Simone Garland is a registered mental health nurse working in the health and social care sector. She is also a wellbeing coach at mental health service The Wandering Mind. Here Simone outlines how to spot anxiety in patients, in light of the significant rises in mental health issues expected post-pandemic.
Anxiety is a common mental health condition, in 2013 it was estimated to have affected over 8 million people in the UK.1 Since those figures were published, anxiety appears on the rise with more young people and adults meeting the threshold for a formal diagnosis. A 2020 study looking at the impact of the Covid-19 pandemic has shown the condition is becoming more common with the reported symptoms of stress, anxiety and depression all being significantly higher in participants compared with previous published norms.2
The difficulty anxiety poses for nurses and other health practitioners is the condition in its simplest form is completely normal. Anxiety is triggered by a natural stress response; identify potential danger or threat and prime the body for fight or flight. In relation to practice, if you were facing a patient to give them the results of a recent investigatory procedure, you would expect them to be feeling a degree of anxiety.
Anxiety becomes problematic when it is disproportionate to the situation, prolonged over time or affects the person’s ability to live their life how they want to.
Types of anxiety
There are many types of anxiety that can fracture a person’s quality of life in different ways. Alongside these common types there are also other specific conditions where anxiety plays a part of their symptoms but is not the primary diagnosis, such as irritable bowel syndrome (IBS).
Generalised anxiety disorder (GAD)
GAD is a very common anxiety disorder reported to affect around 5% of the UK population.3 GAD can sometimes be difficult to diagnose as it can impact specific areas of a person’s life whilst at the same time being difficult for the patient to pinpoint exactly what they feel anxious about.
Common symptoms include a feeling of being on edge most of the time and a feeling of dread or that something bad is going to happen. Because there are such a wide range of possible symptoms 4 it’s likely that two people with the diagnosis might have two very different experiences of anxiety.
Panic disorder is characterised by sudden attacks of intense fear or worry. The attacks elicit an extremely physical response including; shaking, heart palpitations, sweating and difficulty breathing.
Panic attacks usually feel out of the blue for the sufferer but can create a vicious cycle alongside generalised anxiety as the person will become worried they might have another attack and start to avoid anything seen as a potential trigger.
This broadly covers disorders where someone may have an intense fear of specific things or situations. Coming face to face with the phobia or even just thinking of the phobia can trigger anxiety which is normally out of proportion to the actual threat posed.
Phobias can range from those that affect specific areas of your life, such as a fear of flying, to those that encroach into many or every aspect of daily life, such as agoraphobia which is a fear of leaving the house.
Those with social anxiety experience similar symptoms to GAD but these are specifically related to social situations. Social anxiety is more common than other anxiety conditions and seen more often in women than men.5 It is also highly likely to be linked to other disorders such as substance misuse, PTSD and depression.5
Post Traumatic Stress Disorder (PTSD)
PTSD is an anxiety disorder triggered by experiencing a traumatic event. It is not fully understood why PTSD is triggered in some people and not others. It is an extremely complex condition that can cause debilitating symptoms such as flash backs, nightmares, panic attacks and depression. It is difficult to manage PTSD without professional treatment and support, frequently people with PTSD rely on unhelpful coping strategies such as substance abuse, alcohol and isolation.6
Managing and assessing patient needs
Unless the patient is having a panic attack or describing symptoms that are clearly anxiety driven, it can be hard for nurses to spot anxiety as a condition rather than an appropriate response. Time with a patient may be limited to single interaction or you might only see them for a short amount of time on an infrequent basis.
What to look out for
Anxiety presents itself in many different forms. At times the patient may not recognise what they are feeling is anxiety . The condition can trigger intense physical reactions including palpitations, dizziness, chest pains and breathlessness. It’s common for people who experience their first anxiety attack (or panic attack) to feel like they’re having a heart attack. These physical manifestations can make it difficult for the patient to realise anxiety as the underlying cause and for the clinician to identify during appointments.
Signs of anxiety that you can pick up on:
● Communication is largely supported by non-verbal cues and body language; it can be a tool for nurses to pick up on subtle undertones. Do they appear open and comfortable with you or are they making themselves small and unnoticeable?
● A shaking hand and sweaty palm might be appropriate to your appointment but is this more than you would expect?
● Hyperventilation can be a sign of anxiety. Deep, rapid breathing could signal that they’re overbreathing to counteract the feeling of anxiety. This could also be noticed if they seem to be tense or finding it difficult to concentrate.
● Do they seem on high alert to their surroundings, appearing jumpy or on edge?
● If you have regular appointments with your patient, has their presentation changed since you first met them or have they started to ‘did not attend’ (DNA) appointments?
Questions to ask
Bringing up the conversation of anxiety should be done delicately, especially if the patient hasn’t offered it up themselves.
Reflecting what you’re seeing or hearing back to them can be a way of starting a conversation about what they’re experiencing.
Questions such as ‘I can see that you seem very tense today, is there anything you’re worried about?’, or ‘You seem to be finding it hard to slow down your breathing, how are you feeling?’ can be helpful in starting to talk about anxiety.
Other questions you could explore with your patient, if they are willing to can include:
● Asking about any physical symptoms that the patient may be experiencing.4
● Ask if there is anything worrying them at the minute, related to what brings them to you today or in general, again be mindful of any non-verbal signals.
● Are they experiencing any additional stressors such as work demands or family responsibilities?
● Have they been drinking alcohol more than usual or using illicit substances?
● Do they have a support network? Are they at risk or currently experiencing isolation and loneliness?
A study looking at the impact of Covid-19 and associated social isolation on mental and physical wellbeing 7 in adults over 50 years old found that in the six weeks following the first national lockdown there was an increase of men and women reporting feeling worse on the anxiety components of Hospital Anxiety Depression scale (HADS). 8
Is it new for the new normal?
A rise in psychiatric conditions, including anxiety, are linked to the Covid-19 pandemic, and are predicted to continue well past the easing of restrictions.
Many studies have attempted to monitor changes to the prevalence of mental health conditions over the last 18 months. Even when rates started to fall for the nation, they remained highest across cohorts of young people, lower income households, people living with a mental illness, those with children and urban areas.9
Despite a clear correlation emerging between the increase of mental health issues and the ‘new normal’ post pandemic, we should all be mindful not to normalise mental illness. It is likely that you will encounter more patients experiencing anxiety as a disorder for the first time or to a higher intensity if they already live with the condition. For many, you might be the first or only point of professional contact.
If you feel your patient is experiencing anxiety, first and foremost offer them reassurance. If you have them available, provide them with self help information such as leaflets or signposts to charities that can provide generic guidance (some links to charities can be found below). Some localities have self referral routes to psychological therapies or mental health services which can be beneficial to talk through as an option for your patient, especially if they have voiced they would like to talk to a mental health professional.
If appropriate follow up appointments can help to monitor presentation, provides your patient with reassurance that someone is going to be checking back in with them and can encourage them to follow through with seeking further guidance and support.
At times there may be situations where you have a concern for the severity of anxiety your patient is presenting with. NICE guidance describes a moderate mental health problem as making a patient’s daily life much more difficult than usual with severe conditions making daily life extremely difficult.10 These times may call for you to take action on behalf of your patient, this could involve liaising with their GP or making a referral to mental health services for them.
National anxiety charities:
● Anxiety UK
● No Panic
● Social Anxiety UK
To complete relevant mental health CPD modules on Nursing in Practice Learning, click here.
2. Kings College London. COVID-19 pandemic significantly increased anxiety and depression in the UK
3. NHS. Overview: Generalised Anxiety Disorder in Adults
4. NHS. Symptoms: Generalised Anxiety Disorder in Adults
5. National Institute for Health and Clinical Excellence (NICE). Social anxiety disorder: recognition, assessment and treatment of social anxiety disorder
7. Robb CE, de Jager CA, Ahmadi-Abhari S, et al. Associations of Social Isolation with Anxiety and Depression During the Early COVID-19 Pandemic: A Survey of Older Adults in London, UK. Front Psychiatry. 2020;11:591120. Published 2020 Sep 17. doi:10.3389/fpsyt.2020.591120
8. Stern A. The Hospital Anxiety and Depression Scale, Occupational Medicine, Volume 64, Issue 5, July 2014, Pages 393–394, https://doi.org/10.1093/occmed/kqu024
9. The Health Foundation. Emerging evidence on COVID-19’s impact on mental health and health inequalities
10. National Institute for Health and Care Excellence (NICE). Common mental health problems: identification and pathways to care