Patients with severe anxiety may experience panic, depersonalization or derealization, or become irrational.
Anxiety is different than fear. The two conditions share some similarities but have many differences. Fear is a natural emotional reaction to an impending threat. It has a direct cause and promotes safety. Anxiety is the expectation of an imagined or potential threat. It tends to be vague and unfocused. Fear is commonly combined with an acute arousal of the autonomic system needed for fight or flight and thoughts and behaviors associated with immediate danger and escape. Anxiety can affect emotions, thought processes, bodily sensations, and behaviors. With anxiety, vigilance, preparation for future threats, caution, and avoidant behaviors are more common.undefined#ref1">1
Anxiety is a physiologic response that can result from genetic vulnerabilities and psychosocial stressors. It can cause feelings of dread, apprehension, and worry in response to a perceived fear or stressor. Experiencing anxiety can affect how a patient functions on a daily basis and responds to care.
A patient’s memories, experiences, and social situations play intricate roles in the experience of stress and the development of anxiety. The patient may experience vague stress stemming from past pain and suffering or fear.12 Because these experiences are unique to each person, understanding the patient’s stress and anxiety may be difficult.
Anxiety is characterized by:3
An anxiety disorder often occurs concomitantly with physical, emotional, or mental illnesses or substance abuse. These other issues can hide or aggravate anxiety symptoms. Assessment for an anxiety disorder must be part of a comprehensive examination that includes a detailed history, physical assessment, review of symptoms, and assessments of associated functional impairments, current psychosocial issues, and other contributing factors.5,16
Patients may experience different levels of anxiety, which have different effects on daily functioning. Mild anxiety promotes productivity and problem solving because of increased mental focus. With moderate and severe anxiety, the ability to focus becomes increasingly difficult, and the anxiety symptoms become more intense and significantly impair the ability to function. During panic, the patient loses mental focus, and personality disorganization occurs, potentially to the point of experiencing depersonalization or derealization, or disruptions in consciousness or amnesia.13
Anxiety disorder is the most prevalent psychiatric illness and interferes with a patient’s ability to function.2 According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), anxiety disorders include:1
Other conditions that have anxiety as a primary component or symptom include obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), acute stress disorder, adjustment disorders,1 and major depression.2 The most common anxiety disorders are generalized anxiety disorder, specific phobia, and social phobia.2 Women are more likely to experience a generalized anxiety disorder than men.1
Anxiety disorders can be treated in a variety of settings, depending on the severity of symptoms and the interventions required for safe care. In most cases, anxiety disorders can be treated effectively with psychological interventions, which are recommended as the first-line treatment.14 Practitioners should begin with low-intensity, minimally intrusive interventions and move to more high-intensity, invasive therapies, using a stepped approach. Common treatments include cognitive behavioral therapy (CBT), relaxation techniques, and pharmacologic treatment. In addition, support and self-help groups may be beneficial.5
Pharmacologic treatments are effective in treating more severe anxiety disorders and anxiety disorders that have not responded well to psychological interventions. Medication therapy is generally continued for at least 1 year4 because of the high risk of relapse. Medication selection can vary depending on the specific anxiety disorder, severity and complexity of the disorder, age of the patient, comorbid conditions, likelihood of accidental overdose or deliberate self-harm, cost, patient preference, and prior therapies.3
Medications commonly used for anxiety disorders include:
Benzodiazepines and antipsychotics should not be used unless indicated. Combination medication treatment may be indicated for patients with more complex or refractory disorders.3
The efficacy and side effects of medications should be assessed frequently, especially when medication therapy begins or changes.
Rationale: A physical and neurologic assessment can help determine if the anxiety is primary or secondary to a separate psychiatric illness, medical illness, or substance use.
Rationale: Patients may not feel comfortable experiencing or expressing anxiety symptoms or have knowledge of healthy coping strategies to manage them. Consequently, they may automatically use defense mechanisms or unhealthy coping strategies that protect them against feeling anxiety.
When patients cope with anxiety, they must use effective, not maladaptive, defense mechanisms. Maladaptive defense mechanisms may interfere with care and patient and family cooperation with treatment. Effective defense mechanisms help patients solve problems and follow instructions.
Rationale: Engaging the patient in a discussion of what has worked or not worked provides valuable information for planning care.
Rationale: A safe environment can help the patient feel accepted and promote verbalization of anxiety.
Rationale: Ensuring that the patient and family understand the strategies for treatment promotes acceptance of treatment. Involving the patient creates an exchange of information and shared decision-making, which improves outcomes.
Rationale: The patient may determine that he or she does not want to accept a recommended strategy.
Rationale: Maintaining optimal nutrition, hygiene, sleep, and relaxation activities can improve adaptive coping mechanisms, ultimately reducing anxiety severity.
Nelson, H.D. and others. (2020). Screening for anxiety in adolescent and adult women: A systematic review for the Women's Preventive Services Initiative. Annals of Internal Medicine, 173(1), 29-41. doi:10.7326/M20-0579
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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