Javaid, S.F. and others. (2023). Epidemiology of anxiety disorders: Global burden and sociodemographic associations. Middle East Current Psychiatry, 30, Art. No.: 44. doi:10.1186/s43045-023-00315-3
7. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program. Retrieved October 9, 2024, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
8. Koskinen, M.-K., Hovatta, I. (2023). Genetic insights into the neurobiology of anxiety. Trends in Neurosciences, 46(4), 318-331. doi:10.1016/j.tins.2023.01.007
9. National Institute of Mental Health (NIMH). (2024). Anxiety disorders. Retrieved October 9, 2024, from https://www.nimh.nih.gov/health/topics/anxiety-disorders
10. Steele, D. (2023). Chapter 27: Anxiety-related, obsessive-compulsive, trauma- and stressor-related, somatic, and dissociative disorders. In D. Steele (Ed.), Keltner’s psychiatric nursing (9th ed., pp. 316-340). St. Louis: Elsevier.
11. Szuhany, K.L., Simon, N.M. (2022). Anxiety disorders: A review. JAMA, 328(24), 2431-2445. doi:10.1001/jama.2022.22744
12. U.S. Preventive Services Task Force and others. (2023). Screening for anxiety disorders in adults: US Preventive Services Task Force recommendation statement. JAMA, 329(24), 2163-2170. doi:10.1001/jama.2023.9301
13. Valdes, B. and others. (2021). Recognition and treatment of psychiatric emergencies for health care providers in the emergency department: Panic attack, panic disorder, and adverse drug reactions. Journal of Emergency Nursing, 47(3), 459-468. doi:10.1016/j.jen.2021.01.004
14. Zingela, Z. and others. (2022). The psychological and subjective experience of catatonia: A qualitative study. BMC Psychology, 10(1), 173. doi:10.1186/s40359-022-00885-7

ADDITIONAL READINGS

Andrews, G. and others. (2018). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian and New Zealand Journal of Psychiatry, 52(12), 1109-1172. doi:10.1177/0004867418799453

Walter, H.J. and others. (2020). Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 59(10), 1107-1124. doi:10.1016/j.jaac.2020.05.005

Clinical Review: Kristin Bursey, MSN, APRN, PMHNP-BC, RN, PMH-BC, PHN, RDH

Published: November 2024