SESSION 05

PROVISION OF CARE TO CLIENTS WITH

ANXIETY AND FEAR DISORDER USING
NURSING PROCESS

BY MALAKATETE F. U
 OBJECTIVES

At the end of this session a learner is expected to be able

to:
• Differentiate between anxiety, stress and fear disorder
• Describe the causes of anxiety disorder
• Identify various types of anxiety disorder (Generalized
anxiety, Panic disorder, Post-traumatic stress disorder,
and phobia)
• Explain the Levels of anxiety
• Explain the clinical features of anxiety.
• Describe treatment modalities relevant to anxiety disorder
• Provide specific nursing care to client with anxiety
disorder
 DEFINITION OF ANXIETY, STRESS
AND FEAR
ANXIETY
•Is nonspecific, unpleasant feeling of discomfort,
with physiologic and psychological symptoms
that generally result from perception of a threat
to safety and security.
OR
•Vague diffuse apprehension that is associated
with feelings of uncertainty and helplessness.
 .

• Anxiety is a normal emotion.

• It is a brain's way of reacting to
stress and alerting the person on
potential danger ahead.
• Generalized response to an
unknown threat or internal conflict.
 .

ANXIETY DISORDERS
•Are patterns of symptoms and
behavior in which anxiety is either
the primary disturbance or
secondary problem that is
recognized when the primary
symptoms are removed
 .
STRESS
•Is a state of disequilibrium that occurs when
there is a disharmony between demands
occurring within an individual’s internal or
external environment and his/ her ability to
cope with those demands.
•Stressor is the demand from within an
individual’s internal or external environment
that elicits a physiological and/ or
psychological response.
 .

STRESS MANAGEMENT
•Various methods used by individuals to reduce
tension and other maladaptive responses to
stress in their lives.
•Includes:
 Relaxation exercises
 Physical exercise
 Music
 Mental imagery or any other technique that is
successful for a person
 .

FEAR
•Is a anxiety as a result of consciously
recognized and realistic danger
•The danger can be specific stimulus
occurring in the present, or in anticipation or
expectation of a future threat perceived as a
risk to body or life.
•Focused on known external danger
 .

• The object of fear is real/

external/ known/ objective
 .

PHOBIA
•Is exaggerated, pathologic fear
of some specific type of
stimulus or situation.
 TYPES OF ANXIETY DISORDER

I: GENERALIZED ANXIETY DISORDER (GAD)

•Is also known as anxiety neurosis
• A disorder characterized by chronic (at least 6
months) unrealistic and excessive anxiety and
worry.
• An individual with GAD experiences excessive or
unreasonable worry or apprehension.
• The intensity of the worry is out of proportion to
the actual likelihood of the anticipated event
 .

II: PANIC DISORDER

•Is characterized by acute and
unprovoked discrete periods of intense
fear or discomfort (panic attacks) due to
intense acute psychic and somatic
anxiety symptoms, which are expected
and not triggered by situation.
 .

• Panic disorder is an anxiety

disorder where a person
regularly have sudden attacks
of panic or fear.
.
 .

PANIC ATTACK 
•Is a sudden episode of intense
fear that triggers severe physical
reactions when there is no real
danger or apparent cause.
,
 .

III: POST-TRAUMATIC STRESS DISORDER (PTSD)

•A syndrome of symptoms that develops
following a psychologically distressing event
that is outside the range of usual human
experience (e.g., rape, war).
•The individual is unable to put the experience
out of his or her mind and has nightmares,
flashbacks, and panic attacks
 .

IV: PHOBIC DISORDER

•Severe phobic behavior patterns
that render the individual
dysfunctional.
•Avoidance of the feared object or
situation serves to assuage anxiety
 .
IV: SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
•The fear of being humiliated in social situations.

V: SPECIFIC PHOBIA
•A persistent fear of a specific object or situation,
other than the fear of being unable to escape
from a situation (agoraphobia) or the fear of
being humiliated in social situations (social
phobia)
 LEVELS OF ANXIETY DISORDERS

a. Mild Anxiety
•Prepares the body for constructive action
•Slight muscle tension.
•Good eye contact
•Slightly irritable
•Alertness
•Aware of surrounding
 .

b. Moderate Anxiety
•Prepares the body for protection
•Moderate muscle tension
•Increased blood pressure, pulse rate,
respiration
•Slight perspiration
•Difficult sitting still
•Increased rate of speech
 .

• Sporadic eye contact

• Slow pacing
• Increased irritability
• Difficult concentration
• Easily distracted
• Decreased span of attention
 .

c. Severe anxiety
•Prepares the body for flight and fight
•Extreme muscle tension
•Increased perspiration
•Continuous and rapid pacing
•Loud and rapid speech
•Poor eye contact
•Somatic symptoms, sleep disturbance
 .

• Extreme discomfort
• Feeling of dread/ fear
• Hypersensitivity
• Disoriented
• Delusions and hallucination
• Use mal-adoptive copping mechanism
 .

d. Panic
•Actual flight, fight or immobilization
•Suicide attempt or violence
•Eye fixed, hysterical or mute, incoherent
•Feeling totally drained
•Desperation/ hopelessness
•Feeling overwhelmed and out of control
 .

• Rage (extreme/ violent anger)

• Disorganized perception
• Disorganized irrational reasoning
CAUSES OF ANXIETY DISORDER

• The following are the major factors that

cause Anxiety Disorders:

a. Predisposing Factors
• Genetic inherited influence
• Environmental factors
• Personality factors – anxious (avoidant)
personality disorder.
• Early childhood separation
 .

b. Precipitating
•Current stresses
•Life events associated with fear of loss.

c. Perpetuating Factors
•Are those factors that cause an existing
psychiatric disorder to continue
•Example: Social withdrawal
 .

CAUSES OF PANIC DISORDER

•Genetic factors
•Childhood parental death or separation from
mother.
•Overanxious personalities
•Excessive caffeine intake, injections of
sodium lactate, sympathomimetic drugs and
carbon dioxide.
 CLINICAL SYMPTOMS OF ANXIETY
DISORDERS
• Major clinical symptoms for Anxiety
Disorders include:
• Feeling of threat
• Difficulty in concentrating
• Distractible
• Tense and unable to relax
• Early insomnia and night mares
• Irritability
• Noise intolerance
 .

• Lability of mood
• Depersonalization
• Hallucinations
• Perceptual disturbances.
• Not triggered by situation
• Intense fear or discomfort
TREATMENT MODALITIES RELEVANT TO
ANXIETY DISORDERS
• The Treatment modalities relevant to Anxiety
Disorders include;

a. Individual Psychotherapy
• Insight-oriented psychotherapy
• Focuses on helping patients understand the
hypothesized unconscious meaning of the
anxiety, the symbolism of the avoided situation,
the need to repress impulses, and the secondary
gains of the symptoms.
 .

• Most clients experience a marked

lessening of anxiety when given the
opportunity to discuss their difficulties
with a concerned and sympathetic
therapist.
 .
b. Cognitive Therapy
•The cognitive model relates how individuals
respond in stressful situations to their
subjective cognitive appraisal of the event.
• Cognitive therapy strives to assist the
individual to reduce anxiety responses by
altering cognitive distortions.
• Anxiety is described as being the result of
exaggerated, automatic thinking.
 .

• Cognitive therapy for anxiety is brief and

time limited, usually lasting from 5 to 20
sessions.
• Brief therapy discourages the client’s
dependency on the therapist, which is
prevalent in anxiety disorders, and
encourages the client’s self-sufficiency.
 .
c. Behavior Therapy
Various techniques have been tried,
including:
• Covert Desensitization (pt helped to overcome anxiety by
learning to relax while imagining anxiety-producing stimulus) and
Habit-Reversal Therapy (HRT). These may
include a system of positive and negative
reinforcements in an effort to modify a certain
anxiety disorder eg: the hair-pulling behaviors
during anxious.
 .
• Other forms of behavioral therapy includes:
• Systematic desensitization
• The client is gradually exposed to the phobic
stimulus, either in a real or imagined situation
• Implosion therapy/ Flooding
• Is a therapeutic process in which the client must
imagine situations or participate in real-life
situations that he or she finds extremely
frightening for a prolonged period of time
 .

d. Psychopharmacotherapy
•Administer Pharmacological treatment
such as antidepressants and
benzodiazepines.
• Example: diazepams for up to four
weeks, in the longer term use
antidepressants.
 .

e. Situational exposure and anxiety

management techniques and skills such
as muscle relaxation techniques (Relaxation
therapy)
 .

f. Milieu Management or therapy

•Is a safe, structured, group treatment
method for mental health cases.
•It involves using everyday activities and a
conditioned environment to help people with
interaction in community settings.
•Is a flexible treatment intervention that may
work together with other treatment methods.
 SPECIFIC NURSING CARE TO CLIENT
WITH ANXIETY DISORDER

• Each type of anxiety may have its

specific nursing interventions.
• The following are key nursing
interventions for reducing anxiety:
• Provide a calm and quiet environment
to identify and reduce stimulation
which includes exposure to situations
and interactions with other patients that
might provoke anxiety.
 .
• Ask patient to identify what and
how they feel to help them increase
their recognition of what is happening
to them
• Encourage patients to describe and
discuss their feelings with you.
• It helps patient increase their awareness
of the connection between feelings and
behaviours
 .

• Help patient identify

possible causes of their
feelings.
• It helps to assist patient in
connecting their feelings with
earlier experiences
 .

• Listen carefully for patients’

expressions of helplessness and
hopelessness.
• It helps to assess for self-harm, patient
may be suicidal because they want to
escape their pain and do not think that
they will ever feel better.
• A co morbid major depression may also
be present.
 .

• Ask patient whether they feel

suicidal or have a plan to hurt
themselves.
• It helps to assess for self-harm
and initiate suicide precautions
if necessary
 .

• Plan and involve patients in

activities such as going for walk
or playing recreational games.
• It helps patient release nervous
energy and to discourage
preoccupation with the self
 .
The following are key nursing
interventions for problem solving for a
patient with anxiety:
•Discuss with the patients their
present and previous coping
mechanisms.
• It helps to reinforce effective
adaptive behaviour
 .

• Discuss with patients the

meaning of problems and
conflicts.
• It helps patients appraise stressors,
explore their personal values, and
define the scope and seriousness
of their problem
 .

• Use supportive confrontation

and teaching.
• To increase patients’ insight into
the negative effects of their
maladaptive and dysfunctional
coping behaviours
 .
• Assist patients with exploring
alternative solutions and behaviors.
• To increase adaptive coping mechanism
• Encourage patient to test new
adaptive coping mechanism through
role playing or implementation.
• To provide an opportunity for a patent to
practice new behaviour
 .

• Teach patients’ relaxation exercises.

• To reduce the level of anxiety.
• These technique help the client or patient
manage the anxiety in their own
• Promote the use of hobbies and
recreational activities.
• It helps patient to deal with routine
feelings of stress and anxiety
 .
The following are key nursing interventions for
problem solving with the patient of anxiety:
•Stay with the patient who is having panic attack
and acknowledge the patient’s discomfort
•Maintain a calm style and demeanour
•Speak in shot, simple sentences, and give one
direction a time in a calm tone of voice
•If the patient is hyperventilating, provide a brown
paper bag and focus on breathing with the patient
 .

• Allow patients to pace or cry, which

enables the release of tension and energy
• Communicate with the patient that you are
in control and will not let anything happen
to them
• Move or direct a patient to a quieter, less
stimulating environment.
• Do not touch these patients; touching can
increase feelings of panic
 .
• Ask patients to express their perceptions
or fears about what is happening to them.
• It helps patients reduce anxiety to a more
manageable and comfortable level
• Normalize patient’s fears related to their
physical symptoms
• Remind patients that the panic attack
episode will be over in less than 10
minutes
 .

The following are key nursing

interventions for Posttraumatic Stress
Disorder and Acute Stress Disorder:
•Be non-judgemental and honest: offer
empath and support; acknowledge any
unfairness or injustices related to the
trauma.
• Building trust may be difficulty for patients.
 .
• Assure patients that their feelings and
behaviours are typical reaction to serious
trauma.
• Rationale: patients often believe that they are
going crazy
• Help patients to recognize the connections
between the trauma experience and their
current feelings, behaviour, and problems.
• Rationale: patients often are unaware of these
connections
 .
• Help patients evaluate past behaviours in
the context of current values and
standards.
• Rationale: patients often have guilt about past
behaviours and are judgemental of
themselves.
• Encourage safe verbalization of feelings,
especially anger.
• It helps to repress or supress the feelings
 .

• Encourage adaptive coping

strategies, such as exercise,
relaxation techniques, and sleep –
promoting strategies.
• Rationale: patients might have been
using maladaptive or dysfunctional
coping to avoid dealing with feelings
and issues.
 .

• Encourage patients to establish or

re-establish relationships.
• Rationale: relationships (needed for
assistance and support) might have
been affected by patients’
suspiciousness or fear of asking for
help.
 SUMMARY

• The anxiety causes significant distress and

impairment in interpersonal, social, or
occupational functioning.
• Causes of panic disorder includes genetic
factors, childhood parental death or
separation from mother, overanxious
personalities and excessive caffeine intake,
injections of sodium lactate, sympathomimetic
drugs and carbon dioxide.
 EVALUATION

• What are the causes of anxiety disorder?

• What are the various types of anxiety
disorder?
• What are the physical symptoms of
anxiety?
 REFERENCES
• DSM – V TR (2013). Diagnostic and Statistical Manual of Mental Health
Disorders, Washington
• Habber, J, Leah, A and Schudy, S. (2000). Comprehensive Psychiatric
Nursing. McGraw Hill book Company
• Keltner, N.L., and Steel, D. (2015). Psychiatric Nursing. (7th Ed).
Elsevier.
• Mbatia, J, Kilonzo G, and Hauli, J (2004). Mental Health; A Basic Manual
for General Health Workers in Primary Health Care. MEHATA
Publication, Dar es Salaam
• Ndetei, D (2006). Clinical Psychiatry and Mental Health. AMREF, Nairob
• Townsend, M.C., (2013). Essentials of Psychiatric Mental Health Nursing.
Concepts of Care in Evidence – Based Practice. (6th Ed). F.A. Davis
Company
• WHO (2000). Collaborating Centre for Mental Health Disorders; Australia