Module 10: Stressors Affecting Levels of Anxiety

Learning Objectives:

Key Focus Areas:

Key Terms:

Stressors Affecting Levels of Anxiety (Anxiety and Related Disorders)

Anxiety is a normal part of life, but excessive or persistent anxiety can become debilitating. Stressors – internal or external events that trigger stress – can precipitate varying levels of anxiety and related disorders. This module provides an in-dept​aafp.org​aafp.orguate nursing students on anxiety levels, defense mechanisms, anxiety disorders (including OCD), dissociative disorders, somatic symptom and related disorders, and evidence-based nursing interventions. Cultural and aafp.orgiderations and trauma-informed care principles are integrated throughout. Case studies and NCLEX-style questions are included to reinforce learning.

Levels of Anxiety

Psychiatric nurse theorist Hildegard Peplau identified four levels of anxiety: mild, moderate, severe, and panic【3†L148-L156】【3†L175-L183】. Each level is characterized by different physiological and psychological responses. Understanding these levels helps nurses tailor interventions appropriately【3†L148-L156】.

Mild Anxiety

Mild anxiety is part of everyday living and can actually be adaptive. At this level, perception is heightened and one’s senses are sharpened【3†L154-L162】. The individual is alert and may feel restless or irritable, but not overwhelmed. Signs/Symptoms: Mild tension-relieving behaviors such as fidgeting, nail-biting, or foot-tapping are common【3†L154-L162】. There may be butterflies in the stomach or slight muscle tension, but the person can learn and problem-solve effectively. Neurobiological Basis: Mild anxiety triggers the sympathetic “fight-or-flight” response minimally – perhaps a slight increase in adrenaline and alertness – which can improve focus. Nursing Implications: Mild anxiety is normal and can motivate learning and action. The nurse should encourage the patient to verbalize feelings and cope (e.g. using humor or exercise) since the patient can process information well at this stage. Teaching can be effective when anxiety is mild because attention is focused.

Clinical Tip: Mild anxiety can be beneficial – it often provides the ener​aafp.orgntration needed to complete tasks or confront challenges (like studying for an exam or getting to an appointment on time). The nurse can help patients harness mild anxiety positively by reinforcing effective coping (deep breathing, exercise)【3†L148-L156】.

Moderate Anxiety

In moderate anxiety, the person’s perceptual field narrows and some details are excluded from observation【3†L163-L171】. The individual can still attend to relevant information but may require redirection. Signs/Symptoms: Moderate anxiety causes selective inattention – the person may focus only on immediate concerns and block out periphery. They may feel tension, pounding heart, faster pulse and respirations, sweating, and mild gastrointestinal discomfort【3†L163-L172】. Voice tremors or shakiness can occur, and the person might report difficulty concentrating but can still follow directions. Neurobiological Basis: The sympathetic nervous system is more stimulated, with higher levels of epinephrine and norepinephrine leading to tachycardia, increased breathing, and mild fight-or-flight somatic symptoms. Nursing Implications: The nurse should remain calm and provide a quiet environment, as external stimuli may be distracting【5†L1937-L1945】. Use therapeutic communication – speak in simple sentences and ensure the patient’s understanding. Encourage the patient to talk about what is causing their anxiety and to use coping strategies that have worked before (e.g. breathing exercises, walking)【5†L1937-L1945】. At moderate anxiety, patients may benefit from problem-focused coping (breaking tasks into smaller steps) and emotion-focused coping (relaxation techniques)【3†L148-L156】.

Severe Anxiety

Severe anxiety greatly reduces the perceptual field – t​ncbi.nlm.nih.govcus on a specific detail or several scattered details and have difficulty noticing their environment even when pointed out【3†L175-L183】. Signs/Symptoms: Learning and problem-solving are not possible at this level. The individual may feel dazed or confused. Behavior becomes more automatic and aimed at reducing anxiety (e.g. pacing). Physical symptoms intensify: headache, nausea, dizziness, insomnia are common, as well as trembling, a pounding heart, hyperventilation, and a sense of impending doom【3†L177-L184】. The person may be restless, angry, or withdrawn. Neurobiological Basis: The amygdala (the brain’s fear center) is hyperactive, and stress hormones (adrenaline, cortisol) surge, preparing the body for danger even if no real threat exists【90†L133-L141】【90†L135-L143】. This heightened limbic activity floods the body with physiological arousal. Nursing Implications: Safety becomes a priority. The nurse should remain with the patient and provide a calm, reassuring presence【5†L1955-L1963】. Communication should be firm, short, and simple (e.g. “Take a deep breath with me”)【5†L1955-L1963】, since the patient cannot process complex information. Reduce environmental stimuli – move the person to a quiet setting. Physical needs must be attended: ensure adequate fluid intake (they may be perspiring heavily), offer a blanket if shivering, and encourage rest because severe anxiety can exhaust the patient【5†L1961-L1969】. If the patient is pacing, provide high-calorie fluids or finger foods to prevent dehydration and maintain energy【5†L1961-L1969】. Do not leave a severely anxious patient alone.

Nursing Priority: For severe anxiety, patient safety and basic needs take priority. The nurse should stay with the patient and remain calm. Use a low-pitched voice and short, simple statements to help the patient feel secure【5†L1955-L1963】. If the patient is experiencing hyperventilation, assist them in sl​aafp.orgbreathing (e.g. breathe with them, use a paper bag if needed). Keep expectations minimal until the anxiety decreases – do not try to teach or problem-solve at this stage.

Panic Level Anxiety

Panic is the most extreme level of anxiety, marked by dysregulated behavior and loss of reality orientation【3†L193 - L199】. The individual is unable to focus on the environment and may even experience derealization (feeling the world is not real) or depersonalization (feeling detached from oneself)【18†L421-L429】. Signs/Symptoms: The person may scream, run about wildly, or completely withdraw. Hallucinations or delusions can occur if panic is prolonged【3†L195-L199】. They may be terrified and feel they are “going crazy” or dying【18†L421-L429】【18†L423-L430】. Physiologically, panic causes severe flight-or-flight activation: the individual might experience chest pain, shortness of breath, dizziness, faintness, a sense of choking, palpitations, and trembling【18†L400-L408】【18†L412-L420】. This state cannot be sustained indefinitely and may lead to exhaustion. Neurobiological Basis: Panic involves an acute surge of stress hor​ncbi.nlm.nih.govelming autonomic arousal. The brain’s alarm system is in overdrive – amygdala firing intensely and the person’s prefrontal cortex (reasoning center) essentially offline. It is akin to being in true imminent danger (even if no danger exists). Nursing Implications: During panic, immediate intervention is required. The nurse’s role is to k​ncbi.nlm.nih.govafe and prevent self-harm or harm to others. Remain with the patient and stay calm; although the patient may not acknowledge your presence, a calm voice can be grounding. Use short commands (“Sit down.” “You are safe. I will help you.”) and repeat them gently【5†L1955-L1963】. Do not attempt any teaching or ask the patient to make decisions – they are incapable of rational thought. If the environment cannot be controlled (e.g. in a busy emergency room), it may be necessary to move the patient to a small, quiet room. Ensure physical needs are met after the peak panic subsides – the patient may be exhausted, dehydrated, or physically hurt from frantic movements. In some cases, short-term use of anti-anxiety medication (e.g. a benzodiazepine) is indicated to break the panic cycle, but any medication should be given in collaboration with the prescribing provider and with careful monitoring.

Key Concept: The body’s stress response (sympathetic nervous system activation) underlies many symptoms of anxiety. Mild and moderate anxiety produce manageable increases in alertness and tension, but severe anxiety and panic trigger a flood of stress hormones that can overwhelm the individual’s coping ability【90†L133-L141】【90†L135-L143】. Nurses must recognize escalating anxiety early and intervene to prevent progression to panic, if possible.

Adaptive vs. Maladaptive Defense Mechanisms

When facing stress and anxiety, people often unconsciously use defense mechanisms to protect themselves from psychological harm. Defense mechanisms are mental processes (often unconscious) that reduce or avoid anxiety by distorting reality in some way【66†L124-L133】【66†L133-L140】. Everyone uses defense mechanisms – they are normal unless used to an extreme.

Adaptive (healthy) defense mechanisms can alleviate anxiety in an acceptable way and help individuals achieve their goals【6†L217-L220】. In contrast, maladaptive defense mechanisms (especially when overused) may distort reality, hinder relationships, or inhibit problem-solving, ultimately exacerbating anxiety or creating other issues【6†L217-L220】. It’s important to note that the adaptiveness of a defense mechanism often depends on context – a mechanism can be helpful in one situation and harmful in another【12†L160-L168】. Below are common defense mechanisms, roughly categorized by their relative adaptiveness:

There are many other named defense mechanisms (e.g. intellectualization – focusing on logic/fact​ncbi.nlm.nih.govion【13†L233-L241】, or undoing – trying to symbolically “reverse” a wrongdoing by an action). The key for nurses is to recognize when a patient might be using a defense mechanism and determine if it’s helping or hindering their coping. Adaptive defenses (like humor, altruism, or seeking support) should be encouraged. Maladaptive defenses that interfere with treatment or safety (like denial of illness, or projection that causes conflict) should be addressed carefully. Often, simply increasing a patient’s awareness of their patterns in a nonjudgmental way (for example, gently pointing out when a patient who is anxious about their illness starts rationalizing or minimizing symptoms) can help them consider new coping strategies. In some cases, referral to counseling for techniques like cognitive-behavioral therapy can help the patient replace maladaptive defenses with healthier responses【66†L96-L104】【66†L131-L139】.

Example – Adaptive vs. Maladaptive: A patient awaiting surgery feels anxious. If they use adaptive mechanisms, they might talk about their fears with family (seeking support) or engage in distraction by watching a funny movie (humor). If they use a maladaptive mechanism, they might refuse to acknowledge the need for surgery at all (denial) or lash out at staff for minor issues (displacement of anxiety as anger). The nurse’s role is to recognize these behaviors and respond therapeutically – e.g., respectfully correcting misinformation (to address denial) or setting gentle limits on aggression while encouraging expression of feelings in a safe manner.

According to psychological research, defense mechanisms can be adaptive or maladaptive depending on severity and context【12†L160-L168】. An occasional use of denial (such as initial shock after a diagnosis) can give a person time to process reality – a transient adaptive use. However, persistent denial is maladaptive. Thus, understanding defense mechanisms helps nurses anticipate patient responses to stress and plan care. For instance, a patient with illness anxiety disorder might use somatization (expressing emotional distress as physical symptoms) as their defense; a nurse would validate the patient’s symptoms and gradually help link them to stressors rather than purely physical causes.

Anxiety-Related Disorders

When anxiety becomes excessive, persistent, or out of proportion to reality, it may be classified as an anxiety disorder. Anxiety disorders are among the most common mental health conditions, affecting up to 30% of adults at some point【67†L381-L389】【67†L405-L413】. Unlike everyday anxiety, anxiety disorders cause significant distress and impairment, and the anxiety does not go away but often worsens over time without treatment【6†L228-L236】【6†L231-L238】. The major anxiety disorders include Generalized Anxiety Disorder (GAD), Panic Disorder, Phobias (including specific phobias and social anxiety disorder), and related conditions like Obsessive-Compulsive Disorder (OCD) (which is now its own category in DSM-5 but historically linked to anxiety). Each disorder has distinctive features, but all share the core theme of excessive fear or worry.

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder is characterized by chronic, excessive worry about multiple aspects of life (work, school, health, finances, etc.) that is difficult to control and persists for at least six months【17†L336-L344】【17†L338-L347】. The worry is significantly disproportionate to the actual likelihood or impact of the feared events. Individuals with GAD oft​ncbi.nlm.nih.govnxiety shifting from one concern to another.

Signs/Symptoms: GAD is accompanied by at least three of the following: restlessness or feeling “on edge,” being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbances【17†L339-L347】【17†L349-L357】. Patients often report feeling tense or keyed up most days. Physical symptoms like trembling, twitching, sweating, nausea, and headaches are common due to prolonged muscle tension and autonomic arousa​ncbi.nlm.nih.gov​ncbi.nlm.nih.govis:** GAD is associated with dysregulation in brain areas like the amygdala and prefrontal cortex, which may lead to overestimating threats. There is often decreased inhibitory neu​ncbi.nlm.nih.govof GABA (which normally calms neural activity) and imbalances in serotonin and norepinephrine. These neurochemical factors contribute to a heightened state of anxiety. Genetics can play a role, and early life stress or trauma is a known risk factor.

Nursing implications: A hallmark of GAD is that the worry is difficult to control and persists despite reassurance. Nursing assessment should identify what the patient’s primary worries are and any precipitants. Encourage the patient to verbalize their concerns – sometimes voicing the “what ifs” can reduce their power. Provide calm, realistic reassurance without dismissing the patient’s feelings (e.g., “I understand you feel very anxious about all these things. Let’s talk through them.”). Because GAD patients may also have physical symptoms like insomnia or GI upset, address those (e.g., offer relaxation techniques for muscle tension, suggest avoiding excessive caffeine which can heighten anxiety). Education is important: explain that GAD is a recognized condition that can be treated, which can itself be relieving (the patient might feel “I’m not alone or crazy for feeling this way”). On a medical-surgical floor, for example, a GAD patient might constantly hit the call bell with worries – in such cases, a scheduled brief check-in by the nurse can pre-empt constant calls and provide the patient a sense of security. Treatment typically includes psychotherapy (especially Cognitive Behavioral Therapy) and/or medication (SSRIs or buspirone are first-line, with short-term benzodiazepines only if absolutely needed)【44†L33-L41】【44†L61-L69】. Teach the patient about breathing exercises and grounding techniques for when worry escalates. Over time, help them learn to challenge their anxious thoughts (CBT techniques) and practice coping strategies.

Example: A 40-year-old patient with GAD might say, “I can’t stop worrying that something will go wrong – my job, my kids, my finances, everything.” The nurse can respond, “It sounds exhausting to feel on edge about so many things. Let’s take them one at a time. Right now, in the hospital, your job and finances are stable for the moment. Your focus can be on recoverin​aafp.org involve the hospital social worker if you need help with bills or time off. How are you feeling right now physically?” This approach acknowledges the patient’s worries and provides concrete reassurance and resources, helping to contain the anxiety.

Panic Disorder

Panic Disorder involves recurrent, unexpected panic attacks, along with persistent concern about having more attacks or changing behavior to avoid them【18†L436-L444】【18†L446-L454】. A panic attack is a sudden surge of intense fear or discomfort that peaks within minutes, accompanied by at least four of the classic symptoms: palpitations, sweating, trembling, shortness of breath, choking sensation, chest pain, nausea, dizziness, chills or hot flashes, paresthesias (numbness/tingling), derealization or depersonalization, fear of losing control or “going crazy,” or fear of dying【18†L400-L408】【18†L417-L425】. During a panic attack, people often truly feel they are in mortal danger – many first-time attacks lead patients to seek emergency care for what they believe is a heart attack or other life-threatening event.

In Panic Disorder, these attacks occur “out of the blue,” not in response to a specific phobic stimulus (though they can become associated with certain situations over time). After an attack, the individual worries persistently about having another or the implications (“Am I losing my mind? What if I collapse in public?”) and/or they avoid places or activities for fear they might trigger an attack【18†L436-L444】. This concern and avoidance must last at least one month for the diagnosis【18†L436-L444】.

Signs/Symptoms: Beyond the acute panic attacks themselves, patients with panic disorder often develop anticipatory anxiety – a chronic nervousness about when the next attack will strike. They may start avoiding situations like driving, being in crowds, or leaving home (if they associate those with prior attacks). Agoraphobia (fear of being in places where escape might be difficult or help unavailable) can develop in about one-third of patients with panic disorder【18†L447-L454】【18†L478-L485】. For example, a person might refuse to go to the mall or open spaces due to fear of panicking there. Patients may also excessively seek medical tests to rule out other causes (desperate for reassurance that nothing is physically wrong).

Neurobiological basis: Panic attacks are a false alarm of the body’s emergency response. The locus coeruleus in the brainstem (a major norepinephrine center) is implicated in triggering panic, as are dysfunctions in the amygdala and respiratory control centers. Some individuals with panic disorder have heightened sensitivity to carbon dioxide levels or breathing changes – known as “false suffocation alarm.” There is evidence of genetic predisposition. Neurotransmitters involved include norepinephrine (elevated in panic), serotonin, and GABA (likely reduced, hence why benzodiazepines which enhance GABA can abort panic).

Nursing implications: During a panic attack, the nursing priority is to stay with the patient and ensure safety. Panic attacks are terrifying; the patient may genuinely believe they are dying. Remain calm and reassure the patient that the symptoms, while frightening, are not immediately dangerous (after ruling out medical issues). Use short phrases such as “I know this is scary, but you are not having a heart attack. This will pass. I will stay with you.” Encourage the patient to slow their breathing – coach breathing by counting or using a paper bag if hyperventilation is severe. It can help to have the patient focus on you: “Look at me and breathe with me.” Simple grounding techniques (having them feel the chair, touch an object) can reduce feelings of unreality. Once the acute panic subsides, provide a quiet environment for recovery (dim lights, minimal stimulation).

Long-term, educate the patient about panic disorder: the fight-or-flight symptoms, how panic attacks can be managed and are treatable. Many patients feel embarrassed or fearful of future attacks; teach them relaxation techniques to practice daily (deep abdominal breathing, progressive muscle relaxation) so that these become second nature if an attack starts. Encourage compliance with treatment: SSRIs or SNRIs are first-line medications for preventing panic attacks (typically starting at low doses to avoid initial agitation), and cognitive-behavioral therapy (CBT) – especially panic-focused CBT – is highly effective【44†L33-L41】【44†L69-L72】. CBT often involves interoceptive exposure (therapist-guided exposure to panic-like sensations, such as spinning in a chair to induce dizziness, so the patient learns those sensations are not dangerous). Beta-blockers (e.g. propranolol) might be used situationally if triggers are known, though they’re more common for performance anxiety. If the patient has agoraphobia, a gradual exposure therapy plan will be needed to regain lost ground – for example, first stepping outside the home with a trusted person, then a short trip to the store, etc., slowly reducing avoidance. Nursing should involve developing a plan with the patient: identify safe coping statements (“This​aafp.org​aafp.orgd it before.”) and perhaps using a scale for anxiety so they can communicate when they feel panic rising.

Case in point: Panic disorder often first presents in young adulthood. A college student experiencing their first panic attack in class might suddenly feel palpitations, sweating, shortness of breath, and intense fear of collapsing. The school nurse or responding clinician will find no cardiac issues and recognize these as panic symptoms. Explaining this to the student (“Your heart tests are normal. What you had is called a panic attack, and it can happen even when you’re not truly in danger.”) is crucial. Many panic disorder patients go from doctor to doctor convinced something is undetected inside them; a nurse’s empathetic explanation can help break that cycle and direct them to appropriate help (like therapy). Panic disorder patients are often relieved to hear that their terrifying symptoms are a known, treatable condition and that they are not “going crazy.”

Phobias

A phobia is an intense, irrational fear of a specific object, situation, or activity that is actively avoided or endured only with extreme anxiety【18†L454-L462】【18†L470-L477】. The fear is out of proportion to the actual danger posed. Exposure to the phobic stimulus almost invariably provokes immediate anxiety or a panic attack. Common specific phobias include animals (e.g. spiders – arachnophobia【18†L458-L462】, snakes), natural environments (heights, storms, water), blood-injection-injury (needles, seeing blood – which can uniquely cause a vasovagal faint response rather than tachycardia), and situational (flying, elevators, enclosed spaces). By definition, the person recognizes the fear is excessive or unreasonable (except perhaps in young children), yet they feel powerless to control it【69†L13-L16】. To be diagnosed, the phobic avoidance or fear must significantly impair the person’s life or cause marked distress, and typically last 6 months or more【18†L470-L477】.

Signs/Symptoms: When confronted (or anticipating confrontation) with the phobic stimulus, the person experiences anxiety symptoms often similar to a panic response: heart racing, sweating, shortness of breath, etc., or in milder cases just intense dread. The individual goes to great lengths to avoid the feared object or situation. For example, someone with a driving phobia may completely avoid driving, or a person with a dog phobia might only walk on routes they know are dog-free. Even talking about or seeing pictures of the feared object can trigger anxiety. Children with phobias might cry, tantrum, freeze, or cling to a parent when faced with the stimulus【17†L370-L378】【17†L380-L387】.

One important phobia subtype is Social Anxiety Disorder (Social Phobia) – fear of social or performance situations where one might be scrutinized or negatively evaluated by others【17†L370-L378】. People with social anxiety disorder fear acting in a way that will embarrass or humiliate them (e.g., saying something foolish, showing anxiety symptoms like blushing or trembling). Common feared situations include public speaking, meeting strangers, eating or writing in front of others. This can lead to avoidance of school, work presentations, or social gatherings. Social anxiety disorder often emerges in the teens and can significantly impair academic or occupational functioning if severe.

Another is Agoraphobia, which is often linked with panic disorder but can be diagnosed separately. Agoraphobia is the fear of being in situations where escape might be difficult or help unavailable if one develops panic-like symptoms【18†L447-L454】【18†L478-L485】. Classic agoraphobic fears include using public transportation, being in open spaces (parking lots, bridges) or enclosed spaces (theaters), standing in line or being in a crowd, or being outside of home alone【18†L478-L485】. The person avoids these or needs a companion. In extreme cases, individuals become essentially homebound.

Neurobiological basis: Phobias often develop through a combination of classical conditioning (a frightening experience paired with an object – e.g., being bitten by a dog leading to dog phobia), observational learning (seeing someone else harmed or fearful), and genetic predisposition (some people have more anxious temperaments). The amygdala and fear circuitry in the brain are involved – the phobic object triggers an amygdala alarm response out of proportion. There may be evolutionary preparedness for some phobias (snakes, heights historically posed threats).

Nursing implications: When caring for a patient with a known phobia, respect their fear and avoid exposing them to the trigger without preparation. If a hospital patient has a needle phobia, for example, find ways to ease blood draws (topical anesthetics, having them lie down, distraction techniques). Do not belittle the fear (“Oh come on, it’s just a tiny dog, it can’t hurt you”) – phobic individuals know intellectually the object isn’t truly dangerous, but their anxiety is involuntary. Instead, use empathy: “I understand that even though you logically know the dog is harmless, it causes you real panic. Let’s focus on how you can stay calm.” In an acute setting if the phobic stimulus is present (like the patient with arachnophobia spots a spider in the room), promptly address it (remove the spider) and then assist the patient with calming down.

The mainstay treatment for phobias is therapy, especially Exposure Therapy【44†L69-L72】. Systematic desensitization (gradual exposure paired with relaxation) or flooding (intense sustained exposure, used less often) are techniques to extinguish the fear response. Nurses in mental health settings may collaborate in exposure exercises – for instance, practicing holding a toy snake before looking at a real snake, etc., under a therapist’s guidance. For social anxiety disorder, CBT focusing on cognitive restructuring of negative self-beliefs and social skills training is effective. Group therapy can also help, as patients slowly engage with a safe social group. Medications are generally adjunctive. For predictable phobic situations (like flying, or MRI procedures in claustrophobia), a one-time dose of a benzodiazepine or a beta-blocker (like propranolol) can reduce autonomic symptoms. SSRIs may be prescribed for social anxiety or agoraphobia especially if panic disorder co-exists.

Patient education: Teach patients about the high success rate of exposure therapies – many are understandably avoidant of treatment because it involves facing their fear. Motivate them by sharing that phobias are very treatable and that facing the fear in a controlled way can retrain their brain’s response. If the patient is in ongoing therapy, encourage them to follow through with homework assignments (e.g. practicing a relaxation technique or a small exposure step) and celebrate their successes in confronting fears.

Obsessive-Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder is characterized by the presence of obsessions, compulsions, or both, which are time-consuming (taking more than an hour a day) or cause significant distress or impairment【20†L988-L996】【20†L1002-L1009】. Obsessions are unwanted, intrusive thoughts, urges, or images that cause marked anxiety or distress【20†L1015-L1023】. Common obsessions include fears of contamination (germs, dirt), recurring doubts (wondering “did I turn off the stove?” repeatedly), a need for symmetry or exactness, or aggressive or horrific impulses (e.g., a sudden image of harming one’s child, which is very disturbing to the person). The individual typically attempts to ignore or suppress obsessions, or neutralize them by performing a compulsion. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rigid rules【20†L1024-L1032】. The behaviors are aimed at reducing anxiety or preventing a feared event, but they are excessive or not realistically connected to what they are intended to prevent【20†L1024-L1032】. For example, a person obsessed with germs may wash hands for hours; someone with an obsession about things being in order might arrange and rearrange items constantly until “it feels right.”

Signs/Symptoms: Common compulsions include excessive cleaning (handwashing, cleaning household items)【20†L1026-L1034】, checking (doors locked, appliances off)【20†L1032-L1038】, counting, repeating actions a certain number of times, arranging objects symmetrically, or mental compulsions like praying or repeating words silently. The content of obsessions and compulsions can vary widely:

Individuals with OCD usually have insight – they know their obsessions are a product of their own mind and recognize that their compulsions are excessive or unreasonable, yet they feel unable to stop【21†L1064-L1072】. This insight can vary (some have “poor insight” and firmly believe their compulsions will prevent disaster)【21†L1064-L1072】. Importantly, performing the compulsion temporarily relieves the anxiety caused by the obsession, which negatively reinforces the behavior. OCD can consume a person’s life – for example, someone may spend hours getting ready due to ritualized dressing, making them late to work consistently (occupational impairment)【20†L1004-L1011】【20†L1039-L1047】. Relationships can suffer (family members might become involved in enabling rituals, or become frustrated).

Neurobiological basis: OCD has a significant biological component. Brain imaging shows abnormal activity in the cortico-striato-thalamo-cortical (CSTC) circuits, particularly increased metabolism in the orbital frontal cortex, cingulate gyrus, and caudate nucleus【21†L1085-L1093】. Serotonin is strongly implicated – hence SSRIs at high doses can alleviate symptoms. Genetics play a role; OCD tends to run in families. There is also a subtype of childhood-onset OCD associated with streptococcal infection (PANDAS), suggesting an autoimmune process affecting the basal ganglia【21†L1093-L1101】. Psychologically, people with OCD often attach extreme significance to their thoughts (thinking “having this terrible thought is as bad as doing it”), a phenomenon called “thought-action fusion,” which fuels anxiety and ritualizing.

Nursing implications: When caring for a person with OCD, it’s important to assess both obsessions and compulsions. Often patients are embarrassed and may try to hide their symptoms. Provide a nonjudgmental environment so they feel safe discussing their intrusive thoughts or rituals. Do not abruptly stop a compulsion when the patient is in the midst of one – preventing a ritual without helping the patient cope will spike their anxiety. For example, if a patient is repeatedly checking a door lock, simply telling them “stop it” is likely to cause panic or anger. Instead, during initial treatment allow time for rituals, and gradually work on decreasing them. In an acute care setting, you might schedule periods for the compulsive behavior, gradually shortening them, to help the patient feel some control (e.g., “You can have 10 minutes to wash your hands after meals” if they usually take 30 minutes). Ensure basic needs are met – OCD rituals can take priority over eating, sleeping, etc., so the nurse may need to structure the schedule (e.g., “Let’s eat first, then you can spend 15 minutes on your ritual.”).

Teach the patient grounding techniques or alternative behaviors to manage urges. For instance, delay technique (“try to wait 5 minutes before starting your ritual”) and breathing exercises when anxiety hits. Praise any success in resisting or shortening rituals – positive reinforcement helps. When the patient is not highly anxious, engage in cognitive discussion: help them examine the likelihood of their fear coming true, or the impact the OCD has on their life. However, avoid logical debates during an obsession’s peak – their anxiety is too high for rational talk at that moment.

Medications: As mentioned, SSRIs (such as fluoxetine, sertraline, paroxetine, fluvoxamine) are first-line pharmacotherapy for OCD and o​ncbi.nlm.nih.govdoses than used for depression【22†L1120-L1128】. It can take 10-12 weeks to see significant improvement【22†L1118-L1125】, so encourage adherence even if results are not immediate. Clomipramine (a tricyclic) is another effective agent, often used for treatment-resistant cases. If a patient has co-occurring tic disorder, an antipsychotic may be added in low dose【22†L1120-L1128】. Ensure the patient knows that initially SSRIs may cause some side effects and that continuing the medication is important for full benefit.

The gold standard therapy is Exposur​ncbi.nlm.nih.gove Prevention (ERP), a form of CBT specifically for OCD【22†L1133-L1141】. In ERP, the patient is systematically exposed to the source of their obsession (e.g., touching something “contaminated”) and then prevented from performing the compulsion (not allowing immediate handwashing), learning over time that the anxiety will abate without the ritual and that no catastrophe follows【22†L1133-L1141】. This is challenging therapy but highly effective. As a nurse, if involved in outpatient care or collaborating with therapists, encourage the patient through this process, help them with relaxation techniques to manage the anxiety during exposure, and celebrate the small victories (like touching a doorknob and waiting 5 minutes to wash).

Patient teaching: OCD patients and families benefit from education that OCD is a biologically-based illness – it is *n​ncbi.nlm.nih.gov being “crazy” or “immoral” (especially when obsessions are aggressive or sexual in nature, patients may feel ashamed). Emphasize that having a horrific tho​ncbi.nlm.nih.govan they will act on it – it’s a symptom of OCD. Family therapy or education can help relatives not to participate in rituals (like not providing endless reassurance or checking for the patient, which can reinforce OCD). Instead, family can support by reminding the patient of therapy strategies and encouraging them in a calm way.

Nursing Priority for OCD: Ensure safe performance of compulsions and gradually set limits as tolerated. For example, a compulsive hand-washer may harm their skin – the nurse can provide a mild soap or moisturizer and gently guide them to wash less frequently by scheduling and positive feedback. The priority is not to eliminate the behavior overnight, but to prevent self-harm and start building alternative coping mechanisms for anxiety. Over time, with effective therapy and possibly medication, the goal is that the patient will spend less time on rituals and regain normal routines【20†L1039-L1047】【20†L1043-L1051】.

Dissociative Disorders

Dissociative disorders involve a disruption or discontinuity in consciousness, memory, identity, or perception of the self【25†L193-L201】【25†L205-L213】. In essence, dissociation is a defense mechanism where the mind “compartmentalizes” or separates certain memories or thoughts from normal consciousness in response to overwhelming stress or trauma. These disorders are often linked to severe trauma, especially in childhood, as a way to cope with experiences that are unbearable. The three major types are Depersonalization/Derealization Disorder, Dissociative Am​coryabarnes.medium.com​coryabarnes.medium.comugue), and Dissociative Identity Disorder (DID)【25†L195-L203】【25†L197-L200】.

Depersonalization/Derealization Disorder

In Depersonalization/Derealization Disorder, the person experiences episodes of feeling detached from themselves (depersonalization), from their surroundings (derealization), or both. Depersonalization is described as feeling like an outside observer of one’s own thoughts, body, or actions – as if one is in a dream or not really inhabiting one’s body. Patients often say things like, “It’s like I’m watching myself in a movie,” or “I feel unreal, like a robot.” Derealization is a sense of unreality or strangeness of the environment – people or objects may seem foggy, lifeless, or visually distorted. Example: A patient in a busy ER after an accident might suddenly feel like “this isn’t actually happening” and that the room or people aren’t real – a derealization episode.

During these episodes, reality testing remains intact – the person knows these feelings are not actually true, which differentiates depersonalization/derealization from psychosis. They know, for instance, that they are not truly a robot or in a dream, but feel that way. This insight can actually cause distress: they might fear they are “going crazy” because they have such bizarre sensations. Episodes can last just moments or recur over years. Onset is often in adolescence, and episodes may be triggered by severe stress, trauma, fatigue, or intoxication (certain drugs can precipitate similar feelings).

Nursing implications: Patients experiencing depersonalization/der​ncbi.nlm.nih.gov​ncbi.nlm.nih.govly aloof or anxious and might have trouble expressing what’s wrong (“I just feel not real”). The nurse should stay calm and provide grounding. Grounding techniques help reorient the person: for example, have them hold a cold object (to feel sensation), describe their surroundings in detail, or engage in physical activity like walking. Gently reassure them: “You are here with me, I know it feels strange, but you are safe.” Avoid arguing about the feeling (don’t say “Snap out of it, you are real” – they know that logically, but the feeling persists). Instead validate that it’s a known phenomenon that can happen under stress. Reduce environmental stressors if possible (lower noise, offer a quiet space). If episodes are frequent, assess for a history of trauma or current extreme stress – these often underlie dissociative symptoms.

Treatment of depersonalization/derealization is typically psychotherapy (such as grounding techniques in therapy, trauma-focused therapy if relevant, sometimes cognitive techniques to address the distress about the episodes). No specific medication stops the episodes, but treating co-occurring anxiety or depression can help (SSRIs or mood stabilizers may be used in some cases). Educate patients that while the sensations are disturbing, they are not dangerous and often worsen with anxiety about them – learning relaxation and distraction when episodes start can shorten the duration.

Dissociative Amnesia (with Fugue)

Dissociative Amnesia is characterized by an inability to recall important autobiographical information, usually of a traumatic or stressful nature, that cannot be explained by ordinary forgetfulness【75†L213-L220】【75†L215-L223】. It’s more extensive than typical “I forget things when I’m stressed.” For example, a person may have no memory of an entire violent assault they experienced, or a combat veteran mi​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. The memory loss is most often localized (a specific event or period is wiped out) or selective (bits and pieces of an event are forgotten)【75†L215-L223】. In rarer cases it can be generalized – the person forgets their entire life history (who they are, where they live, etc.)【75†L215-L223】【75†L221-L228】. The onset is usually sudden, following severe psychosocial stress or trauma.

A specifier of this disorder is Dissociative Fugue【75†L215-L223】【75†L231-L239】. In a fugue state, an individual with dissociative amnesia unexpectedly travels away from home or work (sometimes even hundreds of miles) and may assume a new identity, all while being amnesic for their past (they do not remember who they really are or details of their life)【75†L229-L238】【75†L231-L239】. Fugue states can last hours to months. For example, a man disappears after a traumatic event; weeks later he’s found in another state working under a different name, with no memory of his life before. When the fugue ends, the previous memories return but there is often amnesia for the fugue period.

Signs/Symptoms: Aside from the memory loss, the person may appear confused, perplexed, or in fugue may seem to be wandering aimlessly. Often, once they are in a safe environment, memories might spontaneously return, or at least partial recall happens. During the amnesic phase, they may experience significant distress or, conversely, they may have a la belle indifférence-like calm (particularly in fugu​ncbi.nlm.nih.govloss of memory, which itself is notable. It’s crucial to rule out neurological causes for memory loss (like seizures, brain injury, or intoxication) – dissociative amnesia is a diagnosis of exclusion after medical workup is negative.

Nursing implications: In a protected environment (like a hospital), gentle support and safety are key. Do not pressure the patient to remember. Memory may return on its own, and pushing recall too quickly can provoke anxiety or distress. Instead, orient the person to who they are (if known) and maintain a calm, simple routine. If the patient doesn’t remember their identity at all, treat them as you would any patient – with respect and reassurance that you will keep them safe while things are sorted out. Ensure safety especially if the person is distressed by their lack of memory (risk of self-harm or panic). Once medical causes are ruled out, involve mental health professionals. Techniques like guided imagery, hypnosis, or interviews with drug facilitation (like a sedative interview) are sometimes used by speci​ncbi.nlm.nih.gov​ncbi.nlm.nih.govies carefully, but these are beyond a nurse’s scope. The nurse, however, might facilitate by providing a quiet, trusting environment for such therapy sessions.

Educate family (if present​aafp.org​aafp.orgred – seeing a loved one not recall them is hard; they should gently reintroduce themselves and share memories with​psychiatry.org​psychiatry.orgnt. Over time, psychotherapy will work on uncovering and processing whatever trauma led to the amnesia so that the patient can saf​ncbi.nlm.nih.gov​ncbi.nlm.nih.govport by encouraging expression of feelings as memory returns and monitoring for depression or PTSD sy​nurseslabs.com​nurseslabs.comh returned memories.

Most dissociative amnesias resolve spontaneously, especially when the person is removed from the stressful situation. Once m​ncbi.nlm.nih.gov, the person is at risk for distress, shame, or depression related to what they recall or actions during the fugue. Provide emotional supp​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov for coping with the precipitating trauma, which is often necessary to prevent future episodes.

Dissociative Identity Disorder (DID)

Formerly known as Multiple Per​ncbi.nlm.nih.gov​ncbi.nlm.nih.govissociative Identity Disorder is perhaps the most extreme outcome of dissociation. It is defined by the presence of two or more dist​ncbi.nlm.nih.gov​ncbi.nlm.nih.govidentities that recurrently take control of the individual’s behavior, accompanied by inability to recall important personal information coryabarnes.medium.com​coryabarnes.medium.comle by ordinary forgetfulness【75†L211-L218】. These personality states (often called “alters”) may have their own name, age, gender, posture, memories, and behaviors. Typically there is a “host” personality (often the one corresponding to the perso​frontiersin.org​frontiersin.orge unaware of the others) and one or more “alters” which can differ in remarkable ways. Transitions between identities (sometimes called “switching”) are often triggered by stress, and can be sudden (within seconds) or gradual.

**Signs/Symptoms:​ncbi.nlm.nih.govth DID might refer to themselves in the first person plural (“we”) or in third person, or be observed speaking in different tones or accents at different times. Others might notice unexplained changes in attire, handwriting, or skills (one identity might be right-handed and anothe​ncbi.nlm.nih.gov​opentextbc.cale). There are often episodes of amnesia – the person “loses time” when an alternate identity is in control, leading to memory gaps for certain events (they might find objects or notes they don’t remember, or be called by a different name by someone who met them during a switch). It’s common for individuals with DID to have associated symptoms like depression, flashbacks of trauma, nightmares, and self-harm or suicidal tendencies (some identities may harbor intense trauma memories or negative beliefs). Importantly, in some cultures these experiences may be seen or explained as possession by a spirit or other being【75†L211-L218】. In fact, DSM-5 notes that in some cultures, the alternate identity may be interpreted as an experience of possession (which still meets criteria if it’s involuntary and distressing)【75†L211-L218】.

Etiology: DID is strongly linked to severe, chronic childhood trauma – often repeated physical or sexual abuse at an early age, or other profound neglect/trauma【31†L133-L141】【31†L135-L144】. The prevailing theory is that a young child, unable to physically escape horrific abuse, copes by “escaping” in their mind – i.e., dissociating. Over time, dissociated memories and feelings form separate identities. Each identity may serve a function (for instance, one might hold anger, another might function in daily life, another might come out to handle sexual abuse, etc.). DID is a controversial and complex disorder, but it is recognized as a genuine condition in DSM-5, distinct from culturally normative possession or from psychotic disorders (in DID, the different identities are not hallucinations; they are dissociated parts of self).

Nursing implications: Establishing trust and safety is the absolute foundation when working with DID. These patients have often experienced extreme betrayal of trust in childhood, so a consistent therapeutic relationship is key. The nurse may initially interact with what appears to be the host or one identity, but should be prepared that other identities may emerge especially under stress or triggers. Do not show shock or judgment when an identity switches. For example, if an alter that is a young child comes out (speaks in a childlike voice), the nurse can gently engage at that level – perhaps comforting the “child” alter with a soft tone and assuring safety. It’s not helpful to insist on speaking to the “real” person at that moment; instead, meet the patient where they are. Over time, as trust builds, the patient (with therapy) will work toward more communication and cooperation between identities.

Safety is a priority: some identities might have self-destructive tendencies or carry traumatic memories that overwhelm them. Suicide risk assessment is crucial because DID patients have high rates of self-harm and suicide attempts. If an identity expresses suicidal thoughts, take it as seriously as if the whole person does – because any part in control could act on those thoughts. Ensure the environment is free of means for self-harm if such risk is present.

Grounding techniques are useful for all dissociative disorders – help the patient stay in the present. If the patient begins to dissociate or switch due to a trigger (say they start to “drift off” or you notice a change in demeanor indicating a switch), use grounding: “You’re here now, at the hospital, and it’s [date]. I’m [Name], your nurse. You are safe.” Simple sensory grounding (holding an ice cube, focusing on the details of the room) can help.

Do not force recollection of trauma. Intensive trauma processing is the domain of a skilled therapist over a long time. The nurse should instead ensure the patient has coping strategies for dealing with any flashbacks or emotional floods that come with recollections. Assist with stress management: patients with DID benefit from learning calming strategies (deep breathing, mindfulness) to reduce unplanned switching.

Collaboration with the treatment team is important. The primary treatment for DID is long-term psychotherapy aimed at integrating the identities or at least achieving harmonious co-existence. Some patients may not fully “merge” identities but learn to manage transitions such that their life is not chaotic. Pharmacologic treatment is usually symptom-targeted (e.g., antidepressants for depression, prazosin for PTSD-related nightmares, etc.) – there is no medication that “cures” DID, but comorbid conditions (anxiety, depression) often require treatment. Educate about medications as you would normally, being mindful that some identities may be unaware of others’ medication compliance (so implementing cues like daily pill boxes and written schedules can be useful).

Family or social support can be tricky. If family were perpetrators of abuse, obviously they may not be involved. But if supportive family exist, they should learn about DID so they don’t panic if a switch happens and so they can help the patient with grounding and safety.

Finally, maintain professional boundaries and consistency. Patients with DID might unconsciously re-enact interpersonal dynamics – for instance, one identity might become very attached to a nurse as a “safe parent” figure, while another identity might distrust the nurse. Team communication (consistent approaches among staff) will help avoid splitting. Document observations objectively (e.g., “Patient spoke in a noticeably different tone and referred to self as ‘Jenny’ (third person) for about 20 minutes, then was unable to recall this period”). This helps the treatment team track identity shifts and possibly communicate with the treating therapist about patterns.

Trauma-informed approach: All care for DID must be trauma-informed (see section on Trauma-Informed Care). The existence of DID implies extreme trauma history. Ensure the patient has control and choice whenever possible in their care to counter the powerlessness they felt in childhood. For example, ask for preferences (Which arm do you prefer for an IV? Is it okay if I touch your shoulder to help guide you back to bed?). Always explain procedures and never force anything unless absolutely medically necessary, as these patients can be easily re-traumatized by feelings of being helpless or confined. Simple measures like asking permission before a physical exam and allowing a support person (if appropriate) during anxiety-provoking situations can make a big difference.

Somatic Symptom and Related Disorders

In Somatic Symptom and Related Disorders, individuals experience physical symptoms that cannot be fully explained by a medical condition, and these symptoms are associated with excessive thoughts, feelings, or behaviors related to the symptoms【33†L96-L104】. The suffering is real for the patient, even if medical tests are normal. These disorders lie at the interface of medicine and psychiatry – often patients first present in primary care or specialty clinics with physical complaints. It’s essential for nurses to recognize these disorders so patients can be treated with empathy and appropriate interventions rather than unnecessary medical procedures.

The major disorders in this category are Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder (Functional Neurological Symptom Disorder), and Factitious Disorder (including Munchausen syndrome). (Note: Malingering – faking illness for external gain – is not a psychiatric disorder, but it may be considered in differential diagnosis.)

Somatic Symptom Disorder (SSD)

In Somatic Symptom Disorder, the patient has one or more physical symptoms – which may have an identified medical cause, or may not – but importantly, the patient’s thoughts and anxiety about the symptoms are excessive and disproportionate【33†L96-L104】. The individual spends an extreme amount of time and energy on health concerns, often to the detriment of other aspects of life. Symptoms can be specific (like localized pain) or vague (fatigue). The key is the psychobehavioral features: persistent thoughts like “This symptom must mean I have a terrible disease,” high levels of anxiety about health or symptoms, and/or excessive time devoted to symptoms (repeated doctor visits, medical tests, researching).

A patient with SSD might, for example, have years of fluctuating pain in various body parts and truly suffer from it, constantly seeking an explanation even after many normal workups. In DSM-IV, this might have been labeled “somatization disorder” or “pain disorder,” but DSM-5 combined these into SSD【33†L100-L109】. Many patients previously labeled as “hypochondriacs” actually fall under SSD if they have prominent somatic symptoms (as opposed to just health anxiety without symptoms, which is Illness Anxiety Disorder).

Signs/Symptoms: Common somatic symptoms include pain (headaches, back pain, joint pain), gastrointestinal problems (nausea, bloating), cardiopulmonary symptoms (shortness of breath, palpitations), or neurologic-like symptoms (weakness, dizziness). The symptoms may change over time but there is almost always something troubling the patient. The patient often has a long, complicated medical history file – multiple diagnostic tests (often all negative) and specialist evaluations. They frequently seek reassurance but the reassurance never reduces their worry for long – soon after tests come back normal, they may shift focus to another symptom or suspect a different illness. They might also be very sensitive to medication side effects (reporting many adverse reactions). It is not uncommon for these patients to become frustrated with the medical system, feeling dismissed or that “no one can find what’s wrong with me.”

Neurobiological and psychosocial basis: There is evidence that somatic symptom disorder patients experience heightened body sensation awareness and may have a low threshold for perceiving physical discomfort. Some research suggests abnormal brain activation in regions processing emotions and pain. Psychologically, often these patients have difficulty expressing emotional distress, and it gets channeled into physical symptoms (sometimes called somatization). A history of trauma or illness in the family can be risk factors. It’s important to note the symptoms are not deliberate – the patient isn’t “faking.” The pain or symptom is real to them, but it stems from a complex mind-body interaction.

Nursing implications: The first step is a thorough assessment to validate that appropriate medical evaluation has been done. Nurses should ensure we’re not missing a medical condition. Assuming serious pathology is ruled out, the focus turns to addressing the patient’s health concerns in a supportive way without reinforcing maladaptive behavior. It’s a delicate balance. Establish one primary care provider if possible (to avoid doctor-shopping and repeated tests); as a nurse, communicate closely with that provider. Treatment often uses the strategy of regularly scheduled brief visits rather than symptom-driven visits【33†L96-L104】. For example, the patient is seen once a month to discuss how they’re doing, rather than every time a new symptom arises – this provides consistent support but reduces urgent medical utilization.

During interactions, listen empathically. These patients often feel nobody believes them. A validating statement like, “I know you’re experiencing real pain and it’s affecting your life,” can build trust. Avoid dismissive comments like “It’s all in your head.” Instead, you might say, “Stress and emotions can actually cause or worsen physical symptoms. Let’s look at all factors that might be influencing your health.” Help the patient make connections gently: “I notice your worst flare-ups happened after your divorce proceedings – what do you think about that?” Some patients will resist a psychological explanation; don’t force it, but persist in holistic care.

Encourage gradual shift of focus from symptoms to functioning. For example, instead of asking each visit, “How is your pain scale today?” ask “What activities were you able to do this week?” Even if pain persists at a 5/10, perhaps they managed to go grocery shopping or attend a social event. Praise improvements in function. Set small goals, like walking for 10 minutes a day, even if pain is there, reinforcing that increasing activity safely will not harm them even if it’s uncomfortable. Over time this can reduce the disability.

Limit setting may be needed on excessive healthcare behaviors. For instance, if a patient wants a fourth MRI this year, the provider might say, “We have done thorough testing which is normal. We will not do more scans at this time; instead, we will work on managing your symptoms.” The nurse can support this by explaining the concept of sensitization – more tests can sometimes make anxiety worse or even cause harm (false positives, radiation exposure), and it’s better to focus on coping.

Introduce the idea of mental health referral carefully: frame therapy as a way to help with stress resulting from their symptoms, rather than “because it’s all psychological.” For example, “Chronic symptoms can take a toll on mood and coping – our counselor is really good at helping people find ways to feel better emotionally, which often helps physically too.” Therapies like CBT have evidence for somatic disorders【33†L96-L104】, aiming to reduce catastrophizing about symptoms and improve daily functioning. Nurses can underline that mind-body approaches (relaxation training, biofeedback, stress management) have been shown to reduce physical symptoms even in other conditions (like blood pressure or chronic pain), so it makes sense to try.

On the medical side, avoid invasive procedures or habit-forming drugs unless absolutely indicated. Somatic symptom patients can become frequent users of pain meds or anxiolytics – which can lead to dependency without truly addressing the underlying issues. Work with the team to use non-pharmacological pain management as much as possible (heat packs, gentle exercise, PT, relaxation). If medications are used, SSRIs or SNRIs might help by treating underlying anxiety/depression, and sometimes they have a secondary benefit of pain modulation (e.g., duloxetine for fibromyalgia-like pain).

Document objectively the symptoms and the results of exams. This helps show patterns and also protects against over-testing. Also note the patient’s affect and any stressors mentioned at visits.

Patient education: Teach the patient about the concept of the mind-body connection in a non-stigmatizing way. For instance: “Have you ever had butterflies in your stomach when nervous? That’s a classic example of how stress can cause a real physical feeling. We think something similar might be happening with your symptoms – your body is under a lot of stress which can cause real pain, even if scans are normal. The good news is, by working on stress and coping, you may actually feel better physically.” Over time, the patient may come to accept psychological contributors. Encourage small shifts like engaging in enjoyable activities despite symptoms (to prevent total life takeover by illness).

Illness Anxiety Disorder (Hypochondriasis)

Illness Anxiety Disorder is essentially health anxiety in the absence of significant somatic symptoms. The person is excessively worried that they have or will get a serious illness, even though they may have few or no physical symptoms【36†L96-L100】【36†L122-L130】. Any mild symptom (like a minor cough or a mole) is interpreted as a sign of severe disease (like lung cancer or melanoma). If somatic symptoms are present at all, they are very mild, and it’s the anxiety that is prominent. This disorder was previously known as hypochondriasis (though DSM-5 split hypochondriasis into Illness Anxiety vs Somatic Symptom disorders depending on whether physical symptoms are present)【33†L100-L107】.

Signs/Symptoms: Individuals with illness anxiety frequently check their bodies for signs of illness – e.g., examining skin moles repeatedly, checking pulse or blood pressure often. They might constantly seek reassurance from doctors, friends, or the internet (which often backfires; reading about diseases can increase their conviction that they have them). Alternatively, some have a maladaptive avoidance – they avoid doctor appointments or hospitals for fear of finding out they have dreaded diseases. They typically have a long history of anxiety about health, often dating to early adulthood, and it can wax and wane. For example, a person might be convinced they have ALS after feeling muscle twitches, then after tests are normal they shift to fearing multiple sclerosis when they get a headache, etc. Their level of worry is disproportionate – normal test results or medical opinions do not calm them, or only briefly do so (“the tests miss something”). They often research diseases excessively. It’s not delusional (they can imagine being ill but also can at times acknowledge the possibility they are overreacting), and it’s not just general anxiety – it’s specifically health-focused.

Nursing implications: Patients with illness anxiety might present similarly to those with somatic symptom disorder (frequent healthcare visits), but the difference is minimal physical findings. They are coming more for evaluation of feared illnesses than for relief of actual symptoms. They often require frequent reassurance, but giving reassurance directly can become a trap (they soon doubt it). A technique used in therapy and can be supported by nursing is to shift the goal from seeking 100% certainty about health (impossible) to coping with uncertainty. For example, if a patient says “I just need another MRI to be sure I don’t have a brain tumor,” one could respond: “It sounds like your anxiety is very high. What would it mean to you if the MRI is normal? Would you feel completely safe from illness? Sometimes even after tests, you’ve still felt worried, right? Maybe we should focus on how to manage this worry itself.” This gently points out the pattern without dismissing the fear.

Like SSD, a consistent provider approach is helpful. Too many tests can actually reinforce the illness anxiety (each test implies “maybe there is something to find”). So the healthcare team should avoid jumping to invasive diagnostics for every new concern unless red-flag signs truly warrant it. Regular check-ups (e.g., a monthly or quarterly appointment) can be scheduled so the patient knows they have an outlet for their concerns – this can prevent unscheduled emergency visits. During scheduled visits, the provider can perform a focused exam to satisfy both parties that no new serious illness is apparent, then shift to discussing stress, life, coping. The nurse’s role in such visits is to provide empathy (“It must be hard feeling so worried about your health all the time”) and slowly encourage engaging in life despite fears.

If a patient avoids medical care out of fear (some do), building trust is key: perhaps they finally come in one day convinced they have advanced cancer but were too afraid to see anyone. Approach with calm and matter-of-fact assessment, do necessary exams to show you’re taking their concerns seriously, but also address anxiety: “I know it took courage to come today. Let’s work together step by step.”

Education: Explain that anxiety can actually produce physical sensations (like palpitations or aches) and that the goal of treatment is to break the cycle of worry and sensations feeding each other. Cognitive-behavioral therapy is very effective for illness anxiety – it helps patients challenge catastrophic misinterpretations of benign symptoms【36†L122-L130】【36†L125-L132】. Nurses can support CBT techniques by asking patients to consider alternative explanations (“What else could that twinge be, other than cancer? Maybe just a muscle spasm?”) and to work on reducing behaviors that maintain anxiety (like constant googling of symptoms). Instead of googling, maybe they can distract with a healthy activity, etc.

Medication: SSRIs or SNRIs can reduce the underlying anxiety and are often utilized, particularly if the health anxiety is part of a broader anxiety or depressive disorder. Nurses should encourage compliance and explain that these medications do not mean “it’s all in your head”, but rather help the brain’s anxiety circuits to calm, which should reduce the intense worry about illness.

Follow-up: These patients benefit from knowing they have support. The nurse can schedule a phone call between appointments just to check in (“How are you doing with the worry this week? Any techniques helping?”). This structured attention can paradoxically reduce excessive unscheduled contact because the patient feels cared for and heard.

Conversion Disorder (Functional Neurological Symptom Disorder)

Conversion Disorder is characterized by neurological symptoms (motor or sensory) that are not consistent with medical or neurological conditions, often preceded by psychological stress【12†L175-L183】【38†L119-L127】. In other words, the person “converts” emotional distress into a physical neurologic symptom. Classic examples include sudden paralysis of a limb, blindness, mutism, seizures (nonepileptic attacks), or loss of sensation – all without organic pathology. The patient is not faking; the symptoms occur involuntarily, but exam findings often show discrepancies (e.g., in conversion paralysis, reflexes may be normal, or in conversion blindness, the patient navigates a room without injury despite saying they can’t see). This disorder often appears abruptly in the context of stress.

Signs/Symptoms: Conversion symptoms can involve almost any voluntary motor or sensory function:

Typically, a thorough medical workup finds no neurological disease. It’s common for conversion symptoms to not follow anatomical pathways – for instance, a patient’s entire hand may be numb (a “glove anesthesia”), which doesn’t match how nerves innervate the hand; or they might be paralyzed but certain reflexes are intact, suggesting intact pathways.

Psychosocial context: There is often an antecedent stressor or conflict. For example, a soldier who subconsciously cannot face combat might develop a sudden blindness with no medical cause; or someone who feels intense anger that they cannot express might develop a paralyzed arm (symbolically preventing acting out). Historically, this was “hysterical” blindness or paralysis. It’s thought to be an unconscious escape from or expression of stress.

Neurobiology: Interestingly, brain imaging in conversion has shown changes in blood flow in areas related to motor control and emotion – there is something neurologically real going on, but it’s triggered by psychological factors rather than structural lesions.

Nursing implications: Always remember to treat conversion symptoms as real in effect – the patient cannot move the limb or cannot see, even though no organic cause has been found. Do not accuse them of faking or try to “prove” they can do it. For instance, if a patient has conversion paralysis of legs, you would still provide assistance with mobility (wheelchair, physical therapy involvement) to prevent falls or injury. At the same time, avoid reinforcing disability: encourage gradual use of the affected part as much as possible and normal activities, without excessive attention to the symptom. A nursing approach often used is the “supportive normalization”: e.g., “The tests we did are all normal. That’s actually good news – it means no damage. Sometimes our bodies can do strange things under stress. With time and therapy, I expect you’ll regain use of your legs. Let’s focus on keeping you as strong as possible.” This kind of statement avoids telling them “nothing is wrong” (which they’d hear as “you think I’m faking!”) but also sets a positive expectation for recovery.

If the patient displays la belle indifférence (odd lack of concern), the nurse should still acknowledge the situation (“I notice you don’t seem very worried about not being able to walk; some people might find that strange, but sometimes the mind works in curious ways. Let’s concentrate on your rehab.”). Do not pointedly challenge them about the indifference – it may be an unconscious coping mechanism.

Psychologically, once immediate needs are addressed, you can gently help the patient identify any stressors that occurred before onset. For example: “Sometimes these symptoms can happen after a very stressful event. Did anything difficult happen around the time this started?” The patient may or may not make the connection. If they do acknowledge, say, a trauma, then validate and let them know psychological support (like counseling) could be beneficial in recovery.

Safety: If the symptom is seizures, ensure precautions as with any seizure (protect from injury during events, though note these non-epileptic attacks often have no postictal phase and the patient might actually respond to voice). If blindness, ensure the environment is arranged safely and assist with ADLs as needed, while encouraging attempts to function (maybe use orientation cues or mobility training if prolonged).

Avoid unnecessary interventions: Once diagnosed (or strongly suspected) conversion, avoid repetitive tests as it can perpetuate the sick role. Work in the team to consolidate care: likely a neurologist or physician has explained tests are normal. Reinforce that understanding positively (“The MRI was clear. That’s excellent – your brain is healthy. Now our goal is to help your body relearn to move.”).

Rehabilitation therapy (physical or occupational therapy) often helps conversion motor symptoms, not only by maintaining muscle tone but by indirectly helping the patient recover function through practice – even if the origin is psychological, using the limb in PT can facilitate improvement. The nurse should actively collaborate with therapists and encourage participation: “Physical therapy is part of your treatment to help you walk again; I’ll help get you there and back.”

Patient/family education: Conversion disorder can be confusing for families – they may either doubt the patient or be overly solicitous. Explain in simple terms: “Medical tests show that the problem isn’t in the nerves or brain structure. Stress can cause real physical symptoms – the mind and body are connected. The treatment approach is to support [the patient] and help them cope with stress. We expect improvement.” Emphasize that the patient isn’t choosing this, and also that recovery is usually good. Indeed, conversion symptoms often spontaneously remit especially if stress is relieved.

Prognosis is generally good, but recurrence can happen if underlying issues aren’t resolved. Therefore, after acute care, referral to psychotherapy is important (such as trauma-focused therapy if indicated, or cognitive-behavioral therapy to learn better stress responses). Nurses in discharge planning should ensure appropriate mental health follow-up even if the patient is hesitant (perhaps framing it as “follow-up for your condition” rather than explicitly saying “psychologist for your stress” if stigma is an issue).

Factitious Disorder (including Munchausen Syndrome)

Factitious Disorder is a condition wherein an individual intentionally feigns or induces physical or psychological symptoms purely to assume the sick role, without obvious external incentives【41†L96-L104】【41†L117-L125】. In other words, the person’s goal is not concrete gain (like money, avoiding work, or obtaining drugs – that would be malingering), but rather the internal desire to be seen as ill or injured. They may secretly inflict injury on themselves or tamper with tests to produce symptoms. Factitious disorder can be imposed on self or another (the latter formerly called Munchausen syndrome by proxy when a caregiver, usually a parent, induces illness in someone else, usually a child).

Signs/Symptoms (Imposed on Self): These patients often present with dramatic stories about their symptoms and extensive knowledge of medical terminology. They might go to different hospitals (doctor shopping) when one team begins suspecting them. Common behaviors include adding blood to urine samples, taking small doses of poison or insulin to produce symptoms, infecting themselves, or simply lying about symptoms (like claiming seizures that are never witnessed by staff). They frequently are willing to undergo risky tests or surgeries and often have surgical scars from multiple procedures. A classic clue is inconsistency or textbook-like recurrence of issues when under observation: for instance, as soon as the invasive test shows nothing, a new symptom emerges. They may eagerly accept tests and treatment even if painful (because it validates their sick role). If confronted, they typically become angry and may leave against medical advice, then show up elsewhere.

Psychological profile: Factitious disorder is associated with underlying personality disorders, often borderline personality traits, or a history of trauma/illness in childhood. There can be a deep need for attention and nurturance. Because it is intentional, it can be hard for clinicians to remain empathetic – these patients can elicit frustration or feelings of deception. But it’s crucial to remember this is a mental disorder – they are driven by a psychological need, even if behavior is deceitful.

Factitious Disorder Imposed on Another (FDIA): Here, an individual (commonly a mother) causes or fabricates illness in someone under their care (commonly her child) to get attention by proxy. This is considered a form of abuse – the child is being harmed for the caregiver’s psychological need【64†L897-L904】【64†L898-L906】. Clues include a child with recurrent unexplained illnesses, discrepancies between reported and observed conditions, symptoms that stop when the child is away from the caregiver, and a caregiver who is oddly keen on medical tests or procedures and comfortable in the hospital environment. FDIA cases are often discovered via covert video surveillance in hospitals or careful monitoring (for example, a mother adding something to a child’s IV, or smothering the child to cause apnea).

Nursing implications (Factitious on Self): Maintaining a non-confrontational approach is key. If a nurse suspects factitious disorder (e.g., inconsistencies in the story, labs that show evidence of tampering like lab values not correlating or multiple hospitalizations with no findings), they should discreetly communicate with the healthcare team. Often a single provider (like a hospitalist or primary doctor) will take lead to avoid unnecessary interventions and to steer the workup appropriately. Avoid openly accusing the patient, as this typically causes them to flee and seek care elsewhere, continuing the cycle. Instead, the strategy is to manage the patient in a way that minimizes harm (don’t subject them to high-risk procedures unless absolutely necessary) and possibly get psychiatric consultation for underlying issues.

Nurses should meticulously document observations: e.g., “At 2100, patient’s blood glucose was 250 with no insulin ordered. At 2130, found patient handling the glucometer lancet; recheck of glucose from new fingerstick was 110.” Such documentation could support detection of self-harmful fabrication. Ensure safety measures: for example, if they have factitious hypoglycemia suspected (inducing low blood sugar by insulin or sulfonylureas), the patient should not have access to insulin (have staff store and administer needed insulin rather than allowing patient to keep any). If factitious infection is suspected (injection of feces into IV, etc.), perhaps limit IV access or use line covers.

Establishing a consistent, empathetic nurse-patient relationship can be tough because these patients might lie or create crises that frustrate staff. But if a particular nurse can gain some trust, they might become a point of stability. Therapeutic communication might involve acknowledging the patient’s emotional needs indirectly: “You seem to have been through so many medical encounters; that must be hard. We want to help you be as healthy as possible.” The ultimate treatment is psychotherapy, but patients rarely voluntarily seek psychiatric help for this specifically (they typically don’t admit to the deception).

Outcome goals are tricky – in factitious disorder, complete cessation of behavior is difficult. The initial goal is often to manage the condition such that the patient doesn’t undergo unnecessary harm. A long-term goal would be that the patient engages in mental health treatment to address underlying issues (like trauma, low self-esteem, need for attention) and gradually stop the factitious behaviors. As a nurse, if you see a pattern of unnecessary admissions, you might help coordinate with case management and psych services to develop a care plan that addresses both medical and psychological needs.

Ethical/legal: Factitious disorder imposed on another is abuse, thus a nurse is mandated to report if suspected【64†L897-L904】【64†L898-L902】. For example, if a child has unexplained recurrent poisoning and you suspect the parent, involve the healthcare team and follow protocols to inform child protective services. The child’s safety comes first – that may mean an inpatient video monitoring or separation trial to collect evidence. It’s very delicate; the perpetrator often appears very caring and convincing. As a nurse, never confront the suspected caregiver directly – that could endanger the child if they flee. Instead, quietly share concerns with the attending physician or social worker so appropriate investigative steps are taken.

For factitious on self, an ethical challenge is not feeding into the false illness but still caring for the patient. It's acceptable (even necessary) at some point for the healthcare team to have an honest discussion with the patient once immediate crises are managed. For instance, a psychiatrist might gently confront: “We haven’t found a medical cause for your symptoms. Sometimes people cause symptoms themselves because they’re dealing with emotional pain. Is it possible this is happening for you?” This ideally should be done by a psychiatric professional. The nurse’s role is to support the patient if they become upset and ensure they know they are not being abandoned.

Summary: Factitious disorder is about the need to be seen as ill. Approach with empathy but also protect the patient from invasive interventions. Encourage psychological evaluation tactfully. In the acute setting, treat the symptoms they present (e.g., if they say they have pain, you can still give non-opioid analgesics as appropriate; if they self-induced a real infection, treat it). Over time, hopefully the healthcare system coordinates to reduce repetitive hospitalizations (some hospitals develop care plans like “If patient X presents with Y symptoms, do minimal evaluation and ensure psych follow-up”).

Clinical example: A patient frequently shows up in the ER with acute abdominal pain and a story of having familial Mediterranean fever requiring IV opioids. She undergoes multiple negative laparoscopies. Nurses note that each admission, as soon as a particular nurse shows sympathy, she clings to them and then reports a new symptom (like blood in urine) when discharge approaches. Over time, the team suspects factitious disorder. They implement a plan: minimize invasive tests, hold a multidisciplinary meeting with the patient involving a psychiatrist. The psychiatrist finds a history of childhood hospitalization where the patient felt loved, suggesting she unconsciously seeks that caring environment again. The patient is slowly engaged in therapy. In subsequent ER visits, the plan is followed – quick medical screening, then a psych consult. Eventually, the visit frequency drops. This kind of outcome is ideal but requires consistent team strategy.

Nursing Interventions Across All Levels and Disorders

Patients suffering from anxiety and related disorders require a holistic nursing approach that addresses their physical symptoms, emotional needs, environmental triggers, and communication styles. Nursing interventions can be grouped into several categories: pharmacologic, psychotherapeutic (non-pharm), environmental (milieu), and communication/education strategies. Regardless of the specific disorder, certain principles apply: ensure safety, establish trust, validate the patient’s feelings, and encourage adaptive coping. Interventions should be tailored to the patient’s level of anxiety (mild vs. severe) and specific condition (e.g., panic vs. dissociation vs. somatic complaints).

Pharmacologic Interventions

Medications can be very useful in managing anxiety disorders and related conditions, either on a short-term basis to relieve acute symptoms or long-term to reduce frequency/intensity of episodes. Nurses play a critical role in administering medications, monitoring effects, and educating patients about them.

Overall, nurses should take a medication reconciliation and adherence role – many patients with anxiety might take benzodiazepines from one doctor, SSRIs from another, and perhaps herbal supplements (like kava or valerian). Educate about interactions (for example, warn not to combine kava kava with benzodiazepines due to excess sedation, and note that kava can harm the liver). Encourage patients that medications for anxiety are most effective when combined with therapy and self-management – pills help symptoms, but building coping skills is equally important.

Psychotherapeutic Interventions (Therapies and Coping Strategies)

Nurses do not typically conduct formal psychotherapy, but they implement many therapeutic techniques and reinforce skills that patients learn in counseling. A basic nursing role is to encourage patients to engage in therapy and practice the skills taught. Some key therapy modalities for these disorders:

Environmental and Milieu Interventions

The care environment should be structured to promote a sense of safety and calm for anxious patients. Key considerations include:

Therapeutic Communication and Patient Education

How the nurse communicates with anxious patients is one of the most potent interventions. Key principles include being calm, clear, and empathetic:

Finally, patience and empathy are the core of communication. Anxiety can be chronic and relapse-prone; patients may ask the same questions repeatedly or need continual reassurance. Remain patient – this in itself is healing, as the patient learns the nurse is a steady presence who won’t get angry or abandon them due to their anxiety. Empathy statements like, “I can imagine how exhausting it is to feel on edge all the time,” can make the patient feel understood and more open to guidance.

By integrating these pharmacological, therapeutic, environmental, and communication strategies, nurses can significantly alleviate patients’ anxiety levels and improve their ability to function. Often it’s the combination of interventions – medication to take the edge off, therapy skills to cope, a calm environment, and a supportive nurse-patient relationship – that provides the best outcomes【44†L69-L72】【44†L33-L41】. The following case studies and practice questions will illustrate the application of these interventions for specific disorders.

Clinical Case Studies

Case Study 1: Panic Disorder
Background: J.S. is a 28-year-old graduate student who arrives in the ER with chest pain and shortness of breath. She is pale, clutching her chest, and hyperventilating. Her heart rate is 130, and she repeatedly says, “I think I’m dying, please don’t let me die!” Cardiac workup is negative; the ER physician diagnoses an acute panic attack. This is the third ER visit for J.S. in two months with similar symptoms.
Assessment: The psychiatric RN finds J.S. trembling and fearful. J.S. describes episodes of sudden intense fear that peak within minutes, during which she experiences racing heart, sweating, choking sensations, dizziness, and fear she’s having a heart attack. She now lives in fear of the next attack, avoiding going out alone. She’s had to quit her part-time job and is struggling in school.
Nursing Interventions: In the ER, the nurse immediately engages in a calming presence – she brings J.S. to a quiet area and stays by her side. She coaches J.S. in slow breathing (“Let’s inhale slowly... now exhale... good.”) and uses grounding statements (“Your heart tests are normal; I know it’s hard to believe, but you are safe. I’m right here.”). A PRN dose of lorazepam is given, and within 15 minutes J.S.’s acute panic subsides. Once calmer, J.S. begins to cry, expressing embarrassment and hopelessness: “I feel so crazy. What if this happens when I’m driving? I avoid going anywhere now.” The nurse uses therapeutic listening and validation, saying, “You’ve been through a frightening experience; no wonder you’re worried about it happening again.” She gently educates J.S. that these episodes are panic attacks, a treatable condition – explaining the fight-or-flight response and how it misfires. Together they discuss triggers; J.S. realizes her first attack happened during a very stressful exam week. The nurse teaches J.S. a panic plan: at the first sign of symptoms, practice deep breathing, use positive self-talk (“This is a panic attack, it will pass, I am not dying”), and possibly use a prescribed fast-acting med if directed. The nurse provides a handout on CBT techniques for panic and helps J.S. schedule a follow-up with the hospital’s anxiety clinic.
Outcome: By discharge, J.S. is no longer in crisis. She feels relieved that others have had this problem (“You mean I’m not the only one? That actually makes me feel better.”). She expresses willingness to try therapy and medication (an SSRI is started) now that she understands what’s happening. Three weeks later, J.S. follows up in the anxiety clinic. She reports one mild panic episode since – she used the breathing exercises and it resolved without ER care. She’s attending CBT group therapy for panic disorder and gradually rebuilding her confidence to resume normal activities.

Case Study 2: Dissociative Identity Disorder (DID)
Background: “Marie,” a 34-year-old woman, is admitted to a psychiatric unit after a suicide attempt. On initial interview, the nurse finds Marie quiet and guarded. Her history reveals severe childhood abuse. As the nurse gently asks about how she’s feeling, Marie suddenly falls silent, then speaks in a small child-like voice: “I don’t want to talk about bad things.” She refers to herself as “Missy” and curls up in a chair. The nurse recognizes this as a possible alternate personality (alter). Later, “Marie” returns to a normal adult voice but has no memory of the previous conversation.
Assessment: The team assesses that Marie has Dissociative Identity Disorder with at least two alters (an adult host and a young child alter named “Missy,” possibly others). Marie reports frequent gaps in memory (finding clothes she doesn’t remember buying, people calling her by names she doesn’t recognize). She often “loses time” during stress. The suicide attempt was triggered by hearing traumatic voices in her head, after which she “woke up” with wrist cuts she doesn’t recall making.
Nursing Interventions: The nurse develops a trauma-informed care plan. She establishes ground rules of safety with Marie and any alters that emerge: no self-harm allowed on the unit, staff must be informed if urges arise. Each shift, the nurse makes a point to introduce herself and orient Marie: “Hi Marie, I’m ____, your nurse today. You’re at Green Valley Hospital, and today is Monday.” Knowing that an alter (Missy) may surface, the nurse remains consistent and empathetic with all “parts” of Marie. When “Missy” appears, the nurse gently engages by perhaps offering a coloring book or stuffed animal (to comfort the child alter) and saying “It’s okay, you’re safe here. You sound like you’re feeling scared.” She does not push for information but might say, “If Marie is not here right now, that’s okay. I can talk with you, Missy. We will keep you safe.” This acceptance helps build trust. Safety planning is crucial: the nurse collaborates with Marie to create a written contract that if she feels suicidal or an alter wants to self-harm, she will notify staff immediately. They develop a grounding routine for when Marie starts to dissociate: e.g., focus on a cold object, describe the room, use her five senses. Staff consistently use this routine when they notice her “spacing out.” Over the next few days, other alters manifest (one angry teenage persona). The nurse remains neutral and sets kind limits if that alter becomes threatening: “I understand you’re angry, but I won’t let you hurt Marie or anyone here. You can journal your feelings instead.” The nurse educates Marie that DID is a coping mechanism from trauma and that treatment (long-term therapy) can help her feel more whole and in control. She reinforces the idea that all parts of her have protected her in some way. The immediate goal is helping Marie develop communication and cooperation among her alters (the inpatient DID group therapy addresses this). The nurse may facilitate an internal dialogue by asking, “Can the part of you that feels strong reassure the part that feels like a little girl that you’ll handle things now?” This intervention, done with guidance from the therapist, begins to break down the barriers between identities.
Outcome: By discharge, Marie is no longer actively suicidal. She has a list of coping strategies (grounding techniques, calling a specific friend when overwhelmed, taking medication as prescribed). She also has an outpatient therapist specializing in DID. Marie (host) tells the nurse, “Missy says thank you for the teddy bear you gave her – she feels safer.” This remarkable statement indicates Marie’s growing awareness of her alters. The nurse praises her insight and encourages her to continue nurturing that communication in therapy. Marie leaves the hospital with a sense that her condition was finally understood rather than dismissed. She remains stable for the next several months and engages in intensive trauma therapy to work toward integrating her identities.

Case Study 3: Conversion Disorder
Background: A 40-year-old male factory worker, Mr. D., is admitted to the neurology service for evaluation of sudden paralysis of his left arm. All medical tests (MRI, nerve conduction studies) are normal, and a consulting psychiatrist diagnoses Conversion Disorder (Functional Neurologic Symptom Disorder). Mr. D.’s paralysis began one week after he witnessed a fatal accident at work where he was operating a machine that malfunctioned (his coworker was killed). Mr. D. is distraught about the incident and, notably, the machine was on his left side. Now his left arm is limp, though reflexes are intact and there is inconsistency (staff noticed at times he moves the arm during sleep).
Assessment: Mr. D. does not appear to be consciously faking; he genuinely cannot move his arm when asked. Interestingly, he is somewhat calm about the paralysis, saying with a flat affect, “Well, at least I don’t have to use that machine again.” (This hints at la belle indifférence). He expresses guilt about his coworker’s death. He also says, “Maybe God punished my arm because I couldn’t save him.”
Nursing Interventions: The rehab nurse on the neurology unit takes a dual approach: addressing the physical disability and the psychological stress. First, she ensures Mr. D.’s basic self-care needs are met – helping him learn one-handed techniques for dressing and feeding. She involves physical therapy to keep his left arm muscles from atrophy (range of motion exercises) and occupational therapy to practice functional tasks. Positive reinforcement is used: when Mr. D. makes slight movements without realizing (once he flexed his fingers when distracted), the nurse gently points it out: “I saw your fingers move a little just now – that’s a good sign; it means your arm has the ability to move.” He was surprised but this planted a seed of hope. The nurse maintains a matter-of-fact, supportive attitude – she does not overly cater to the paralysis (no excessive pity) but also does not challenge him aggressively. She sets up a daily routine where Mr. D. attempts to use his arm in simple tasks after relaxation exercises. For instance, she guides him through a breathing exercise then asks him to try to lift a light object with the affected arm. Initially, he cannot, and becomes anxious. The nurse uses calm reassurance: “It’s okay; your arm isn’t cooperating yet. Let’s try again tomorrow. Your body may improve when it’s ready.” Meanwhile, she engages him in talking about the accident gently (since it’s likely related). He shares feelings of guilt and horror. The nurse offers empathetic listening: “That was a traumatic event. No wonder your mind and body are overwhelmed.” She introduces the idea that stress can cause physical symptoms: “Sometimes after something like this, the body responds in surprising ways, like your arm shutting down for a while. But as you heal emotionally, I expect your arm will improve too.” This frames the paralysis as reversible. She teaches him stress-management techniques (which also serve as conversion symptom treatment) – journaling about the accident (therapeutic emotional processing), and a ritual of lighting a candle in memory of his coworker (finding closure). As trust builds, the nurse asks if he’s willing to meet with the psychiatrist for therapy; he agrees. They begin working on the idea that forgiving himself might “release” his arm from the guilt. Over a week, Mr. D. shows subtle improvement: one day, during a relaxed conversation, he briefly lifts his left arm to scratch his head before “realizing” and dropping it. The nurse smiles and encourages him: “See, your arm remembers how to move when you aren’t thinking too hard about it!” This evidence helps convince him that there’s no physical damage.
Outcome: By discharge, Mr. D. has about 50% return of motor function in the arm. He is able to wiggle his fingers and flex the elbow, though fine motor and full strength aren’t back yet. He is more emotionally open about the trauma and has agreed to continue outpatient therapy. On the last day, he confides to the nurse, “Sometimes I feel like maybe I didn’t want to use that arm... because it reminds me of the accident.” This insight is major progress – he’s recognizing the mind-body link. The nurse validates this and reiterates that as he forgives himself and regains confidence, his arm should continue to improve. Mr. D. is discharged to a physical medicine rehab program and psychological counseling. Three months later, he sends a thank-you note: his arm is fully functional again, and he has started a new position at work away from the site of the accident. He writes, “I realized my arm was waiting for my heart to heal.” Nurses played a pivotal role in guiding him to that realization with compassion and patience.

These case studies highlight tailored nursing approaches for different disorders – from the immediate calming and safety measures in panic, to the long-term trust and grounding needed in DID, to the combined physical/psychological support in conversion disorder. In all cases, holistic care addressing both mind and body helped the patients move toward recovery.

NCLEX-Style Practice Questions

1. A patient with panic disorder suddenly begins to hyperventilate and says, “I feel dizzy – I think I’m going to die!” What is the nurse’s priority action?

2. A patient with Obsessive-Compulsive Disorder is continually late to group therapy because of a lengthy handwashing ritual. Which nursing response is most therapeutic?

3. The nurse is caring for a patient with Generalized Anxiety Disorder who frequently says, “I just know something terrible is going to happen to my family while I’m here in the hospital.” Which response by the nurse utilizes cognitive reframing?

4. A patient with PTSD from a sexual assault is admitted for care. She becomes highly anxious whenever a male staff member enters the room. What is the best trauma-informed intervention by the nurse?

5. The nurse is evaluating outcomes for a patient with Illness Anxiety Disorder (hypochondriasis). Which behavior by the patient suggests positive progress?

6. A patient is diagnosed with Somatic Symptom Disorder with predominant pain. Which statement by the patient suggests she is internalizing a healthier view of her symptoms after treatment?

References (APA Style)

  1. Ernstmeyer, K., & Christman, E. (Eds.). (2022). Nursing: Mental Health and Community Concepts. Eau Claire, WI: Chippewa Valley Technical College – Open RN. (Chapter on Anxiety Disorders – levels of anxiety and interventions)【3†L154-L163】【5†L1955-L1963】

  2. Locke, A. B., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American Family Physician, 91(9), 617-624.【44†L33-L41】【44†L61-L69】

  3. American Psychiatric Association. (n.d.). What are Anxiety Disorders? Retrieved 2025, from psychiatry.org 【67†L381-L389】【69†L13-L16】

  4. National Institute of Mental Health. (2019). Obsessive-Compulsive Disorder. Retrieved from nimh.nih.gov (NIMH Fact Sheet)【20†L988-L996】【20†L1015-L1023】

  5. Belleza, M. (2024). Dissociative Disorders. Nurseslabs. Retrieved 2025, from nurseslabs.com 【75†L211-L219】【75†L229-L238】

  6. D’Souza, R. S., & Hooten, W. M. (2023). Somatic Symptom Disorder. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.【33†L96-L104】

  7. French, J. H., & Hameed, S. (2023). Illness Anxiety Disorder. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.【36†L96-L104】【36†L122-L130】

  8. Peeling, J. L., & Muzio, M. R. (2023). Functional Neurologic Disorder (Conversion Disorder). In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.【38†L119-L127】【39†L1-L4】

  9. Carnahan, K. T., & Jha, A. (2023). Factitious Disorder. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.【41†L96-L104】【41†L117-L125】

  10. Barnes, C. A. (2023, September 25). Anxiety in Different Cultures: A Comparative Perspective. Medium. Retrieved 2025, from medium.com 【54†L78-L86】【54†L81-L89】

  11. Roche-Miranda, M. I., Subervi-Vázquez, A. M., & Martinez, K. G. (2023). Ataque de nervios: The impact of sociodemographic, health history, and psychological dimensions on Puerto Rican adults. Frontiers in Psychiatry, 14, Article 1013314.【51†L283-L287】【51†L283-L291】

  12. Rizvi, M. B., Conners, G. P., & Rabiner, J. (2025). New York State Child Abuse, Maltreatment, and Neglect. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. (Factitious Disorder Imposed on Another as child abuse)【64†L897-L904】

  13. Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: SAMHSA. (Six principles: Safety, Trustworthiness, Peer support, Collaboration, Empowerment, Cultural considerations)【31†L133-L141】【56†L5-L8】

Stressors Affecting Levels of Anxiety (Anxiety and Related Disorders)

Anxiety is a normal part of life, but excessive or persistent anxiety can become debilitating. Stressors – internal or external events that trigger stress – can precipitate varying levels of anxiety and related disorders. This module provides an in-dept​aafp.org​aafp.orguate nursing students on anxiety levels, defense mechanisms, anxiety disorders (including OCD), dissociative disorders, somatic symptom and related disorders, and evidence-based nursing interventions. Cultural and aafp.orgiderations and trauma-informed care principles are integrated throughout. Case studies and NCLEX-style questions are included to reinforce learning.

Levels of Anxiety

Psychiatric nurse theorist Hildegard Peplau identified four levels of anxiety: mild, moderate, severe, and panic【3†L148-L156】【3†L175-L183】. Each level is characterized by different physiological and psychological responses. Understanding these levels helps nurses tailor interventions appropriately【3†L148-L156】.

Mild Anxiety

Mild anxiety is part of everyday living and can actually be adaptive. At this level, perception is heightened and one’s senses are sharpened【3†L154-L162】. The individual is alert and may feel restless or irritable, but not overwhelmed. Signs/Symptoms: Mild tension-relieving behaviors such as fidgeting, nail-biting, or foot-tapping are common【3†L154-L162】. There may be butterflies in the stomach or slight muscle tension, but the person can learn and problem-solve effectively. Neurobiological Basis: Mild anxiety triggers the sympathetic “fight-or-flight” response minimally – perhaps a slight increase in adrenaline and alertness – which can improve focus. Nursing Implications: Mild anxiety is normal and can motivate learning and action. The nurse should encourage the patient to verbalize feelings and cope (e.g. using humor or exercise) since the patient can process information well at this stage. Teaching can be effective when anxiety is mild because attention is focused.

Clinical Tip: Mild anxiety can be beneficial – it often provides the ener​aafp.orgntration needed to complete tasks or confront challenges (like studying for an exam or getting to an appointment on time). The nurse can help patients harness mild anxiety positively by reinforcing effective coping (deep breathing, exercise)【3†L148-L156】.

Moderate Anxiety

In moderate anxiety, the person’s perceptual field narrows and some details are excluded from observation【3†L163-L171】. The individual can still attend to relevant information but may require redirection. Signs/Symptoms: Moderate anxiety causes selective inattention – the person may focus only on immediate concerns and block out periphery. They may feel tension, pounding heart, faster pulse and respirations, sweating, and mild gastrointestinal discomfort【3†L163-L172】. Voice tremors or shakiness can occur, and the person might report difficulty concentrating but can still follow directions. Neurobiological Basis: The sympathetic nervous system is more stimulated, with higher levels of epinephrine and norepinephrine leading to tachycardia, increased breathing, and mild fight-or-flight somatic symptoms. Nursing Implications: The nurse should remain calm and provide a quiet environment, as external stimuli may be distracting【5†L1937-L1945】. Use therapeutic communication – speak in simple sentences and ensure the patient’s understanding. Encourage the patient to talk about what is causing their anxiety and to use coping strategies that have worked before (e.g. breathing exercises, walking)【5†L1937-L1945】. At moderate anxiety, patients may benefit from problem-focused coping (breaking tasks into smaller steps) and emotion-focused coping (relaxation techniques)【3†L148-L156】.

Severe Anxiety

Severe anxiety greatly reduces the perceptual field – t​ncbi.nlm.nih.govcus on a specific detail or several scattered details and have difficulty noticing their environment even when pointed out【3†L175-L183】. Signs/Symptoms: Learning and problem-solving are not possible at this level. The individual may feel dazed or confused. Behavior becomes more automatic and aimed at reducing anxiety (e.g. pacing). Physical symptoms intensify: headache, nausea, dizziness, insomnia are common, as well as trembling, a pounding heart, hyperventilation, and a sense of impending doom【3†L177-L184】. The person may be restless, angry, or withdrawn. Neurobiological Basis: The amygdala (the brain’s fear center) is hyperactive, and stress hormones (adrenaline, cortisol) surge, preparing the body for danger even if no real threat exists【90†L133-L141】【90†L135-L143】. This heightened limbic activity floods the body with physiological arousal. Nursing Implications: Safety becomes a priority. The nurse should remain with the patient and provide a calm, reassuring presence【5†L1955-L1963】. Communication should be firm, short, and simple (e.g. “Take a deep breath with me”)【5†L1955-L1963】, since the patient cannot process complex information. Reduce environmental stimuli – move the person to a quiet setting. Physical needs must be attended: ensure adequate fluid intake (they may be perspiring heavily), offer a blanket if shivering, and encourage rest because severe anxiety can exhaust the patient【5†L1961-L1969】. If the patient is pacing, provide high-calorie fluids or finger foods to prevent dehydration and maintain energy【5†L1961-L1969】. Do not leave a severely anxious patient alone.

Nursing Priority: For severe anxiety, patient safety and basic needs take priority. The nurse should stay with the patient and remain calm. Use a low-pitched voice and short, simple statements to help the patient feel secure【5†L1955-L1963】. If the patient is experiencing hyperventilation, assist them in sl​aafp.orgbreathing (e.g. breathe with them, use a paper bag if needed). Keep expectations minimal until the anxiety decreases – do not try to teach or problem-solve at this stage.

Panic Level Anxiety

Panic is the most extreme level of anxiety, marked by dysregulated behavior and loss of reality orientation【3†L193 - L199】. The individual is unable to focus on the environment and may even experience derealization (feeling the world is not real) or depersonalization (feeling detached from oneself)【18†L421-L429】. Signs/Symptoms: The person may scream, run about wildly, or completely withdraw. Hallucinations or delusions can occur if panic is prolonged【3†L195-L199】. They may be terrified and feel they are “going crazy” or dying【18†L421-L429】【18†L423-L430】. Physiologically, panic causes severe flight-or-flight activation: the individual might experience chest pain, shortness of breath, dizziness, faintness, a sense of choking, palpitations, and trembling【18†L400-L408】【18†L412-L420】. This state cannot be sustained indefinitely and may lead to exhaustion. Neurobiological Basis: Panic involves an acute surge of stress hor​ncbi.nlm.nih.govelming autonomic arousal. The brain’s alarm system is in overdrive – amygdala firing intensely and the person’s prefrontal cortex (reasoning center) essentially offline. It is akin to being in true imminent danger (even if no danger exists). Nursing Implications: During panic, immediate intervention is required. The nurse’s role is to k​ncbi.nlm.nih.govafe and prevent self-harm or harm to others. Remain with the patient and stay calm; although the patient may not acknowledge your presence, a calm voice can be grounding. Use short commands (“Sit down.” “You are safe. I will help you.”) and repeat them gently【5†L1955-L1963】. Do not attempt any teaching or ask the patient to make decisions – they are incapable of rational thought. If the environment cannot be controlled (e.g. in a busy emergency room), it may be necessary to move the patient to a small, quiet room. Ensure physical needs are met after the peak panic subsides – the patient may be exhausted, dehydrated, or physically hurt from frantic movements. In some cases, short-term use of anti-anxiety medication (e.g. a benzodiazepine) is indicated to break the panic cycle, but any medication should be given in collaboration with the prescribing provider and with careful monitoring.

Key Concept: The body’s stress response (sympathetic nervous system activation) underlies many symptoms of anxiety. Mild and moderate anxiety produce manageable increases in alertness and tension, but severe anxiety and panic trigger a flood of stress hormones that can overwhelm the individual’s coping ability【90†L133-L141】【90†L135-L143】. Nurses must recognize escalating anxiety early and intervene to prevent progression to panic, if possible.

Adaptive vs. Maladaptive Defense Mechanisms

When facing stress and anxiety, people often unconsciously use defense mechanisms to protect themselves from psychological harm. Defense mechanisms are mental processes (often unconscious) that reduce or avoid anxiety by distorting reality in some way【66†L124-L133】【66†L133-L140】. Everyone uses defense mechanisms – they are normal unless used to an extreme.

Adaptive (healthy) defense mechanisms can alleviate anxiety in an acceptable way and help individuals achieve their goals【6†L217-L220】. In contrast, maladaptive defense mechanisms (especially when overused) may distort reality, hinder relationships, or inhibit problem-solving, ultimately exacerbating anxiety or creating other issues【6†L217-L220】. It’s important to note that the adaptiveness of a defense mechanism often depends on context – a mechanism can be helpful in one situation and harmful in another【12†L160-L168】. Below are common defense mechanisms, roughly categorized by their relative adaptiveness:

There are many other named defense mechanisms (e.g. intellectualization – focusing on logic/fact​ncbi.nlm.nih.govion【13†L233-L241】, or undoing – trying to symbolically “reverse” a wrongdoing by an action). The key for nurses is to recognize when a patient might be using a defense mechanism and determine if it’s helping or hindering their coping. Adaptive defenses (like humor, altruism, or seeking support) should be encouraged. Maladaptive defenses that interfere with treatment or safety (like denial of illness, or projection that causes conflict) should be addressed carefully. Often, simply increasing a patient’s awareness of their patterns in a nonjudgmental way (for example, gently pointing out when a patient who is anxious about their illness starts rationalizing or minimizing symptoms) can help them consider new coping strategies. In some cases, referral to counseling for techniques like cognitive-behavioral therapy can help the patient replace maladaptive defenses with healthier responses【66†L96-L104】【66†L131-L139】.

Example – Adaptive vs. Maladaptive: A patient awaiting surgery feels anxious. If they use adaptive mechanisms, they might talk about their fears with family (seeking support) or engage in distraction by watching a funny movie (humor). If they use a maladaptive mechanism, they might refuse to acknowledge the need for surgery at all (denial) or lash out at staff for minor issues (displacement of anxiety as anger). The nurse’s role is to recognize these behaviors and respond therapeutically – e.g., respectfully correcting misinformation (to address denial) or setting gentle limits on aggression while encouraging expression of feelings in a safe manner.

According to psychological research, defense mechanisms can be adaptive or maladaptive depending on severity and context【12†L160-L168】. An occasional use of denial (such as initial shock after a diagnosis) can give a person time to process reality – a transient adaptive use. However, persistent denial is maladaptive. Thus, understanding defense mechanisms helps nurses anticipate patient responses to stress and plan care. For instance, a patient with illness anxiety disorder might use somatization (expressing emotional distress as physical symptoms) as their defense; a nurse would validate the patient’s symptoms and gradually help link them to stressors rather than purely physical causes.

Anxiety-Related Disorders

When anxiety becomes excessive, persistent, or out of proportion to reality, it may be classified as an anxiety disorder. Anxiety disorders are among the most common mental health conditions, affecting up to 30% of adults at some point【67†L381-L389】【67†L405-L413】. Unlike everyday anxiety, anxiety disorders cause significant distress and impairment, and the anxiety does not go away but often worsens over time without treatment【6†L228-L236】【6†L231-L238】. The major anxiety disorders include Generalized Anxiety Disorder (GAD), Panic Disorder, Phobias (including specific phobias and social anxiety disorder), and related conditions like Obsessive-Compulsive Disorder (OCD) (which is now its own category in DSM-5 but historically linked to anxiety). Each disorder has distinctive features, but all share the core theme of excessive fear or worry.

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder is characterized by chronic, excessive worry about multiple aspects of life (work, school, health, finances, etc.) that is difficult to control and persists for at least six months【17†L336-L344】【17†L338-L347】. The worry is significantly disproportionate to the actual likelihood or impact of the feared events. Individuals with GAD oft​ncbi.nlm.nih.govnxiety shifting from one concern to another.

Signs/Symptoms: GAD is accompanied by at least three of the following: restlessness or feeling “on edge,” being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbances【17†L339-L347】【17†L349-L357】. Patients often report feeling tense or keyed up most days. Physical symptoms like trembling, twitching, sweating, nausea, and headaches are common due to prolonged muscle tension and autonomic arousa​ncbi.nlm.nih.gov​ncbi.nlm.nih.govis:** GAD is associated with dysregulation in brain areas like the amygdala and prefrontal cortex, which may lead to overestimating threats. There is often decreased inhibitory neu​ncbi.nlm.nih.govof GABA (which normally calms neural activity) and imbalances in serotonin and norepinephrine. These neurochemical factors contribute to a heightened state of anxiety. Genetics can play a role, and early life stress or trauma is a known risk factor.

Nursing implications: A hallmark of GAD is that the worry is difficult to control and persists despite reassurance. Nursing assessment should identify what the patient’s primary worries are and any precipitants. Encourage the patient to verbalize their concerns – sometimes voicing the “what ifs” can reduce their power. Provide calm, realistic reassurance without dismissing the patient’s feelings (e.g., “I understand you feel very anxious about all these things. Let’s talk through them.”). Because GAD patients may also have physical symptoms like insomnia or GI upset, address those (e.g., offer relaxation techniques for muscle tension, suggest avoiding excessive caffeine which can heighten anxiety). Education is important: explain that GAD is a recognized condition that can be treated, which can itself be relieving (the patient might feel “I’m not alone or crazy for feeling this way”). On a medical-surgical floor, for example, a GAD patient might constantly hit the call bell with worries – in such cases, a scheduled brief check-in by the nurse can pre-empt constant calls and provide the patient a sense of security. Treatment typically includes psychotherapy (especially Cognitive Behavioral Therapy) and/or medication (SSRIs or buspirone are first-line, with short-term benzodiazepines only if absolutely needed)【44†L33-L41】【44†L61-L69】. Teach the patient about breathing exercises and grounding techniques for when worry escalates. Over time, help them learn to challenge their anxious thoughts (CBT techniques) and practice coping strategies.

Example: A 40-year-old patient with GAD might say, “I can’t stop worrying that something will go wrong – my job, my kids, my finances, everything.” The nurse can respond, “It sounds exhausting to feel on edge about so many things. Let’s take them one at a time. Right now, in the hospital, your job and finances are stable for the moment. Your focus can be on recoverin​aafp.org involve the hospital social worker if you need help with bills or time off. How are you feeling right now physically?” This approach acknowledges the patient’s worries and provides concrete reassurance and resources, helping to contain the anxiety.

Panic Disorder

Panic Disorder involves recurrent, unexpected panic attacks, along with persistent concern about having more attacks or changing behavior to avoid them【18†L436-L444】【18†L446-L454】. A panic attack is a sudden surge of intense fear or discomfort that peaks within minutes, accompanied by at least four of the classic symptoms: palpitations, sweating, trembling, shortness of breath, choking sensation, chest pain, nausea, dizziness, chills or hot flashes, paresthesias (numbness/tingling), derealization or depersonalization, fear of losing control or “going crazy,” or fear of dying【18†L400-L408】【18†L417-L425】. During a panic attack, people often truly feel they are in mortal danger – many first-time attacks lead patients to seek emergency care for what they believe is a heart attack or other life-threatening event.

In Panic Disorder, these attacks occur “out of the blue,” not in response to a specific phobic stimulus (though they can become associated with certain situations over time). After an attack, the individual worries persistently about having another or the implications (“Am I losing my mind? What if I collapse in public?”) and/or they avoid places or activities for fear they might trigger an attack【18†L436-L444】. This concern and avoidance must last at least one month for the diagnosis【18†L436-L444】.

Signs/Symptoms: Beyond the acute panic attacks themselves, patients with panic disorder often develop anticipatory anxiety – a chronic nervousness about when the next attack will strike. They may start avoiding situations like driving, being in crowds, or leaving home (if they associate those with prior attacks). Agoraphobia (fear of being in places where escape might be difficult or help unavailable) can develop in about one-third of patients with panic disorder【18†L447-L454】【18†L478-L485】. For example, a person might refuse to go to the mall or open spaces due to fear of panicking there. Patients may also excessively seek medical tests to rule out other causes (desperate for reassurance that nothing is physically wrong).

Neurobiological basis: Panic attacks are a false alarm of the body’s emergency response. The locus coeruleus in the brainstem (a major norepinephrine center) is implicated in triggering panic, as are dysfunctions in the amygdala and respiratory control centers. Some individuals with panic disorder have heightened sensitivity to carbon dioxide levels or breathing changes – known as “false suffocation alarm.” There is evidence of genetic predisposition. Neurotransmitters involved include norepinephrine (elevated in panic), serotonin, and GABA (likely reduced, hence why benzodiazepines which enhance GABA can abort panic).

Nursing implications: During a panic attack, the nursing priority is to stay with the patient and ensure safety. Panic attacks are terrifying; the patient may genuinely believe they are dying. Remain calm and reassure the patient that the symptoms, while frightening, are not immediately dangerous (after ruling out medical issues). Use short phrases such as “I know this is scary, but you are not having a heart attack. This will pass. I will stay with you.” Encourage the patient to slow their breathing – coach breathing by counting or using a paper bag if hyperventilation is severe. It can help to have the patient focus on you: “Look at me and breathe with me.” Simple grounding techniques (having them feel the chair, touch an object) can reduce feelings of unreality. Once the acute panic subsides, provide a quiet environment for recovery (dim lights, minimal stimulation).

Long-term, educate the patient about panic disorder: the fight-or-flight symptoms, how panic attacks can be managed and are treatable. Many patients feel embarrassed or fearful of future attacks; teach them relaxation techniques to practice daily (deep abdominal breathing, progressive muscle relaxation) so that these become second nature if an attack starts. Encourage compliance with treatment: SSRIs or SNRIs are first-line medications for preventing panic attacks (typically starting at low doses to avoid initial agitation), and cognitive-behavioral therapy (CBT) – especially panic-focused CBT – is highly effective【44†L33-L41】【44†L69-L72】. CBT often involves interoceptive exposure (therapist-guided exposure to panic-like sensations, such as spinning in a chair to induce dizziness, so the patient learns those sensations are not dangerous). Beta-blockers (e.g. propranolol) might be used situationally if triggers are known, though they’re more common for performance anxiety. If the patient has agoraphobia, a gradual exposure therapy plan will be needed to regain lost ground – for example, first stepping outside the home with a trusted person, then a short trip to the store, etc., slowly reducing avoidance. Nursing should involve developing a plan with the patient: identify safe coping statements (“This​aafp.org​aafp.orgd it before.”) and perhaps using a scale for anxiety so they can communicate when they feel panic rising.

Case in point: Panic disorder often first presents in young adulthood. A college student experiencing their first panic attack in class might suddenly feel palpitations, sweating, shortness of breath, and intense fear of collapsing. The school nurse or responding clinician will find no cardiac issues and recognize these as panic symptoms. Explaining this to the student (“Your heart tests are normal. What you had is called a panic attack, and it can happen even when you’re not truly in danger.”) is crucial. Many panic disorder patients go from doctor to doctor convinced something is undetected inside them; a nurse’s empathetic explanation can help break that cycle and direct them to appropriate help (like therapy). Panic disorder patients are often relieved to hear that their terrifying symptoms are a known, treatable condition and that they are not “going crazy.”

Phobias

A phobia is an intense, irrational fear of a specific object, situation, or activity that is actively avoided or endured only with extreme anxiety【18†L454-L462】【18†L470-L477】. The fear is out of proportion to the actual danger posed. Exposure to the phobic stimulus almost invariably provokes immediate anxiety or a panic attack. Common specific phobias include animals (e.g. spiders – arachnophobia【18†L458-L462】, snakes), natural environments (heights, storms, water), blood-injection-injury (needles, seeing blood – which can uniquely cause a vasovagal faint response rather than tachycardia), and situational (flying, elevators, enclosed spaces). By definition, the person recognizes the fear is excessive or unreasonable (except perhaps in young children), yet they feel powerless to control it【69†L13-L16】. To be diagnosed, the phobic avoidance or fear must significantly impair the person’s life or cause marked distress, and typically last 6 months or more【18†L470-L477】.

Signs/Symptoms: When confronted (or anticipating confrontation) with the phobic stimulus, the person experiences anxiety symptoms often similar to a panic response: heart racing, sweating, shortness of breath, etc., or in milder cases just intense dread. The individual goes to great lengths to avoid the feared object or situation. For example, someone with a driving phobia may completely avoid driving, or a person with a dog phobia might only walk on routes they know are dog-free. Even talking about or seeing pictures of the feared object can trigger anxiety. Children with phobias might cry, tantrum, freeze, or cling to a parent when faced with the stimulus【17†L370-L378】【17†L380-L387】.

One important phobia subtype is Social Anxiety Disorder (Social Phobia) – fear of social or performance situations where one might be scrutinized or negatively evaluated by others【17†L370-L378】. People with social anxiety disorder fear acting in a way that will embarrass or humiliate them (e.g., saying something foolish, showing anxiety symptoms like blushing or trembling). Common feared situations include public speaking, meeting strangers, eating or writing in front of others. This can lead to avoidance of school, work presentations, or social gatherings. Social anxiety disorder often emerges in the teens and can significantly impair academic or occupational functioning if severe.

Another is Agoraphobia, which is often linked with panic disorder but can be diagnosed separately. Agoraphobia is the fear of being in situations where escape might be difficult or help unavailable if one develops panic-like symptoms【18†L447-L454】【18†L478-L485】. Classic agoraphobic fears include using public transportation, being in open spaces (parking lots, bridges) or enclosed spaces (theaters), standing in line or being in a crowd, or being outside of home alone【18†L478-L485】. The person avoids these or needs a companion. In extreme cases, individuals become essentially homebound.

Neurobiological basis: Phobias often develop through a combination of classical conditioning (a frightening experience paired with an object – e.g., being bitten by a dog leading to dog phobia), observational learning (seeing someone else harmed or fearful), and genetic predisposition (some people have more anxious temperaments). The amygdala and fear circuitry in the brain are involved – the phobic object triggers an amygdala alarm response out of proportion. There may be evolutionary preparedness for some phobias (snakes, heights historically posed threats).

Nursing implications: When caring for a patient with a known phobia, respect their fear and avoid exposing them to the trigger without preparation. If a hospital patient has a needle phobia, for example, find ways to ease blood draws (topical anesthetics, having them lie down, distraction techniques). Do not belittle the fear (“Oh come on, it’s just a tiny dog, it can’t hurt you”) – phobic individuals know intellectually the object isn’t truly dangerous, but their anxiety is involuntary. Instead, use empathy: “I understand that even though you logically know the dog is harmless, it causes you real panic. Let’s focus on how you can stay calm.” In an acute setting if the phobic stimulus is present (like the patient with arachnophobia spots a spider in the room), promptly address it (remove the spider) and then assist the patient with calming down.

The mainstay treatment for phobias is therapy, especially Exposure Therapy【44†L69-L72】. Systematic desensitization (gradual exposure paired with relaxation) or flooding (intense sustained exposure, used less often) are techniques to extinguish the fear response. Nurses in mental health settings may collaborate in exposure exercises – for instance, practicing holding a toy snake before looking at a real snake, etc., under a therapist’s guidance. For social anxiety disorder, CBT focusing on cognitive restructuring of negative self-beliefs and social skills training is effective. Group therapy can also help, as patients slowly engage with a safe social group. Medications are generally adjunctive. For predictable phobic situations (like flying, or MRI procedures in claustrophobia), a one-time dose of a benzodiazepine or a beta-blocker (like propranolol) can reduce autonomic symptoms. SSRIs may be prescribed for social anxiety or agoraphobia especially if panic disorder co-exists.

Patient education: Teach patients about the high success rate of exposure therapies – many are understandably avoidant of treatment because it involves facing their fear. Motivate them by sharing that phobias are very treatable and that facing the fear in a controlled way can retrain their brain’s response. If the patient is in ongoing therapy, encourage them to follow through with homework assignments (e.g. practicing a relaxation technique or a small exposure step) and celebrate their successes in confronting fears.

Obsessive-Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder is characterized by the presence of obsessions, compulsions, or both, which are time-consuming (taking more than an hour a day) or cause significant distress or impairment【20†L988-L996】【20†L1002-L1009】. Obsessions are unwanted, intrusive thoughts, urges, or images that cause marked anxiety or distress【20†L1015-L1023】. Common obsessions include fears of contamination (germs, dirt), recurring doubts (wondering “did I turn off the stove?” repeatedly), a need for symmetry or exactness, or aggressive or horrific impulses (e.g., a sudden image of harming one’s child, which is very disturbing to the person). The individual typically attempts to ignore or suppress obsessions, or neutralize them by performing a compulsion. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rigid rules【20†L1024-L1032】. The behaviors are aimed at reducing anxiety or preventing a feared event, but they are excessive or not realistically connected to what they are intended to prevent【20†L1024-L1032】. For example, a person obsessed with germs may wash hands for hours; someone with an obsession about things being in order might arrange and rearrange items constantly until “it feels right.”

Signs/Symptoms: Common compulsions include excessive cleaning (handwashing, cleaning household items)【20†L1026-L1034】, checking (doors locked, appliances off)【20†L1032-L1038】, counting, repeating actions a certain number of times, arranging objects symmetrically, or mental compulsions like praying or repeating words silently. The content of obsessions and compulsions can vary widely:

Individuals with OCD usually have insight – they know their obsessions are a product of their own mind and recognize that their compulsions are excessive or unreasonable, yet they feel unable to stop【21†L1064-L1072】. This insight can vary (some have “poor insight” and firmly believe their compulsions will prevent disaster)【21†L1064-L1072】. Importantly, performing the compulsion temporarily relieves the anxiety caused by the obsession, which negatively reinforces the behavior. OCD can consume a person’s life – for example, someone may spend hours getting ready due to ritualized dressing, making them late to work consistently (occupational impairment)【20†L1004-L1011】【20†L1039-L1047】. Relationships can suffer (family members might become involved in enabling rituals, or become frustrated).

Neurobiological basis: OCD has a significant biological component. Brain imaging shows abnormal activity in the cortico-striato-thalamo-cortical (CSTC) circuits, particularly increased metabolism in the orbital frontal cortex, cingulate gyrus, and caudate nucleus【21†L1085-L1093】. Serotonin is strongly implicated – hence SSRIs at high doses can alleviate symptoms. Genetics play a role; OCD tends to run in families. There is also a subtype of childhood-onset OCD associated with streptococcal infection (PANDAS), suggesting an autoimmune process affecting the basal ganglia【21†L1093-L1101】. Psychologically, people with OCD often attach extreme significance to their thoughts (thinking “having this terrible thought is as bad as doing it”), a phenomenon called “thought-action fusion,” which fuels anxiety and ritualizing.

Nursing implications: When caring for a person with OCD, it’s important to assess both obsessions and compulsions. Often patients are embarrassed and may try to hide their symptoms. Provide a nonjudgmental environment so they feel safe discussing their intrusive thoughts or rituals. Do not abruptly stop a compulsion when the patient is in the midst of one – preventing a ritual without helping the patient cope will spike their anxiety. For example, if a patient is repeatedly checking a door lock, simply telling them “stop it” is likely to cause panic or anger. Instead, during initial treatment allow time for rituals, and gradually work on decreasing them. In an acute care setting, you might schedule periods for the compulsive behavior, gradually shortening them, to help the patient feel some control (e.g., “You can have 10 minutes to wash your hands after meals” if they usually take 30 minutes). Ensure basic needs are met – OCD rituals can take priority over eating, sleeping, etc., so the nurse may need to structure the schedule (e.g., “Let’s eat first, then you can spend 15 minutes on your ritual.”).

Teach the patient grounding techniques or alternative behaviors to manage urges. For instance, delay technique (“try to wait 5 minutes before starting your ritual”) and breathing exercises when anxiety hits. Praise any success in resisting or shortening rituals – positive reinforcement helps. When the patient is not highly anxious, engage in cognitive discussion: help them examine the likelihood of their fear coming true, or the impact the OCD has on their life. However, avoid logical debates during an obsession’s peak – their anxiety is too high for rational talk at that moment.

Medications: As mentioned, SSRIs (such as fluoxetine, sertraline, paroxetine, fluvoxamine) are first-line pharmacotherapy for OCD and o​ncbi.nlm.nih.govdoses than used for depression【22†L1120-L1128】. It can take 10-12 weeks to see significant improvement【22†L1118-L1125】, so encourage adherence even if results are not immediate. Clomipramine (a tricyclic) is another effective agent, often used for treatment-resistant cases. If a patient has co-occurring tic disorder, an antipsychotic may be added in low dose【22†L1120-L1128】. Ensure the patient knows that initially SSRIs may cause some side effects and that continuing the medication is important for full benefit.

The gold standard therapy is Exposur​ncbi.nlm.nih.gove Prevention (ERP), a form of CBT specifically for OCD【22†L1133-L1141】. In ERP, the patient is systematically exposed to the source of their obsession (e.g., touching something “contaminated”) and then prevented from performing the compulsion (not allowing immediate handwashing), learning over time that the anxiety will abate without the ritual and that no catastrophe follows【22†L1133-L1141】. This is challenging therapy but highly effective. As a nurse, if involved in outpatient care or collaborating with therapists, encourage the patient through this process, help them with relaxation techniques to manage the anxiety during exposure, and celebrate the small victories (like touching a doorknob and waiting 5 minutes to wash).

Patient teaching: OCD patients and families benefit from education that OCD is a biologically-based illness – it is *n​ncbi.nlm.nih.gov being “crazy” or “immoral” (especially when obsessions are aggressive or sexual in nature, patients may feel ashamed). Emphasize that having a horrific tho​ncbi.nlm.nih.govan they will act on it – it’s a symptom of OCD. Family therapy or education can help relatives not to participate in rituals (like not providing endless reassurance or checking for the patient, which can reinforce OCD). Instead, family can support by reminding the patient of therapy strategies and encouraging them in a calm way.

Nursing Priority for OCD: Ensure safe performance of compulsions and gradually set limits as tolerated. For example, a compulsive hand-washer may harm their skin – the nurse can provide a mild soap or moisturizer and gently guide them to wash less frequently by scheduling and positive feedback. The priority is not to eliminate the behavior overnight, but to prevent self-harm and start building alternative coping mechanisms for anxiety. Over time, with effective therapy and possibly medication, the goal is that the patient will spend less time on rituals and regain normal routines【20†L1039-L1047】【20†L1043-L1051】.

Dissociative Disorders

Dissociative disorders involve a disruption or discontinuity in consciousness, memory, identity, or perception of the self【25†L193-L201】【25†L205-L213】. In essence, dissociation is a defense mechanism where the mind “compartmentalizes” or separates certain memories or thoughts from normal consciousness in response to overwhelming stress or trauma. These disorders are often linked to severe trauma, especially in childhood, as a way to cope with experiences that are unbearable. The three major types are Depersonalization/Derealization Disorder, Dissociative Am​coryabarnes.medium.com​coryabarnes.medium.comugue), and Dissociative Identity Disorder (DID)【25†L195-L203】【25†L197-L200】.

Depersonalization/Derealization Disorder

In Depersonalization/Derealization Disorder, the person experiences episodes of feeling detached from themselves (depersonalization), from their surroundings (derealization), or both. Depersonalization is described as feeling like an outside observer of one’s own thoughts, body, or actions – as if one is in a dream or not really inhabiting one’s body. Patients often say things like, “It’s like I’m watching myself in a movie,” or “I feel unreal, like a robot.” Derealization is a sense of unreality or strangeness of the environment – people or objects may seem foggy, lifeless, or visually distorted. Example: A patient in a busy ER after an accident might suddenly feel like “this isn’t actually happening” and that the room or people aren’t real – a derealization episode.

During these episodes, reality testing remains intact – the person knows these feelings are not actually true, which differentiates depersonalization/derealization from psychosis. They know, for instance, that they are not truly a robot or in a dream, but feel that way. This insight can actually cause distress: they might fear they are “going crazy” because they have such bizarre sensations. Episodes can last just moments or recur over years. Onset is often in adolescence, and episodes may be triggered by severe stress, trauma, fatigue, or intoxication (certain drugs can precipitate similar feelings).

Nursing implications: Patients experiencing depersonalization/der​ncbi.nlm.nih.gov​ncbi.nlm.nih.govly aloof or anxious and might have trouble expressing what’s wrong (“I just feel not real”). The nurse should stay calm and provide grounding. Grounding techniques help reorient the person: for example, have them hold a cold object (to feel sensation), describe their surroundings in detail, or engage in physical activity like walking. Gently reassure them: “You are here with me, I know it feels strange, but you are safe.” Avoid arguing about the feeling (don’t say “Snap out of it, you are real” – they know that logically, but the feeling persists). Instead validate that it’s a known phenomenon that can happen under stress. Reduce environmental stressors if possible (lower noise, offer a quiet space). If episodes are frequent, assess for a history of trauma or current extreme stress – these often underlie dissociative symptoms.

Treatment of depersonalization/derealization is typically psychotherapy (such as grounding techniques in therapy, trauma-focused therapy if relevant, sometimes cognitive techniques to address the distress about the episodes). No specific medication stops the episodes, but treating co-occurring anxiety or depression can help (SSRIs or mood stabilizers may be used in some cases). Educate patients that while the sensations are disturbing, they are not dangerous and often worsen with anxiety about them – learning relaxation and distraction when episodes start can shorten the duration.

Dissociative Amnesia (with Fugue)

Dissociative Amnesia is characterized by an inability to recall important autobiographical information, usually of a traumatic or stressful nature, that cannot be explained by ordinary forgetfulness【75†L213-L220】【75†L215-L223】. It’s more extensive than typical “I forget things when I’m stressed.” For example, a person may have no memory of an entire violent assault they experienced, or a combat veteran mi​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. The memory loss is most often localized (a specific event or period is wiped out) or selective (bits and pieces of an event are forgotten)【75†L215-L223】. In rarer cases it can be generalized – the person forgets their entire life history (who they are, where they live, etc.)【75†L215-L223】【75†L221-L228】. The onset is usually sudden, following severe psychosocial stress or trauma.

A specifier of this disorder is Dissociative Fugue【75†L215-L223】【75†L231-L239】. In a fugue state, an individual with dissociative amnesia unexpectedly travels away from home or work (sometimes even hundreds of miles) and may assume a new identity, all while being amnesic for their past (they do not remember who they really are or details of their life)【75†L229-L238】【75†L231-L239】. Fugue states can last hours to months. For example, a man disappears after a traumatic event; weeks later he’s found in another state working under a different name, with no memory of his life before. When the fugue ends, the previous memories return but there is often amnesia for the fugue period.

Signs/Symptoms: Aside from the memory loss, the person may appear confused, perplexed, or in fugue may seem to be wandering aimlessly. Often, once they are in a safe environment, memories might spontaneously return, or at least partial recall happens. During the amnesic phase, they may experience significant distress or, conversely, they may have a la belle indifférence-like calm (particularly in fugu​ncbi.nlm.nih.govloss of memory, which itself is notable. It’s crucial to rule out neurological causes for memory loss (like seizures, brain injury, or intoxication) – dissociative amnesia is a diagnosis of exclusion after medical workup is negative.

Nursing implications: In a protected environment (like a hospital), gentle support and safety are key. Do not pressure the patient to remember. Memory may return on its own, and pushing recall too quickly can provoke anxiety or distress. Instead, orient the person to who they are (if known) and maintain a calm, simple routine. If the patient doesn’t remember their identity at all, treat them as you would any patient – with respect and reassurance that you will keep them safe while things are sorted out. Ensure safety especially if the person is distressed by their lack of memory (risk of self-harm or panic). Once medical causes are ruled out, involve mental health professionals. Techniques like guided imagery, hypnosis, or interviews with drug facilitation (like a sedative interview) are sometimes used by speci​ncbi.nlm.nih.gov​ncbi.nlm.nih.govies carefully, but these are beyond a nurse’s scope. The nurse, however, might facilitate by providing a quiet, trusting environment for such therapy sessions.

Educate family (if present​aafp.org​aafp.orgred – seeing a loved one not recall them is hard; they should gently reintroduce themselves and share memories with​psychiatry.org​psychiatry.orgnt. Over time, psychotherapy will work on uncovering and processing whatever trauma led to the amnesia so that the patient can saf​ncbi.nlm.nih.gov​ncbi.nlm.nih.govport by encouraging expression of feelings as memory returns and monitoring for depression or PTSD sy​nurseslabs.com​nurseslabs.comh returned memories.

Most dissociative amnesias resolve spontaneously, especially when the person is removed from the stressful situation. Once m​ncbi.nlm.nih.gov, the person is at risk for distress, shame, or depression related to what they recall or actions during the fugue. Provide emotional supp​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov for coping with the precipitating trauma, which is often necessary to prevent future episodes.

Dissociative Identity Disorder (DID)

Formerly known as Multiple Per​ncbi.nlm.nih.gov​ncbi.nlm.nih.govissociative Identity Disorder is perhaps the most extreme outcome of dissociation. It is defined by the presence of two or more dist​ncbi.nlm.nih.gov​ncbi.nlm.nih.govidentities that recurrently take control of the individual’s behavior, accompanied by inability to recall important personal information coryabarnes.medium.com​coryabarnes.medium.comle by ordinary forgetfulness【75†L211-L218】. These personality states (often called “alters”) may have their own name, age, gender, posture, memories, and behaviors. Typically there is a “host” personality (often the one corresponding to the perso​frontiersin.org​frontiersin.orge unaware of the others) and one or more “alters” which can differ in remarkable ways. Transitions between identities (sometimes called “switching”) are often triggered by stress, and can be sudden (within seconds) or gradual.

**Signs/Symptoms:​ncbi.nlm.nih.govth DID might refer to themselves in the first person plural (“we”) or in third person, or be observed speaking in different tones or accents at different times. Others might notice unexplained changes in attire, handwriting, or skills (one identity might be right-handed and anothe​ncbi.nlm.nih.gov​opentextbc.cale). There are often episodes of amnesia – the person “loses time” when an alternate identity is in control, leading to memory gaps for certain events (they might find objects or notes they don’t remember, or be called by a different name by someone who met them during a switch). It’s common for individuals with DID to have associated symptoms like depression, flashbacks of trauma, nightmares, and self-harm or suicidal tendencies (some identities may harbor intense trauma memories or negative beliefs). Importantly, in some cultures these experiences may be seen or explained as possession by a spirit or other being【75†L211-L218】. In fact, DSM-5 notes that in some cultures, the alternate identity may be interpreted as an experience of possession (which still meets criteria if it’s involuntary and distressing)【75†L211-L218】.

Etiology: DID is strongly linked to severe, chronic childhood trauma – often repeated physical or sexual abuse at an early age, or other profound neglect/trauma【31†L133-L141】【31†L135-L144】. The prevailing theory is that a young child, unable to physically escape horrific abuse, copes by “escaping” in their mind – i.e., dissociating. Over time, dissociated memories and feelings form separate identities. Each identity may serve a function (for instance, one might hold anger, another might function in daily life, another might come out to handle sexual abuse, etc.). DID is a controversial and complex disorder, but it is recognized as a genuine condition in DSM-5, distinct from culturally normative possession or from psychotic disorders (in DID, the different identities are not hallucinations; they are dissociated parts of self).

Nursing implications: Establishing trust and safety is the absolute foundation when working with DID. These patients have often experienced extreme betrayal of trust in childhood, so a consistent therapeutic relationship is key. The nurse may initially interact with what appears to be the host or one identity, but should be prepared that other identities may emerge especially under stress or triggers. Do not show shock or judgment when an identity switches. For example, if an alter that is a young child comes out (speaks in a childlike voice), the nurse can gently engage at that level – perhaps comforting the “child” alter with a soft tone and assuring safety. It’s not helpful to insist on speaking to the “real” person at that moment; instead, meet the patient where they are. Over time, as trust builds, the patient (with therapy) will work toward more communication and cooperation between identities.

Safety is a priority: some identities might have self-destructive tendencies or carry traumatic memories that overwhelm them. Suicide risk assessment is crucial because DID patients have high rates of self-harm and suicide attempts. If an identity expresses suicidal thoughts, take it as seriously as if the whole person does – because any part in control could act on those thoughts. Ensure the environment is free of means for self-harm if such risk is present.

Grounding techniques are useful for all dissociative disorders – help the patient stay in the present. If the patient begins to dissociate or switch due to a trigger (say they start to “drift off” or you notice a change in demeanor indicating a switch), use grounding: “You’re here now, at the hospital, and it’s [date]. I’m [Name], your nurse. You are safe.” Simple sensory grounding (holding an ice cube, focusing on the details of the room) can help.

Do not force recollection of trauma. Intensive trauma processing is the domain of a skilled therapist over a long time. The nurse should instead ensure the patient has coping strategies for dealing with any flashbacks or emotional floods that come with recollections. Assist with stress management: patients with DID benefit from learning calming strategies (deep breathing, mindfulness) to reduce unplanned switching.

Collaboration with the treatment team is important. The primary treatment for DID is long-term psychotherapy aimed at integrating the identities or at least achieving harmonious co-existence. Some patients may not fully “merge” identities but learn to manage transitions such that their life is not chaotic. Pharmacologic treatment is usually symptom-targeted (e.g., antidepressants for depression, prazosin for PTSD-related nightmares, etc.) – there is no medication that “cures” DID, but comorbid conditions (anxiety, depression) often require treatment. Educate about medications as you would normally, being mindful that some identities may be unaware of others’ medication compliance (so implementing cues like daily pill boxes and written schedules can be useful).

Family or social support can be tricky. If family were perpetrators of abuse, obviously they may not be involved. But if supportive family exist, they should learn about DID so they don’t panic if a switch happens and so they can help the patient with grounding and safety.

Finally, maintain professional boundaries and consistency. Patients with DID might unconsciously re-enact interpersonal dynamics – for instance, one identity might become very attached to a nurse as a “safe parent” figure, while another identity might distrust the nurse. Team communication (consistent approaches among staff) will help avoid splitting. Document observations objectively (e.g., “Patient spoke in a noticeably different tone and referred to self as ‘Jenny’ (third person) for about 20 minutes, then was unable to recall this period”). This helps the treatment team track identity shifts and possibly communicate with the treating therapist about patterns.

Trauma-informed approach: All care for DID must be trauma-informed (see section on Trauma-Informed Care). The existence of DID implies extreme trauma history. Ensure the patient has control and choice whenever possible in their care to counter the powerlessness they felt in childhood. For example, ask for preferences (Which arm do you prefer for an IV? Is it okay if I touch your shoulder to help guide you back to bed?). Always explain procedures and never force anything unless absolutely medically necessary, as these patients can be easily re-traumatized by feelings of being helpless or confined. Simple measures like asking permission before a physical exam and allowing a support person (if appropriate) during anxiety-provoking situations can make a big difference.

Somatic Symptom and Related Disorders

In Somatic Symptom and Related Disorders, individuals experience physical symptoms that cannot be fully explained by a medical condition, and these symptoms are associated with excessive thoughts, feelings, or behaviors related to the symptoms【33†L96-L104】. The suffering is real for the patient, even if medical tests are normal. These disorders lie at the interface of medicine and psychiatry – often patients first present in primary care or specialty clinics with physical complaints. It’s essential for nurses to recognize these disorders so patients can be treated with empathy and appropriate interventions rather than unnecessary medical procedures.

The major disorders in this category are Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder (Functional Neurological Symptom Disorder), and Factitious Disorder (including Munchausen syndrome). (Note: Malingering – faking illness for external gain – is not a psychiatric disorder, but it may be considered in differential diagnosis.)

Somatic Symptom Disorder (SSD)

In Somatic Symptom Disorder, the patient has one or more physical symptoms – which may have an identified medical cause, or may not – but importantly, the patient’s thoughts and anxiety about the symptoms are excessive and disproportionate【33†L96-L104】. The individual spends an extreme amount of time and energy on health concerns, often to the detriment of other aspects of life. Symptoms can be specific (like localized pain) or vague (fatigue). The key is the psychobehavioral features: persistent thoughts like “This symptom must mean I have a terrible disease,” high levels of anxiety about health or symptoms, and/or excessive time devoted to symptoms (repeated doctor visits, medical tests, researching).

A patient with SSD might, for example, have years of fluctuating pain in various body parts and truly suffer from it, constantly seeking an explanation even after many normal workups. In DSM-IV, this might have been labeled “somatization disorder” or “pain disorder,” but DSM-5 combined these into SSD【33†L100-L109】. Many patients previously labeled as “hypochondriacs” actually fall under SSD if they have prominent somatic symptoms (as opposed to just health anxiety without symptoms, which is Illness Anxiety Disorder).

Signs/Symptoms: Common somatic symptoms include pain (headaches, back pain, joint pain), gastrointestinal problems (nausea, bloating), cardiopulmonary symptoms (shortness of breath, palpitations), or neurologic-like symptoms (weakness, dizziness). The symptoms may change over time but there is almost always something troubling the patient. The patient often has a long, complicated medical history file – multiple diagnostic tests (often all negative) and specialist evaluations. They frequently seek reassurance but the reassurance never reduces their worry for long – soon after tests come back normal, they may shift focus to another symptom or suspect a different illness. They might also be very sensitive to medication side effects (reporting many adverse reactions). It is not uncommon for these patients to become frustrated with the medical system, feeling dismissed or that “no one can find what’s wrong with me.”

Neurobiological and psychosocial basis: There is evidence that somatic symptom disorder patients experience heightened body sensation awareness and may have a low threshold for perceiving physical discomfort. Some research suggests abnormal brain activation in regions processing emotions and pain. Psychologically, often these patients have difficulty expressing emotional distress, and it gets channeled into physical symptoms (sometimes called somatization). A history of trauma or illness in the family can be risk factors. It’s important to note the symptoms are not deliberate – the patient isn’t “faking.” The pain or symptom is real to them, but it stems from a complex mind-body interaction.

Nursing implications: The first step is a thorough assessment to validate that appropriate medical evaluation has been done. Nurses should ensure we’re not missing a medical condition. Assuming serious pathology is ruled out, the focus turns to addressing the patient’s health concerns in a supportive way without reinforcing maladaptive behavior. It’s a delicate balance. Establish one primary care provider if possible (to avoid doctor-shopping and repeated tests); as a nurse, communicate closely with that provider. Treatment often uses the strategy of regularly scheduled brief visits rather than symptom-driven visits【33†L96-L104】. For example, the patient is seen once a month to discuss how they’re doing, rather than every time a new symptom arises – this provides consistent support but reduces urgent medical utilization.

During interactions, listen empathically. These patients often feel nobody believes them. A validating statement like, “I know you’re experiencing real pain and it’s affecting your life,” can build trust. Avoid dismissive comments like “It’s all in your head.” Instead, you might say, “Stress and emotions can actually cause or worsen physical symptoms. Let’s look at all factors that might be influencing your health.” Help the patient make connections gently: “I notice your worst flare-ups happened after your divorce proceedings – what do you think about that?” Some patients will resist a psychological explanation; don’t force it, but persist in holistic care.

Encourage gradual shift of focus from symptoms to functioning. For example, instead of asking each visit, “How is your pain scale today?” ask “What activities were you able to do this week?” Even if pain persists at a 5/10, perhaps they managed to go grocery shopping or attend a social event. Praise improvements in function. Set small goals, like walking for 10 minutes a day, even if pain is there, reinforcing that increasing activity safely will not harm them even if it’s uncomfortable. Over time this can reduce the disability.

Limit setting may be needed on excessive healthcare behaviors. For instance, if a patient wants a fourth MRI this year, the provider might say, “We have done thorough testing which is normal. We will not do more scans at this time; instead, we will work on managing your symptoms.” The nurse can support this by explaining the concept of sensitization – more tests can sometimes make anxiety worse or even cause harm (false positives, radiation exposure), and it’s better to focus on coping.

Introduce the idea of mental health referral carefully: frame therapy as a way to help with stress resulting from their symptoms, rather than “because it’s all psychological.” For example, “Chronic symptoms can take a toll on mood and coping – our counselor is really good at helping people find ways to feel better emotionally, which often helps physically too.” Therapies like CBT have evidence for somatic disorders【33†L96-L104】, aiming to reduce catastrophizing about symptoms and improve daily functioning. Nurses can underline that mind-body approaches (relaxation training, biofeedback, stress management) have been shown to reduce physical symptoms even in other conditions (like blood pressure or chronic pain), so it makes sense to try.

On the medical side, avoid invasive procedures or habit-forming drugs unless absolutely indicated. Somatic symptom patients can become frequent users of pain meds or anxiolytics – which can lead to dependency without truly addressing the underlying issues. Work with the team to use non-pharmacological pain management as much as possible (heat packs, gentle exercise, PT, relaxation). If medications are used, SSRIs or SNRIs might help by treating underlying anxiety/depression, and sometimes they have a secondary benefit of pain modulation (e.g., duloxetine for fibromyalgia-like pain).

Document objectively the symptoms and the results of exams. This helps show patterns and also protects against over-testing. Also note the patient’s affect and any stressors mentioned at visits.

Patient education: Teach the patient about the concept of the mind-body connection in a non-stigmatizing way. For instance: “Have you ever had butterflies in your stomach when nervous? That’s a classic example of how stress can cause a real physical feeling. We think something similar might be happening with your symptoms – your body is under a lot of stress which can cause real pain, even if scans are normal. The good news is, by working on stress and coping, you may actually feel better physically.” Over time, the patient may come to accept psychological contributors. Encourage small shifts like engaging in enjoyable activities despite symptoms (to prevent total life takeover by illness).

Illness Anxiety Disorder (Hypochondriasis)

Illness Anxiety Disorder is essentially health anxiety in the absence of significant somatic symptoms. The person is excessively worried that they have or will get a serious illness, even though they may have few or no physical symptoms【36†L96-L100】【36†L122-L130】. Any mild symptom (like a minor cough or a mole) is interpreted as a sign of severe disease (like lung cancer or melanoma). If somatic symptoms are present at all, they are very mild, and it’s the anxiety that is prominent. This disorder was previously known as hypochondriasis (though DSM-5 split hypochondriasis into Illness Anxiety vs Somatic Symptom disorders depending on whether physical symptoms are present)【33†L100-L107】.

Signs/Symptoms: Individuals with illness anxiety frequently check their bodies for signs of illness – e.g., examining skin moles repeatedly, checking pulse or blood pressure often. They might constantly seek reassurance from doctors, friends, or the internet (which often backfires; reading about diseases can increase their conviction that they have them). Alternatively, some have a maladaptive avoidance – they avoid doctor appointments or hospitals for fear of finding out they have dreaded diseases. They typically have a long history of anxiety about health, often dating to early adulthood, and it can wax and wane. For example, a person might be convinced they have ALS after feeling muscle twitches, then after tests are normal they shift to fearing multiple sclerosis when they get a headache, etc. Their level of worry is disproportionate – normal test results or medical opinions do not calm them, or only briefly do so (“the tests miss something”). They often research diseases excessively. It’s not delusional (they can imagine being ill but also can at times acknowledge the possibility they are overreacting), and it’s not just general anxiety – it’s specifically health-focused.

Nursing implications: Patients with illness anxiety might present similarly to those with somatic symptom disorder (frequent healthcare visits), but the difference is minimal physical findings. They are coming more for evaluation of feared illnesses than for relief of actual symptoms. They often require frequent reassurance, but giving reassurance directly can become a trap (they soon doubt it). A technique used in therapy and can be supported by nursing is to shift the goal from seeking 100% certainty about health (impossible) to coping with uncertainty. For example, if a patient says “I just need another MRI to be sure I don’t have a brain tumor,” one could respond: “It sounds like your anxiety is very high. What would it mean to you if the MRI is normal? Would you feel completely safe from illness? Sometimes even after tests, you’ve still felt worried, right? Maybe we should focus on how to manage this worry itself.” This gently points out the pattern without dismissing the fear.

Like SSD, a consistent provider approach is helpful. Too many tests can actually reinforce the illness anxiety (each test implies “maybe there is something to find”). So the healthcare team should avoid jumping to invasive diagnostics for every new concern unless red-flag signs truly warrant it. Regular check-ups (e.g., a monthly or quarterly appointment) can be scheduled so the patient knows they have an outlet for their concerns – this can prevent unscheduled emergency visits. During scheduled visits, the provider can perform a focused exam to satisfy both parties that no new serious illness is apparent, then shift to discussing stress, life, coping. The nurse’s role in such visits is to provide empathy (“It must be hard feeling so worried about your health all the time”) and slowly encourage engaging in life despite fears.

If a patient avoids medical care out of fear (some do), building trust is key: perhaps they finally come in one day convinced they have advanced cancer but were too afraid to see anyone. Approach with calm and matter-of-fact assessment, do necessary exams to show you’re taking their concerns seriously, but also address anxiety: “I know it took courage to come today. Let’s work together step by step.”

Education: Explain that anxiety can actually produce physical sensations (like palpitations or aches) and that the goal of treatment is to break the cycle of worry and sensations feeding each other. Cognitive-behavioral therapy is very effective for illness anxiety – it helps patients challenge catastrophic misinterpretations of benign symptoms【36†L122-L130】【36†L125-L132】. Nurses can support CBT techniques by asking patients to consider alternative explanations (“What else could that twinge be, other than cancer? Maybe just a muscle spasm?”) and to work on reducing behaviors that maintain anxiety (like constant googling of symptoms). Instead of googling, maybe they can distract with a healthy activity, etc.

Medication: SSRIs or SNRIs can reduce the underlying anxiety and are often utilized, particularly if the health anxiety is part of a broader anxiety or depressive disorder. Nurses should encourage compliance and explain that these medications do not mean “it’s all in your head”, but rather help the brain’s anxiety circuits to calm, which should reduce the intense worry about illness.

Follow-up: These patients benefit from knowing they have support. The nurse can schedule a phone call between appointments just to check in (“How are you doing with the worry this week? Any techniques helping?”). This structured attention can paradoxically reduce excessive unscheduled contact because the patient feels cared for and heard.

Conversion Disorder (Functional Neurological Symptom Disorder)

Conversion Disorder is characterized by neurological symptoms (motor or sensory) that are not consistent with medical or neurological conditions, often preceded by psychological stress【12†L175-L183】【38†L119-L127】. In other words, the person “converts” emotional distress into a physical neurologic symptom. Classic examples include sudden paralysis of a limb, blindness, mutism, seizures (nonepileptic attacks), or loss of sensation – all without organic pathology. The patient is not faking; the symptoms occur involuntarily, but exam findings often show discrepancies (e.g., in conversion paralysis, reflexes may be normal, or in conversion blindness, the patient navigates a room without injury despite saying they can’t see). This disorder often appears abruptly in the context of stress.

Signs/Symptoms: Conversion symptoms can involve almost any voluntary motor or sensory function:

Typically, a thorough medical workup finds no neurological disease. It’s common for conversion symptoms to not follow anatomical pathways – for instance, a patient’s entire hand may be numb (a “glove anesthesia”), which doesn’t match how nerves innervate the hand; or they might be paralyzed but certain reflexes are intact, suggesting intact pathways.

Psychosocial context: There is often an antecedent stressor or conflict. For example, a soldier who subconsciously cannot face combat might develop a sudden blindness with no medical cause; or someone who feels intense anger that they cannot express might develop a paralyzed arm (symbolically preventing acting out). Historically, this was “hysterical” blindness or paralysis. It’s thought to be an unconscious escape from or expression of stress.

Neurobiology: Interestingly, brain imaging in conversion has shown changes in blood flow in areas related to motor control and emotion – there is something neurologically real going on, but it’s triggered by psychological factors rather than structural lesions.

Nursing implications: Always remember to treat conversion symptoms as real in effect – the patient cannot move the limb or cannot see, even though no organic cause has been found. Do not accuse them of faking or try to “prove” they can do it. For instance, if a patient has conversion paralysis of legs, you would still provide assistance with mobility (wheelchair, physical therapy involvement) to prevent falls or injury. At the same time, avoid reinforcing disability: encourage gradual use of the affected part as much as possible and normal activities, without excessive attention to the symptom. A nursing approach often used is the “supportive normalization”: e.g., “The tests we did are all normal. That’s actually good news – it means no damage. Sometimes our bodies can do strange things under stress. With time and therapy, I expect you’ll regain use of your legs. Let’s focus on keeping you as strong as possible.” This kind of statement avoids telling them “nothing is wrong” (which they’d hear as “you think I’m faking!”) but also sets a positive expectation for recovery.

If the patient displays la belle indifférence (odd lack of concern), the nurse should still acknowledge the situation (“I notice you don’t seem very worried about not being able to walk; some people might find that strange, but sometimes the mind works in curious ways. Let’s concentrate on your rehab.”). Do not pointedly challenge them about the indifference – it may be an unconscious coping mechanism.

Psychologically, once immediate needs are addressed, you can gently help the patient identify any stressors that occurred before onset. For example: “Sometimes these symptoms can happen after a very stressful event. Did anything difficult happen around the time this started?” The patient may or may not make the connection. If they do acknowledge, say, a trauma, then validate and let them know psychological support (like counseling) could be beneficial in recovery.

Safety: If the symptom is seizures, ensure precautions as with any seizure (protect from injury during events, though note these non-epileptic attacks often have no postictal phase and the patient might actually respond to voice). If blindness, ensure the environment is arranged safely and assist with ADLs as needed, while encouraging attempts to function (maybe use orientation cues or mobility training if prolonged).

Avoid unnecessary interventions: Once diagnosed (or strongly suspected) conversion, avoid repetitive tests as it can perpetuate the sick role. Work in the team to consolidate care: likely a neurologist or physician has explained tests are normal. Reinforce that understanding positively (“The MRI was clear. That’s excellent – your brain is healthy. Now our goal is to help your body relearn to move.”).

Rehabilitation therapy (physical or occupational therapy) often helps conversion motor symptoms, not only by maintaining muscle tone but by indirectly helping the patient recover function through practice – even if the origin is psychological, using the limb in PT can facilitate improvement. The nurse should actively collaborate with therapists and encourage participation: “Physical therapy is part of your treatment to help you walk again; I’ll help get you there and back.”

Patient/family education: Conversion disorder can be confusing for families – they may either doubt the patient or be overly solicitous. Explain in simple terms: “Medical tests show that the problem isn’t in the nerves or brain structure. Stress can cause real physical symptoms – the mind and body are connected. The treatment approach is to support [the patient] and help them cope with stress. We expect improvement.” Emphasize that the patient isn’t choosing this, and also that recovery is usually good. Indeed, conversion symptoms often spontaneously remit especially if stress is relieved.

Prognosis is generally good, but recurrence can happen if underlying issues aren’t resolved. Therefore, after acute care, referral to psychotherapy is important (such as trauma-focused therapy if indicated, or cognitive-behavioral therapy to learn better stress responses). Nurses in discharge planning should ensure appropriate mental health follow-up even if the patient is hesitant (perhaps framing it as “follow-up for your condition” rather than explicitly saying “psychologist for your stress” if stigma is an issue).

Factitious Disorder (including Munchausen Syndrome)

Factitious Disorder is a condition wherein an individual intentionally feigns or induces physical or psychological symptoms purely to assume the sick role, without obvious external incentives【41†L96-L104】【41†L117-L125】. In other words, the person’s goal is not concrete gain (like money, avoiding work, or obtaining drugs – that would be malingering), but rather the internal desire to be seen as ill or injured. They may secretly inflict injury on themselves or tamper with tests to produce symptoms. Factitious disorder can be imposed on self or another (the latter formerly called Munchausen syndrome by proxy when a caregiver, usually a parent, induces illness in someone else, usually a child).

Signs/Symptoms (Imposed on Self): These patients often present with dramatic stories about their symptoms and extensive knowledge of medical terminology. They might go to different hospitals (doctor shopping) when one team begins suspecting them. Common behaviors include adding blood to urine samples, taking small doses of poison or insulin to produce symptoms, infecting themselves, or simply lying about symptoms (like claiming seizures that are never witnessed by staff). They frequently are willing to undergo risky tests or surgeries and often have surgical scars from multiple procedures. A classic clue is inconsistency or textbook-like recurrence of issues when under observation: for instance, as soon as the invasive test shows nothing, a new symptom emerges. They may eagerly accept tests and treatment even if painful (because it validates their sick role). If confronted, they typically become angry and may leave against medical advice, then show up elsewhere.

Psychological profile: Factitious disorder is associated with underlying personality disorders, often borderline personality traits, or a history of trauma/illness in childhood. There can be a deep need for attention and nurturance. Because it is intentional, it can be hard for clinicians to remain empathetic – these patients can elicit frustration or feelings of deception. But it’s crucial to remember this is a mental disorder – they are driven by a psychological need, even if behavior is deceitful.

Factitious Disorder Imposed on Another (FDIA): Here, an individual (commonly a mother) causes or fabricates illness in someone under their care (commonly her child) to get attention by proxy. This is considered a form of abuse – the child is being harmed for the caregiver’s psychological need【64†L897-L904】【64†L898-L906】. Clues include a child with recurrent unexplained illnesses, discrepancies between reported and observed conditions, symptoms that stop when the child is away from the caregiver, and a caregiver who is oddly keen on medical tests or procedures and comfortable in the hospital environment. FDIA cases are often discovered via covert video surveillance in hospitals or careful monitoring (for example, a mother adding something to a child’s IV, or smothering the child to cause apnea).

Nursing implications (Factitious on Self): Maintaining a non-confrontational approach is key. If a nurse suspects factitious disorder (e.g., inconsistencies in the story, labs that show evidence of tampering like lab values not correlating or multiple hospitalizations with no findings), they should discreetly communicate with the healthcare team. Often a single provider (like a hospitalist or primary doctor) will take lead to avoid unnecessary interventions and to steer the workup appropriately. Avoid openly accusing the patient, as this typically causes them to flee and seek care elsewhere, continuing the cycle. Instead, the strategy is to manage the patient in a way that minimizes harm (don’t subject them to high-risk procedures unless absolutely necessary) and possibly get psychiatric consultation for underlying issues.

Nurses should meticulously document observations: e.g., “At 2100, patient’s blood glucose was 250 with no insulin ordered. At 2130, found patient handling the glucometer lancet; recheck of glucose from new fingerstick was 110.” Such documentation could support detection of self-harmful fabrication. Ensure safety measures: for example, if they have factitious hypoglycemia suspected (inducing low blood sugar by insulin or sulfonylureas), the patient should not have access to insulin (have staff store and administer needed insulin rather than allowing patient to keep any). If factitious infection is suspected (injection of feces into IV, etc.), perhaps limit IV access or use line covers.

Establishing a consistent, empathetic nurse-patient relationship can be tough because these patients might lie or create crises that frustrate staff. But if a particular nurse can gain some trust, they might become a point of stability. Therapeutic communication might involve acknowledging the patient’s emotional needs indirectly: “You seem to have been through so many medical encounters; that must be hard. We want to help you be as healthy as possible.” The ultimate treatment is psychotherapy, but patients rarely voluntarily seek psychiatric help for this specifically (they typically don’t admit to the deception).

Outcome goals are tricky – in factitious disorder, complete cessation of behavior is difficult. The initial goal is often to manage the condition such that the patient doesn’t undergo unnecessary harm. A long-term goal would be that the patient engages in mental health treatment to address underlying issues (like trauma, low self-esteem, need for attention) and gradually stop the factitious behaviors. As a nurse, if you see a pattern of unnecessary admissions, you might help coordinate with case management and psych services to develop a care plan that addresses both medical and psychological needs.

Ethical/legal: Factitious disorder imposed on another is abuse, thus a nurse is mandated to report if suspected【64†L897-L904】【64†L898-L902】. For example, if a child has unexplained recurrent poisoning and you suspect the parent, involve the healthcare team and follow protocols to inform child protective services. The child’s safety comes first – that may mean an inpatient video monitoring or separation trial to collect evidence. It’s very delicate; the perpetrator often appears very caring and convincing. As a nurse, never confront the suspected caregiver directly – that could endanger the child if they flee. Instead, quietly share concerns with the attending physician or social worker so appropriate investigative steps are taken.

For factitious on self, an ethical challenge is not feeding into the false illness but still caring for the patient. It's acceptable (even necessary) at some point for the healthcare team to have an honest discussion with the patient once immediate crises are managed. For instance, a psychiatrist might gently confront: “We haven’t found a medical cause for your symptoms. Sometimes people cause symptoms themselves because they’re dealing with emotional pain. Is it possible this is happening for you?” This ideally should be done by a psychiatric professional. The nurse’s role is to support the patient if they become upset and ensure they know they are not being abandoned.

Summary: Factitious disorder is about the need to be seen as ill. Approach with empathy but also protect the patient from invasive interventions. Encourage psychological evaluation tactfully. In the acute setting, treat the symptoms they present (e.g., if they say they have pain, you can still give non-opioid analgesics as appropriate; if they self-induced a real infection, treat it). Over time, hopefully the healthcare system coordinates to reduce repetitive hospitalizations (some hospitals develop care plans like “If patient X presents with Y symptoms, do minimal evaluation and ensure psych follow-up”).

Clinical example: A patient frequently shows up in the ER with acute abdominal pain and a story of having familial Mediterranean fever requiring IV opioids. She undergoes multiple negative laparoscopies. Nurses note that each admission, as soon as a particular nurse shows sympathy, she clings to them and then reports a new symptom (like blood in urine) when discharge approaches. Over time, the team suspects factitious disorder. They implement a plan: minimize invasive tests, hold a multidisciplinary meeting with the patient involving a psychiatrist. The psychiatrist finds a history of childhood hospitalization where the patient felt loved, suggesting she unconsciously seeks that caring environment again. The patient is slowly engaged in therapy. In subsequent ER visits, the plan is followed – quick medical screening, then a psych consult. Eventually, the visit frequency drops. This kind of outcome is ideal but requires consistent team strategy.

Nursing Interventions Across All Levels and Disorders

Patients suffering from anxiety and related disorders require a holistic nursing approach that addresses their physical symptoms, emotional needs, environmental triggers, and communication styles. Nursing interventions can be grouped into several categories: pharmacologic, psychotherapeutic (non-pharm), environmental (milieu), and communication/education strategies. Regardless of the specific disorder, certain principles apply: ensure safety, establish trust, validate the patient’s feelings, and encourage adaptive coping. Interventions should be tailored to the patient’s level of anxiety (mild vs. severe) and specific condition (e.g., panic vs. dissociation vs. somatic complaints).

Pharmacologic Interventions

Medications can be very useful in managing anxiety disorders and related conditions, either on a short-term basis to relieve acute symptoms or long-term to reduce frequency/intensity of episodes. Nurses play a critical role in administering medications, monitoring effects, and educating patients about them.

Overall, nurses should take a medication reconciliation and adherence role – many patients with anxiety might take benzodiazepines from one doctor, SSRIs from another, and perhaps herbal supplements (like kava or valerian). Educate about interactions (for example, warn not to combine kava kava with benzodiazepines due to excess sedation, and note that kava can harm the liver). Encourage patients that medications for anxiety are most effective when combined with therapy and self-management – pills help symptoms, but building coping skills is equally important.

Psychotherapeutic Interventions (Therapies and Coping Strategies)

Nurses do not typically conduct formal psychotherapy, but they implement many therapeutic techniques and reinforce skills that patients learn in counseling. A basic nursing role is to encourage patients to engage in therapy and practice the skills taught. Some key therapy modalities for these disorders:

Environmental and Milieu Interventions

The care environment should be structured to promote a sense of safety and calm for anxious patients. Key considerations include:

Therapeutic Communication and Patient Education

How the nurse communicates with anxious patients is one of the most potent interventions. Key principles include being calm, clear, and empathetic:

Finally, patience and empathy are the core of communication. Anxiety can be chronic and relapse-prone; patients may ask the same questions repeatedly or need continual reassurance. Remain patient – this in itself is healing, as the patient learns the nurse is a steady presence who won’t get angry or abandon them due to their anxiety. Empathy statements like, “I can imagine how exhausting it is to feel on edge all the time,” can make the patient feel understood and more open to guidance.

By integrating these pharmacological, therapeutic, environmental, and communication strategies, nurses can significantly alleviate patients’ anxiety levels and improve their ability to function. Often it’s the combination of interventions – medication to take the edge off, therapy skills to cope, a calm environment, and a supportive nurse-patient relationship – that provides the best outcomes【44†L69-L72】【44†L33-L41】. The following case studies and practice questions will illustrate the application of these interventions for specific disorders.

Clinical Case Studies

Case Study 1: Panic Disorder
Background: J.S. is a 28-year-old graduate student who arrives in the ER with chest pain and shortness of breath. She is pale, clutching her chest, and hyperventilating. Her heart rate is 130, and she repeatedly says, “I think I’m dying, please don’t let me die!” Cardiac workup is negative; the ER physician diagnoses an acute panic attack. This is the third ER visit for J.S. in two months with similar symptoms.
Assessment: The psychiatric RN finds J.S. trembling and fearful. J.S. describes episodes of sudden intense fear that peak within minutes, during which she experiences racing heart, sweating, choking sensations, dizziness, and fear she’s having a heart attack. She now lives in fear of the next attack, avoiding going out alone. She’s had to quit her part-time job and is struggling in school.
Nursing Interventions: In the ER, the nurse immediately engages in a calming presence – she brings J.S. to a quiet area and stays by her side. She coaches J.S. in slow breathing (“Let’s inhale slowly... now exhale... good.”) and uses grounding statements (“Your heart tests are normal; I know it’s hard to believe, but you are safe. I’m right here.”). A PRN dose of lorazepam is given, and within 15 minutes J.S.’s acute panic subsides. Once calmer, J.S. begins to cry, expressing embarrassment and hopelessness: “I feel so crazy. What if this happens when I’m driving? I avoid going anywhere now.” The nurse uses therapeutic listening and validation, saying, “You’ve been through a frightening experience; no wonder you’re worried about it happening again.” She gently educates J.S. that these episodes are panic attacks, a treatable condition – explaining the fight-or-flight response and how it misfires. Together they discuss triggers; J.S. realizes her first attack happened during a very stressful exam week. The nurse teaches J.S. a panic plan: at the first sign of symptoms, practice deep breathing, use positive self-talk (“This is a panic attack, it will pass, I am not dying”), and possibly use a prescribed fast-acting med if directed. The nurse provides a handout on CBT techniques for panic and helps J.S. schedule a follow-up with the hospital’s anxiety clinic.
Outcome: By discharge, J.S. is no longer in crisis. She feels relieved that others have had this problem (“You mean I’m not the only one? That actually makes me feel better.”). She expresses willingness to try therapy and medication (an SSRI is started) now that she understands what’s happening. Three weeks later, J.S. follows up in the anxiety clinic. She reports one mild panic episode since – she used the breathing exercises and it resolved without ER care. She’s attending CBT group therapy for panic disorder and gradually rebuilding her confidence to resume normal activities.

Case Study 2: Dissociative Identity Disorder (DID)
Background: “Marie,” a 34-year-old woman, is admitted to a psychiatric unit after a suicide attempt. On initial interview, the nurse finds Marie quiet and guarded. Her history reveals severe childhood abuse. As the nurse gently asks about how she’s feeling, Marie suddenly falls silent, then speaks in a small child-like voice: “I don’t want to talk about bad things.” She refers to herself as “Missy” and curls up in a chair. The nurse recognizes this as a possible alternate personality (alter). Later, “Marie” returns to a normal adult voice but has no memory of the previous conversation.
Assessment: The team assesses that Marie has Dissociative Identity Disorder with at least two alters (an adult host and a young child alter named “Missy,” possibly others). Marie reports frequent gaps in memory (finding clothes she doesn’t remember buying, people calling her by names she doesn’t recognize). She often “loses time” during stress. The suicide attempt was triggered by hearing traumatic voices in her head, after which she “woke up” with wrist cuts she doesn’t recall making.
Nursing Interventions: The nurse develops a trauma-informed care plan. She establishes ground rules of safety with Marie and any alters that emerge: no self-harm allowed on the unit, staff must be informed if urges arise. Each shift, the nurse makes a point to introduce herself and orient Marie: “Hi Marie, I’m ____, your nurse today. You’re at Green Valley Hospital, and today is Monday.” Knowing that an alter (Missy) may surface, the nurse remains consistent and empathetic with all “parts” of Marie. When “Missy” appears, the nurse gently engages by perhaps offering a coloring book or stuffed animal (to comfort the child alter) and saying “It’s okay, you’re safe here. You sound like you’re feeling scared.” She does not push for information but might say, “If Marie is not here right now, that’s okay. I can talk with you, Missy. We will keep you safe.” This acceptance helps build trust. Safety planning is crucial: the nurse collaborates with Marie to create a written contract that if she feels suicidal or an alter wants to self-harm, she will notify staff immediately. They develop a grounding routine for when Marie starts to dissociate: e.g., focus on a cold object, describe the room, use her five senses. Staff consistently use this routine when they notice her “spacing out.” Over the next few days, other alters manifest (one angry teenage persona). The nurse remains neutral and sets kind limits if that alter becomes threatening: “I understand you’re angry, but I won’t let you hurt Marie or anyone here. You can journal your feelings instead.” The nurse educates Marie that DID is a coping mechanism from trauma and that treatment (long-term therapy) can help her feel more whole and in control. She reinforces the idea that all parts of her have protected her in some way. The immediate goal is helping Marie develop communication and cooperation among her alters (the inpatient DID group therapy addresses this). The nurse may facilitate an internal dialogue by asking, “Can the part of you that feels strong reassure the part that feels like a little girl that you’ll handle things now?” This intervention, done with guidance from the therapist, begins to break down the barriers between identities.
Outcome: By discharge, Marie is no longer actively suicidal. She has a list of coping strategies (grounding techniques, calling a specific friend when overwhelmed, taking medication as prescribed). She also has an outpatient therapist specializing in DID. Marie (host) tells the nurse, “Missy says thank you for the teddy bear you gave her – she feels safer.” This remarkable statement indicates Marie’s growing awareness of her alters. The nurse praises her insight and encourages her to continue nurturing that communication in therapy. Marie leaves the hospital with a sense that her condition was finally understood rather than dismissed. She remains stable for the next several months and engages in intensive trauma therapy to work toward integrating her identities.

Case Study 3: Conversion Disorder
Background: A 40-year-old male factory worker, Mr. D., is admitted to the neurology service for evaluation of sudden paralysis of his left arm. All medical tests (MRI, nerve conduction studies) are normal, and a consulting psychiatrist diagnoses Conversion Disorder (Functional Neurologic Symptom Disorder). Mr. D.’s paralysis began one week after he witnessed a fatal accident at work where he was operating a machine that malfunctioned (his coworker was killed). Mr. D. is distraught about the incident and, notably, the machine was on his left side. Now his left arm is limp, though reflexes are intact and there is inconsistency (staff noticed at times he moves the arm during sleep).
Assessment: Mr. D. does not appear to be consciously faking; he genuinely cannot move his arm when asked. Interestingly, he is somewhat calm about the paralysis, saying with a flat affect, “Well, at least I don’t have to use that machine again.” (This hints at la belle indifférence). He expresses guilt about his coworker’s death. He also says, “Maybe God punished my arm because I couldn’t save him.”
Nursing Interventions: The rehab nurse on the neurology unit takes a dual approach: addressing the physical disability and the psychological stress. First, she ensures Mr. D.’s basic self-care needs are met – helping him learn one-handed techniques for dressing and feeding. She involves physical therapy to keep his left arm muscles from atrophy (range of motion exercises) and occupational therapy to practice functional tasks. Positive reinforcement is used: when Mr. D. makes slight movements without realizing (once he flexed his fingers when distracted), the nurse gently points it out: “I saw your fingers move a little just now – that’s a good sign; it means your arm has the ability to move.” He was surprised but this planted a seed of hope. The nurse maintains a matter-of-fact, supportive attitude – she does not overly cater to the paralysis (no excessive pity) but also does not challenge him aggressively. She sets up a daily routine where Mr. D. attempts to use his arm in simple tasks after relaxation exercises. For instance, she guides him through a breathing exercise then asks him to try to lift a light object with the affected arm. Initially, he cannot, and becomes anxious. The nurse uses calm reassurance: “It’s okay; your arm isn’t cooperating yet. Let’s try again tomorrow. Your body may improve when it’s ready.” Meanwhile, she engages him in talking about the accident gently (since it’s likely related). He shares feelings of guilt and horror. The nurse offers empathetic listening: “That was a traumatic event. No wonder your mind and body are overwhelmed.” She introduces the idea that stress can cause physical symptoms: “Sometimes after something like this, the body responds in surprising ways, like your arm shutting down for a while. But as you heal emotionally, I expect your arm will improve too.” This frames the paralysis as reversible. She teaches him stress-management techniques (which also serve as conversion symptom treatment) – journaling about the accident (therapeutic emotional processing), and a ritual of lighting a candle in memory of his coworker (finding closure). As trust builds, the nurse asks if he’s willing to meet with the psychiatrist for therapy; he agrees. They begin working on the idea that forgiving himself might “release” his arm from the guilt. Over a week, Mr. D. shows subtle improvement: one day, during a relaxed conversation, he briefly lifts his left arm to scratch his head before “realizing” and dropping it. The nurse smiles and encourages him: “See, your arm remembers how to move when you aren’t thinking too hard about it!” This evidence helps convince him that there’s no physical damage.
Outcome: By discharge, Mr. D. has about 50% return of motor function in the arm. He is able to wiggle his fingers and flex the elbow, though fine motor and full strength aren’t back yet. He is more emotionally open about the trauma and has agreed to continue outpatient therapy. On the last day, he confides to the nurse, “Sometimes I feel like maybe I didn’t want to use that arm... because it reminds me of the accident.” This insight is major progress – he’s recognizing the mind-body link. The nurse validates this and reiterates that as he forgives himself and regains confidence, his arm should continue to improve. Mr. D. is discharged to a physical medicine rehab program and psychological counseling. Three months later, he sends a thank-you note: his arm is fully functional again, and he has started a new position at work away from the site of the accident. He writes, “I realized my arm was waiting for my heart to heal.” Nurses played a pivotal role in guiding him to that realization with compassion and patience.

These case studies highlight tailored nursing approaches for different disorders – from the immediate calming and safety measures in panic, to the long-term trust and grounding needed in DID, to the combined physical/psychological support in conversion disorder. In all cases, holistic care addressing both mind and body helped the patients move toward recovery.

NCLEX-Style Practice Questions

1. A patient with panic disorder suddenly begins to hyperventilate and says, “I feel dizzy – I think I’m going to die!” What is the nurse’s priority action?

2. A patient with Obsessive-Compulsive Disorder is continually late to group therapy because of a lengthy handwashing ritual. Which nursing response is most therapeutic?

3. The nurse is caring for a patient with Generalized Anxiety Disorder who frequently says, “I just know something terrible is going to happen to my family while I’m here in the hospital.” Which response by the nurse utilizes cognitive reframing?

4. A patient with PTSD from a sexual assault is admitted for care. She becomes highly anxious whenever a male staff member enters the room. What is the best trauma-informed intervention by the nurse?

5. The nurse is evaluating outcomes for a patient with Illness Anxiety Disorder (hypochondriasis). Which behavior by the patient suggests positive progress?

6. A patient is diagnosed with Somatic Symptom Disorder with predominant pain. Which statement by the patient suggests she is internalizing a healthier view of her symptoms after treatment?

References (APA Style)

  1. Ernstmeyer, K., & Christman, E. (Eds.). (2022). Nursing: Mental Health and Community Concepts. Eau Claire, WI: Chippewa Valley Technical College – Open RN. (Chapter on Anxiety Disorders – levels of anxiety and interventions)【3†L154-L163】【5†L1955-L1963】

  2. Locke, A. B., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American Family Physician, 91(9), 617-624.【44†L33-L41】【44†L61-L69】

  3. American Psychiatric Association. (n.d.). What are Anxiety Disorders? Retrieved 2025, from psychiatry.org 【67†L381-L389】【69†L13-L16】

  4. National Institute of Mental Health. (2019). Obsessive-Compulsive Disorder. Retrieved from nimh.nih.gov (NIMH Fact Sheet)【20†L988-L996】【20†L1015-L1023】

  5. Belleza, M. (2024). Dissociative Disorders. Nurseslabs. Retrieved 2025, from nurseslabs.com 【75†L211-L219】【75†L229-L238】

  6. D’Souza, R. S., & Hooten, W. M. (2023). Somatic Symptom Disorder. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.【33†L96-L104】

  7. French, J. H., & Hameed, S. (2023). Illness Anxiety Disorder. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.【36†L96-L104】【36†L122-L130】

  8. Peeling, J. L., & Muzio, M. R. (2023). Functional Neurologic Disorder (Conversion Disorder). In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.【38†L119-L127】【39†L1-L4】

  9. Carnahan, K. T., & Jha, A. (2023). Factitious Disorder. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.【41†L96-L104】【41†L117-L125】

  10. Barnes, C. A. (2023, September 25). Anxiety in Different Cultures: A Comparative Perspective. Medium. Retrieved 2025, from medium.com 【54†L78-L86】【54†L81-L89】

  11. Roche-Miranda, M. I., Subervi-Vázquez, A. M., & Martinez, K. G. (2023). Ataque de nervios: The impact of sociodemographic, health history, and psychological dimensions on Puerto Rican adults. Frontiers in Psychiatry, 14, Article 1013314.【51†L283-L287】【51†L283-L291】

  12. Rizvi, M. B., Conners, G. P., & Rabiner, J. (2025). New York State Child Abuse, Maltreatment, and Neglect. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. (Factitious Disorder Imposed on Another as child abuse)【64†L897-L904】

  13. Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: SAMHSA. (Six principles: Safety, Trustworthiness, Peer support, Collaboration, Empowerment, Cultural considerations)【31†L133-L141】【56†L5-L8】