Anxiety is a feeling of fear and apprehension about a real or perceived threat and may cause excessive worry and heightened tension, affecting important areas of normal functioning (NICE [205]). The source of the feeling may or may not be known (Kennedy Sheldon [144]) and people sometimes refer to it as ‘coming out of the blue’. Different people use different words to describe anxiety, for example ‘stress’, ‘nervousness’ or ‘tension’.

The body has a normal response to fear and stress but, if this response is exaggerated, people might experience a sense of panic. During a panic attack, a number of symptoms can be experienced including palpitations, nausea, trembling, weak legs and dizziness (APA [10]) (Box 5.9). Panic attacks can have a sudden onset and may last 5–20 minutes (MIND [187]). Catastrophic thoughts or images (e.g. having a heart attack, fainting or collapsing) are characteristic of a panic attack and the more frequent and extreme they are the more intense the physiological response becomes (Powell [226]). An indication for many individuals that a panic attack is beginning is a feeling of tightness in the chest or being aware that their breathing is fast. If not managed, this may progress to hyperventilation (Powell [226]).

Anxious feelings can result in physical symptoms related to the ‘flight or fight’ response as the body responds to the threat, real or otherwise (Figure 5.12). The sympathetic nervous system releases adrenaline and other hormones that lead to:

These physical symptoms can be perceived as unpleasant by the patient, resulting in further catastrophic worries and an escalation in physical symptoms; in this way, a vicious cycle ensues (Figure 5.13). It is useful to note that although people may feel faint and dizzy when they are anxious, increased blood pressure will ensure they do not actually faint. The exception to this is when someone has a needle phobia and blood pressure initially increases and then drops, which can result in fainting (Jenkins [139]). One hypothesis regarding the reason for the reduction in blood pressure in people with a needle phobia is that it is an adaptive mechanism that minimizes any potential loss of blood and therefore enhances a person's chance of survival.

Anxiety is a normal and necessary response to threatening events but can become a problem when it is frequent, exaggerated or experienced out of context (Blake and Ledger [20]). There are a number of theories about anxiety, its causes and how to manage it (Powell and Enright [227]); however, all theories consider the role of the situation as well as the patient's thoughts, emotions, physiology and behaviour. To be effective in supporting and communicating with a patient with anxiety, it is necessary to consider the following components of anxiety:

Within the healthcare context, many patients experience anticipatory anxiety, for example worry and anxiety about future appointments, tests and treatments. Patients are frequently required to have tests or treatments that include needles, which are a common fear. McLenon and Rogers’ ([175]) meta‐analysis found that needle fear and phobia were present in the majority of children, 20–50% of adolescents and approximately 20–30% of young adults; they were less prevalent thereafter.

As levels of anxiety increase, a person's awareness and interaction with the environment can decrease, and recall and general function may be impaired (Kennedy Sheldon [144]). Cognitive functions can be affected due to ‘emotional hijacking’ (Goleman [108]). This occurs when the amount of brain activity in the limbic system (the brain's principal emotional system) increases to a level where it ‘hijacks’, or interferes with, the functions of the pre‐frontal cortex (where most executive functions are processed, such as thinking, reasoning and attention). Conversely, some anxiety and worry can be helpful when they orientate a person's behaviour towards appropriate problem‐solving strategies.

Managing generalized anxiety is initially about early recognition and helping people to understand the problem. It is recognized that a person's perception of, or behavioural response to, a situation can exacerbate anxiety. Therefore, it is helpful to provide psychoeducation – that is, an explanation or explanatory model for the development and maintenance of the anxiety (Figures 5.12 and 5.13).

Where possible, it is pertinent to allay the source of anxiety. Nurses have more power than patients in the healthcare setting and may be in a position to help change an anxiety‐provoking situation. Alternatively, they may be able to support patients in thinking through a difficult situation and helping them to identify what they can do to bring about change. Further, nurses can provide patients with information on how to develop or enhance their problem‐solving skills. However, within the healthcare context, many situations or difficulties that provoke anxiety are not changeable or controllable by individuals, so attempting to bring about change can lead to frustration or an experience of failure.

NICE ([205]) promotes a stepped‐care approach to managing anxiety, with psychological interventions tried before pharmacotherapy. People can choose between ‘individual non‐facilitated self‐help, individual guided self‐help or psycho‐educational groups’ (NICE [205], p.7) and various patient resources are available (see www.ntw.nhs.uk/selfhelp). If these interventions are ineffective, individual high‐intensity psychological interventions, such as cognitive–behavioural therapy and relaxation, may be appropriate (Figure 5.14). Third‐wave cognitive–behavioural therapies – such as mindfulness‐based stress reduction (MBSR), mindfulness‐based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), dialectical behavioural therapy (DBT) and compassion focused therapy (CFT) – have a good evidence base for working with anxiety (Gu et al. [114], Leaviss and Uttley [150], Swain et al. [263]). NICE guidelines advocate patient preference as a factor in the selection of psychological interventions, and some patients prefer more exploratory therapies such as counselling.

During initial nursing consultations or conversations, it is important that nurses ask patients about any history of psychological or mental health difficulties. This will enable the nurse, where possible, to adapt their approach and minimize anxiety triggers.