Anxiety is a normal, vague feeling of apprehension in response to a perceived threat; fear is the response to a known, immediate danger. Anxiety becomes a disorder when it is excessive, persistent, and impairing. Anxiety disorders are the most common mental disorders and frequently co-occur with depression and substance use.

Mechanisms — overactive amygdala fear circuits with weak prefrontal control; reduced GABA and serotonin signaling; noradrenergic overactivity (locus coeruleus); genetic temperament (behavioral inhibition); learned avoidance that is negatively reinforced because escaping the feared situation brings immediate relief. Cognitive models emphasize overestimating danger and underestimating coping ability.

Levels of anxiety (Peplau)

DSM-5-TR anxiety disorders

Blood-injection-injury phobia is unique: a brief rise in heart rate and BP is followed by a vasovagal drop (bradycardia, hypotension) and fainting.

Rule out medical causes before labeling symptoms as anxiety — especially the first presentation of chest pain, dyspnea, or palpitations: acute coronary syndrome, dysrhythmias, pulmonary embolism, asthma, hypoglycemia, hyperthyroidism, pheochromocytoma, and caffeine, stimulant, or decongestant use or alcohol and sedative withdrawal. Also screen for depression, suicidal ideation, and substance use (self-medication with alcohol is common).

Psychotherapy — first-line alone or combined with medication

• Cognitive behavioral therapy (CBT): identify and challenge catastrophic thoughts (e.g., distorted beliefs about how others judge the client in social anxiety)
• Exposure therapy: graded, repeated contact with feared situations without escape or safety behaviors, so anxiety falls on its own. Avoidance maintains anxiety
• Systematic desensitization: (1) teach relaxation first, (2) build an anxiety hierarchy from least to most feared, (3) pair relaxation with each step, starting at the lowest (e.g., looking at photos of a bus before standing at the bus stop, then riding one stop with support)
• Applied tension for blood-injection-injury phobia: tense the large muscles of the arms, legs, and trunk to raise BP and prevent fainting
• Relaxation training: progressive muscle relaxation, diaphragmatic breathing, mindfulness

Medications

Listed in priority order.

1. Panic attack — safety and calm presence
   • Stay with the client; remain calm; use short, simple, direct statements
   • Move to a quiet, low-stimulation area
   • Guide slow breathing with the client ("You are safe. Breathe slowly with me")
   • Assess vital signs and physical complaints; in a first presentation with chest pain, exclude a medical emergency (ECG) while giving reassurance
   • Do not ask "why" questions, give lengthy explanations, or teach during panic; explanations and teaching come after anxiety decreases
   • Give prescribed PRN medication if needed
2. Reduce anxiety to a level where learning is possible — acknowledge the feeling; avoid dismissive statements ("Just calm down," "It's all in your mind")
3. Help the client recognize and cope with anxiety — identify triggers and early physical signs; teach breathing, progressive muscle relaxation, grounding, and problem-solving at mild–moderate levels
4. Support exposure, not avoidance — encourage gradual approach to feared situations in collaboration with the treatment plan; do not reinforce avoidance or constant reassurance-seeking
5. Separation anxiety in children — brief, confident goodbyes; predictable routine; coordinate with teachers; praise and reward successful separations; do not allow school avoidance, which strengthens the fear
6. Medication monitoring — sedation, fall risk, benzodiazepine misuse, early SSRI activation, suicidality in young people

Common nursing diagnoses: anxiety; ineffective coping; powerlessness; social isolation; disturbed sleep pattern.

• Panic symptoms are frightening but not physically dangerous once medical causes are excluded; they peak and pass within minutes
• Practice slow breathing and progressive muscle relaxation daily, not only during attacks
• Limit caffeine, nicotine, and energy drinks; avoid alcohol and cannabis as coping tools
• Regular exercise and a consistent sleep schedule reduce anxiety; avoid long daytime naps
• SSRIs/SNRIs take several weeks to help; early jitteriness usually settles
• Benzodiazepines: do not drive until you know the effect; no alcohol or opioids; do not increase the dose on your own; never stop suddenly
• Buspirone must be taken every day to work — it will not relieve an attack in progress
• Facing feared situations step by step is how recovery happens; avoidance makes anxiety grow

• Panic level: stay with the client, brief simple statements, calm environment — no teaching
• Mild anxiety enhances learning; severe and panic levels block it
• Panic attack peaks within minutes; panic disorder = recurrent unexpected attacks + ≥ 1 month of worry
• GAD = excessive, uncontrollable worry about many things ≥ 6 months with muscle tension, restlessness, poor concentration
• Social anxiety = fear of negative evaluation and humiliation → CBT to correct distorted beliefs
• Avoidance maintains anxiety; exposure treats it
• Systematic desensitization starts with relaxation training, then the lowest step of the hierarchy
• Blood-injection-injury phobia → vasovagal fainting → applied tension
• SSRIs/SNRIs are first-line; benzodiazepines short term only (dependence, withdrawal)
• Benzodiazepines: taper, never stop abruptly; danger with opioids and alcohol
• Buspirone: delayed onset, not PRN
• Rule out cardiac, thyroid, hypoglycemic, and substance causes first