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Psychiatric-Mental Health Nursing

17.1 Stress and Anxiety

Psychiatric-Mental Health Nursing17.1 Stress and Anxiety

Learning Objectives

By the end of this section, you will be able to:

  • Define stress and explain how the body reacts to stress
  • Describe coping strategies for stress
  • Discuss the prevalence and impact of anxiety
  • Outline approaches for managing and treating anxiety

Stress is a normal part of life. Everyone experiences it in one form or another, though individual reactions to stress can vary depending on a person’s personality, coping skills, and support systems. Some individuals may be able to handle stress effectively, while others may struggle to cope with stress and experience negative outcomes. Stress and anxiety, while closely related, are distinct concepts in psychological research and practice. The body’s response to external pressures or threats, often resulting in physiological and emotional reactions is called stress. It can be either short-lived (acute) or long-term (chronic) (American Psychological Association, 2022). On the other hand, anxiety is a heightened state of arousal and worry that may not always have a clear external cause. It can manifest as general apprehension about the future or, in more severe cases, as clinically recognized anxiety disorders. While everyone experiences stress and anxiety to some degree, excessive or chronic experiences of these states can affect overall health and well-being (American Psychological Association, 2022) (Figure 17.2).

Chart explaining the differences between stress and anxiety as well as common factors.
Figure 17.2 Stress and anxiety are similar in many ways, but there are also key differences between them. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Definition of Stress

Many factors, including work, relationships, finances, and health problems, can cause stress. Stress is the brain’s initial response to a demand or challenge. When confronted with a situation requiring attention or action, the brain’s hypothalamus initiates a series of chemical releases, activating the sympathetic nervous and adrenal-cortical systems. This activation releases stress hormones, particularly cortisol and adrenaline, which prepare the body for the “fight-or-flight” response. The fight-or-flight response allows individuals to respond rapidly to environmental threats. While this acute stress response can be adaptive in the short term, helping individuals react swiftly to imminent threats, chronic activation due to repeated or sustained stressors can negatively affect physical and mental health (Chu et al., 2022). This response can result in physical symptoms, such as increased heart rate, blood pressure, and breathing rate. In addition to physical symptoms, stress can cause emotional and behavioral reactions, such as anxiety, depression, irritability, and changes in eating and sleeping patterns.

Reactions to stress vary from person to person and can be influenced by factors, such as genetics, personality, coping skills, support systems, and past experiences. Identifying and understanding individual reactions is crucial for developing effective stress management strategies (Fink, 2016). Generally, stress reactions can be classified into three main categories: physiological, emotional, and behavioral. These responses are the body’s way of adapting to a perceived threat or challenge (Figure 17.3).

Images of organs of a body being affected by stress and what occurs as a result.
Figure 17.3 Stress can have numerous effects on the body. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Physiological Reactions to Stress

Physiological reactions are the body’s physical responses to stress. These reactions are primarily driven by the activation of the sympathetic nervous system and the release of stress hormones, such as cortisol and adrenaline. Some common physiological stress reactions include increased heart rate, elevated blood pressure, rapid breathing, tensed muscles, sweating, digestive issues (nausea, diarrhea, or constipation), weakened immune system, and insomnia or sleep disturbances (Figure 17.4).

Chart describing fight or flight response and how it translates to physical effects on the body.
Figure 17.4 The fight-or-flight response is a physiological reaction that can cause a number of physical effects. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The fight-or-flight response, also known as the acute stress response, is a physiological reaction that occurs when an individual perceives a threat or a challenging situation. This response is an evolutionary adaptation that helps prepare the body to either confront the threat (fight) or escape it (flight). When the response is triggered, several physiological changes occur in the body:

  • The heart pumps faster to increase blood flow and oxygen supply to the muscles and vital organs.
  • Arteries constrict, raising blood pressure to deliver more oxygen and nutrients to the muscles.
  • Breathing becomes faster and shallower to take in more oxygen.
  • The liver releases stored glucose and fat to provide the body with additional energy.
  • Pupils dilate to improve vision and awareness of the environment.
  • Blood is redirected from less critical systems (like digestion) to essential muscles and organs (brain, heart, and skeletal muscles) to enhance physical performance.
  • Muscles tense up to prepare for action, improving reaction time and strength.
  • Senses become sharper, enhancing the body’s ability to detect potential threats and respond accordingly.

These physiological changes enable the body to respond quickly and effectively to the perceived threat. However, the fight-or-flight response is designed for short-term situations, and prolonged activation can negatively affect physical and mental health, leading to chronic stress, anxiety, or other stress-related disorders (Fink, 2016).

Stress affects the body physically in various ways, and its effects can be classified into short-term and long-term consequences. Short-term effects of stress include increased heart rate and blood pressure, rapid breathing, tensed muscles, pupil dilation, temporary digestive issues, and increased blood glucose levels.

Short-term stress can be beneficial in some situations by enhancing performance and helping individuals cope with immediate challenges or threats. In contrast, long-term stress—also called chronic or prolonged stress—can have detrimental effects on physical and mental health (Fink, 2016):

  • Long-term stress can weaken the immune system.
  • It can lead to cardiovascular issues, such as persistently elevated blood pressure and heart rate, which can contribute to the development of hypertension, heart disease, and stroke.
  • It increases the risk of developing anxiety, depression, and other mental health issues.
  • If not resolved, it can lead to insomnia or other sleep-related problems, which affect overall health and well-being.
  • It can cause changes in appetite, leading to overeating or undereating and, subsequently, weight gain or loss.
  • It can lead to long-term digestive issues, such as irritable bowel syndrome, ulcers, or gastroesophageal reflux disease.
  • It can disrupt the menstrual cycle in women, cause erectile dysfunction in men, and reduce fertility in both sexes.
  • It can exacerbate conditions like acne, eczema, and psoriasis.

Emotional Reactions to Stress

Stress can also manifest in emotional responses. Different individuals may experience different emotional reactions to stress. Some common emotional responses include anxiety or worry, irritability or anger, feelings of sadness or helplessness, mood swings, difficulty concentrating or making decisions, and emotional exhaustion or burnout (Zhaoyang et al., 2020).

Behavioral Reactions to Stress

Stress can also lead to changes in behavior as individuals try to cope with or adapt to their stressors. Some common behavioral reactions to stress are changes in eating habits (overeating or undereating), sleep disturbances (insomnia or oversleeping), substance misuse (alcohol, drugs, or medications), social withdrawal or isolation, procrastination or avoidance of tasks, aggression or irritability toward others, and decreased work performance or productivity (Attia et al., 2022).

Coping with Stress

Coping with stress is essential for maintaining physical, mental, and emotional well-being. There are numerous strategies and techniques that can help individuals manage stress more effectively that nurses need to promote with clients. Some focus on the source of stress, while others focus on the emotional or physiological response. Other coping methods involve engaging in a healthy lifestyle with adequate social support and limiting exposure to known stressors (Greenberg, 2017).

Coping with stress and fostering resilience are critical for navigating life’s challenges. An individual’s ability to bounce back from adversity, trauma, or significant stress represents their resilience. It does not mean avoiding stress or hardship but developing the skills and attributes necessary to adapt and recover. Factors contributing to resilience include positive relationships, optimism, the ability to make realistic plans and carry them out, and effective communication. By combining effective coping strategies with resilience-building practices, individuals can not only navigate challenges, but also thrive in the face of them (American Psychological Association, 2022).

Problem-Focused Strategies

Problem-focused coping strategies—removing oneself from a stressful situation, practicing time management—involve directly addressing the source of stress by taking action to change, manage, or eliminate the stressor. Problem-focused coping strategies can be effective in managing stress when the stressor is within one’s control but less effective for stressors that are outside one’s control. In such cases, emotion-focused coping strategies, which involve managing emotional reactions to stress, may be more appropriate (Schoenmakers et al., 2015).

Emotion-Focused Strategies

Emotion-focused coping strategies aim to help individuals manage and regulate their emotional responses to stressors. Examples of these strategies include seeking social support, where individuals may confide in trusted friends or family members to gain understanding or emotional solace. Distraction techniques redirect one’s attention away from distressing emotions. Meditation and mindfulness practices can help individuals remain anchored in the present moment, reducing feelings of stress. These strategies can be especially beneficial when stressors are beyond one’s control. Different strategies work for different individuals, and a combination of problem-focused and emotion-focused methods may be most effective in managing stress (Schoenmakers et al., 2015).

A wide range of techniques can help reduce the effects of stress on the body and mind and improve one’s overall well-being. Incorporating one or more of the following techniques into daily life can significantly benefit personal and professional well-being (Davis et al., 2019).

  • Deep breathing exercises: Slow, deep breaths can activate the body’s relaxation response, counteracting stress and promoting calm.
  • Progressive muscle relaxation: This technique involves systematically tensing and relaxing different muscle groups to release physical tension and promote relaxation.
  • Visualization or guided imagery: Imagining a peaceful, calming scene or environment can help reduce stress and promote relaxation.
  • Mindfulness and meditation: Practicing mindfulness or meditation can help individuals become more aware of their emotions, thoughts, and bodily sensations, allowing them to manage stress more effectively.
  • Cognitive restructuring: Reevaluating and reframing negative thoughts or beliefs can help change one’s perspective and reduce emotional stress.
  • Assertiveness training: Developing assertive communication skills can help individuals express their needs and preferences effectively, improving relationships and reducing stress.
  • Time management: Prioritizing tasks, setting realistic goals, and creating schedules can help manage time more effectively and reduce stress related to workload or deadlines.
  • Problem-solving: These techniques involve analyzing the stressor and identifying potential solutions, breaking the problem into smaller, manageable tasks, and creating an action plan to tackle each task systematically.
  • Exercise: Regular physical activity can help reduce stress, improve mood, and promote overall well-being.
  • Seeking social support: Connecting with friends, family, or support groups can provide emotional support, encouragement, and a sense of belonging during stressful times.
  • Techniques, such as mindfulness meditation, yoga (Figure 17.5), tai chi, and qigong, combine physical movement with breath work and mental focus to promote relaxation and reduce stress.
  • The traditional Chinese medicine practice of acupuncture involves inserting thin needles into specific points on the body to promote balance and reduce stress.
  • Massage therapy can help release physical tension, improve circulation, and promote relaxation.
  • The use of essential oils can help reduce stress and promote relaxation. Lavender, bergamot, and chamomile are some examples of essential oils with calming properties.
  • Some dietary supplements, such as omega-3 fatty acids, magnesium, and ashwagandha, may have stress-reducing properties.
  • Cognitive behavioral therapy involves changing negative thought patterns and behaviors to reduce stress and improve coping skills.
  • In some cases, prescription medications, such as antidepressants, anxiolytics, or beta-blockers, may help manage stress.
(a) Photo of people doing yoga in a studio. (b) Photo of acupuncture being applied to leg.
Figure 17.5 Both (a) yoga and (b) acupuncture can be effective techniques for managing and relieving stress. (credit (a): “Yoga Instructor Stretches JBA Members’ Resiliency” by Airman 1st Class Valentina Lopez/U.S. Air Force, Public Domain; credit (b): “Basic Acupuncture” by Kyle Hunter/Wikimedia Commons, Public Domain)

Additionally, dietary choices play a role in stress management. A balanced diet rich in nutrient-dense foods can enhance brain function and provide sustained energy, potentially moderating stress-related mood fluctuations (Hepsomali & Groeger, 2021). Sleep is also foundational to cognitive and emotional functioning and coping with stress; research indicates that adults who regularly obtain adequate hours of restorative sleep are better equipped to handle daily stressors and exhibit improved mood regulation (Vandekerckhove & Wang, 2017). With its capacity to evoke emotions, music has been identified as a powerful therapeutic tool, offering listeners an avenue for emotional release and relaxation (de Witte et al., 2022). The presence of pets, especially dogs and cats, has been linked to reduced stress levels due to their ability to provide unconditional love, tactile comfort, and companionship (Grajfoner et al., 2021). Spiritual involvement, whether through organized religion or personal practices, can offer individuals a sense of purpose and community, providing a broader perspective on life’s challenges and a reservoir of strength (Yan et al., 2019).

Defense Mechanisms

Defense mechanisms are unconscious psychological processes that protect individuals from feelings of anxiety, guilt, or shame, often resulting from stress (Freud, 1966). Table 17.1 lists some common defense mechanisms related to stress.

Defense Mechanism Definition Example
Denial Refusing to accept the reality of a situation or experience, because acknowledging it would be too emotionally painful or overwhelming. A person who drinks alcohol daily insists they do not have a drinking problem. Despite negative consequences due to their drinking, they refuse to accept that their alcohol consumption is problematic.
Repression Pushing uncomfortable thoughts or memories into the unconscious mind to avoid dealing with them consciously. A child who was abused by a family member might have no recollection of the abuse as an adult. The memory is too painful, so the mind buries it deep within the unconscious.
Projection Attributing one’s unwanted thoughts, feelings, or impulses to another person, often as a way of avoiding personal responsibility or guilt. A person feeling guilty about lying might accuse someone else of being dishonest. They project their feelings of dishonesty onto another person.
Displacement Redirecting negative emotions or impulses from their original source to a less threatening target, often to cope with anger or frustration. After a stressful day at work, a husband comes home and yells at his wife. Instead of addressing his anger toward his boss, he displaces it onto a less threatening target.
Rationalization Creating justifications or excuses for one’s behavior or emotions to avoid confronting the real reasons. After not getting promoted, a person might say they did not want the higher responsibility anyway, even if they were previously excited about the possibility.
Intellectualization Focusing on the intellectual aspects of a situation rather than the emotional ones, often as a way of avoiding painful feelings. Instead of expressing the emotional pain of a recent breakup, someone might study the psychological processes of grief and heartbreak, distancing themselves from their feelings by examining the situation purely intellectually.
Reaction formation Behaving in a manner opposite to one’s true feelings to conceal or deny them. A person who harbors feelings of prejudice might go out of their way to be overly kind and generous to individuals from the group they have prejudiced feelings toward. They overcompensate in the opposite direction of their actual feelings.
Sublimation Channeling negative emotions or impulses into socially acceptable behaviors or activities, such as engaging in artistic pursuits or exercise to cope with stress. A person with aggressive tendencies might channel those feelings into contact sports, like boxing or football. This way, they convert their unacceptable urges into a more acceptable form.
Regression Reverting to earlier stages of development or behaviors typically associated with childhood to cope with stress or difficult emotions. An adult, when facing marital problems, might start to act childishly, throwing tantrums or sulking, reverting to an earlier stage of development.
Undoing Attempting to “undo” or compensate for an undesirable thought, feeling, or action by engaging in behaviors that symbolically negate it. After saying something hurtful to a friend, a person might be excessively kind or generous to them in an attempt to “undo” the harm they caused.
Identification Adopting the characteristics, beliefs, or behaviors of another person or group, often as a way of managing feelings of insecurity or inadequacy. A bullied child might start emulating the behavior of his bully, trying to feel powerful by identifying with the aggressor.
Table 17.1 Common Defense Mechanisms (Bailey & Pico, 2020)

Defense mechanisms are not inherently harmful, as they can temporarily help individuals navigate stressful situations. If an individual overuses or only relies on defense mechanisms, however, it may adversely affect personal growth and self-awareness (Sekowski, 2022). When addressing the use of defense mechanisms by clients, nurses should employ active listening and nonjudgmental communication rather than confronting the defense mechanism directly, which may exacerbate the client’s stress or anxiety. Create a safe and trusting environment where clients feel understood and respected. Open-ended questions encourage clients to explore and express their feelings. Client education might be helpful when appropriate, but it is essential to approach this with sensitivity, ensuring it does not invalidate the client’s feelings or experiences. Through empathy, patience, and self-awareness, nurses can support clients in navigating their defense mechanisms to benefit their overall well-being (Bailey & Pico, 2020).

Prevalence and Impact of Anxiety

Anxiety, or feelings of fear, dread, or uneasiness, is a natural and normal emotional response to stress or threat. When anxiety becomes excessive or persistent, however, it can interfere with daily activities and impact an individual’s quality of life. Anxiety can range from mild to severe and can present differently in each individual. If left untreated, it can significantly affect an individual’s mental and physical health (American Psychiatric Association, 2013).

Psychosocial Considerations

Stress and Anxiety in Nursing Students

Stress and anxiety in nursing students can arise from academic pressures, clinical experiences, or the impending responsibility of client care.

Common triggers of stress and anxiety in nursing students include:

  • clinical mistakes or perceived errors
  • fear of harming clients
  • high academic workload
  • balancing personal, work, and academic lives
  • peer and instructor evaluations

Manifestations of stress and anxiety include:

  • reduced cognitive function and focus
  • impaired clinical decision-making
  • decrease in academic performance
  • physical symptoms, such as insomnia, headaches, or palpitations
  • emotional symptoms, such as feelings of inadequacy and depression

Coping strategies for stress and anxiety include:

  • peer support and mentorship
  • stress management and relaxation techniques
  • professional counseling services
  • adequate preparation and training for clinical settings
  • feedback and positive reinforcement from instructors

Anxiety among nursing students is a significant concern that can influence their academic performance, clinical experiences, and overall well-being (Comparcini et al., 2022).

Causes of Anxiety

Anxiety disorder is a complex mental health condition stemming from, and exacerbated by, various genetic, biological, and environmental factors. Scientists believe genetic factors play a role in the development of anxiety: Studies have shown that individuals with a family history of anxiety disorders are more likely to develop the condition (Bandelow & Michaelis, 2015). Brain development is another crucial factor in the development of anxiety. The amygdala, responsible for processing emotional responses, has been shown to be hyperactive in individuals with anxiety disorders (Bandelow & Michaelis, 2015). Additionally, the prefrontal cortex, responsible for regulating emotional responses, may not function properly in individuals with anxiety.

Environmental factors, such as parenting style, life events, and social influences, can also contribute to the development of anxiety. For example, parental overprotection, criticism, and rejection have been linked to increased anxiety in children. Traumatic life events, such as abuse or neglect, can also increase the risk of developing anxiety disorders. Social influences, such as peer pressure and exposure to stressful environments, can also contribute to the development of anxiety (Bandelow & Michaelis, 2015).

Anxiety has been examined and interpreted from various theoretical perspectives over the years. The cognitive perspective emphasizes the role of maladaptive thoughts and beliefs in the development of anxiety disorders, while the behavioral perspective focuses on the role of learning and conditioning. The psychodynamic perspective suggests that anxiety arises from unresolved conflicts and repressed impulses. In contrast, the humanistic perspective emphasizes the importance of self-actualization and personal growth in preventing and treating anxiety disorders. The biological perspective examines the role of neurotransmitters and brain structures in the development of anxiety disorders. This perspective emphasizes the interaction between genetic and environmental factors, as research has shown that anxiety disorders can be inherited (Barlow & Durand, 2015).

Incidence of Anxiety

Anxiety is a prevalent mental health condition affecting millions of individuals worldwide. In the United States alone, an estimated 19.1 percent of adults had an anxiety disorder in the past year. The prevalence of any anxiety disorder was higher for females (23.4 percent) than for males (14.3 percent) but was similar across age groups. An estimated 31.1 percent of U.S. adults experience an anxiety disorder at some time in their lives (National Institute of Mental Health, 2023).

Among anxiety disorders, generalized anxiety disorder (GAD) is one of the most commonly diagnosed conditions, affecting 6.8 million adults or 3.1 percent of the U.S. population (Anxiety and Depression Association of America, 2022). Panic disorder and social anxiety disorder (SAD) are also prevalent, with reported twelve-month prevalence rates of 2.7 percent and 7.1 percent, respectively (Anxiety and Depression Association of America, 2022). Specific phobias affect 19.3 million adults, or 9.1 percent of the U.S. population (Anxiety and Depression Association of America, 2022).

Signs and Symptoms of Anxiety

Anxiety is characterized by feelings of fear, apprehension, and unease, often accompanied by physical symptoms, such as sweating, palpitations, and shortness of breath. According to the American Psychiatric Association (APA), the signs and symptoms of anxiety can include excessive worry or fear about a specific situation or object, avoidance of certain situations, panic attacks, restlessness, irritability, muscle tension, and difficulty sleeping. In addition, individuals with anxiety may experience gastrointestinal symptoms, such as nausea or diarrhea, and difficulty concentrating or completing daily tasks (2013). Specific signs and symptoms are listed in Table 17.2.

Type Sign or Symptom Description
Physical Palpitations A feeling that the heart is pounding or racing
Tremors or shaking Especially noticeable in the hands
Sweating Excessive sweating even in cool environments
Shortness of breath Feeling unable to take a deep breath
Gastrointestinal Issues Nausea, stomach cramps, or diarrhea
Fatigue Feeling unusually tired or drained
Sleep disturbances Difficulty falling or staying asleep or nightmares
Cognitive Excessive worry Constant concern about grades, clinical performance, or other issues
Difficulty concentrating Struggling to focus on lectures, readings, or practical tasks
Indecisiveness Difficulty making decisions
Memory issues Forgetting learned material, misplacing items, or struggling with recall
Behavioral Avoidance Evading certain situations or tasks due to fear of failure or judgment
Procrastination Continually postponing tasks
Restlessness Unable to sit still, constantly fidgeting or moving
Isolation Pulling away from friends, family, or fellow students
Emotional Feeling overwhelmed A sensation that everything is too much to handle
Mood swings Rapid shifts in mood from high to low
Irritability Easily annoyed or angered
Sense of impending doom A constant feeling that something terrible is about to happen
Table 17.2 Signs and Symptoms of Anxiety

Techniques to Measure Anxiety

Because anxiety is a subjective experience, it can be challenging to measure objectively. Several techniques are available to assess anxiety levels in individuals (Rose & Devine, 2014). One commonly used method is for individuals to self-report information about their subjective experiences of anxiety, for example, through interviews or questionnaires. These measures can include the State-Trait Anxiety Inventory (STAI) and the Beck Anxiety Inventory (BAI), which assess general and specific anxiety symptoms, respectively (Julian, 2011).

Another technique is to monitor changes in the body’s physiological responses to anxiety, such as heart rate, blood pressure, and respiration rate. These measures can be obtained using instruments like electrocardiograms (ECGs), electroencephalograms (EEGs), and skin conductance response (SCR) devices (Kyriakou et al., 2019).

Additionally, behavioral measures can provide insight into an individual’s level of anxiety. For example, the approach-avoidance task is a common measure of anxiety that assesses how individuals respond to threatening or anxiety-provoking stimuli (Rose & Devine, 2014).

There are different levels of anxiety that a person can experience. Some levels can be regularly handled, whereas other levels can cause functional impairment.


Mild anxiety is a normal and expected response to stressors and does not typically interfere with daily activities. Individuals may experience feelings of nervousness or apprehension, but they can manage their symptoms and continue to function normally (American Psychiatric Association, 2013).

Though often viewed negatively, mild anxiety can have several positive aspects and adaptive functions. Mild anxiety can make individuals more alert and ready to face upcoming challenges by sharpening their senses and attention. Mild anxiety can sometimes push individuals into an optimal zone of arousal, enhancing performance, especially in situations that require focus, like exams or presentations. The slight unease from mild anxiety can act as a motivating force, pushing individuals to prepare, study, or practice. Mild anxiety can sometimes act as a signal that there is a problem to address, prompting individuals to think creatively and come up with solutions. Experiencing and coping with mild anxiety can help individuals develop resilience and better adapt to future stressors. Experiencing anxiety can increase one’s empathy and understanding toward others who face mental health challenges (American Psychiatric Association, 2013).


Increased feelings of worry or fear characterize moderate anxiety, which may be accompanied by physical signs, such as sweating, trembling, or rapid heart rate. Individuals may also experience difficulty concentrating and avoid situations that trigger their anxiety (American Psychiatric Association, 2013).


Severe anxiety is an intense level of anxiety in which individuals may experience overwhelming feelings of panic, terror, or dread. Physical symptoms, such as chest pain or difficulty breathing, may be severe and require medical attention. Individuals with severe anxiety may also have difficulty functioning in daily life and may require professional treatment (American Psychiatric Association, 2013).

Severe anxiety profoundly impacts an individual’s behaviors, thought processes, and problem-solving capacities. Individuals experiencing severe anxiety may avoid situations or locations associated with anxiety, limiting their daily activities (Robinson et al., 2013). They might also exhibit restlessness or procrastination due to anticipatory stress or resort to substance misuse as a coping mechanism (FHE Health, 2016). Cognitively, individuals with severe anxiety commonly display catastrophic thinking, visualizing the worst possible scenarios (Kishikawa et al., 2022). They are prone to rumination, repeatedly reflecting on distressing events without resolution, and might also demonstrate perfectionism, viewing any shortcoming as a personal failure (American Psychiatric Association, 2020).


Panic is a specific level of anxiety characterized by sudden and intense feelings of fear or terror, often accompanied by physical symptoms, such as chest pain, sweating, trembling, and a rapid heartbeat. Panic attacks can occur unexpectedly, or specific situations or stimuli can trigger them. Treatment for panic often involves cognitive behavioral therapy or medication, and a proper diagnosis is essential to develop an effective treatment plan (American Psychiatric Association, 2013).

Psychosocial Considerations

Panic in a Nursing Student

Panic involves sudden and intense feelings of fear or terror, often accompanied by physical symptoms. These episodes can be overwhelming and disruptive.

Physical symptoms can include:

  • Palpitations: rapid heart rate or skipped beats
  • Trembling: shaking or shivering without an apparent cause
  • Shortness of breath: a sensation of being unable to breathe
  • Chest pain: feeling pressure or discomfort in the chest
  • Dizziness: feeling lightheaded or faint
  • Nausea: upset stomach or urge to vomit
  • Chills or hot flashes: sudden temperature changes without environmental reasons

Cognitive and emotional symptoms can include:

  • Fear of losing control: an overwhelming belief that everything is out of their control
  • Fear of dying: intense concern that death is imminent
  • Detachment: feeling disconnected from oneself or the environment, also known as derealization or depersonalization

Potential triggers in nursing students can include:

  • Clinical stress: encountering real-life medical scenarios, especially emergencies
  • Academic pressure: anxiety over grades, exams, and performance evaluations
  • Lack of sleep: irregular hours or night shifts can disrupt sleep patterns
  • Caffeine overconsumption: relying heavily on caffeinated drinks to stay awake

Coping strategies can include:

  • Deep breathing: Slowing down and focusing on breathing can help reduce panic symptoms.
  • Grounding techniques: Tactics like the “5-4-3-2-1” sensory method can help reconnect individuals to the present moment (Smith, 2018) (Figure 17.6).
  • Seek support: Talking to a trusted friend, mentor, or professional can help process and manage the episode.
Chart describing five ways to stay grounded using the five senses: things you can see, feel, hear, smell, and taste.
Figure 17.6 Grounding using the five senses is an effective way to cope with panic. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Cognitive Distortions and Anxiety

Cognitive distortions are patterns of negative thinking often associated with higher anxiety levels. According to the cognitive model, anxious individuals tend to interpret ambiguous or uncertain situations negatively, leading to increased fear and anxiety. One common cognitive distortion related to anxiety is catastrophizing, which involves imagining the worst possible outcome of a situation and exaggerating its potential negative consequences. An example would be a student making a small mistake on a project. The distortion of catastrophizing might lead the student to believe they would fail the course and, as a result, ruin their entire life. Another distortion is all-or-nothing thinking, which involves viewing situations as completely good or completely bad without any shades of gray. All-or-nothing thinking might lead an individual to see their ability as an artist as either perfect or entirely flawed, based on the reception of a single piece. This thinking can lead to anxiety because it creates unrealistic expectations and increases the likelihood of disappointment or failure. Other anxiety-related cognitive distortions include overgeneralization, jumping to conclusions, and personalization. These distortions can be targeted by cognitive behavioral therapy, which aims to help individuals identify and challenge their negative thought patterns to reduce anxiety symptoms (Rnic et al., 2016).

Treating Anxiety

Anxiety can significantly impair an individual’s quality of life. Fortunately, several effective treatments are available to help manage and alleviate anxiety symptoms. The choice of treatment depends on the severity of symptoms, individual preferences, and other factors. Still, some of the most commonly used treatments for anxiety include psychotherapy, self-help strategies, and medications (American Psychiatric Association, 2013).


Psychotherapy is a widely used treatment approach for anxiety. One of the most effective forms of psychotherapy is cognitive behavioral therapy, which helps individuals identify and change negative patterns of thought and behavior contributing to their anxiety. CBT is based on the idea that thoughts, feelings, and behaviors are interconnected. If an individual changes one, the other two can also change. For example, by changing negative thought patterns, people can influence their feelings and behaviors (Nakao et al., 2021). Other types of psychotherapy may also be effective for managing anxiety symptoms. Some examples of these methods are cognitive restructuring, which involves identifying and challenging negative thoughts and replacing them with more balanced and positive ones, and acceptance and commitment therapy (ACT), which is an approach that combines aspects of acceptance and mindfulness strategies with commitment and behavior-change strategies. The primary aim is to promote psychological flexibility, which is the ability to be open, adaptable, and effective in the presence of difficult emotions or thoughts (Schuman-Olivier et al., 2020).

Excessive and persistent fear, worry, and avoidance behaviors characterize anxiety. One commonly used treatment for anxiety is desensitization, an exposure therapy that involves gradually exposing the individual to the feared stimulus or situation until they no longer experience anxiety in response to it (Nash, 2022). For example, if someone fears needles, they might first be instructed to imagine a needle. Then, the individual might look at a picture of a needle. Once the individual can successfully do these things, they might progress to holding a syringe without a needle, then on to watching someone receive an injection, then to receiving a mock injection with the needle cap, and finally receiving a real injection. Research has shown that desensitization effectively treats anxiety, including specific phobias. It allows individuals to confront and overcome their fears in a safe and controlled environment, leading to long-term improvements in their mental health and quality of life (Craske et al., 2014).

Nonpharmacological and Self-Help Approaches

Relaxation techniques, such as progressive muscle relaxation and deep breathing exercises, can help reduce physical symptoms of anxiety and promote feelings of calm and relaxation. Exercise and physical activity have also been shown to be effective in reducing anxiety symptoms. Other nonpharmacological approaches that may be helpful for anxiety include dietary changes, such as reducing caffeine and alcohol intake, and complementary or alternative therapies, such as acupuncture and massage therapy. Overall, nonpharmacological approaches can be effective in treating anxiety and may be particularly beneficial for individuals who prefer not to take medication or who have had limited success with medication (Bandelow et al., 2015).


A technique, biofeedback (Figure 17.7) involves monitoring and controlling physiological responses to improve physical and mental health. The technique can be useful in treating anxiety, as it can help individuals learn how to manage their physiological responses to stress and anxiety. Biofeedback can measure various physiological responses, including heart rate, blood pressure, muscle tension, and skin conductance. In addition, biofeedback can be used with other anxiety disorder treatments, such as CBT. Combining biofeedback and CBT has been shown to reduce anxiety symptoms and improve overall mental health effectively (Gevirtz, 2013).

Person sitting at computer wearing biofeedback monitoring device
Figure 17.7 During a biofeedback session, a therapist uses computers to monitor a client's physiological responses to stressors and stimuli related to anxiety. (credit: “Biofeedback training program for post-traumatic stress symptoms” by Army Medicine/Wikimedia Commons, CC BY 2.0)


Hypnosis is a noninvasive and nonpharmacological approach to treating anxiety that aims to alter an individual’s thoughts, feelings, and behaviors (Hasbi & Effendy, 2019). Hypnotherapy involves inducing a trancelike state in the client and providing suggestions to modify their thoughts and behaviors. This treatment can help individuals with anxiety learn how to manage their symptoms and improve their coping strategies (Hasbi & Effendy, 2019).

Pharmacological Treatments

Medication therapy is commonly used to treat anxiety. The most commonly prescribed medications for anxiety are benzodiazepines, buspirone, and antidepressants, specifically SSRIs and SNRIs (Strawn et al., 2018).


Benzodiazepines work by enhancing the effects of the neurotransmitter gamma-aminobutyric acid (GABA), which has a calming effect on the brain. Benzodiazepines can quickly relieve acute anxiety symptoms, making them especially useful for immediate or short-term relief. Chronic use, even over a short period (a few weeks), however, can lead to physical and psychological dependence. Withdrawal symptoms can be severe and include insomnia, increased anxiety, tremors, and, in extreme cases, seizures (Rosenbaum, 2020) (Table 17.3).

Drug Name Use Duration of Action
Diazepam (Valium) Anxiety, muscle relaxant, alcohol withdrawal, seizures Long acting
Alprazolam (clonazepam (Klonopin)) Anxiety, panic disorder Intermediate acting
Lorazepam (Ativan) Anxiety, insomnia due to anxiety, status epilepticus, alcohol withdrawal Intermediate acting
Clonazepam (Klonopin) Panic disorder, seizures Long acting
Chlordiazepoxide (Librium) Alcohol withdrawal, anxiety Long acting
Oxazepam (Serax) Anxiety, alcohol withdrawal Short to intermediate acting
Table 17.3 Most Commonly Prescribed Benzodiazepines (Dubovsky & Marshall, 2022)


Buspirone is a medication commonly used to treat anxiety. It is classified as an anxiolytic, which means that it works to reduce feelings of anxiety and tension. Buspirone works by binding to certain receptors in the brain that are involved in the regulation of mood and anxiety, specifically the serotonin 5-HT1A receptors. Unlike benzodiazepines, buspirone is not associated with the risk of dependence or withdrawal symptoms. It also does not have sedative effects, so it can be taken during the day without interfering with everyday activities. Buspirone can take several weeks to start working and may cause side effects, such as nausea, dizziness, and headaches. It may also be less effective than other medications for some individuals with anxiety disorders (Melaragno, 2021).


Antidepressants are commonly used to treat anxiety, particularly SSRIs and SNRIs (Mayo Clinic, 2019). These medications work by increasing the availability of serotonin and norepinephrine in the brain, which can help regulate mood and reduce anxiety symptoms (Bandelow et al., 2015). Studies have shown that antidepressants can effectively treat anxiety, but the response to antidepressants can vary widely among individuals, and it may take several weeks or months to reduce anxiety symptoms significantly. Additionally, some individuals may experience side effects, such as nausea, dizziness, and sexual dysfunction. Antidepressants are often used with psychotherapy, such as cognitive behavioral therapy, to achieve optimal treatment outcomes (National Institute of Mental Health, 2023) (Table 17.4).

Drug Name Class Use
Fluoxetine (Prozac) SSRI Generalized anxiety disorder, panic disorder, OCD, depression
Sertraline (Zoloft) SSRI Generalized anxiety disorder, panic disorder, OCD, social anxiety disorder, PTSD, depression
Paroxetine (Paxil) SSRI Generalized anxiety disorder, panic disorder, social anxiety disorder, OCD, PTSD, depression
Citalopram (Celexa) SSRI Generalized anxiety disorder, depression
Escitalopram (Lexapro) SSRI Generalized anxiety disorder, depression
Venlafaxine (Effexor XR) SNRI Generalized anxiety disorder, panic disorder, social anxiety disorder, depression
Duloxetine (Cymbalta) SNRI Generalized anxiety disorder, depression, neuropathic pain
Table 17.4 Most Commonly Prescribed Antidepressants for Anxiety (Mayo Clinic, 2019)
Abbreviations: OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress disorder; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor

Other Medications

Beta-blockers, such as propranolol, can be used to treat anxiety disorders. These medications target the physical symptoms of anxiety, such as tachycardia, flushing, and shaking (National Institute of Mental Health, 2023). Gabapentin, a medication commonly used to treat seizures and nerve pain, has also been studied for its potential effectiveness in treating anxiety disorders. Although the exact mechanism of action is unclear, gabapentin is thought to increase the release of the inhibitory neurotransmitter GABA, which can help reduce feelings of anxiety. Several small studies have suggested that gabapentin may effectively treat anxiety disorders, such as generalized anxiety disorder, social anxiety disorder, and panic disorder. It requires more research, however, and it has side effects, such as dizziness, drowsiness, and confusion, and it can also be habit-forming if used for extended periods (Berlin et al., 2015).

Nursing Care for Clients with Anxiety

Nursing interventions for anxiety should be tailored to the specific needs of the individual, and any treatment plan should be developed in collaboration with all members of the health-care team (American Nurses Association, 2022). Some of the most common interventions involve assessing the client’s level of anxiety, including the severity and duration of symptoms; creating a quiet and soothing environment, which can help reduce the client’s anxiety and promote relaxation; and encouraging relaxation techniques, such as deep breathing exercises, progressive muscle relaxation, and guided imagery. There is a need to assist the client in the development of coping strategies, such as positive self-talk, distraction techniques, and problem-solving skills. It is also important to educate the client and their family or caregivers about anxiety, its symptoms, and available treatments. People who understand their condition often feel more in control. Nurses may also administer and manage prescribed medications, such as benzodiazepines or SSRIs, or refer the client to other health-care professionals, support groups, or community resources that can provide additional support and assistance.


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