Anxiety Disorders Nursing Guide

Understanding Anxiety Disorders

Anxiety disorders are the most common mental health conditions globally, affecting ~1 in 5 people. They are characterised by excessive fear, worry, or anxiety that is disproportionate to the actual threat and causes significant functional impairment.

Normal Anxiety vs Disorder

Normal Anxiety	Anxiety Disorder
Proportionate to threat	Disproportionate or without clear trigger
Time-limited	Persistent (> 6 months for GAD)
Motivating	Impairing (work, relationships, daily function)
Resolves when threat passes	Persistent even when safe

Physical Symptoms of Anxiety (Fight-or-Flight Response)

Palpitations, tachycardia
Chest tightness or pain
Shortness of breath, hyperventilation
Sweating, tremor, hot flushes

Nausea, GI upset, diarrhoea
Dizziness, light-headedness
Dry mouth
Muscle tension, headache

Important: Always exclude organic causes of anxiety symptoms — hyperthyroidism (tachycardia, sweating), phaeochromocytoma (episodic hypertension), cardiac arrhythmias, hypoglycaemia, stimulant drug use, caffeine, withdrawal states.

Classification of Anxiety Disorders

Generalised Anxiety Disorder (GAD)

Excessive worry about multiple topics ≥6 months
Difficult to control worrying
3+ symptoms: restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance
Most common anxiety disorder

Panic Disorder

Recurrent unexpected panic attacks (peak intensity within 10 minutes)
≥4 somatic symptoms: palpitations, chest pain, dyspnoea, dizziness, paraesthesia, depersonalisation
Anticipatory anxiety between attacks
Agoraphobia often develops as a complication

Social Anxiety Disorder

Fear of social situations where scrutiny may occur
Fear of embarrassment, humiliation, or negative evaluation
Avoidance of social/performance situations
Interferes with occupational/social function

Specific Phobia

Marked fear of specific object/situation (spiders, heights, injections, blood)
Immediate anxiety response on exposure
Avoidance or endurance with extreme distress
Blood-injection-injury phobia causes vasovagal syncope (lay patient flat)

OCD (Obsessive-Compulsive Disorder)

Now classified separately (not anxiety disorder in DSM-5)
Obsessions: intrusive, unwanted, distressing thoughts
Compulsions: repetitive behaviours to reduce obsessional distress
Recognises obsessions as own thoughts (ego-dystonic)

PTSD

Exposure to actual/threatened death, serious injury, or sexual violence
4 clusters: intrusion, avoidance, negative cognitions/mood, hyperarousal
Symptoms >1 month
Flashbacks, nightmares, hypervigilance

Panic Attack — Features (4 or more)

Cardiovascular	Respiratory	Neurological	Other
Palpitations, tachycardia	Shortness of breath, choking feeling	Dizziness, light-headedness	Sweating, hot/cold flushes
Chest pain/tightness	Hyperventilation	Paraesthesia (tingling)	Nausea
		Derealisation / depersonalisation	Fear of dying or losing control

Panic attack vs cardiac event: Always rule out cardiac, respiratory, and other organic causes. ECG, blood glucose, and thyroid function are first-line investigations when anxiety disorder is suspected in a new presentation.

Psychological Treatments

Cognitive Behavioural Therapy (CBT) is the first-line psychological treatment for all anxiety disorders. It addresses the cognitive (thinking) and behavioural (avoidance) maintaining factors.

Disorder	First-Line Psychological Therapy	Duration
GAD	CBT — worry-based techniques, relaxation, problem-solving	8–15 sessions
Panic disorder	CBT with interoceptive exposure (exposure to bodily sensations)	8–12 sessions
Social anxiety	CBT with social exposure hierarchy	12–16 sessions
Specific phobia	Exposure therapy (systematic desensitisation)	1–5 sessions
OCD	CBT with ERP (Exposure and Response Prevention)	12–20 sessions
PTSD	Trauma-focused CBT (TF-CBT) or EMDR	8–12 sessions

Self-Help Techniques Nurses Can Teach

4-7-8 breathing: Inhale 4 seconds, hold 7 seconds, exhale 8 seconds — activates parasympathetic system
Box breathing: Inhale 4 sec → hold 4 → exhale 4 → hold 4 — used by military for acute anxiety
5-4-3-2-1 grounding: Name 5 things you see, 4 you touch, 3 you hear, 2 you smell, 1 you taste
Progressive muscle relaxation (PMR)
Mindfulness — evidence-based in GAD; compatible with Islamic meditation/dhikr practices

Pharmacological Treatment

Drug Class	First-Line For	Key Points
SSRIs (sertraline, escitalopram)	GAD, panic disorder, social anxiety, PTSD, OCD	First-line medication; takes 4–6 weeks for full effect; initial anxiety increase in first 1–2 weeks — warn patients
SNRIs (venlafaxine, duloxetine)	GAD, social anxiety, PTSD	Second-line; duloxetine useful if concurrent pain
Buspirone	GAD	Non-addictive; takes 2–4 weeks; suitable for long-term; no sedation
Pregabalin	GAD	Rapid onset; sedation; controlled drug in many countries due to misuse potential
Beta-blockers (propranolol)	Performance anxiety (situational)	Reduces physical symptoms (tachycardia, tremor); not for generalised anxiety
Benzodiazepines (diazepam, lorazepam)	Short-term acute anxiety/panic	NOT for long-term use — dependence, tolerance, withdrawal; maximum 2–4 weeks

Benzodiazepines: Addictive — risk of dependence within weeks. Should only be used for acute crisis management (e.g., acute panic attack with chest pain in A&E), not as maintenance therapy. Long-term use leads to cognitive impairment, falls in elderly, and difficult withdrawal (seizure risk if abrupt discontinuation).

SSRI Warning when starting: Paradoxical increase in anxiety is common in weeks 1–2. Start at low dose (e.g., sertraline 25mg, escitalopram 5mg) and titrate after 2 weeks. Patient education prevents premature discontinuation.

Nursing Management of Anxiety

Therapeutic Communication

Active listening — allow patient to express fears without judgment or interruption
Validate emotions: "I can hear how distressing this feels for you"
Do not minimise symptoms ("just relax", "don't worry") — invalidates experience
Provide clear, calm, consistent explanations of all procedures
Avoid overly detailed negative prognosis — focus on what IS known and what CAN be done

Acute Panic Attack — Nursing Response

Stay calm and present — your demeanor directly influences the patient
Ensure safety — move to quiet area if possible
Reassure: "You are safe. This is a panic attack. It will pass. I will stay with you."
Guide controlled breathing: slow down breathing rate ("breathe with me")
Grounding technique: ask them to name 5 things they can see
Loosen tight clothing; position upright if comfortable
Avoid paper bag breathing — can cause CO₂ retention (outdated practice)
Assess for hyperventilation: tingling, carpopedal spasm — reassurance usually sufficient
Document episode, duration, triggers, response to interventions

Patient Education

Explain the physiological basis of anxiety (fight-or-flight) in simple terms
Teach breathing techniques, grounding strategies
Explain SSRI side effects and importance of not stopping suddenly
Sleep hygiene education (poor sleep worsens anxiety)
Caffeine reduction — caffeine is anxiogenic
Regular physical exercise has strong evidence for reducing anxiety
Refer to community/online CBT resources

Anxiety in Medical Settings

Anxiety is extremely common in medical/surgical patients and is often under-recognised. GCC nurses across all specialties should be competent in basic anxiety management.

Pre-operative anxiety — thorough explanation, involve patient in plan, relaxation techniques, consider anxiolytic premedication in consultation with anaesthetist
ICU-related anxiety/PTSD — ICU environment causes significant psychological trauma; humanising ICU care (open visiting, diaries, music) reduces PTSD rates
Needle/blood phobia — common barrier to healthcare; lie flat before venepuncture, warn before needle insertion, applied tension technique for blood phobia
Cancer-related anxiety — common at diagnosis, recurrence, treatment changes; refer to oncology psychology team

GCC-Specific Anxiety Considerations

Somatisation of Anxiety in GCC Culture ▼

In many GCC and Middle Eastern cultures, psychological distress is more commonly expressed through physical (somatic) symptoms — chest pain, headache, fatigue, GI symptoms — rather than explicitly reporting "anxiety" or "stress." This is culturally normative and does not indicate the patient is being dishonest. Nurses should explore physical symptoms with sensitivity and gently introduce the mind-body connection when therapeutically appropriate.

Expat Workers & Anxiety in GCC ▼

GCC countries have large expat workforces (construction, domestic workers, healthcare). Common anxiety triggers include: separation from family, financial pressure, language barriers, uncertain visa/employment status, poor living conditions, and limited access to mental health services. Nurses should be aware of these structural determinants of mental health and signpost to available support including embassy services, community mental health, and crisis lines.

Religious Coping & Anxiety Management ▼

Religious coping is a major psychological resource for GCC Muslim patients. Prayer (salah), Quranic recitation, dhikr (remembrance of God), and trust in divine will (tawakkul) are deeply meaningful anxiety management strategies. Nurses should encourage and facilitate religious practices as complementary to clinical treatment. Prayer times should be respected; ICU teams should alert families/Imams for religious support. Mindfulness techniques can be framed within Islamic contemplative practices.

PTSD in GCC Contexts — War, Displacement, Trauma ▼

GCC countries host significant numbers of refugees and migrants from conflict-affected regions (Yemen, Syria, Iraq, Somalia, Afghanistan). These populations have high rates of PTSD, complex trauma, and anxiety. Nurses should screen for trauma history sensitively, be aware of trauma responses (including hypervigilance during clinical procedures), and advocate for access to trauma-informed care. Interpreters should be used — never family members as interpreters for mental health disclosures.

Hajj/Umrah & Anxiety ▼

Hajj is an intensely emotional spiritual event that can also trigger acute anxiety responses, particularly in patients with pre-existing anxiety disorders who stop medication for the journey, or elderly pilgrims with cognitive impairment who become disoriented. Hajj medical teams should ensure continuity of psychiatric medications and have capacity for acute anxiety and panic management within Hajj medical tents.

MCQ Practice — Anxiety Disorders

Q1. A patient presents to A&E with sudden onset palpitations, chest tightness, shortness of breath, dizziness, and fear of dying. ECG and troponin are normal. The episode lasted 12 minutes. What is the most likely diagnosis?

A) Atrial fibrillation

B) Pulmonary embolism

C) Panic attack

D) Acute coronary syndrome

✅ C — Panic attacks have multiple somatic symptoms peaking within 10 minutes, with normal investigations. Cardiac and respiratory causes must be excluded first, but this clinical picture with normal ECG and troponin = panic attack.

Q2. What is the first-line psychological treatment for most anxiety disorders including GAD, panic disorder, social anxiety, and PTSD?

A) Psychodynamic therapy

B) Supportive counselling only

C) Cognitive Behavioural Therapy (CBT)

D) Benzodiazepine therapy

✅ C — CBT is the most evidence-based psychological treatment across all major anxiety disorders. For PTSD, trauma-focused CBT (TF-CBT) or EMDR are first-line. Benzodiazepines are only for short-term crisis management, not first-line treatment.

Q3. A patient with GAD has been started on sertraline 50mg. They call after 5 days saying their anxiety feels WORSE. What is the most appropriate response?

A) Immediately stop the sertraline as it is worsening their condition

B) Double the dose as the initial dose is too low

C) Reassure them that an initial increase in anxiety in the first 1–2 weeks is expected and to continue the medication

D) Add a benzodiazepine and continue indefinitely

✅ C — SSRIs cause a paradoxical initial increase in anxiety in the first 1–2 weeks due to initial 5-HT1A autoreceptor activation. Patients must be warned about this before starting. Full therapeutic effect takes 4–6 weeks. Stopping prematurely deprives patients of effective treatment.

Q4. A patient with blood phobia requires venepuncture and has a history of vasovagal syncope when seeing blood. What is the BEST position and approach?

A) Seated upright to allow them to see exactly what is happening

B) Standing so they can leave quickly if distressed

C) Lying flat (supine) to prevent vasovagal syncope; look away from the needle

D) Semi-reclined with the arm raised above the heart

✅ C — Blood-injection-injury phobia uniquely causes vasovagal syncope (bradycardia + hypotension from parasympathetic surge). Lying flat prevents loss of consciousness. Applied tension technique (tensing muscles to raise BP) is also used. Patient should look away.

Anxiety Disorders — Nursing Guide