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Dealing with Difficult Patients: Fear and anxiety

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By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC


Fear is usually defined as a natural response to a real danger. Everyone has experienced it at one time or another. The usual response to fear is to assess the situation, determine whether it is a real danger—as opposed to a misperception—and then take steps to handle the problem.

Fear may disrupt our lives. We may experience restless sleep, difficulty concentrating, or loss of appetite. However, most people are able to handle or avoid their fears and move on.

Here are some ways you can help patients handle their fears:

  • Determine exactly what is causing the fear. Getting the patient’s description of what he or she is afraid of is very important. Don’t make assumptions.
  • Caution the patient not to intensify the fear by his or her own self-talk.
  • You can help the patient problem-solve his or her fear by asking the patient to answer the question “What is the worst that can happen?” Then, discuss with the patient whether he or she could live with that, or point out the odds of that happening.
  • Ask the patient, “What is the most likely thing that can happen?” You can prompt the patient to visualize the situation and how he or she might respond, and offer alternatives as appropriate.
  • Help the patient take actions that might protect him or her, if needed.
  • Encourage the patient to decide for him or herself when he or she is ready to face the fear.


The lowdown on anxiety disorders

But anxiety is another story. Constant anxiety can interfere with daily living and cause a wide variety of both physical and emotional illnesses. When anxiety is out of hand, it can become a serious medical illness. Anxiety disorders are chronic and relentless, and can grow progressively worse if not treated. Here is a brief description of the most frequently occurring anxiety disorders:

  • Generalized anxiety disorder (GAD): excessive, unrealistic worry that lasts for more than six months. Physical symptoms include trembling, insomnia, dizziness, and irritability.
  • Obsessive-compulsive disorder (OCD): persistent, recurring thoughts that exaggerate anxiety or fears; the need to do something (compulsion) to rid oneself of the recurring thought (obsession). For more information about obsessive-compulsive behaviors, please see Chapter 13.
  • Panic disorder: severe distress that causes the individual to believe he or she is having a health problem (such as a heart attack) or will lose control.
  • Post-traumatic stress disorder (PTSD): a cluster of symptoms that persist after experiencing a traumatic event (war, sexual or physical assault, unexpected death of a loved one, disaster).
  • Social anxiety disorder: an individual’s extreme anxiety that he or she is being judged by others or a belief that he or she is behaving in a way that might cause embarrassment (Anxiety, NIMH).

Assessing level of anxiety and interventions
This table can help you determine your patient’s level of anxiety and what you can do to relieve it.

Level of Anxiety Physical Symptoms Cognitive / Perceptual Manifestations Interventions
Mild Some muscle tension. Elevated alertness and awareness.

Listen, help talk out situation.
Moderate Moderate muscle
 BP, P, R.
Feeling nervous and jittery.
Inability to communicate.
Offer simple choices. Give clear directions. Offer physical outlet. Breathe into a paper bag.
Severe Extreme muscle tension.
Heart pounding & sweating
Distorted perceptions.
All of the above, as needed. Orient to surroundings. Correct any misperceptions. Medications may be needed.
Panic Muscle tension increases to the point of needing to move, often aimlessly, sometimes violently. Overwhelmed.
All of the above, as needed. Safety is first concern. Call for help. Medication is usually required.


Strategy time: Develop a plan for relapse
People with chronic illnesses may experience additional anxiety during periods of relapse of their illness because of concerns about their family and/or their own welfare. Helping them develop a plan to follow during relapse may alleviate some of their anxiety. When their symptoms are well controlled, work with them to develop a treatment plan to share with their family members and healthcare providers when they begin to show signs of relapse. Then, when they need to rely on others for help, they will be assured that they still have some say in the plan of their care.

A plan of action includes specific items that need to be addressed during relapse. It is important to consider all of the patient’s daily responsibilities when developing the plan of action, and it may take some time to address all concerns. Include these in the plan:

  • The patient’s wishes for the care of children, pets, and plants, if needed
  • Who the patient wants to manage his or her business, pay bills, and handle financial matters
  • What treatment facility and care providers the person would like to attend to him or her
  • Who needs to be notified, and how best to contact them

Plans of action can also include the following documents:

  • An advance directive for treatment, which is written during remission to help outline treatment during relapse. An advance directive can be very useful, particularly when symptoms of fear, suspicion of others, or paranoia emerge in those with mental disorders.
  • A durable power of attorney, which designates who will be in charge of making decisions when the patient cannot make decisions for him or herself.
  • A power of attorney for managing financial records when the patient is unable to do so. He or she may want someone to cosign important items such as home mortgages (WebMD).