anx ietyanx ietyanx ietyUnderstanding common

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KATHRYN MURPHY, NP, MSN, DNSNursing Faculty • Hawaii Community College • Hilo, Hawaii

DEMANDING JOB responsibilities, family obligations, andchallenging relationships can add stress to our lives andmake anyone feel anxious. Stress and anxiety are a nor-mal part of living. Some stress, in fact, can be a goodthing because it makes us more alert and helps us makebetter decisions.

In most instances, stress and anxiety do their job, andthen they disappear when the stressor goes away. At leastthat’s what’s supposed to happen. But for millions of peo-ple, it doesn’t: The loss of a stressor doesn’t mean the loss ofthe anxiety. Anxiety becomes a constant companion anddisrupts the person’s daily functions, such as job perfor-mance and relationships.

That’s when anxiety ceases to be normal and insteadbecomes a disorder. Because anxiety disorders are socommon in the United States, it’s important for you to

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Understanding commonAnxious moments:

The most frequently occurring of all psychiatricdisorders, anxiety disorders affect 23 millionAmericans, or 1 in 4.These disorders canseriously hamper aperson’s health andlifestyle. Find out whatyou can do to help themcope with their disorderand get the pharmacologicand psychotherapeuticcare they need.

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know the different types of anxietydisorders, their signs and symptoms,and their treatment options (see Thestats on anxiety). That’ll help you bet-ter help your patients.

Let’s start with what causes ananxiety disorder.

A combination of factorsDifferent anxiety disorders may ex-hibit different etiologies. However,experts agree that a combination offactors contributes to the develop-ment of an anxiety disorder. Thesefactors include external events (stres-sors like divorce or job loss), genet-ics, and biochemical alterations.

Genetics play a strong role in anxi-ety disorders. A person may have agenetic predisposition that makes himmore sensitive to stress; he experi-ences more anxiety that leads to ananxiety disorder. Similar to diabetes,having close relatives with a history ofan anxiety disorder puts a person atincreased risk for an anxiety disorder.If one identical twin suffers from ananxiety disorder, for example, the sec-ond twin is likely to be diagnosedwith one too.

Biochemical alterations happenwhen there’s an imbalance of neuro-transmitters, the chemical vehiclesthat help pave the way for smoothtransmission of nerve impulses.Neurons produce neurotransmittersand store them in the synaptic vesi-cles until they’re needed. Any re-leased neurotransmitter that isn’tused for impulse transmission is sentback to storage through a “reuptake”mechanism.

Serotonin and gamma-aminobu-tyric acid (GABA) are two neuro-transmitters that play a role in anxi-ety. Low levels of serotonin increaseanxious feelings. GABA modulatesthe release of norepinephrine (NE),decreasing neuron excitability andeasing anxious feelings. Without suf-ficient GABA, activity in the neurons

rises, leading to anxiety. See Benzodi-azepines aid in the function of GABA.

Another biochemical-related fac-tor for anxiety may be excessiverelease of NE. This is caused byhyperactivity of the autonomic ner-vous system and arousal of the limbicsystem, which prepare the person forincreased mental and physicaldemands. Normally, activation of theautonomic nervous system kicks therelease of NE into high gear. NEfloods the neuron synapse, leading toincreased heart rate, blood pressure,respirations, and alertness to help theperson cope with the perceived stres-sor (fight-or-flight response). Butwhen this system is overactive, thesephysiologic responses go overboardand an anxiety disorder results. Overtime the level of NE will decrease,which also will contribute to anxietyand depression.

Before we move on, let’s stop andtest your knowledge of anxiety disor-ders so far.

Self-Test1. True or false: An increase inGABA decreases anxiety.

2. True or false: An increase inthe norepinephrine level leads to adecrease in the heart rate andblood pressure.

A spectrum of disordersThe physical symptoms of anxietydisorders—increased heart rate,blood pressure, and respirations; di-aphoresis; and restlessness—can bepretty distressing. It’s not surprising,

then, that anxiety is one of the mostcommon reasons people seek med-ical attention. The person may com-plain of dizziness or cognitive prob-lems like forgetfulness, a shortattention span, or difficulty concen-trating. He might report other signsand symptoms, such as appetitechanges, irritability, decreased libido,or urinary frequency or urgency.Age and cultural factors can also af-fect how an anxiety disorder mani-fests (see Age, culture, and anxiety).

Not all anxiety disorders are creat-ed alike, though. They may havesome characteristics in common,such as emotional distress that inter-feres with everyday life, but they alsohave unique signs and symptoms andmay require unique treatmentapproaches that won’t work foranother type of anxiety disorder.And, not everyone who has a certaintype of anxiety disorder will react thesame; in some people, the disorderwill be milder than in others.

So given the prevalence of anxietydisorders and their variety, it’simportant for you to understand theins and outs of the different types ofdisorders. Let’s take a closer look atfive of them: panic disorder, general-ized anxiety disorder, phobic disor-der, obsessive-compulsive disorder,and posttraumatic stress disorder.

Panic disorderMore than 15% of the adult popu-lation experiences panic attacks atsome time in their lives, yet only3.5% meet the American Psycho-logical Association’s criteria for

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The stats on anxiety • One in four people in the United States exhibits symptoms of an anxiety disordersometime in life. • Women are twice as likely as men to suffer from an anxiety disorder. • Anxiety disorders are the most prevalent mental illness in older adults and children. • Almost 9% of children suffer some disruption in daily functioning from anxiety disorders, and more than 17% of children exhibit mild symptoms of anxiety.

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panic disorder, as indicated in theDiagnostic and Statistical Manual ofMental Disorders, 4th edition, textrevision (DSM-IV-TR).

To understand the differencebetween a panic attack and a full-blown panic disorder, consider thisexample. A woman with a fear of fly-ing is scheduled to take a businesstrip. Shortly after takeoff, she beginsto experience the physiologic symp-toms of a panic attack: shortness ofbreath, racing heart, diaphoresis,chest pain with palpitations, and feel-ings of doom. Once she’s off theplane and on firm ground, the symp-

toms go away. She doesn’t have thesesymptoms in any other situation.

So that’s a panic attack. Now, sup-pose the same woman is sitting inher living room and watching one ofher favorite television programs. Shesuddenly begins to experience thephysiologic symptoms she generallyexperiences only when she’s flying.That same day, while she’s wateringher houseplants, it happens again.About a month later, she’s walkingdown the hall at her office and—youguessed it—she has another panicattack. And now she’s really worriedbecause she doesn’t know why this is

happening, when it’ll happen again,and what she can do to avoid theattacks.

That’s a panic disorder. There’sno rhyme or reason to the panicattacks: They occur in everyday situ-ations that normally wouldn’t causesomeone to panic, and they occurunpredictably, from several times aday to once every couple of months.They’re characterized by at least fourof the physiologic symptoms Idescribed at the beginning of thisdiscussion of panic disorder. Theseverity of these symptoms can rangefrom mild, with little effect on a per-son’s daily life, to paralyzing panicthat stops a person from experienc-ing a normal life.

Panic disorder can also be accom-panied by agoraphobia, a fear ofbeing trapped in situations or placeswhere escape is difficult or impossi-ble, causing panic. Agoraphobia canprogress to the point that the personbecomes isolated and incapable ofleaving the safety of her home.

Generalized anxiety disorderThink of the person affected bygeneralized anxiety disorder (GAD)as a “constant worrier.” We allworry from time to time, of course.So when does normal worryingcross the line to GAD? It all comesdown to the duration of the anxietyand how much the anxiety affectsthe person’s life. A person withGAD has a pervasive anxiety thatoccurs more days than not for atleast 6 months and that interfereswith his daily life and creates signifi-cant distress. Even minor dailyevents can push the anxiety button.The most frequently occurringsymptoms of GAD are nervousness,restlessness, tachycardia, shortnessof breath, insomnia, and agitation.

GAD usually starts in the seconddecade of life, is chronic, and is oftenaccompanied by depression. Al-

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Age, culture, and anxietyA patient’s age and cultural background can affect your evaluation of his level of anxi-ety. Evaluation of anxiety disorders in children, for example, is often difficult becausemany other psychiatric disorders share similar symptoms. Restlessness, difficulty con-centrating, and increased aggression are some of the symptoms present in anxiety dis-orders, but they could also indicate depression or attention-deficit disorder.

Anxiety disorders manifest differently in various cultural groups. For example,African-Americans are more likely to suffer from phobias than whites. Different cul-tures respond to anxiety according to cultural beliefs, customs, and health prac-tices. For example, what a person in New York considers to be normal anxiety dif-fers from what a person in South Africa thinks.

Calming effectNeuron

GABAreceptor

Benzodiazepines

Benzodiazepines aid in the function of GABA

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though the exact etiology of GAD isunknown, it’s associated with biolog-ic factors, low self-esteem, and gen-der (it’s more common in womenthan in men).

Phobic disorderPhobic disorders can occur as spe-cific phobias or as a general socialphobia.

Specific phobias are characterizedby a persistent and excessive fear inthe presence of a particular situation,event, or object. The avoidance, anx-ious anticipation, or distress causedby this phobia interferes significantlywith the person’s normal routine, jobor school, and social interactions.Often the person feels distress abouthaving the phobia.

Social phobia is the persistent fearand avoidance of situations that

expose the person to potentialembarrassment, such as publicspeaking or eating in a restaurant.The person with this phobia has anintense and persistent feeling ofbeing closely scrutinized and judgedin a negative way. More than 10% ofthe population suffers from this dis-order, and it occurs equally in menand women. A person with socialphobia may pick life situations orjobs where his disorder will have aminimal effect on his daily activities.

Obsessive-compulsive disorder Obsessive-compulsive disorder(OCD) usually begins in adolescenceor early adulthood and becomeschronic. Obsessions are intrusive, re-current thoughts, impulses, or im-ages that cause distress. Commonobsessive themes include fear of

contamination or a need for order.Compulsions are recurrent, persistentbehaviors that are done in responseto the obsession, such as repeatedhand washing.

Many of us have some obsessive-compulsive tendencies. But whenobsessions and compulsions interferewith daily functioning or cause greatdistress, a person is diagnosed withOCD.

Posttraumatic stress disorderPosttraumatic stress disorder(PTSD) is described by the DSM-IV-TR as the development of spe-cific symptoms after exposure to anextreme traumatic event that in-volved a personal threat to that per-son or others around him or her.

When we think of PTSD, weoften think of the soldier returning

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Medications to manage anxietyClassBenzodiazepines

None

SSRIs

SSNRIs

TCAs

Beta-blockers

ExamplesDiazepam (Valium),lorazepam (Ativan),chlordiazepoxide(Librium), alprazolam(Xanax)Buspirone (BuSpar)

Fluoxetine (Prozac), ser-traline (Zoloft), paroxe-tine (Paxil), fluvoxamine(Luvox)

Venlafaxine (Effexor),duloxetine (Cymbalta)

Clomipramine (Anafranil),desipramine (Norpramin),imipramine (Tofranil)

Propranolol (Inderal),atenolol (Tenormin)

ActionsIncrease GABA, which is aninhibitory neurotransmitter

Not completely understood;may act directly on recep-tors in the limbic system, apart of the brain that dealswith emotionsBlock the reuptake of sero-tonin, resulting in anincrease in available sero-tonin

Block the reuptake of sero-tonin and norepinephrine,resulting in increased levels ofserotonin and norepinephrine

Inhibit reuptake of norepi-nephrine and serotonin bydifferent mechanisms

Block the beta-adrenergicreceptors in the sympatheticnervous system, causing arelaxation response

When usedTransient anxiety,acute panic attack

Anxiety

All types of anxi-ety disorders,including panicdisorders, OCD,PTSDDepression,anxiety disorders

Panic disorder,phobic disorder,OCD, PTSD

Panic disorder,GAD

Possible adverse effectsSedation, drowsiness, slowed cog-nition, abuse or dependency, with-drawal symptoms

Nausea, headache, lightheaded-ness; does not seem to produce tol-erance or dependence like benzodi-azepines

Sexual dysfunction, gastrointestinalupset, mild sedation, restlessness(often decrease after 2 to 4 weekson the medication); discontinuationsyndrome; serotonin syndromeSexual dysfunction, gastrointestinalupset, mild sedation, restlessness(often decrease after 2 to 4 weekson the medication); discontinuationsyndrome; serotonin syndromeAnticholinergic effects such as drymouth, dry eyes, constipation,weight gain, and sedation; cardiacarrhythmiasOrthostatic hypotension, dizziness

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from war. The soldier had beenexposed to graphic images of peoplebeing killed in horrific ways, andwhen he returns home, he may con-tinue to experience these imagesthrough “flashbacks.” Flashbacksmay keep the soldier from healthyrelationships or productive jobs, andhe may experience insomnia ornightmares, emotional numbing,heightened alertness, or increasedanxiety.

War isn’t the only trauma thatcan trigger PTSD. Others includerape, sexual abuse, an airplanecrash, or a fire. The survivors ofthe trauma often express guilt andpersistently question their ownsurvival.

PTSD can also occur in childrenwho have experienced a significanttrauma, such as incest or seeing afamily member murdered.

Let’s stop again and try a few morequestions about anxiety disorders.

Self-Test3. A woman gets on an elevatorand begins sweating, havingshortness of breath and palpita-tions, and experiences a feeling ofdoom. These are characteristic ofa. OCD.b. panic attack.c. GAD.

4. A man who constantly washeshis hands for fear of becomingdirty is experiencinga. panic disorder.b. social phobia.c. OCD.

The value of medicationsPharmacologic therapy is an ef-fective method of treating thesymptoms of a variety of anxietydisorders. Benzodiazepines, anti-depressants, and beta-blockers arecommonly used (see Medications tomanage anxiety).

Benzodiazepines are used to treattransient anxiety symptoms com-monly seen in panic disorder,GAD, and social phobia. They’reespecially useful in managing theacute symptoms of panic attacks oracute anxiety. If a woman experi-ences panic attacks when she goesshopping at a mall, for example, shecan take diazepam ahead of time toease her symptoms.

Benzodiazepines have a range ofduration, from short- to long-acting.These drugs work by increasing theneurotransmitter GABA. When abenzodiazepine is prescribed for oneof your patients, warn him aboutpossible slowed cognition. Tell himnot to drink alcohol (alcohol willintensify the central nervous effects),operate heavy machinery, or drivewhile on benzodiazepines. It’simportant to discontinue these med-ications slowly to avoid withdrawalsymptoms.

Buspirone isn’t structurally relatedto the benzodiazepines, but it exertsa similar effect to help reduce anxi-ety. It’s particularly useful in patientswith a history of substance abuse orsleep apnea. Buspirone needs 1 to 2weeks to take effect, and daily dosingis necessary to ensure a therapeuticresponse.

Selective serotonin reuptake in-hibitors (SSRIs) are often used totreat anxiety because of their effec-tiveness and low adverse effect pro-file. They exert their activity bydecreasing the reuptake of serotoninby the presynaptic neuron, resultingin more serotonin being available inthe synaptic cleft.

SSRIs are effective in treating alltypes of anxiety disorders. They maybe helpful in the patient with fre-quent panic attacks, and, at highdoses, they’re effective in treatingthe symptoms of OCD or PTSD.

The adverse effects of SSRIs oftendecrease after 2 to 4 weeks on the

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High-affinityGABA

receptor

Benzodiazepines facilitate GABA receptor binding

GABAmodulin

GABA

GABA

GABA

High-affinityGABA

receptorGABA

GABA

GABA

benzodiazepine

Benzodiazepines facilitate GABA receptor binding

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medication. Switching from oneSSRI to another can alleviate persis-tent adverse effects.

SSRIs can interact with otherdrugs such as warfarin (Coumadin),cardiac medications, and diabeticmedications. This can cause onemedication level to be too high whilethe other medication level may betoo low. In other words, patients tak-ing warfarin and an SSRI may needto be closely monitored. The war-farin dose may have to be increasedor decreased in response to thisdrug-drug interaction.

You also need to be aware of thepotential for discontinuation syn-drome or serotonin syndrome.Gradually discontinuing an SSRIwill help to prevent discontinuationsyndrome, which causes symptomslike dizziness, headache, diarrhea,insomnia, irritability, nausea, anddepression.

Serotonin syndrome is a potentiallylife-threatening drug interaction thatcan occur when another medicationthat increases the serotonin level isgiven to a patient already taking anSSRI. Signs and symptoms of this syn-drome are high temperature (hyper-thermia), restlessness, tachycardia,labile blood pressure, changes in men-tal status, diaphoresis, and tremors.You need to recognize this syndromeearly because it progresses rapidly toseizures, respiratory failure, and coma.

If you suspect a patient is experi-encing serotonin syndrome, immedi-ately discontinue all medications,notify the health care provider, andtreat the patient’s symptoms. Thehealth care provider may order med-ications to block the effects of theSSRIs, treat hyperthermia, and man-age seizures.

Selective serotonin norepineph-rine reuptake inhibitors (SSNRIs)work similarly to SSRIs by blockingthe reuptake of serotonin and norep-inephrine. This increases the amount

of these neurotransmitters availableat the synapse. The adverse effectsare similar to those of SSRIs.

Tricyclic antidepressants (TCAs)are effective in treating panic disor-der, PTSD, and phobic disorder.Clomipramine is one of the mosteffective drugs in relieving symptomsof OCD.

TCAs are older than SSRIs andless expensive, but they have moreunpleasant adverse effects. To helplessen discomfort from the anti-cholinergic effects of TCAs, teachyour patient to drink plenty of fluidsand to increase fruit and fiber con-sumption to prevent constipation.You also need to know that TCAscan cause fatal cardiac dysrhythmias,especially when taken as an overdoseby a patient attempting suicide.

Beta-blockers such as propranololare used to treat panic disorder andGAD, as well as PTSD and socialanxiety disorder in some cases,although the U.S. Food and DrugAdministration has not approvedthem for those indications. They’realso prescribed to manage hyperten-sion. Because of the possibility oforthostatic hypotension, teach apatient taking these drugs to riseslowly when moving from a sitting tostanding position.

Time to take another break andfind out how much you’ve learnedabout anxiety disorders.

Self-Test5. Benzodiazepines increase thelevel of a. GABA.b. norepinephrine.c. serotonin.

6. Clomipramine, desipramine,and imipramine are examples ofa. SSRIs.b. TCAs.c. beta-blockers.

That’s the last of the questions.You can find out how you did bychecking the answers at the end ofthe article.

Next, let’s look at the role of psy-chotherapy in treating anxiety disor-ders.

Talking the talkIn psychotherapy, or “talk” therapy,a person with an anxiety disordermeets with a professional to talkabout issues and feelings. This is vitalin the treatment of anxiety disorders.For patients with mild anxiety, psy-chotherapy may be sufficient, butmost people do better with a combi-nation of psychotherapy and phar-macologic therapy. Psychodynamicapproaches used to treat anxiety dis-orders include cognitive-behavioraltherapy, psychodynamic therapy, andgroup therapy.

Cognitive-behavioral therapy isboth clinically effective and cost effec-tive in treating anxiety disorders. Itsgoal is to change the “automaticthoughts” that occur spontaneouslyand contribute to dysfunctional think-ing. In this type of therapy, psycho-logical pain is thought to be causednot by what happens to a person, butwhat the person thinks it means.

A person with an anxiety disordermay have faulty cognitive processesthat interpret each event as a cata-strophe. For example, someone expe-riences car trouble on a snowy road.A person with an anxiety disorderstarts to think of all the negativethings that can occur as a result of thecar trouble, such as getting muggedor freezing to death. These thoughtsincrease anxious feelings. A personwho doesn’t have an anxiety disorderviews the stressor of car trouble real-istically and plans how to get help.The two different conclusions areinfluenced by each person’s “auto-matic” thoughts and result in differ-ent emotional responses.

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The cognitive-behavioral therapistuses cognitive restructuring to helpthe person change his or her auto-matic thoughts and, thus, the emo-tional response. The therapist pointsout the errors of thinking and logicthat underlie the anxiety disorderand then uses behavioral therapy tochange these dysfunctional cognitivepatterns.

Cognitive-behavioral therapistsbelieve that anxiety is a learnedresponse to stressors. If a child growsup with a father with GAD, forexample, that child will learn tooverreact to stressors. Cognitive-behavioral therapists will help theperson unlearn these maladaptiveresponses to stressors.

One tool cognitive-behavioraltherapists use is exposure or desen-sitization therapy. This form ofcognitive-behavioral therapy usesrelaxation techniques to help a per-son systematically tolerate smallincrements of exposure to anxiety-producing situations. For example,let’s return to the woman we dis-cussed earlier who was afraid to fly.The therapist would first teach herrelaxation techniques such as deepbreathing and progressive musclestretching. Next, the therapist wouldask the woman to talk about flyingon an airplane. After that, thewoman might be asked to watch pos-itive movies about flying. Trips to

the airport, getting on a plane, andfinally flying a short distance may bethe next steps. The woman woulduse her relaxation techniques to helpher cope with each situation.

Psychodynamic therapy links anxi-ety to trauma or conflicts that hap-pened in childhood. For example, aman with PTSD who was abused asa child doesn’t feel good about him-self as an adult. The therapist helpsthe man make the link between thepast abuse and the current feeling.

Exploring how the anxiety disor-der affects different parts of a per-son’s life is also important in thistype of therapy.

Group therapy provides theopportunity for a person with ananxiety disorder to meet with otherswho are experiencing the same prob-lem. Being able to share feelings withothers—and knowing that othershave similar feelings—helps the per-son heal. Group members may havesuggestions for how to cope witheveryday events or relationships.

When a patient is being treatedfor an anxiety disorder, whether withpsychotherapy or pharmacologictherapy, it’s important for you toprovide emotional support. SeeNursing care points for ideas on howyou can help.

Mind-body connectionAs nurses, we understand the connec-tion between the mind and the body,and that puts us in an ideal positionto help patients who have anxiety dis-orders. Through our holistic ap-proach to care, we can work effec-tively to ease patients’ anxiety andhelp them live rewarding lives. LPN

Selected referencesAmerican Psychiatric Association. Diagnostic andStatistical Manual of Mental Disorders (DSM-IV-TR),4th edition, text revision. Washington, DC,American Psychiatric Association, 2000.

Antai-Otong D. Anxiety disorders: Helping yourpatient conquer her fears. Nursing2003. 33(12):36-41, December 2003.

Kaiman C. PTSD in the aging World War IIcombat veteran. AJN, American Journal of Nursing.103(11):32-40. November 2003.

McIntosh A, et al. Clinical guidelines for themanagement of anxiety. Management of anxietypanic disorder, with or without agoraphobia, andgeneralised anxiety disorder in adults in primary,secondary and community care. December 2004.http://www.guidelines.gov/summary/summary.aspx?doc_id=6248&nbr=004008&string=anxiety.Accessed December 1, 2006.

Murphy K. Anxiety: When is it too much? Nurs-ing made Incredibly Easy! 3(5):22-23, 25-31, 33,September/October 2005.

National Institute of Mental Health. Anxiety disorders. http://www.nimh.nih.gov/healthinformation/anxietymenu.cfm. Accessed Decem-ber 1, 2006.

Tefera L, et al. Anxiety. http://www.emedicine.com/EMERG/topic35.htm. Accessed December1, 2006.

Self-Test Answers

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On the Web

Anxiety Disorders Association of America: http://www.adaa.orgAnxiety Network: http://www.anxietynetwork.comNational Center for PTSD: http://www.ncptsd.va.govObsessive-Compulsive Foundation: http://www.ocfoundation.orgPsychCentral: http://psychcentral.comPTSD Alliance: http://www.ptsdalliance.org

1-true, 2-false, 3-b, 4-c, 5-a, 6-b

Nursing care points• Explain the condition to the patient and family. Remind them that the patientdoesn’t have control over his symptoms. Part of the treatment for an anxiety disorderwill be to learn how to control the anxiety.• Help the patient identify early signs of anxiety so he can take appropriate actions,such as breathing exercises.• Teach the patient about medications, including how they work and their adverse effects.• Help the patient manage any rituals associated with OCD. For example, he mayneed to establish a set time limit to perform the ritual until therapy or medication canhelp him eliminate the need for the ritual.• Teach the patient to avoid any substance that increases anxiety, such as caffeine,nicotine, and alcohol.• Support the patient who is undergoing psychotherapy.