“I am so worried...I can't stop thinking... if I could just sleep . . . what if . . .”
Anxiety reached epidemic proportions in the 1990s and has worsened in the wake of economic instability and terrorism (Bourne, 2005). In 2005, over 18% of people in the United States experienced symptoms of anxiety although only about one-third sought treatment (Anxiety and Depression Association of America [ADAA], 2013a; Kessler, Chiu, Demler, Merikangas, & Walters, 2005). In 2010, anxiety disorders were one of the major contributors to disability (U.S. Burden of Disease Collaborators, 2013). The National Institute of Mental Health (NIMH) reports anxiety disorders continue to affect 40 million adults (18%) in a given year. Over their lifetime, women are 60% more likely to experience anxiety than men (NIMH, 2013). Anxiety disorders are the most common mental illness in the United States (ADAA, 2013a).
The long-term effects of undiagnosed and undertreated anxiety disorders result in psychosocial and occupational dysfunctions, drug and alcohol abuse, overeating, and increased risk of suicide. Generalized anxiety disorder (GAD) affects 6.8 million adults or 3.1% of the U.S. population (ADAA, 2013a) and the annual cost of disability attributed to GAD is estimated at well over $42 billion (Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007).
Many of the patients we care for as Advanced Practice Nurses are riddled with anxiety. Although anxiety can have physical pathology, we believe that what we often see in patients is the lack of peace since the mind is attacked by anxiety, worry, and fear. The purpose of this article is to help healthcare providers understand anxiety, its prevalence and common treatments, and explore underlying spiritual issues that may fuel anxiety and rob patients of inner peace.
PEACE VERSUS ANXIETY
Culture has one definition of peace but there is a different definition in the Bible. The cultural view stresses the importance of self-actualization and lack of conflict between people. Generally, when people speak about peace, it is within the framework of freedom—for society and for individuals. Although most understand that freedom comes with a cost, freedom alone does not ensure internal peace of mind and spirit.
The word “peace” originally comes from the Hebrew word Shalom representing soundness, health, prosperity, and general well being. Shalom implies nothing is missing or broken in the lives of God's people (Strong, 2012). In the Tanakh or Old Testament Scriptures, inward shalom was the gift to the righteous who chose to put their trust in God (i.e., Job 22:21). Isaiah 26:3 states, “You will keep in perfect peace him whose mind is steadfast because he trusts in you” (NIV 84). Many of the psalms speak about peace (i.e., Psalm 4:8, 29:11, 119:165). Shalom is the peace that results from a spirit, soul, and body completely at rest because of perfect trust in God.
In contrast, the Bible provides a vivid description of anxiety that would occur if the Israelites chose not to follow God:
You will live in constant suspense, filled with dread both night and day, never sure of your life. In the morning you will say, ‘If only it were evening!’ and in the evening, ‘If only it were morning!’—because of the terror that will fill your hearts and the sights that your eyes will see. Deuteronomy 28:66-67, NIV84
Furthermore, anxiety is contagious. Deuteronomy 20:8 states, “Then the officers shall add, ‘Is any man afraid or fainthearted? Let him go home so that his brothers will not become disheartened too.’”
Jesus is referred to as the Prince of Peace (Isaiah 9:6), one who brings peace (Roman 5:1), and God is the God of peace (Romans 15:33). Jesus talked about peace, saying, “Peace I leave with you; my peace I give you. I do not give to you as the world gives. Do not let your hearts be troubled and do not be afraid” (John 14:27, NIV). A common salutation of the first century apostles was “Peace, from God our Father and the Lord Jesus Christ” (Galatians 1:3; Ephesians 1:2; Philippians 1:2). Perhaps one of the strongest passages about how to find and remain peaceful is Philippians 4:6-9 (NIV84):
Do not be anxious about anything, but in everything, by prayer and petition, with thanksgiving, present your requests to God. And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus. Finally, brothers, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think about such things. Whatever you have learned or received or heard from me, or seen in me—put it into practice. And the God of peace will be with you.
From Scripture we learn that God's plan for us is to have peace, but for many the opposite is true as they live in constant anxiety.
Anxiety is the response to an ambiguous sense of threat or danger, now or in the future. In contrast, fear is the response to a real and often serious threat of imminent danger. Despite these differences, anxiety and fear have similar physiologic and emotional responses (Comer, 2012). Anxiety is a natural response in humans as a necessary warning signal, but becomes pathological when excessive and uncontrollable. It is normal to have a “case of nerves” about an upcoming important event (final exam, job interview) or things like paying bills or performing in public. But it is not normal to constantly worry and have such significant distress one cannot function in daily life.
Anxiety disorders are mental illnesses that share common features of excessive fear and anxiety that lead to changes in behavior (i.e., avoidance, obsessions) and exhibit with certain physical disturbances (i.e., stomach pain, heart pounding). Anxiety disorder is excessive and irrational anxiety and at times, panic attacks. Twelve categories of anxiety disorders are included in the new Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (American Psychiatric Association, 2013) as shown in Table 1. Post-traumatic stress disorder (PTSD) is no longer categorized as an anxiety disorder but is in a new category “Trauma and Stress or Related Disorders.” Obsessive-compulsive disorder (OCD) also is in a new category “Obsessive Compulsive and Related Disorders.”
Each anxiety disorder has specific guidelines for diagnosis, and it should be noted that diagnoses can be complicated by other psychiatric disorders or co-morbid conditions. Unfortunately, patients may have multiple anxiety disorders as their condition progresses and the mind and body are held captive by symptoms. Anxiety disorders are challenging to patients and their family and caregivers because patients often cannot specify what they fear or why they are anxious.
There is no clear pathophysiology for anxiety disorders, but physical and emotional symptoms are believed to be due to a disrupted modulation within the central nervous system and brain. Several neurotransmitter systems have been implicated, including serotoninergic and noradrenergic systems, as well as the gamma-aminobutyric acid (GABA) system. In anxiety disorder, it is thought that there is insufficient activation of the serotoninergic system and a hyperactivation of the noradrenergic system (Comer, 2012).
Understanding of the neurobiology of anxiety disorders has advanced significantly in recent years. We know the brain has two fear pathways. A fast pathway mediated by the amygdala mobilizes the body to flee a threat by initiating the “fight or flight” response. A slower pathway mediated by the prefrontal cortex takes several milliseconds longer and can interpret whether a stimulus is truly dangerous or not. If the stimulus turns out to be harmless, the prefrontal cortex can slow down the rapid amygdala activation. It is known that panic, phobias, and generalized anxiety appear to involve one circuit of the brain, although OCD involves a different circuit (Comer, 2012; Sadock & Sadock, 2007).
High cortisol levels have been found where anxiety is present. The amygdala signals the hypothalamus to secrete a corticotrophin releasing factor, which signals the pituitary to release an adrenocorticotropic hormone. The release of this hormone stimulates the adrenal glands to secrete cortisol. It is thought that repeated stimulation of the adrenal glands over time to release cortisol may prevent the amygdala from properly turning off the “fight or flight” response (Comer, 2012; Sadock & Sadock, 2007).
Individuals with unhealthy lifestyles, poor coping skills, and environmental stressors including emotional, physical, or sexual abuse, are more prone to anxiety disorders. Risk factors, including poor social support, low socioeconomic status, and low educational levels may increase the probability of the development of anxiety disorders (Sadock & Sadock, 2007). The development of anxiety also may be a learned behavior. For example, approximately 15% to 20% of children with at least one agoraphobic parent become agoraphobic themselves (Culpepper, 2002).
Research also points to possible genetic risk factors for anxiety disorders. One genetic risk surrounds the involvement of a single nucleotide, polymorphism (C[-1019] G), on a serotonin transporter gene 5-HT1A. This common functional variation effects serotonin signaling. If a patient is born with a short form of the gene, it results in decreased serotonin release at postsynaptic targets in the forebrain. With the short form, a patient may be more vulnerable to life stressors and more likely to develop an anxiety or mood disorder, although being less responsive to selective serotonin reuptake inhibitor (SSRIs) medications (Fakra et al., 2009).
A risk factor for anxiety that has not been adequately researched is a lack of spiritual faith and standards. In the last 30 to 50 years, we have experienced a great deal of environmental and social order chaos. It is difficult to adjust to the increased pace of modern society and rapid technological change. People today also are faced with a barrage of differing worldviews and moral standards. In a postmodern world of subjective truth, the ability to judge between right and wrong seems more complicated. Biblical standards such as the Ten Commandments (Exodus 20) or the Golden Rule (Matthew 7:12) seem outdated. Researchers have found that religion and faith play a significant role in health and response to illness (Koenig, King, & Carson, 2012), and it is likely changing societal factors and lack of spirituality play a role in anxiety today.
SYMPTOMS OF ANXIETY DISORDER
Symptoms of generalized anxiety disorder or GAD may be manifested in various presentations including a physiological response, a psychological response, or behavioral changes. A patient may describe a combination of responses. The body's stress response is designed to be acute and limited to a short period of time. When stress becomes chronic, it can disturb the physical and mental health of a patient. Most pathophysiology textbooks differentiate between the acute and chronic effects of stress on the body. An acute stress response is associated with an expected “fight or flight” reaction causing an increase in heart rate, oxygen intake, and mental activity. A patient may manifest a pounding headache, cold moist skin, and a stiff neck. In a truly life-threatening situation, these changes are considered healthy, normal responses intended to divert blood to more essential bodily functions. For example, increases in blood flow to large muscles would enable someone to physically respond to danger by increasing his/her strength or ability to move rapidly (Comer, 2012; Porth, 2010).
Stress significantly elevates blood pressure and heart rate, causes bronchodilation, increases blood sugar levels, and diminishes the inflammatory and immune responses in the body (Gould & Dyer, 2011). These changes can have a profound impact on a patient who has preexisting conditions, such as heart problems, respiratory diseases, or diabetes. For example, a patient with heart disease may respond to stress with dysrhythmias. The body usually recovers quickly from the physiological changes resulting from stressors, but when acute stressors are continuous or when a normal adaptation to stress is impaired, individuals suffer more chronic effects.
On a psychological level, patients with GAD typically report more subjective symptoms such as a state of apprehension or uneasiness, along with complaints of depression; they may experience crying spells. They often cannot identify a cause for the constant state of worry, but constantly feel on edge as if something bad is about to happen. As generalized anxiety escalates, it can manifest as near panic or panic disorders. Patients may complain of feeling detached and express fears of dying or going crazy. Other physical symptoms include pounding heartbeat, sweating palms, dizziness and feeling faint, tunnel vision, shaking, and crying. Most patients describe it as the most terrifying feeling they have ever had and trips to the emergency room are not uncommon. According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2010), in 2008 there were over 3 million emergency room visits attributed to anxiety.
On a behavioral level, patients may report that anxiety sabotages their ability to act, express themselves, or deal with everyday situations such as driving, going to work, or shopping. They often feel confused and have short attention spans. These feelings may cause them to change their behaviors in anticipation of the anxiety. For example, they may avoid going places or give up driving. As GAD progresses, worry cannot be controlled and eventually affects health, family, work, and finances.
PATHOPHYSIOLOGY OF STRESS
The connections between stress responses and diseases have been well researched. Prolonged stress results in large amounts of glucocorticoids being released; effects of cortisol, aldosterone, and ADH cause retained sodium and water, increased blood pressure, and increased blood volume. The physiologic effects of stress may result in “hypertension, heart failure, insomnia, tension headaches, peptic ulcer disease, fatigue and increased risk for infection and diabetes” (Gould & Dyer, 2011, p. 195; Comer, 2012).
Disease processes caused or aggravated by chronic stress from anxiety can be found in numerous body systems. For instance, prolonged vasoconstriction may cause inflammation resulting in damage to the gastrointestinal system. Stress has been indicted for its role in peptic ulcers, ulcerative colitis, nausea, diarrhea, and periodontitis. Chronic infections are likely to be aggravated under stressful situations as noted by herpes simplex that often erupts during a crisis. Skin is responsive to stress as evidenced by its aggravation of eczema and acne. More serious are the long-term impacts of severe stress. Chronic elevation of blood pressure may “lead to cardiac disease and chronic severe vasoconstriction may lead to acute renal failure” (Gould & Dyer, 2011, p. 196; Comer, 2012).
Other potential complications due to chronic stress include depression of the inflammatory response and the immune system. These decreases in defenses may set individuals up for opportunistic infections that might not become pathologic in an otherwise healthy individual. Further, a “lack of a normal inflammatory response may mask symptoms of infection or cause a delay in healing” (Gould & Dyer, 2011, p. 197). Psychological stressors, whether acute or chronic, can lead to maladaptive responses. The impact of this and other traumatic events are thought to create symptoms due to exaggerated activation of the sympathetic nervous system. Prevention of stress is indicated to decrease the potential consequences of stress on physical and mental health.
THERAPIES FOR ANXIETY
When someone has symptoms of an anxiety disorder, removing one contributing cause will not eliminate anxiety. Likewise, there is no single treatment that can eliminate anxiety. Anxiety problems appear from diverse sources operating on numerous levels that require a combination of different treatment regimens. Approach to treatment should always start with supportive listening and as appropriate, education about anxiety and fear. Healthcare providers can assist patients in understanding their anxiety is treatable and manageable, and in some cases, curable. Practical applications include the need to address the role a person's thoughts play in their anxiety, and possible lifestyle modification to reduce or diminish symptoms.
Cognitive behavior therapy (CBT) has been shown to be as effective as medication and is the most commonly used therapy in treating anxiety (ADAA, 2013b; Culpepper, 2002). CBT involves multiple sessions with mental healthcare professionals trained in CBT techniques. Therapy addresses the response patients have to the irrational thoughts of anxiety and panic with a focus on replacement of negative cognition with positive thoughts. Treatment is based on the theory that the patient develops a negative feedback loop by reacting and thinking negatively during a panic attack. Negative behavior includes avoidance of anxiety producing situations thus reinforcing anxiety and panic. In CBT, patients are taught to recognize unwarranted worry and actions and replace such thinking and actions with more realistic problem-solving thoughts and strategies (Covin, Ouimet, Seeds, & Dozios, 2008).
Faith-based or religious CBT uses faith-based concepts to replace negative ideas (Ceramidas, 2012; Koenig, 2012). Christian CBT “employs the use of biblical Scripture or faith-based concepts that recognize God as Creator and One who is interested in the well-being of humankind” (Ceramidas, 2012, p. 43). This type of CBT uses God's Word as found in the Bible to replace negative thinking. Duke University Center for Spirituality, Theology, and Health is researching the role of religious CBT in managing depression and stress in chronic illness with promising results (Koenig, 2012).
Biblical Framework Counseling (BFC) is “based on the belief that the Bible is adequate to treat the root causes of mental disorders that are not otherwise physiologically caused” (Oji, 2010, p. 76). BFC is treatment based on spiritual means with Scripture as the guide for therapy and as a model for living. The Bible admonishes us to think about God and his Son, Jesus; to dwell on whatever is worthy of awe and adoration, and to strive to keep our thoughts in harmony with God's promises and standards (Romans 12:2; Philippians 4:8-9). As a person recognizes and trusts God's power and authority, a sense of peace is possible (John 14:27). In 2 Timothy 1:7 we are reminded that “For God hath not given us the spirit of fear, but of power, and of love and of a sound mind” (KJV).
Other psychological therapies reported by the ADAA (2013b) for treating anxiety are Exposure Therapy, Acceptance and Commitment Therapy, Dialectical Behavior Therapy, Interpersonal Therapy, and Eye Movement Desensitization and Reprocessing. Additional activities that can help reduce anxiety are relaxation therapy, exercise and stretching, patient self-monitoring of thoughts and irrational thinking, and recognition of triggers of anxiety.
The number of medications available for the treatment of anxiety disorders has increased in the past decade. The selection of a specific medication is based on patient symptoms, adverse-effect profiles of the drug, and the existence of co-morbid disorders (Kaven, Elsasser, & Barone, 2009). Medications, although effective, need to be prescribed with caution and accompanied by other interventions. Table 2 offers a comprehensive list of medications used in treatment of anxiety disorders and mechanisms of action.
SSRIs and selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) have been the mainstay of treatment and first in line of accepted therapy for anxiety disorders. Major advantages for using such agents are their effects on depression and the fact that these medications are not addictive. Side effects include weight gain, insomnia, sexual dysfunction, nausea, and agitation. There is a delay in onset, so treatment usually begins a few weeks before symptoms are reduced. Withdrawal symptoms such as nausea, paresthesias, dizziness, and insomnia are common and therefore these medications need to be discontinued with a slow taper over several weeks.
Benzodiazepines are widely used for anxiety since these medications have a rapid onset and are very effective at controlling anxiety symptoms. Benzodiazepines suppress the output of neurotransmitters that interpret fear. The most commonly prescribed are Lorazepam (Ativan), clonazepam (Klonopin), and alprazolam (Xanax). Prescriptions for these medications increased from 1998 to 2008 by 17% to 94 million a year. There were 46 million prescriptions written for alprazolam in 2010 which was an increase of more than 23% over the previous year, making it the most prescribed psychotropic (National Library of Medicine National Institute of Health, 2011). Benzodiazepines can be addictive and lead to daytime sedation and confusion, differ in potency and duration, and may put elderly patients at risk for injury. Discontinuation of these drugs should be done gradually and over several weeks or months to help decrease withdrawal symptoms.
WHOLE PERSON CARE
To treat patients holistically, healthcare providers must consider the physiologic, psychological, and spiritual needs of their patients. Nurses are on the front lines of healthcare, and as such, are in a position to recognize abnormal anxiety and the associated symptoms. Nurses can provide insight and patient education on the impact stressors have on health and well-being. They are in a situation that allows them the opportunity to demonstrate caring and provide presence. Sweat (2012) in her discussion of how to put care back into spiritual care, reminds that “real care involves being present by actively listening and asking good questions” (p. 247). Nurses have gifts of empathy and compassion, which makes them especially cognizant of the emotional status of their patients. Smith (2007) defined presence as “an intervention that includes being physically present, but also includes being psychologically present as part of the nurse patient relationship” (p. 82). Presence is evident by behaviors that reflect caring. Recognition of the need for a strong support system is essential to decrease the risk of ongoing stresses for patients and caregivers. A well-informed nurse may know of nonprofit agencies and faith community organizations that are able to deliver practical help, providing needed physical and emotional support.
When nurses recognize and anticipate stressors for patients, they can provide anticipatory guidance. Preventative teaching may include information about how things such as fatigue, inadequate nutrition, or lack of emotional support can decrease one's ability to cope with stress. Besides teaching about the need for rest and a healthy diet, patient education can include concrete examples, such as how even moderate exercise can improve coping mechanisms and how spiritual support can help ameliorate stress. Other suggestions to minimize stress include relaxation techniques, imagery, music and art therapy, massage therapy, and biofeedback (Gould & Dyer, 2011; Porth, 2010). Massage therapy, for example, can provide physiologic relaxation for some patients to relieve stress and minimize its impact. Each patient is unique and what works for one patient may not work for another. For Christian patients practicing thankfulness, choosing to do what is right, worship, meditation on Scripture, and bringing concerns to God in prayer (i.e., Ephesians 5:1-20; Philippians 4:6-7) help decrease anxiety. The importance of recognizing maladaptive behaviors such as alcohol abuse, stress eating, smoking, or other coping behaviors likely to cause additional stress in the long term should be included in patient teaching.
Nursing interventions need to include meeting spiritual needs. To be effective, therapy must identify the root causes of anxiety, and the possibility of a spiritual component should be considered. Nurses can explore spirituality and encourage patients to connect with their faith and spiritual experts or refer to spiritual resources. Issues such as guilt, lack of forgiveness, lack of meaning and purpose, and fear can be addressed by spiritual counselors.
As Christians, we believe God's Word brings healing and offers wisdom for dealing with anxiety. Jesus spoke to issues of fear when he stated, “Do not worry about your life, what you will eat or drink; or about your body, what you will wear. Is not life more important than food, and the body more important than clothes?” (Matthew 6:25, NIV84). God wants us to focus on him and his presence and care in our lives. God knows we are better off when our minds are set on what is above, not on the things that are of the earth (Colossians 3:2). Jesus reminds us that worry does not add to our lives, “Who of you by worrying can add a single hour to his life?” (Matthew 6:27).
A significant blessing of the good news of salvation through Jesus Christ is redemption. God wipes away our past and encourages us to remember the miraculous ways we have experienced him and his presence. God has an open line of direct communication always available to us. He cares about the things that concern us. God is the healer of hearts and the lifter of heads (i.e., Psalm 3:1-4). Although God can use medications, therapy, and other treatments to provide patients with relief, those who want to experience the peace of God's presence are encouraged to spend time getting to know him well. The amazing by-product for those whose roots are firmly placed in God is strength and a peace that “transcends all understanding” (Philippians, 4:7). God wants to be our resource, and nothing can love the soul or sooth the mind better than the Creator.
* Anxiety and Depression Association of America—http://www.adaa.org
* National Alliance on Mental Illness—http://www.nami.org
* National Institute of Mental Health—http://www.nimh.nih.gov/health/topics/anxiety-disorders
* Biblical Framework Counseling—http://www.biblicalframeworkcounseling.org