Causes, signs and treatments of anxiety RESEARCH

T h e s e i n t e r v e n t i o n s c a n h e l p y o u r p a t i e n t r e l a x a n d m a k e h i s

W HEN YOU CHECK ON YOUR PATIENTS, DO YOU FRE- quently find them jittery, crying, or having trou­ ble sleeping? If you’re like many nurses, the answer is yes— but do you recognize these as signs of anxiety? If not, you should.

Because anxiety can often go unrecognized, many patients never receive the help they need. Here’s how to recognize the telltale signs and provide appropriate treatment.

What causes anxiety? A patient may become anxious if he lacks information about his symptoms or illness; receives a new or unex­

toms of panic are more severe than those of anxiety. The patient may feel smothered, dizzy, or faint; or he may experience tachycardia, trembling, numbness, chills, or chest pain. He may feel as if he’s going crazy, losing control, or dying.

What you can do to help To determine if your patient’s anxious, assess his sub­ jective responses to stressors (what he’s feeling) and his objective responses (what you observe). For more in­ formation, see Recognizing Anxiety.

Each time you come in contact with your patient, view it as an opportunity to reduce his anxiety. You can

Help your patient break free from

pected diagnosis; feels discomfort or pain from tests, procedures, or surgery; can’t pay his medical bills; or has unresolved family crises. Just waiting for test re­ sults or anticipating painful procedures is enough to make most patients anxious.

When a patient is anxious, he may have a rapid pulse rate, increased respirations and blood pressure, periph­ eral vasoconstriction, and dry mouth. Be aware that some patients may appear cool, calm, and self-con­ tained but are still anxious. Others become angry and aggressive, make threats, or refuse to cooperate. Know how to differentiate the stages of anxiety: • mild—causes an increase in alertness and percep­ tiveness • moderate—results in selective inattention, causing the patient to focus on only one thing at a time • severe—results in a tendency to focus on small, irrel­ evant things. In this stage, the patient can’t communi­ cate intelligibly and his behavior may be disorganized and erratic. If severe anxiety progresses to panic, the patient may become immobilized or exhausted.

Panic is an unexpected attack of intense fear. Symp-

BY BARBARA DOSSEY, RN, MS, FAAN Director, Holistic Nursing Consultants Santa Fe, N.M.

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start by making him feel comfortable when he’s around you and answering his questions about his illness or procedures.

Always listen closely to what he has to say, especial­ ly about his problems. Try not to offer simplistic solu­ tions to complex emotional problems. Rather, give sound answers and show him that you care.

You can also teach your patient to reduce anxiety using five different types of techniques. Let’s look at each one in detail.

1 . B ehavioral Before using behavioral techniques, help your patient get into a comfortable position and turn off the televi­ sion. Then place a do-not-disturb sign on his door to minimize interruptions. Use these methods: • Relaxation exercises. Ask your patient to focus his attention on slow, relaxed breathing. Tell him to inhale for a count of 4 seconds and then exhale for 4 seconds. He should keep his upper chest still, allow­ ing his abdomen to rise during inspiration and fall during exhalation.

In addition to breathing exercises, teach him pro­ gressive m uscle relaxation— deliberately tensing muscle groups and then slowly releasing the tension.

h o s p i t a l i z a t i o n m o r e p l e a s a n t

For example, have him begin with the muscles in his toes and slowly work up his body, ending with facial muscles.

Also encourage him to use autogenics, in which he chooses a positive inner phrase and repeats it aloud until he feels relaxed. Or, encourage him to pray, if this appeals to him. A fundamental language for some peo­ ple, prayer can evoke a deep state of relaxation.

For best results, ask your patient to participate in relaxation exercises several times a day for 20 minutes at a time, especially before or during a procedure, surgery, or treatment. • Imagery. Begin with several minutes of relaxation

encourage him to redefine that role. Tell him to think of himself instead as someone who’s hired a surgeon to perform an important surgery. By taking responsibility and making important decisions, he’ll feel more in con­ trol. • Self-talk. Help your patient create a positive self-dia­ logue or phrase that he can repeat to himself when he’s anxious. Explain that negative self-talk or internal con­ versation can impede his healing. For example, he may say to himself, / can't stand this disease; it’s all I think about. But you can encourage him to repeat a positive phrase that will increase his confidence and sense of control, such as, I can deal with this disease one day at

exercises and then have your patient imagine himself in a calm, tranquil place. Tell him to choose a spot where he feels comfortable and safe, such as a favorite room in his home, a Caribbean island, the Colorado mountains, or another special place. For example, tell him to imagine that he’s on the beach— seeing the sights, smelling the ocean, and hearing the waves crash along the shore. • Music therapy. Have the patient sit or lie in a quiet, comfortable position and listen to the music of his choice for 20 minutes. Make sure your facility has var­ ious musical tapes: easy listening, jazz, classical, popu­ lar, folk, and contemporary music. Listening to music can change a person's emotions, behavior, and physical responses to stress.

2 , C o g n i t iv e • Reframing. Help your patient identify stressors and negative thoughts and behaviors and then take a more positive view. For example, if your patient thinks he doesn’t have time for surgery, help him reframe his thinking and see his hospitalization as just 4 days out of his year. Stress that he’ll feel better and healthier and perhaps live longer. • Redefining. If your patient sees himself as a victim,

a time. I have the strength to relax and recover. • Assertiveness. Teach your patient to be more assertive, especially if he tells you that his physician or spouse is pressuring him to do something against his will. Tell him to ask a lot of questions so that he under­ stands his procedures and treatments. Teach him that he’s in control of his body and health—not his physi­ cian or nurse.

3 . P h y s i c a l • Exercise. Take your patient for a walk around the unit or teach him exercises he can do on his own, such as stretching. • Healthy eating. Have your patient choose healthy meals and snacks, but make sure he’s following his pre­ scribed meal plan. Minimize stimulants by reducing his caffeine intake—suggest that he drink herbal teas, water, and juice. • Therapeutic massage. Schedule massages for your patient once or twice a day, and encourage him to get plenty of rest. • Handicrafts. Encourage the patient to participate in a favorite hobby, such as sewing or carving wood. • Self-care activities. Tell him to take warm baths or showers while doing his breathing exercises.

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4 . E m o tio n a l • Humor. Help your patient discov­ er, express, o r appreciate humor. Laughing may help keep his mind off of his problem o r pain. Give him a funny movie, audiotape, or book. • Personal interactions. Identify the people in your patient’s life who help him cope, as well as those who

d o n ’t. If you notice that someone always makes him feel upset o r de­ pressed, encourage him to lim it his interaction w ith that person. Ask those who m ake him feel good (such as his family, close friends, and clergy) to visit o r call frequent­ ly. Tell your patient to talk about his worries w ith his family and friends, so they can help him cope. • Journals/letters. S u g g est that your patient keep a journal and re­ cord factual or subjective interpre­ tations o f events, thoughts, feel­ ings, and plans. This will prom pt him to think about his situation and perhaps help him sort out his feel­ ings. • Reducing frustration. Help your patient identify events and stimuli that frustrate him. For example, if h e ’s frustrated by the equipm ent h e ’s

attached to, explain the importance o f each device. Also, give him real­ istic expectations o f his hospitaliza­ tion. Tell him how long you expect him to be in the hospital and when he should begin to feel better and gain strength. Reducing his frustra­ tion early can prevent anxiety. • Adaptive denial. If your patient

can ’t cope w ith his illness or hos­ pitalization, let him deny o r sup­ press it for now. T his can reduce anxiety in severely ill patients. Wait for signs that he’s ready to learn m ore about his condition.

If your patient doesn’t respond to re­ laxation exercises, imagery, music, or other nonpharmacologic nursing inter­ ventions, he may require medication. Work with his physician in choosing the right medication, keeping in mind that short-acting drugs with minimal adverse effects are best.

The physician will probably pre­ scribe a benzodiazepine, which ef­ fectively controls anxiety, has a fair­ ly rapid onset, is generally well tol­ erated, and doesn’t disrupt sleep. For a patient who has mild to moderate

anxiety, the physician typically or­ ders oral diazepam (Valium), 2 to 5 mg b.i.d. to q.i.d., but may order up to 10 mg o f intravenous diazepam (given in 1- to 2-mg increments) if the patient has acute anxiety.

For a patient w ho’s panicky, the physician may prescribe alprazolam (Xanax), 0.25 to 0.5 mg b.i.d. or t.i.d., gradually increasing the dose to 4 mg/day. After taking alprazo­ lam, the patient should begin to calm down within 1 hour. Or, the physician may prescribe lorazepam (Ativan), 2 to 6 mg RO. daily in divided doses, not exceeding 10 mg daily. Lorazepam can also be admin­ istered intram uscularly or intra­ venously, 0.05 mg/kg— not to ex­ ceed 4 mg daily.

A lth o u g h antian x iety m edica­ tions can alleviate sym ptom s, a patient should take them for only a few days to a few weeks. If a patient requires long-term medication, talk with his physician about referring him to a nurse-therapist or mental health counselor.

Helping patients cope By teaching these an x iety -red u c­ ing strategies, you can help anx­ ious patients cope w ith th eir ill­ nesses. R ecognizing your p atien t’s anxiety and teaching him how to relax is sure to help him recover faster and m ake his hospital stay m ore pleasant. S

SELECTED REFERENCES Achterberg, J„ et al.: Rituals o f Healing. New York, Bantam, 1994. Blair, D„ and Ramones, V.: “Psychopharmacologic Treatment o f Anxiety,” Journal o f Psychosocial Nursing and Mental Health Services. 32(7):49-53, July 1994. Dossey, B., et al.: "Holistic Healing with Relax­ ation, Imagery, Music, and Touch," in The Art o f Caring (audiocassette). Gaithersburg, Md., Aspen Publishers, Inc., 1995. Dossey, B., et al.: Holistic Nursing: A Handbook fo r Practice, 2nd edition. Gaithersburg, Md., Aspen Publishers, Inc., 1995.

R e c o g n i z i n g a n x i e t y

S u b j e c t i v e c h a r a c t e r i s t i c s

T h e p a t i e n t e x p e r i e n c e s : • i n c r e a s e d m u s c l e t e n s i o n

• t i g h t b r e a t h i n g

• a s e n s e o f i m p e n d i n g d o o m

• d i f f i c u l t y f a l l i n g a s l e e p

• t i n g l i n g i n h a n d s a n d f e e t

• a c o n t i n u o u s f e e l i n g o f

a p p r e h e n s i o n

• " b u t t e r f l i e s " i n h i s s t o m a c h

• c o n c e r n a b o u t c h a n g e s i n h i s

h e a l t h s t a t u s a n d i l l n e s s o u t c o m e

• r e s t l e s s n e s s .

O b j e c t i v e c h a r a c t e r i s t i c s

Y o u o b s e r v e t h a t t h e p a t i e n t h a s : • a w r i n k l e d b r o w a n d s t r a i n e d f a c i a l

e x p r e s s i o n

• s w e a t y p a l m s

• s p e e c h - p a t t e r n c h a n g e s

• i n t e r r u p t e d s l e e p p a t t e r n s

• t a c h y p n e a a n d t a c h y c a r d i a

• p s y c h o m o t o r a g i t a t i o n : h e 's e a s i l y

s t a r t l e d a n d i s r e s t l e s s a n d j i t t e r y

• m e a n i n g l e s s g e s t u r e s

• h y p e r v i g i l a n c e ( s c a n s e n v i r o n m e n t )

• s p e l l s o f c r y i n g .

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