01
Levels of Anxiety
The most heavily tested anxiety concept — know what the client can and cannot do at each level.
Anxiety is a normal physiological response to a perceived threat. At low levels it improves performance, but at higher levels it impairs functioning. Peplau identified four levels of anxiety that nurses must be able to recognize because the appropriate intervention depends on the level.
- Mild
- Enhanced perception, alertness, motivation to problem-solve. Sees, hears, and grasps more than usual. Physical: slight tension, fidgeting, increased questioning. Best intervention: Encourage learning. Excellent state for teaching and decision-making.
- Moderate
- Narrowed perceptual field. Selective inattention — sees only what is pointed out. Physical: voice tremors, increased HR/RR, mild tachycardia, diaphoresis, GI upset. Best intervention: Stay with the client. Speak calmly with short, simple sentences. Redirect to one topic at a time.
- Severe
- Greatly reduced perceptual field. Focuses on one specific detail. Problem-solving impaired. Physical: headache, dizziness, nausea, trembling, hyperventilation, palpitations, severe tachycardia. Best intervention: Stay with the client. Use a calm low voice. Decrease stimuli. Encourage slow breathing. Anxiolytic medications may be appropriate.
- Panic
- Loss of rational thought. Disturbed perception, unable to focus, may have hallucinations. Cannot communicate or follow directions. Physical: dilated pupils, severe trembling, immobility or wild flailing, chest pain, fear of dying or losing control. Best intervention: SAFETY first. Stay with client. Speak in short clear sentences. Decrease stimuli. Medications usually required. Never leave alone.
Test-Taking Tip: Match Intervention to Level
NCLEX questions often describe a level of anxiety and ask for the best nursing intervention. Mild anxiety = teaching opportunity. Moderate = stay calm, short sentences. Severe = decrease stimuli, slow breathing. Panic = safety, stay with client, never leave alone.
Defense Mechanisms (Coping with Anxiety)
- Denial — refusing to acknowledge reality. "I do not have cancer."
- Displacement — transferring feelings from one target to another. Angry at boss, yells at spouse.
- Projection — attributing one's own thoughts to others. "She hates me" when the person actually hates her.
- Rationalization — making excuses to justify behavior. "I failed because the test was unfair."
- Reaction Formation — expressing the opposite of true feelings. Hates someone but acts overly kind.
- Regression — returning to an earlier developmental stage. Hospitalized adult wants parent at bedside.
- Repression — involuntarily blocking unpleasant thoughts from consciousness.
- Sublimation — channeling unacceptable urges into acceptable activities. Aggression into sports.
- Suppression — conscious effort to push unpleasant thoughts aside. "I'll think about that tomorrow."
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02
Generalized Anxiety Disorder (GAD)
Excessive worry about everyday events most days for 6 months or more.
Diagnostic Criteria
- Excessive anxiety and worry about a variety of events or activities
- Present on more days than not for at least 6 months
- The person finds it difficult to control the worry
- Associated with at least 3 of 6 physical symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
- Causes clinically significant distress or impairment in functioning
Nursing Interventions
- Help the client identify triggers and patterns of anxiety
- Teach relaxation techniques: deep breathing, progressive muscle relaxation, guided imagery
- Encourage regular exercise — reduces anxiety symptoms
- Limit caffeine and stimulants — they worsen anxiety
- Cognitive-behavioral therapy (CBT) is first-line treatment
- SSRIs and SNRIs are first-line medications (NOT benzodiazepines long-term)
03
Panic Disorder
Recurrent unexpected panic attacks plus persistent worry about future attacks.
Panic Attack Features
- Abrupt onset of intense fear or discomfort that peaks within minutes
- Includes 4 or more symptoms:
- Palpitations, pounding heart, tachycardia
- Sweating, trembling, shaking
- Shortness of breath or feeling of smothering
- Chest pain or discomfort
- Nausea or abdominal distress
- Dizziness, lightheadedness, faintness
- Chills or hot flashes
- Numbness or tingling sensations
- Derealization (feeling unreal) or depersonalization (detached from self)
- Fear of losing control or "going crazy"
- Fear of dying
Panic Disorder Diagnostic Criteria
- Recurrent unexpected panic attacks
- At least one attack followed by 1 month or more of:
- Persistent concern or worry about additional attacks
- Significant maladaptive behavior changes related to the attacks (avoiding places or activities)
Nursing Care During an Acute Panic Attack
- Do
- Stay with the client · Speak in short, simple sentences with a calm voice · Decrease environmental stimuli — move to a quiet area · Help the client focus on slow breathing · Reassure the client they are safe and the attack will pass · Administer PRN medications if non-pharmacological measures are insufficient
- Do NOT
- Leave the client alone · Provide long explanations or detailed information · Allow the client to remain in a stimulating environment · Have client breathe into a paper bag (outdated, not recommended) · Dismiss feelings or minimize the experience · Use medications as the FIRST intervention
Agoraphobia
- Often develops with panic disorder
- Fear of being in places where escape would be difficult or help unavailable if a panic attack occurs
- Common feared situations: public transportation, open spaces, enclosed spaces, crowds, being outside the home alone
- Severe cases may lead to being homebound
04
Phobias
Persistent, irrational fear of a specific object or situation that is disproportionate to actual danger.
Types of Phobias
- Specific Phobia
- Fear of a specific object or situation. Examples: animals (spiders, snakes), natural environment (heights, water), blood/injection/injury, situational (flying, elevators).
- Social Anxiety Disorder
- Fear of social situations involving possible scrutiny or judgment. Examples: public speaking, eating in public, meeting new people, being observed.
- Agoraphobia
- Fear of places where escape would be difficult or help unavailable. Examples: crowds, public transit, open or enclosed spaces, being outside home alone.
Treatment
- Cognitive-behavioral therapy (CBT) — first-line treatment
- Systematic desensitization — gradual, controlled exposure to the feared stimulus paired with relaxation techniques
- Exposure therapy — controlled exposure to feared stimuli
- SSRIs — for social anxiety disorder
- Beta-blockers — can be used short-term for performance anxiety (controls physical symptoms like tremor)
Nursing Approach to Phobias
Do not force the client to confront the feared object. Acknowledge that the fear feels real even though it may seem irrational. Help the client identify situations where the phobia interferes with functioning, and support engagement with therapy. Encourage discussion of triggers and emotional response in a safe environment.
05
Obsessive-Compulsive Disorder (OCD)
Recurrent obsessions and/or compulsions that consume time and cause distress.
Key Definitions
- Obsessions
- Recurrent, persistent, intrusive thoughts, urges, or images that cause anxiety. Examples: fear of contamination, fear of harming others, need for symmetry, intrusive religious or sexual thoughts.
- Compulsions
- Repetitive behaviors or mental acts that the person feels driven to perform to reduce anxiety from obsessions. Examples: hand washing, counting, checking, arranging items, repeating words silently.
The behaviors are not pleasurable — the person performs them to relieve the distress caused by the obsessions. They are aware the behaviors are excessive but feel unable to stop.
Diagnostic Criteria
- Presence of obsessions, compulsions, or both
- Consume more than 1 hour per day OR cause significant distress or impairment
- Not attributable to substances or another medical condition
Nursing Interventions
- Do NOT interrupt compulsive behaviors abruptly — this increases anxiety dramatically
- Allow time for the client to perform rituals, especially early in treatment
- Provide structured schedule with adequate time for rituals plus other activities
- Do not reinforce the rituals or participate in them
- Help client identify the connection between obsessions and compulsions
- As treatment progresses, gradually limit time spent on rituals
- Monitor skin integrity (e.g., excessive hand washing can damage skin)
- SSRIs are first-line medications; doses are often higher than for depression
- CBT with exposure and response prevention (ERP) is highly effective
Common Test Question: Stopping Compulsions
If a client is performing a hand-washing ritual and the nurse needs to give a medication on time, the nurse should NOT interrupt the ritual or force the client to stop. Allow the ritual to finish, then administer the medication. Abrupt interruption causes severe anxiety. As trust and treatment progress, the time spent on rituals can be gradually decreased.
? A client with OCD insists on washing hands before taking morning medications, which will make the med pass late. What should the nurse do?
Allow the ritual to finish, then administer the medication. Abruptly interrupting a compulsion causes severe anxiety and damages the therapeutic relationship. Schedule medications at times that accommodate the ritual whenever possible.
06
PTSD & Acute Stress Disorder
Response to traumatic events — distinguished by timing and duration of symptoms.
What Counts as Trauma
- Exposure to actual or threatened death, serious injury, or sexual violence
- Can occur through:
- Directly experiencing the event
- Witnessing the event in person
- Learning the event happened to a close family member or friend
- Repeated or extreme exposure to aversive details (first responders, military)
Acute Stress Disorder vs PTSD
- OnsetAcute Stress Disorder
- Within 3 days to 1 month of the event
- OnsetPTSD
- More than 1 month after the event
- DurationAcute Stress Disorder
- 3 days to 1 month
- DurationPTSD
- More than 1 month (may be lifelong)
- Symptoms
- Both share re-experiencing, avoidance, negative mood, hyperarousal — acute stress disorder is shorter duration; may resolve or progress to PTSD
Four Symptom Clusters of PTSD
- Re-experiencingIntrusion
- Flashbacks (reliving the event as if it is happening), nightmares, intrusive memories, distress with reminders
- Avoidance
- Avoiding people, places, conversations, or activities that remind the client of the trauma
- Negative Mood & Cognition
- Persistent negative beliefs about self or world, distorted blame, persistent fear/horror/anger/guilt, detachment from others, inability to feel positive emotions
- Hyperarousal
- Irritability, angry outbursts, reckless behavior, hypervigilance, exaggerated startle response, sleep disturbance, concentration problems
Nursing Interventions During a Flashback
- Stay with the client — never leave alone during a flashback
- Speak in a calm, soft voice — do not match the client's distress
- Orient to the present — use the client's name, state the current time and place, remind them they are safe
- Use grounding techniques — have client identify objects in the room (5 things you see, 4 you hear, 3 you can touch)
- Ensure safety — the client may not recognize the surroundings and could try to escape or fight
- Do NOT restrain unless absolutely necessary — this can re-traumatize
- Do NOT ask detailed questions about the traumatic event during the flashback
Trauma-Informed Care Principles
- Safety — physical and psychological
- Trustworthiness — consistent, predictable behavior from staff
- Choice — offer choices whenever possible to restore sense of control
- Collaboration — involve client in care decisions
- Empowerment — recognize and build on client strengths
Key Concept: Trauma-Informed Approach
The trauma-informed nurse does NOT ask "What is wrong with you?" but instead asks "What happened to you?" This shifts the perspective from labeling behavior as problematic to understanding it as a response to traumatic experiences. Many psychiatric symptoms make sense in the context of past trauma.
07
Therapeutic Communication & De-escalation
The cornerstone of psychiatric nursing — how you respond matters as much as what you do.
Therapeutic Communication Techniques
- Active Listening
- Maintaining eye contact, nodding, leaning forward. Shows the nurse values what the client is saying.
- Silence
- Pausing without speaking. Allows the client to think and gather thoughts.
- Open-Ended Questions
- "How are you feeling today?" Encourages elaboration and discussion.
- Reflection
- Client: "I cannot sleep." Nurse: "You cannot sleep?" Encourages further exploration of feelings.
- Restating
- Repeating the main idea in different words. Verifies understanding and shows attention.
- Clarifying
- "I am not sure I understand. Can you explain?" Ensures accurate communication.
- Focusing
- "Let's go back to what you said about your mother." Helps client concentrate on important topic.
- Offering Self
- "I will stay with you for a while." Provides presence and support.
- Presenting Reality
- "I understand you hear that voice, but I do not hear it." Without arguing, gently reorients client to reality.
NON-Therapeutic Communication (Avoid)
- Giving advice — "You should leave him." Removes client's autonomy.
- Asking "why" — "Why do you feel that way?" Sounds judgmental, puts client on defense.
- False reassurance — "Everything will be fine." Dismisses feelings.
- Approval/Disapproval — "That is a great decision." Implies the nurse is judging.
- Changing the subject — avoids difficult topics.
- Defending — protecting staff or self instead of addressing concerns.
- Closed questions — "Did you take your medication?" Limits to yes/no.
- Probing — "Tell me more about your sex life." Invasive without rapport.
De-escalation Techniques (Aggression vs Anger)
Anger is a feeling. Aggression is a behavior. The neurotransmitter associated with aggression is serotonin (low levels) along with disrupted dopamine and norepinephrine pathways. De-escalation aims to prevent aggression by addressing anger early.
- Recognize early warning signs: pacing, clenched fists, raised voice, glaring
- Maintain a calm voice and demeanor — do not match the client's intensity
- Provide personal space — at least 4 feet, more for higher agitation
- Keep your hands visible and avoid sudden movements
- Stay between the client and the exit — for your own safety
- Acknowledge feelings — "I can see you are very upset right now."
- Set firm limits without threats — "I cannot allow you to threaten staff. Let's go somewhere quiet to talk."
- Offer choices when possible — restores sense of control
- Avoid arguing or being defensive
- Call for backup early — do not wait until the situation escalates further
Benefits of De-escalation
De-escalation prevents physical aggression, reduces use of restraints and seclusion, decreases injuries to staff and clients, improves the therapeutic relationship, and reduces the need for sedating medications. It is always preferred over physical intervention.
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Anxiolytic Medications
Medications used to treat anxiety disorders — key facts and nursing implications.
Benzodiazepines
- Examples
- Alprazolam (Xanax), lorazepam (Ativan), diazepam (Valium), clonazepam (Klonopin), midazolam (Versed)
- Onset
- Rapid (minutes to 1 hour)
- Use
- Acute anxiety, panic attacks, alcohol withdrawal, seizures, pre-procedure sedation
- Mechanism: Enhance GABA (the brain's main inhibitory neurotransmitter), producing calming effect
- Adverse effects: Sedation, drowsiness, dizziness, ataxia, paradoxical agitation (especially in older adults), respiratory depression (especially with opioids or alcohol)
- Tolerance and dependence: Develop quickly — intended for short-term use only (2-4 weeks)
- Never stop abruptly — withdrawal can cause seizures, severe anxiety, agitation, and is potentially life-threatening
- Avoid alcohol — potentiates CNS depression
- Antidote: Flumazenil for benzodiazepine overdose (caution: can precipitate seizures in dependent clients)
SSRIs & SNRIs (First-Line for Long-Term Anxiety)
- SSRIs: sertraline, escitalopram, paroxetine, fluoxetine
- SNRIs: venlafaxine, duloxetine
- First-line for GAD, panic disorder, social anxiety, PTSD, OCD (OCD often needs higher doses)
- Onset: 4-6 weeks for full anxiolytic effect
- Initially may INCREASE anxiety — warn the client and start at lower doses
- Do NOT stop abruptly — discontinuation syndrome
Buspirone (Buspar)
- Non-benzodiazepine anxiolytic
- Onset: 2-4 weeks — not effective for acute anxiety
- No sedation, no respiratory depression, no dependence, no withdrawal
- Used for GAD — good option for clients with substance use history
Beta-Blockers
- Propranolol — controls physical symptoms of anxiety (tremor, tachycardia)
- Used for performance anxiety (public speaking, musicians, test-taking)
- Does NOT treat psychological anxiety — only physical symptoms
Benzodiazepine Risks: Important for the Exit Exam
Respiratory depression — especially when combined with opioids or alcohol. Most important adverse effect to assess for. Falls in older adults — sedation, dizziness, ataxia increase fall risk. Dependence — develops in weeks, not months. Always intended for short-term use. Withdrawal seizures — never stop abruptly after extended use. Paradoxical reactions — some clients (especially elderly and children) become more agitated, not calmer.
? A patient with GAD asks why their SSRI doesn't seem to be working after 1 week. What is the best response?
SSRIs take 4–6 weeks for full anxiolytic effect. It's also normal for anxiety to temporarily increase at the start. Reassure the client to continue the medication as prescribed and follow up with their provider if symptoms worsen significantly.
09
Frequently Asked Questions
Common student questions on this topic.
What is the difference between fear and anxiety?
Fear is a response to a real or known threat — the source is identifiable. Anxiety is a response to a perceived or unknown threat — the source is vague or in the future. Mild anxiety can be motivating; moderate causes selective attention; severe distorts perception; panic causes loss of rational thought, perceptual distortions, possible immobility or random behavior. Match interventions to the level — calm reassurance for mild, structured directions for severe.
How do I differentiate a panic attack from a heart attack?
Symptoms overlap (chest pain, sweating, palpitations, dyspnea, sense of doom). Always rule out cardiac causes first in any patient with chest pain — ECG, troponin. Panic attacks: peak within 10 minutes, resolve in 20–30 minutes, often triggered by stress, more common in young adults, may have tingling/derealization. MI: pain usually substernal/crushing, may radiate to arm/jaw, doesn't resolve quickly, often with diaphoresis and nausea. When in doubt, evaluate medically.
What therapeutic communication should I use with an anxious patient?
Use a calm, low voice and short, simple sentences (anxiety narrows attention). Stay with the patient; don't leave them alone. Avoid "why" questions (sound interrogative) — use "what" and "how." Validate feelings ("This sounds really frightening"). Help them name the feeling. Once calmer, encourage deep breathing. Save problem-solving and teaching for after the anxiety has decreased. Never minimize ("There's nothing to worry about").
What is the difference between PTSD and acute stress disorder?
Both follow a traumatic event with symptoms like intrusive memories, avoidance, hyperarousal, and negative mood. Acute stress disorder = symptoms last 3 days to 1 month after the event. PTSD = symptoms last more than 1 month. Treatment: trauma-focused CBT, EMDR (eye movement desensitization), prazosin for nightmares, SSRIs (sertraline, paroxetine are FDA-approved for PTSD). Benzodiazepines are generally avoided long-term — limited evidence of benefit and dependence risk.
What are the most common anxiety disorders and their key features?
GAD: excessive worry about multiple things for > 6 months. Panic disorder: recurrent unexpected panic attacks + fear of future attacks. Phobias: persistent irrational fear of specific objects or situations (heights, flying, social situations). Social anxiety disorder: fear of social scrutiny. Agoraphobia: fear of being in places where escape is difficult. OCD is now classified separately. Treatment: CBT + SSRIs are first-line for most.
What is the difference between OCD compulsions and rituals?
Obsessions = intrusive, unwanted thoughts. Compulsions = repetitive behaviors performed to reduce the anxiety from obsessions (hand washing, checking, counting, ordering). The behavior must take > 1 hour/day or cause significant distress. Do NOT interrupt the compulsion initially — it increases anxiety. Allow the ritual, then work with the patient to gradually reduce it. SSRIs (especially higher doses) + exposure-and-response-prevention therapy are first-line.
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