Anxiety
Anxiety is the most common psychiatric symptom and can result in significant impairment. A subjective reaction to a real or imagined threat, anxiety is a nonspecific feeling of uneasiness or dread. It may be mild, moderate, or severe. Mild anxiety may cause slight physical or psychological discomfort. Severe anxiety may be incapacitating or even life-threatening.
Everyone experiences anxiety from time to time — it’s a normal response to actual danger, prompting the body (through stimulation of the sympathetic and parasympathetic nervous systems) to purposeful action. It’s also a normal response to physical and emotional stress, which can be produced by virtually any illness. In addition, anxiety can be precipitated or exacerbated by many nonpathologic factors, including lack of sleep, poor diet, and excessive intake of caffeine or other stimulants. However, excessive, unwarranted anxiety may indicate an underlying psychological problem.
History and physical examination
If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient’s anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.
If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or caffeine intake and alleviated by rest, tranquilizers, or exercise.
Obtain a complete medical history, especially noting drug use. Then perform a physical examination, focusing on any complaints that may trigger or be aggravated by anxiety.
If the patient’s anxiety isn’t accompanied by significant physical signs, suspect a psychological basis. Determine the patient’s level of consciousness (LOC) and observe his behavior. If appropriate, refer the patient for psychiatric evaluation.
Medical causes
❑ Acute respiratory distress syndrome. Acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Other respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.
❑ Anaphylactic shock. Acute anxiety usually signals the onset of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, a barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.
❑ Angina pectoris. Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.
❑ Asthma. With allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, a productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.
❑ Autonomic hyperreflexia. The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.
❑ Cardiogenic shock. Acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; a weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.
❑ Chronic obstructive pulmonary disease (COPD). Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.
❑ Heart failure. With heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.
❑ Hyperthyroidism. Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur.
❑ Mitral valve prolapse. Panic may occur in patients with mitral valve prolapse, referred to as the click-murmur syndrome. The disorder may also cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click, followed by an apical systolic murmur.
❑ Mood disorder. Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. With the depressive form, chronic anxiety occurs with varying severity. Associated findings include dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. With the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.
❑ Myocardial infarction (MI). With MI, a life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. It can be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.
❑ Obsessive-compulsive disorder. Chronic anxiety occurs with obsessive-compulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational, but is unable to control them. Anxiety builds if he can’t perform these acts and diminishes after he does.
❑ Pheochromocytoma. Acute, severe anxiety accompanies pheochromocytoma’s cardinal sign: persistent or paroxysmal hypertension. Common associated signs and symptoms include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, a severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.
❑ Phobias. With phobias, chronic anxiety occurs along with a persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational, but can’t suppress it.
❑ Pneumonia. Acute anxiety may occur with pneumonia because of hypoxemia. Other findings include a productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.
❑ Pneumothorax. Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It’s accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.
❑ Postconcussion syndrome. Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated signs and symptoms include irritability, insomnia, dizziness, and a mild headache. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension.
❑ Posttraumatic stress disorder. Posttraumatic stress disorder occurs in the patient who has experienced an extreme traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.
❑ Pulmonary edema. With pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and a thready pulse. The patient’s skin may be cool, clammy, and cyanotic.
❑ Pulmonary embolism. With pulmonary embolism, acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and a low-grade fever.
❑ Rabies. Anxiety signals the beginning of the acute phase of rabies, a rare disorder, which is commonly accompanied by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.
❑ Somatoform disorder. Somatoform disorder, which usually begins in young adulthood, is characterized by anxiety and multiple somatic complaints that can’t be explained physiologically. The symptoms aren’t produced intentionally, but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.
Other causes
❑ Drugs. Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.
Special considerations
Supportive care usually helps relieve anxiety. Provide a calm, quiet atmosphere and make the patient comfortable. Encourage him to express his feelings and concerns freely. If it helps, take a short walk with him while you’re talking. Or, try anxiety-reducing measures, such as distraction, relaxation techniques, or biofeedback.
Pediatric pointers
Anxiety in children usually results from painful physical illness or inadequate oxygenation. Its autonomic signs tend to be more common and dramatic than in adults.
Geriatric pointers
In an elderly patient, distractions from ritual activity may provoke anxiety or agitation.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Nervousness
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Nervousness
» Next page: Violent behavior (Handbook of Signs & Symptoms (Third Edition))
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