Anxiety Disorders Nursing CE Course

2.0 ANCC Contact Hours AACN Category A

Syllabus

Background

Anxiety disorders such as generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), panic disorder, phobias such as arachnophobia (fear of spiders), social anxiety disorder, agoraphobia (abnormal fear of places or situations that cause you to panic and feel trapped), and obsessive-compulsive disorder (OCD) are the most common psychiatric disorders affecting at least one-third of the population at least once during their lifetime (Bandelow & Michaelis, 2015). Even though anxiety is an expected and normal emotion, excessive amounts of worry, panic, or nervousness that lasts for prolonged periods and affect activities of daily living is pathological and indicative of a disorder requiring medical attention (National Institute of Mental Health [NIMH], 2018). People with anxiety related disorders typically experience disruptions in doing daily activities, or when dealing with stress, they often have intrusive thoughts, excessive worry, and have difficulty focusing on tasks. More women suffer from anxiety disorders then men, and populations more prone to anxiety disorders include those under the age of 35 and people with chronic conditions (Blanco et al., 2014). While anxiety disorders can affect any individual of any age, those who are more at-risk include adolescents and those in occupations that involve public health or the military (Nierengarten, 2019). Nursing staff and healthcare professionals must be able to identify protective and risk factors, and coping mechanisms that the patient can utilize to help manage their anxiety. Ensuring good rapport and developing a trusting nurse-patient relationship is the key to working with patients who suffer from these disorders. Anxiety is prevalent among the American population, and people who are diagnosed with an anxiety disorder are much more likely to be admitted to an inpatient psychiatric facility (Bandelow & Michaelis, 2015).

Anxiety Disorder Epidemiology

Anxiety is one of the most common types of disorders within the United States, and more than half of individuals diagnosed with depression will also suffer from an anxiety disorder as well (Babu, Sreedevi, John, & Krishnapillai, 2019). There are many forms of anxiety, such as GAD, PTSD, panic disorder, OCD, and several other closely related disorders such as testing anxiety, social anxiety, separation anxiety, selective mutism, and various phobia-related disorders. Patients who experience a major life event, recent trauma, change, or stressor are more prone to anxiety (NIMH, 2018; Nierengarten, 2019).

      The neurotransmitters dopamine, gamma-aminobutyric acid (GABA), serotonin, and norepinephrine are all involved in the regulation of, and response to stress. When an individual suffers from an anxiety disorder, typically, this will involve chemical imbalances in the brain, which cause inappropriate responses to stress, changes in mood, or excitement. An individual who experiences anxiety may produce lower levels of dopamine or serotonin, which results in easier excitability, inappropriate responses to stress, and higher levels of anxiety. Other individuals may have problems associated with the area of the brain called the amygdala, which regulates emotional responses like fear and anxiety. The hippocampus is also believed to play a role in emotions (Baek, Lee, & Kim, 2019). Those suffering from PTSD or other panic disorders may also experience chemical imbalances of norepinephrine (the fight or flight response hormone) (Klumpp, Kinney, Bhaumik, & Fitzgerald, 2019).

Risk factors for anxiety disorders include biological relatives with anxiety disorders, comorbid psychological conditions, low self-esteem, past history of, or current substance abuse, poor socialization skills/childhood shyness, job loss, death of a family member or friend, family conflict, divorce or separation, sexual assault or rape victim, a victim of domestic violence, poverty or financial problems, and a traumatic event (Blanco et al., 2014; NIMH, 2018).

It is also believed that environmental factors and genetics play a role, as well as life-stressors and socioeconomic status. It is widely believed that neurotransmitters, chemical imbalances, genetics, and environmental factors all play a role in the pathophysiology of anxiety disorders (Nielsen et al., 2019). For example, PTSD is caused by a traumatic life event. In addition to potential chemical imbalances and environmental factors, PTSD patients have been exposed to some form of psychological trauma, which then causes flashbacks, sleep disturbances, and intrusive thoughts (Martin-Cuellar, Lardier, Atencio, Kelly, & Montañez, 2019).

Generalized Anxiety Disorder

      GAD is characterized by an intense and excessive amount of worry often regarding everyday stressors or events, with an inability to appropriately cope with such stress (Wen, LeMoult, McCabe, & Yoon, 2019). This excessive worry negatively impacts the individual’s daily life, career, education, and family. It is persistent worry that can be triggered by major life events, extreme stress, or everyday tasks. This worry severely impairs their ability to focus and complete tasks. Signs and symptoms can include restlessness, irritability, intrusive thoughts, headaches, body aches, inability to concentrate, and persistent worry (Khazaie et al., 2019). This disorder can adversely affect the patient’s overall health and outcomes related to their care (Panganiban, Yeow, Zugibe, & Geisler, 2019).

Patients suffering from GAD should be encouraged to be involved in their care and decision-making processes regarding their treatment, provided a calm, therapeutic environment, and be given opportunities to verbalize how they feel. The nurse should actively listen to these patients, approach them in a calm, reassuring manner, maintain safety, and assess patients for suicidal ideations, or self-harming behaviors (Zainal & Newman, 2018). Nursing staff should make every effort to gain the trust of their patients and develop a good rapport, encourage the patient to express their feelings, and maintain a professional and therapeutic relationship. Medications the nurse may expect to administer are selective serotonin reuptake inhibitors (SSRIs) such as escitalopram (Lexapro) or sertraline (Zoloft), benzodiazepines such as alprazolam (Xanax) or clonazepam (Klonopin), and other drugs such as azapirones (Khazaie et al., 2019). Azapirones like buspirone (Buspar) are commonly prescribed to treat symptoms of anxiety such as irritability, nervousness, and fear; they are often given in combination with other medications and types of therapy (Howland, 2015). Beta-blockers such as metoprolol (Toprol, commonly prescribed for high blood pressure) can also be used to treat the physical symptoms of anxiety which include trembling, heart palpitations, sweating, and tachycardia experienced during stressful life events. Patients should be cautioned that they can cause hypotension and bradycardia which can lead to dizziness, weakness, and fatigue (NIMH, 2016, 2018).

Post-Traumatic Stress Disorder

PTSD is a psychological disorder caused by a traumatic event that incudes flashbacks, sleep disturbances, depressed mood, and anxiety (Denke & Denham, 2019). The amygdala and the hippocampus are believed to play major roles in PTSD as both of these areas involve regulating emotions and memories (Baek et al., 2019). Signs and symptoms of PTSD include hypervigilance, irritability, flashbacks, fear, sleep disturbances, anxiety, nightmares, depression, social isolation, and anxiety (Scott, 2019). Some public health and safety occupations are at a higher risk of developing panic disorders, especially PTSD. PTSD involves an emotional response that can be triggered when reminded of past events, and cause severe panic and worry. 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, Fifolt, Adams, Ford, & McCormick, 2019).

Something that should be taken into consideration when working with victims of domestic violence is that often when a victim makes the decision to leave their abuser, the domestic relations court in many states does not recognize witnessing abuse as a form of abuse. Research shows the negative impact that witnessing abuse can have on children, and the effect it can have on 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. The nurse must evaluate clients at-risk who show signs of being abused, follow proper facility protocol, and make appropriate referrals to maintain the safety of the patients and their children (Paul, 2018). Special 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 all the necessary resources and information to remain safe, and continue to work towards recovering from the abuse and treating the resulting PTSD (Laing, Heward-Belle, & Toivonen, 2018).

Nurses need to encourage patients to be involved in their care and incorporate methods to develop a trusting nurse-patient relationship in order to communicate with patients who suffer from PTSD effectively (Paintain & Cassidy, 2018). These patients require a calm and therapeutic environment that encourages the expression of feelings, fears, and incorporates different types of 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. Psychotherapy and cognitive therapies can be utilized to treat PTSD, such as trauma focused psychotherapy, exposure therapy (exposing patients to their fear and helping them manage their fear), and cognitive restructuring (assisting patients in recognizing the traumatic memories and develop a deeper understanding of it). Antidepressants are the most commonly prescribed medications for PTSD, which is often used in conjunction with psychotherapies such as talk therapy (Herbert et al., 2019; NIMH, 2016). Medications approved to treat PTSD are the SSRIs sertraline (Zoloft) and paroxetine (Paxil), although fluoxetine (Prozac), and venlafaxine (Effexor, a serotonin and norepinephrine reuptake inhibitor [SNRI]) are also commonly used. Benzodiazepines, and antipsychotic agents may be utilized in refractory or special cases (Herbert et al., 2019; US Department of Veterans Affairs, 2018).

Panic Disorder

      Panic disorder is characterized by panic attacks, which are episodes that involve sudden and intense fear, or feelings of terror (Oguz, Celikbas, Batmaz, Cagli, & Sungur, 2019). Patients who suffer from panic disorder have typically been affected by a major traumatic event or are currently or recently affected by a major life stressor. Symptoms during a panic attach may include tachycardia, tachypnea, diaphoresis, trembling, extreme fear, or a sense of impending doom. There are several factors that can contribute to panic disorder, such as major life stress, genetics, biological and psychological malfunction, and environmental factors (Strauss, Kivity, & Huppert, 2019).

      Nurses should generally maintain a calm approach, and develop a good rapport and trusting relationship with the patient. A nonjudgmental approach should be utilized, and a safe therapeutic environment, with decreased stimuli, should be maintained (Kealy, Goodman, & Ogrodniczuk, 2017). Patients should be given a chance to verbalize their feelings, and encouraged to be involved in their care and decision-making regarding treatments, therapies, and medications prescribed. Patient education should be provided regarding coping mechanisms and protective factors, as this is imperative to the success of treating the patient, and improving patient outcomes. The nurse can assist a patient experiencing a panic attack by maintaining an environment with decreased stimuli, and helping the patient to focus and concentrate on things unrelated to the immediate stressor causing the panic attack. Different therapies utilized to treat panic disorder include cognitive-behavioral therapy (CBT), exposure and response prevention (ERP) therapy, desensitization, relaxation techniques, and psychotherapy (Strauss et al., 2019).

      Medications utilized to treat panic disorder include antidepressants, benzodiazepines, and anticonvulsants. Antidepressants are considered first-line, and often include SSRIs, SNRIs, or tricyclic antidepressants for long-term use. However, for short-term use, providers may utilize benzodiazepines such as lorazepam (Ativan) or alprazolam (Xanax) to help treat severe panic or anxiety (Kealy et al., 2017; NIMH, 2016). Patients who suffer from panic attacks will often suffer from other anxiety disorders or depression and benefit most from incorporating long-term and short-term options. Providers will often utilize a combination of different therapies and more than one type of medication when treating panic disorder (Wootton & MacGregor, 2018).

Obsessive-Compulsive Disorder

      OCD is a disorder in which the patient experiences repetitive or reoccurring thoughts (obsessions) and behaviors (compulsions) due to fears or intrusive thoughts (Yildirim & Boysan, 2019). 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, Khanna, & Jain, 2019). People with a family history seem to be more likely to have the disorder, and slightly more women are affected than men (Skapinakis, Politis, Karampas, Petrikis, & Mavreas, 2019). There is not as much known about this disorder as other anxiety disorders, but it is widely believed that both genetic, and environmental factors are involved in its development (Yildirim & Boysan, 2019).

Encouraging patients to express and verbalize thoughts is important when it comes to nursing care, as well as developing a good rapport with the patient. Nurses 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). Patients who suffer from this disorder may benefit from CBT and ERP therapy. Patients with OCD may be placed on SSRIs, tricyclic antidepressants, anxiolytics, or benzodiazepines (Højgaard et al., 2019). Clomipramine (Anafranil, a tricyclic), fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft) are the most commonly used medications. These will typically need to be dosed higher than seen in depression treatment, and the nurse should educate the patient that it takes 8-12 weeks before symptoms will begin to improve (NIMH, 2016). Another treatment option that has been found to be extremely successful in patients with OCD is deep brain stimulation (DBS), which involves placing electrodes in targeted areas of the brain were impulses are then sent through the electrodes to help regulate brain activity (NIMH, 2019).

Nursing Considerations for Anxiety Disorders

      Understanding the disease process, contributing factors, and medical history is paramount in the treatment of anxiety disorders. Nurses must be able to identify ways to assist patients in developing coping skills to manage increased levels of anxiety, nervousness, and even when experiencing panic. Nurses should remain nonjudgmental, open-minded, and develop a good rapport with the patient (D’Errico et al., 2019). Nurses must maintain a calm approach and be understanding when interacting with patients experiencing anxiety. Approaching a patient and exhibiting signs of anxiety will only escalate, confuse, or stress the patient even more (Stannah, 2019).

      Nurses must maintain an open mind, be good communicators, be patient, and be able to respond appropriately when working with patients who suffer from anxiety disorders. Communication is important when working with patients who suffer from anxiety related disorders as nurses must take into consideration how their tone of voice, presence, body language, and facial expressions can directly impact the message they are attempting to send to patients or convey. Nurses should actively listen to their patients and promote the patient’s understanding of their condition in order to reduce anxiety levels and inappropriate responses to stress (Klumpp et al., 2019). Nurses must speak directly to their patients in a calm, yet assertive manner, and be able to incorporate strategies, appropriate nursing interventions, and coping techniques into the patient’s plan of care. When a patient is experiencing higher levels of anxiety, the nurse should reduce stimuli, and be honest and open in order to effectively assist them (Stannah, 2019).

      Incorporating exercise, hobbies, and different activities that can assist patients in focusing their energy and reducing their anxiety is important when formulating and initiating a patient’s plan of care. This can assist the patient in identifying ways to cope with increased levels of stress, reduce feelings of anxiety, promote patient health and overall wellbeing, foster a sense of self-worth, and focus their energy appropriately (McDowell, Dishman, Gordon, & Herring, 2019). These methods can be utilized to prevent and reduce the need for medications such as benzodiazepines, which have a high addiction rate and are often short-acting (Vigne et al., 2019).

      Incorporating non-pharmacological methods into the patient’s plan of care, educating the patient regarding these techniques, and utilizing less invasive and restrictive methods to assist patients in the identification and care of their condition can dramatically reduce anxiety and assist patients in developing successful coping mechanisms (Antoniadou, Kokkinos, & Markos, 2019). Patients need to identify and utilize ways to cope with stress, and reduce anxiety and maladaptive mechanisms related to anxiety. Nurses must investigate coping mechanisms that work for individual patients and incorporate these mechanisms into the plan of care. It is important to reduce the need for prescription medications, especially medications found to be more addictive and habit-forming, such as benzodiazepines. Incorporating activities, nonpharmacological interventions, coping mechanisms, and patient education can assist in reducing the need for short-term or addictive medications, and increase the patient’s understanding of, and ability to manage their own condition (Difrancesco et al., 2019).

Treatment for Anxiety Disorders

      Patients with OCD, PTSD, panic disorder, and GAD seem to respond best to a combination of therapies utilized in conjunction with one another. Different types of therapy and treatments are most effective in treating anxiety disorders, as many patients benefit from both counseling services, medication, and different types of relaxation techniques (Riordan & Singhal, 2018). The gold standard is psychotherapy and medications (NIMH, 2018). It is imperative that healthcare workers collaborate and utilize several different methods to achieve the best possible patient outcomes. Anxiety disorders usually benefit most from treatments that include therapy, medication, stress management techniques, relaxation techniques, and non-pharmacological coping techniques to help reduce intrusive thoughts and incorporate calm into the patient’s daily life (Skapinakis et al., 2019).

      Therapies that could potentially benefit patients with anxiety disorders are CBT, meditation, psychotherapy, and exposure therapy. CBT is goal-oriented and involves problem solving and changing the way in which patients may think or cope with stressors (Wolitzky-Taylor et al., 2018). Meditation is another method utilized to manage anxiety disorders (Lemay, Hoolahan, & Buchanan, 2019). Meditation can be used to assist patients in focusing, reducing intrusive or worrisome thoughts, and helping calm patients by staying in the current moment (Montero-Marin, Garcia-Campayo, Pérez-Yus, Zabaleta-del-Olmo, & Cuijpers, 2019). Psychotherapy was found to be useful in treating anxiety disorders as well as other psychiatric disorders (Hoffman, 2019). Exposure therapy, desensitization, and ERP therapy have also been shown to be beneficial in treating patients with different anxiety disorders in combination with other forms of treatment. These therapies expose the patient to the object or situation that causes the fear or anxiety, and incorporates relaxation techniques (Højgaard et al., 2019; Meindl, Saba, Gray, Stuebing, & Jarvis, 2019).

      Understanding the patient’s protective and risk factors is important in identifying ways to increase knowledge regarding the use of non-pharmacological methods and successful coping mechanisms in patients suffering from anxiety disorders (Hoffman, 2019). It can also assist in identifying appropriate therapies, treatment options, and medications that may be beneficial to each individual patient. Therapies incorporated into the care plan should be based on patient preferences and understanding what therapies have the most potential for improving patient outcomes. Protective factors include music, exercise, socialization, family, reading, and supportive relationships (Primananda, M., & Keliat, 2019).

      Medications utilized to treat anxiety disorders often include antidepressants, anxiolytics, benzodiazepines, antipsychotics, sedatives, anticonvulsants, and antihistamines (Da Cruz, Giacchero Vedana, do Carmo Mercedes, & Inocenti Miasso, 2016). Depending upon the type of anxiety disorder and the individual patient the provider may prescribe either an SSRI, SNRI, or tricyclic antidepressants. Tricyclics often have more adverse effects than the newer SSRIs/SNRIs but may be as effective in inhibiting the reuptake of serotonin and norepinephrine. The most common adverse effects seen with antidepressants include weight gain, nausea/vomiting, sleepiness, diarrhea, and sexual dysfunction. Patients should also be warned of possible serotonin syndrome: an increased level of serotonin caused by a drug interaction leading to hallucinations, agitation, elevated temperature, and severe blood pressure changes. Pregnant patients or women of childbearing age should be warned that potential fetal risk cannot be ruled out for most antidepressants (NIMH, 2016). Benzodiazepines are the most commonly utilized to treat anxiety disorders despite only being intended for short-term use and the high potential for addiction, abuse, and tolerance. They can be used as a first-line therapy for GAD, but the patient must be aware that they are schedule IV or II controlled substances, depending on the state. Common adverse effects include dizziness, confusion, drowsiness, nausea, headache, blurred vision, and nightmares. They can also cause withdrawal symptoms if they are not tapered slowly (Balon et al., 2019; NIMH, 2016). Most benzodiazepines are not known to be safe for use during pregnancy. This is one of the many reasons that benzodiazepines are often considered a second-line treatment behind antidepressants for chronic anxiety, although they may be used as needed for breakthrough symptoms (NIMH, 2018). Buspirone (Buspar) is approved for use in chronic anxiety. It is not a controlled substance, and works by activating dopamine and serotonin receptors in the brain. Unfortunately, it needs to be taken daily and does not work for everyone. Common adverse effects include nausea, headache, dizziness, nervousness, lightheadedness, sleep disturbance, and excitement. It is also safer to take during pregnancy than benzodiazepines (NIMH, 2016). Either typical or atypical antipsychotics may also be utilized in caring for patients with anxiety disorders with certain psychotic symptoms. Atypical antipsychotic medications are especially beneficial for panic disorders and PTSD as they have a positive effect on neurotransmitters involved in these disorders and a much lower potential for abuse then benzodiazepines (Weber, Wehr, & Duchemin, 2016). Anticonvulsants and sedatives have also been found effective in treating anxiety disorders by reducing the output associated with specific neurons within the amygdala associated with fear and anxiety (Jawna et al., 2016).

Future Research and Trends

      Research has shown promise regarding the understanding of anxiety disorders’ pathophysiology, etiology, and treatment. Researchers have determined that there are multiple factors that contribute to anxiety disorders, including psychological, biological, environmental, and genetic (Vasa, Keefer, Reaven, South, & White, 2018). More research is still needed regarding anxiety disorders’ effects on neurotransmitters, activity in different regions within the brain, and genetics (Wu, Szpunar, Godovich, Schacter, & Hofmann, 2015). More research is needed regarding medications and the successful treatment of anxiety disorders in order to improve patient outcomes and the effectiveness of different treatments. It is important more research is done to identify ways to increase the effectiveness of different treatment options and improve medication compliance among patients suffering from anxiety disorders (Vasa et al., 2018). CBD has been shown to reduce anxiety in certain patients with social anxiety and enhance fear extinction in PTSD. Unfortunately, these studies all used acute dosing only in small sample sizes, so further research is needed to assess safety, effectiveness and establish dosing (Blessing, Steenkamp, Manzanares, & Marmar, 2015). A study using nabilone (Cesamet, a synthetic THC capsule currently FDA approved for nausea and vomiting related to chemotherapy) in PTSD patients showed a consistent decrease in nightmare frequency (Mouhamed et al., 2018).

      Patients may also benefit from research focused on non-traditional treatment such as herbal supplements, therapeutic touch, tapping, faith healing, and acupuncture. Combining these treatments together can be very beneficial to the patient as long as the providers and healthcare team review and understand any possible interactions and complications associated with combining these therapies. Providers should treat the patient holistically and consider alternative treatments that have the potential to improve patient outcomes, and at the same time address health disparities and comorbidities associated with anxiety disorders (Vasa et al., 2018).

      Fear generalization, which is the use of previous aversive experiences to inform similar situations in the future, is another area that warrants future research in order to improve patient outcomes and address knowledge gaps in our understanding of anxiety disorders (Dymond, Dunsmoor, Vervliet, Roche, & Hermans, 2015). Research should focus on identifying causes of anxiety, panic attacks, or even PTSD and ways to reduce and treat symptoms related to anxiety disorders.  The use of positive psychological interventions to reduce anxiety should be investigated; non-pharmacological methods can often dramatically improve patient outcomes more than certain medications, especially short-term medications (Brown, Ospina, Celano, & Huffman, 2019).

Conclusion

      Anxiety disorders such as GAD, PTSD, OCD are extraordinarily prevalent among the American population (Blanco et al., 2014). One-third of the American population will experience some form of anxiety at some point in their lifetime, it is one of the most common psychiatric illnesses and often affects more women than men (Bandelow & Michaelis, 2015). Nurses must be able to maintain a safe therapeutic environment, be great communicators, develop trust and a good rapport with patients in order to help them achieve the best possible outcomes (D’Errico et al., 2019). Nurses must also incorporate methods that increase medication adherence, improve understanding, and identify coping mechanisms that can assist patients in reducing anxiety and decreasing the need for short-acting medication such as benzodiazepines whenever possible (Vigne et al., 2019). It is imperative that nurses understand the different types of disorders, the appropriate therapies and treatment options for each. The utilization of a combination of multiple treatments and possibly complementary adjuncts can assist nursing staff in improving patient outcomes and gaining a deeper understanding regarding anxiety disorders (Bandelow & Michaelis, 2015). Future research should be conducted to identify new ways to treat and better care for patients and to gain a deeper understanding of the underlying pathophysiology (Dymond et al., 2015).


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