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Chapter: Psychiatric Mental Health Nursing : Anxiety, Anxiety Disorders, and Stress-Related Illness

Anxiety as a Response to Stress

Stress is the wear and tear that life causes on the body (Selye, 1956).



Stress is the wear and tear that life causes on the body (Selye, 1956). It occurs when a person has difficulty deal-ing with life situations, problems, and goals. Each person handles stress differently: One person can thrive in a situ-ation that creates great distress for another. For example, many people view public speaking as scary, but for teach-ers and actors, it is an everyday, enjoyable experience. Marriage, children, airplanes, snakes, a new job, a new school, and leaving home are examples of stress-causing events.


Hans Selye (1956, 1974), an endocrinologist, identified the physiologic aspects of stress, which he labeled the gen-eral adaptation syndrome. He used laboratory animals to assess biologic system changes; the stages of the body’s physical responses to pain, heat, toxins, and restraint; and, later, the mind’s emotional responses to real or perceived stressors. He determined three stages of reaction to stress:


In the alarm reaction stage, stress stimulates the body to send messages from the hypothalamus to the glands (such as the adrenal gland, to send out adrenaline and norepinephrine for fuel) and organs (such as the liver, to reconvert glycogen stores to glucose for food) to pre-pare for potential defense needs.


·    In the resistance stage, the digestive system reduces function to shunt blood to areas needed for defense. The lungs take in more air, and the heart beats faster and harder so it can circulate this highly oxygenated and highly nourished blood to the muscles to defend the body by fight, flight, or freeze behaviors. If the per-son adapts to the stress, the body responses relax, and the gland, organ, and systemic responses abate.


·    The exhaustion stage occurs when the person has re-sponded negatively to anxiety and stress: body stores are depleted or the emotional components are not re-solved, resulting in continual arousal of the physiologic responses and little reserve capacity.


Autonomic nervous system responses to fear and anxi-ety generate the involuntary activities of the body that are involved in self-preservation. Sympathetic nerve fibers “charge up” the vital signs at any hint of danger to prepare the body’s defenses. The adrenal glands release adrenalin (epinephrine), which causes the body to take in more oxy-gen, dilate the pupils, and increase arterial pressure and heart rate while constricting the peripheral vessels and shunting blood from the gastrointestinal and reproductive systems and increasing glycogenolysis to free glucose for fuel for the heart, muscles, and central nervous system. When the danger has passed, parasympathetic nerve fibers reverse this process and return the body to normal operat-ing conditions until the next sign of threat reactivates the sympathetic responses.


Anxiety causes uncomfortable cognitive, psychomotor, and physiologic responses, such as difficulty with logical thought, increasingly agitated motor activity, and elevated vital signs. To reduce these uncomfortable feelings, the person tries to reduce the level of discomfort by imple-menting new adaptive behaviors or defense mechanisms. Adaptive behaviors can be positive and help the person to learn, for example, using imagery techniques to refocus attention on a pleasant scene, practicing sequential relax-ation of the body from head to toe, and breathing slowly and steadily to reduce muscle tension and vital signs. Neg-ative responses to anxiety can result in maladaptive behav-iors such as tension headaches, pain syndromes, and stress-related responses that reduce the efficiency of the immune system.


People can communicate anxiety to others both ver-bally and nonverbally. If someone yells “fire,” others around them can become anxious as they picture a fire and the possible threat that represents. Viewing a distraught mother searching for her lost child in a shopping mall can cause anxiety in others as they imagine the panic she is experiencing. They can convey anxiety nonverbally through empathy, which is the sense of walking in another person’s shoes for a moment in time (Sullivan, 1952).

Examples of nonverbal empathetic communication are when the family of a client undergoing surgery can tell from the physician’s body language that their loved one has died, when the nurse reads a plea for help in a client’s eyes, or when a person feels the tension in a room where two people have been arguing and are now not speaking to each other.


Levels of Anxiety


Anxiety has both healthy and harmful aspects depending on its degree and duration as well as on how well the per-son copes with it. Anxiety has four levels: mild, moderate, severe, and panic (Table 13.1). Each level causes both physiologic and emotional changes in the person.

Mild anxiety is a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve prob-lems, think, act, feel, and protect himself or herself. Mild anxiety often motivates people to make changes or to engage in goal-directed activity. For example, it helps students to focus on studying for an examination.


Moderate anxiety is the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated. In moderate anxiety, the person can still process information, solve problems, and learn new things with assistance fromothers. He or she has difficulty concentrating independently but can be redirected to the topic. For example, the nurse might be giving preoperative instructions to a client who is anxious about the upcoming surgical procedure. As the nurse is teaching, the client’s attention wanders but the nurse can regain the client’s attention and direct him or her back to the task at hand.


As the person progresses to severe anxiety and panic, more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantly. A person with severe anxiety has trouble thinking and reasoning. Muscles tighten and vital signs increase. The person paces; is restless, irritable, and angry; or uses other similar emotional–psychomotor means to release tension. In panic, the emotional–psychomotor realm predominates with accompanying fight, flight, or freeze responses. Adrenaline surge greatly increases vital signs. Pupils enlarge to let in more light, and the only cognitive process focuses on the person’s defense.


Working with Anxious Clients


Nurses encounter anxious clients and families in a wide variety of situations such as before surgery and in emer-gency departments, intensive care units, offices, and clin-ics. First and foremost, the nurse must assess the person’s anxiety level because that determines what interventions are likely to be effective.


Mild anxiety is an asset to the client and requires no direct intervention. People with mild anxiety can learn and solve problems and are even eager for information. Teach-ing can be very effective when the client is mildly anxious.


In moderate anxiety, the nurse must be certain that the client is following what the nurse is saying. The client’s attention can wander, and he or she may have some difficulty concentrating over time. Speaking in short, simple, and easy-to-understand sentences is effective; the nurse must stop to ensure that the client is still taking in information correctly. The nurse may need to redirect the client back to the topic if the client goes off on an unrelated tangent.


When anxiety becomes severe, the client no longer can pay attention or take in information. The nurse’s goal must be to lower the person’s anxiety level to moderate or mild before proceeding with anything else. It is also essential to remain with the person because anxiety is likely to worsen if he or she is left alone. Talking to the client in a low, calm, and soothing voice can help. If the person cannot sit still, walking with him or her while talking can be effective. What the nurse talks about matters less than how he or she says the words. Helping the person to take deep even breaths can help lower anxiety.


During panic-level anxiety, the person’s safety is the pri-mary concern. He or she cannot perceive potential harm and may have no capacity for rational thought. The nurse must keep talking to the person in a comforting manner, even though the client cannot process what the nurse is saying. Going to a small, quiet, and nonstimulating envi-ronment may help to reduce anxiety. The nurse can reas-sure the person that this is anxiety, that it will pass, and that he or she is in a safe place. The nurse should remain with the client until the panic recedes. Panic-level anxiety is not sustained indefinitely but can last from 5–30 minutes.

When working with an anxious person, the nurse must be aware of his or her own anxiety level. It is easy for the nurse to become increasingly anxious. Remaining calm and in control is essential if the nurse is going to work effectively with the client.


Short-term anxiety can be treated with anxiolytic medications (Table 13.2). Most of these drugs are benzo-diazepines, which are commonly prescribed for anxiety. Benzodiazepines have a high potential for abuse and dependence, however, so their use should be short-term, ideally no longer than 4 to 6 weeks. These drugs are designed to relieve anxiety so that the person can deal more effectively with whatever crisis or situation is caus-ing stress. Unfortunately, many people see these drugs as a “cure” for anxiety and continue to use them instead of learning more effective coping skills or making needed changes.

Stress-Related Illness


Stress-related illness is a broad term that covers a spectrum of illnesses that result from or worsen because of chronic, long-term, or unresolved stress. Chronic stress that is repressed can cause eating disorders, such as anorexia ner-vosa and bulimia. Repressed stress can cause physical symptoms with no actual organic disease, called somatoform disorders . Stress can also exacerbate the symptoms of many medical illness, such as hypertension and ulcerative colitis. Chronic or recurrent anxiety resulting from stress may also be diagnosed as an anxiety disorder.



Anxiety disorders are diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change but becomes chronic and permeates major por-tions of the person’s life, resulting in maladaptive behav-iors and emotional disability. Anxiety disorders have many manifestations, but anxiety is the key feature of each (American Psychiatric Association [APA], 2000). Types of anxiety disorders include the following:


·    Agoraphobia with or without panic disorder


·    Panic disorder


·    Specific phobia


·    Social phobia


·    OCD


·    Generalized anxiety disorder (GAD)


·    Acute stress disorder


·    Posttraumatic stress disorder.


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