An OT in home health interviews an older adult who is unable to go grocery shopping for fear of having an attack of shortness of breath, chest pain, sweaty palms, and a racing heart. At a university occupational therapy clinic, a college student admits that he has been late for class because he feels he must check his car ignition repeatedly to be sure that it is really off before he can get out of his vehicle. In a rehabilitation hospital unit, during a treatment session for arthritis, a woman has problems with shortness of breath and such extreme nervousness that she can’t initiate the treatment and admits to not sleeping well and feeling frightened “all the time.” A middle-aged salesman in an acute psychiatric unit has altered his driving routes because he has become extremely fearful when driving over bridges and under freeway overpasses. A child referred for learning disabilities says she doesn’t want to go to school and pretends to be sick. A recently married former business executive becomes unable to leave her house. An elderly client in a skilled nursing facility isolates herself in her room due to fear of falling. Although these symptoms are quite varied, moderate to severe levels of anxiety can cause all of these behaviors.

 

 

Anxiety is a feeling of alertness and concern that readies an individual to take some sort of action.¹ A part of everyday life, it involves heightened awareness or worry. For example, anxiety about passing an exam may motivate us to study, or anxiety about a deadline may motivate us to finish a project. Anxiety about bills may motivate us to work harder, or anxiety about retirement may galvanize us to save money. Anxiety can also compel us to take action to protect ourselves from a threat. For example, anxiety about walking to her car may cause a woman to have her keys handy, and anxiety may cause her to run when approached by a stranger at night. Anxiety is different from fear in that fear involves the intellectual evaluation of something that may be threatening, while anxiety is the emotional component to that appraisal. In the case of a stranger approaching at night, fear may cause her to make a quick judgment of the person and situation, while the associated anxiety results in her running. All major positive or negative events or changes in our lives can cause some degree of anxiety. Even happy events, such as vacations, cause some anxiety.

 

Anxiety is a sensation that permeates our reaction to stress and the unknown. The “fight or flight” response is the immediate physiological response of the body to stress, shunting blood away from digestive organs toward the muscles and mobilizing the body to meet the challenge of a stressor. Physical signs of the stress response include shortness of breath, palpitations, sweating, clammy hands, dry mouth, dizziness, nausea, diarrhea, flushes or chills, frequent urination, and sometimes a feeling of having a “lump in the throat.” All of us have felt some of these symptoms, particularly after a frightening experience, such as a traffic accident or a stranger approaching in the dark. Anxiety can impact the quality of life and interfere with all occupational performance areas, patterns, contexts, and environments so that it prohibits participation and good health.² That is, it can precipitate social withdrawal, interfere with activities of daily living or instrumental activities of daily living, and interrupt routines and habits. When it markedly interferes with everyday living and occupational performance, it is known as clinical anxiety and should be treated.  In addition to the physiological symptoms and signs, anxiety also depends on the subjective experience of the person and his or her ability to cope and regulate his or her emotions.

 

 

Trait or chronic anxiety — enduring personality style that manifests anxiety that persists, developing around new stressors after immediate problems are resolved

 

Acute anxiety — time-limited anxiety that diminishes with resolution of the problem

 

Anticipatory anxiety — predictive anxiety in response to future actual or imagined situations

 

Free-floating anxiety — generalized anxiety, which may be vague in origin

 

 

The revised 2008 edition of Occupational Therapy Practice Framework² specifies coping and regulation of emotions in the occupational therapy domain and practice. Coping and regulation are listed as aspects of a person and as a client factor, and they are skills to be learned or practiced by clients. In addition, sleep and rest have been added as an occupational performance in occupational therapy’s domain. Intervention for sleep and rest greatly expands the possibilities for treatment for a variety of populations and disorders, including anxiety disorders.

 

The number of words to describe anxiety — worry, nervousness, edginess, alarm, panic, uneasiness — attests to its pervasiveness in everyday life. Anxiety can be mild, moderate, or severe, and it can even escalate to panic. ³ Mild anxiety is part of the tension of everyday life, and a person may actually see, hear, and comprehend more effectively when slightly anxious, such as a student making sure he catches every point in a class lecture. Moderate anxiety causes an individual to focus on immediate concerns, such as meeting a deadline for writing a paper, and to selectively block out tangential information. A severely anxious person is so focused on specific details that he or she can’t think of anything else, and behavior becomes directed toward relieving the anxiety. Panic is associated with loss of control and a sense of dread, with increased motor activity, reduced ability to relate to others, and distorted perceptions.¹ An example would be a student who is unable to attend class or hand in an assignment because he is so concerned about the difficulty of the material and believes he is not passing the course.

 

 

Everyday, “normal” anxiety that propels one to act is almost always associated with anticipation of future events and is universal, compelling people to act, cope, or perform more efficiently. However, when anxiety hinders rather than helps, the response is greater than expected, or the anxiety persists after the stimulus is removed, then the anxiety is abnormal, no longer serviceable, and disruptive of everyday functioning. Abnormal anxiety has been likened to a faulty burglar alarm that persists or signals non-existent danger.⁴ It becomes disabling without stimulating positive action to ward off distress.³ Prolonged or severe symptoms of anxiety may be evidence of an anxiety disorder. Severe anxiety can arise under persistent stress or extreme change. For example, a person recovering from a heart attack may have a level of anxiety that prevents successful rehabilitation if he or she is afraid of exercising and resuming normal activities.

 

However, research seems to indicate that symptoms of anxiety may have a genetic or biochemical basis, and anxiety can even arise without the presence of a major stressor. Recent research has focused on the amygdala, a part of the brain where a “harm avoidance” response may be etched.^5,6 A disruption of neurotransmitters — norepinephrine, serotonin, and gamma-aminobutyric acid (GABA), an inhibitor neurotransmitter — is thought to play a role in anxiety.^5,6 Neuropeptide substance P (SP) and neurokinins, proteins, and receptors that function as cotransmitters for serotonin and GABA also contribute to anxiety.⁷

 

Abnormalities in brain function or structure in such areas as the limbic system, the temporal lobe, and the brain stem have also been implicated in anxiety disorders.⁸ Magnetic resonance imaging (MRI) scans of the brain suggest a genetic susceptibility to anxiety as individuals with anxiety have been found to have less gray matter and weaker mood-regulating circuit connections.⁶ When anxiety symptoms appear suddenly and inexplicably, these patients can become extremely distressed.

 

Anxiety disorders are among the most prevalent and disabling psychiatric disorders, affecting more than 25 million Americans;⁹ 4% to 5% of the population may have one in their lifetime.³ Young and middle-age adults are significantly impacted by anxiety, with 13.3% of Americans ages 18 to 54 affected; women outnumber men, two to one. ¹⁰ Anxiety can also be detected in infants and toddlers, leading to or as a result of problems with attachment systems.^1,11

 

Productivity can be significantly impacted. In one study of more than 27,000 people, those with anxiety disorders were more likely to experience absenteeism from work (30%) than those with substance abuse disorders (20%). When individuals had both disorders, the likelihood of absenteeism increased to 34%.¹²

 

A two-year study¹³ of 2,646 working men and women identified that a poor working environment, especially those that are psychologically demanding or limit individual decision-making abilities, are a source of stress that can contribute to the development of anxiety disorders. The study also showed that development of anxiety disorders was not mediated by a sense of job security or the presence of an adequate social support system in the workplace.

 

Anxiety disorders are among the most common psychiatric illnesses of the elderly, though the symptoms tend to be milder if the disorder appears for the first time late in life.¹⁴ Recent studies suggest that these illnesses are even more prevalent in the elderly than previously thought. Anxiety may affect older adults with COPD,¹⁵ and there is research that shows that older people fear falling and become isolated and anxious due to this fear.¹⁶ Anxiety symptoms are common both in older adults who are depressed and those who are not.¹⁷

 

The symptoms of anxiety can be closely associated with medical problems and often coexist with other psychiatric disorders. Anxious and depressed patients tended to have higher healthcare costs because of higher utilization of medical, rather than psychiatric, care. Effective recognition and treatment of anxiety, however, have been associated with improvement in management of medical conditions and a decreased economic burden — for example, reduced A1c levels in individuals with diabetes.¹⁸ Conversely, medical problems, substance abuse or withdrawal, and medications can cause anxiety symptoms.

 

Psychiatric disorders involving anxiety and depression are also present in a significant number of cancer patients. One study of women receiving treatment for breast cancer revealed a 39.6% prevalence of anxiety.¹⁸

 

Anxiety disorders also frequently occur in individuals who have chronic medical illnesses, including infections and irritable bowel syndrome.^1,19 Up to one-fourth of children may experience anxiety after infection with B-hemolytic streptococcus infections.²⁰

 

HIV-positive individuals with anxiety disorders receiving antiretroviral therapy are less likely to achieve the desired therapeutic viral suppression response than their nonanxious counterparts.¹⁸ To view an evidenced-based clinical guideline on mental health care and HIV, go to http://guideline.gov/summary/summary.aspx?doc_id=9029&nbr=004888&string=anxiety+AND+disorders.

 

One National Institute of Mental Health-sponsored study revealed that nearly half of adults with anxiety disorders also had psychiatric disorders during childhood. The researchers discovered links between specific anxiety disorders in adulthood and childhood. For example, adults with post-traumatic stress disorder (PTSD) are more likely to have histories of extreme defiance and conduct disorders in childhood, and adults with obsessive-compulsive disorder are likely to have experienced delusional beliefs and hallucinations as children. Phobias diagnosed in adulthood tended to be linked to specific phobias that occurred during childhood.²¹

 

Common Anxiety Disorders 

 

OTs are likely to find anxiety in clients in all practice areas, including home, physical rehabilitation, extended care facilities, school and pediatric settings. It is a disorder that is not limited to any age or setting.^{3,22, 23} The major diagnostic groups related to anxiety are listed in the DSM-IV-TR.²⁴ It is important to know the diagnostic categories to recognize the signs and symptoms of anxiety and also because specific interventions are targeted to specific diagnoses. The most common anxiety disorders are generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, phobias, and post-traumatic stress disorder.

 

Generalized anxiety disorder (GAD) is excessive and unreasonable anxiety and worry that lasts at least six months. It is more common in women than in men, and it may begin at any time during life, although it is more common in younger individuals. Symptoms of GAD may include restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleeping problems. These symptoms are extremely distressing, and patients feel unable to control them. Patients often recognize that the worry is far out of proportion to the actual situation.²⁵ Those suffering from GAD may still be able to function socially and at work, but if GAD is severe, these symptoms can be very disabling. GAD often begins in late childhood, leading to disability in the prime of life. Later in life, GAD is more likely to occur along with major depression.²⁶

 

Panic disorder affects about 1.7% of the population and is twice as common in women as in men.⁹ This disorder is characterized by recurrent attacks that can produce dizziness, faintness, palpitations, trembling, sweating, nausea, numbness, flushes or chills, and chest pain. The patient may think that he or she is dying. These feelings usually come on suddenly and usually last several minutes. Panic disorder may be accompanied by substance abuse, depression, or suicidal impulses.⁸ At the same time, similar symptoms may be caused by many medical conditions, including hyperthyroidism, hypoglycemia, mitral valve prolapse, heavy use of caffeine, and substance abuse.^1,26

 

Patients may alter their lives to avoid anything that they fear might set off a panic attack — avoiding the grocery store because of fear that the trip could trigger an attack, for example. About one-third of the people with panic disorder also develop agoraphobia, which is a fear of being in places or situations from which escape might be difficult, or where help may not be available if an attack occurs.²⁶ This condition leads to restriction of activity in respect to destination and conditions of travel. It is not in itself a disorder, but it is included in the description of some anxiety disorders.

 

Obsessive-compulsive disorder is equally present in men and women. It occurs in about 2.3% of all people, and it usually first appears in teens or young adults.¹⁰ Prevalence of OCD in children may be higher than previously thought, and some cases of OCD in young people may be linked to a prior streptococcal infection.^27,28 Obsessions are recurrent and persistent thoughts, impulses, or images that are regarded as unwanted and inappropriate. For example, a person might have obsessive thoughts about germs and dirt. While hand washing and avoiding physical contact with obviously soiled areas are reasonable, individuals with this type of obsession cannot stop thinking that their hands are contaminated, in spite of taking normal precautions.

 

Compulsions are repetitive behaviors, such as excessive hand washing, hair pulling, hoarding, or mental acts like counting or repeating words silently, that the person feels driven to do in an attempt to neutralize the obsessions or reduce tension. The person with obsessive thoughts about germs and dirt may repeatedly wash or scrub his hands to the degree that his hands will become raw.

 

Obsessions and compulsions go far beyond what is logical and reasonable, and these thoughts and behaviors are often disturbing and disruptive to daily routines and social relationships.^3,9 They can be extremely time-consuming, so they often interfere with occupational functioning and work, school, social, self-care, and homemaking routines^.3 People usually recognize that their behavior is senseless, but sometimes they do not.

 

Phobias are classified as either social or specific. A social phobia, also diagnosed as social anxiety disorder, is a fear of being terribly humiliated or embarrassed in a social setting, such as a fear of public speaking. The prevalence of social anxiety disorder is estimated to be as high as 3.8% of U.S. adults, occurring equally among men and women; however, it is often undetected and undertreated.^10,27 Specific phobias are intense, irrational fears of certain things or situations, such as cats, snakes, elevators, flying, or driving. Specific phobias are more common than social phobias, occurring in more than 8.7% of Americans.¹⁰ Although some fears may seem fairly common, a phobia is present when the fear interferes with the person’s ability to function, particularly in work or social situations. For example, a person may quit a job when duties expand to public speaking or refuse dates with potential friends and mates. Phobic individuals make every effort to avoid the situation or thing that causes such dread.

 

Post-traumatic stress disorder occurs from 20% to 25% of the time when a person is exposed to a traumatic event in which the person experienced or witnessed serious injury, death, or a grave threat to him- or herself or others.²⁹ The person’s response involves intense fear, horror, or helplessness. Natural disasters, wars, terrible accidents, and crimes can cause long-lasting emotional trauma in both witnesses and victims. While PTSD is difficult to predict, some factors appear to increase the risk. Elements found to increase the likelihood of developing PTSD within a year after a traumatic event include high levels of symptomatic distress during the year following the event, prior trauma, history of stimulant intoxication, and female gender.^10,29 Sexual assault or molestation is the most likely trigger event for PTSD, but children who have lived in violent families or communities, been removed from their parents, and lived in foster care typically will develop PTSD.¹⁰ Sleep-related complaints, evident as early as one month after the traumatic event, are also an early predictor of the development of chronic PTSD.²⁹

 

This disorder involves recurring intrusive memories of the event, troubling nightmares, and even flashbacks where the person feels that he or she is actually reliving the event. Certain cues may set off intense distress, and the person tends to become hyperalert and hypervigilant. For example, a veteran of combat might react to a sudden loud noise by dropping to the ground and trying to take cover, or a child may reject hugs or be unable to concentrate in school, although the actual event may have occurred a week to many years ago. Individuals also talk about feeling emotionally numb, and some have difficulty with outbursts of anger. Flashbacks can be prolonged, and the individual can seem quite agitated for some time after. Symptoms tend to become worse when the individual is under stress.

 

Acute stress disorder is similar to PTSD in respect to the exposure to a traumatic event and the response of horror, terror, and powerlessness. However, the symptoms develop within one month of the event and last only from two days to one month. In addition to experiencing at least one symptom of each PTSD cluster, such as flashbacks, dreams, and avoidance of stimuli, the individual may also exhibit dissociative symptoms, such as numbing, depersonalization, derealization, or amnesia.^3,25 For example, the world may seem dreamlike, and the individual may feel her or his feelings and body are disconnected. After the major California earthquake in 1989, many people experienced these symptoms, but they abated after a short time.

 

Substance-Induced Anxiety Disorder — The physiological effect of a drug medication or toxin causes substance-induced anxiety — such as that produced by use of albuterol for those with asthma or NoDoz or benzadrine for college students who are studying all night. This anxiety may present in the variety of ways that have been described thus far. It is important to remember that anxiety can be the result of a condition or medication and to rule out such causes when you encounter a client with anxiety.

 

Once the OT recognizes the signs and symptoms of anxiety, the next logical step is to evaluate the client with a focus on learning about the anxiety.

 

 

If you suspect that a patient has an anxiety disorder, what should you do first? As with any other disorder, a good history is extremely important, and an OT needs to assess the quantity and quality of the anxiety symptoms.^1,3 When did these symptoms first appear? Can the client recall ever feeling this way before? What is happening in the client’s life? Have there been recent changes or stressors? How does the patient feel about these changes, and how is he or she coping?^1,3 What has been done to try to relieve these symptoms? Also ask about social support and personal relationships. One study of 4,688 adults revealed stressful relationships and lack of social support increase anxious episodes.³⁰ Investigate the use of current prescription or over-the-counter medications, as side effects of medications can cause symptoms of anxiety.

 

Find out whether any of the patient’s symptoms could be caused by a physical condition, such as asthma or COPD.¹⁵ The possibility of substance abuse must be explored, because individuals may try to cope by abusing drugs or alcohol. Does the client ever feel depressed? Although this is a difficult subject to approach, does your patient think that life is not worth living, and has he thought about suicide? Significant numbers of individuals with severe anxiety and panic disorders consider or attempt suicide to escape the sometimes-unbearable symptoms.²⁶

 

Sometimes, medical tests or treatments can produce anxiety, either temporarily or long-term, especially if they are confining or constricting, producing claustrophobia — an abnormal fear or dread of closed spaces.³¹ Continuous positive airway pressure therapy, prescribed to treat sleep apnea, is especially anxiety-producing, as are MRIs and CT scans. Even devices that are not confining can promote anxiety — up to 37% of clients implanted with cardioverter-defibrillators have anxiety.³²

 

Does the client seem very distressed by these symptoms? The level of distress is usually high in anxiety disorders, and patients may cry, shake, wring their hands, pace, perspire, and appear frightened.^1,3 Their voices may even shake as they talk, and their respirations and heart rate may be elevated.^1,3 Muscle tension may be obvious in their posture and movements. If family members are present, determine whether they appear exasperated, supportive, or unaware of the degree of the symptoms. Be sure to ask about sleep habits.²

 

Think young and screen often! Anxiety disorders, like many other mental health disorders, are quite likely to appear at an early age. Research supported by the National Institute of Mental Health found that half of all lifetime cases of mental illness begin by age 14 and that delays in diagnosis are common.²⁶ Anxiety affects American children significantly, especially in adverse family environments³³ where there is low socioeconomic status and maltreatment. Children most often manifest anxiety as OCD, GAD, and phobias. They also tend to internalize their problems and have inhibited temperaments.³⁴ An evidence-based clinical guideline for the assessment and treatment of anxiety disorders among children can be reviewed at http://guideline.gov/summary/summary.aspx?doc_id=10549&nbr=005512&string=anxiety+AND+disorders.

 

 

The goal of intervention for very anxious clients is to lower their anxiety level.^1,3 Sometimes a quieter, less stimulating environment is helpful. For ongoing anxiety problems, goals should focus on helping clients learn how to tolerate a certain level of anxiety, as the expectation that patients can become completely free from anxiety may be unrealistic. Clients can learn to relax through relaxation training and progressive relaxation.^1,3 They might think about a peaceful image, such as a secluded beach, or they can be taught to consciously relax each muscle group, starting with the toes and progressing up toward the head. OTs should caution these individuals not to use caffeine and other stimulants.

 

Patients who appear to have a high level of anxiety need to be referred to a mental health professional for further evaluation. Some of the treatments used for anxiety disorders include biofeedback, cognitive behavioral therapy, medications, psychotherapy, or a combination of therapies.^1,3 In therapy, clients discover that their symptoms are due to anxiety and learn methods to control and manage the anxiety. The therapist may be a social worker, marriage and family counselor, psychologist, or psychiatrist. Cognitive-behavioral therapy teaches patients to react differently to the symptoms of anxiety, for instance telling themselves, “This is a panic attack symptom. I am not really having a heart attack.” For some phobia and panic disorder sufferers, therapists may go out with the patient to practice managing the anxiety in situations they dread. Group therapy or support groups are also very helpful.^1,3

 

While help is available, up to 70% of people with anxiety disorders go untreated each year. Some may shun traditional modalities for treatment interventions, lacking access or fearing stigma. Technological advances that may expand treatment access include Internet-based therapy, computer-guided and virtual reality programs, and self-help programs.^35,36 Not surprisingly, therapeutic interventions delivered through these new methods have been especially well-received by young adults.³⁶ The National Institute for Health and Clinical Excellence has published a clinical guideline on the use of computerized cognitive behavior therapy for depression and anxiety at http://guideline.gov/summary/summary.aspx?doc_id=9087&nbr=004901&string=anxiety+AND+disorders.

 

 

Specifically, there are many occupational therapy tools for assessing anxiety and contributing to the occupational profile. Assessing the level of impairment will highlight the extent that anxiety interferes in daily life activities and areas of occupation.

 

Anxiety will affect areas of occupation in the following ways:^2,3

 

Anxiety may manifest in client factors primarily in difficulty regulating emotions, concentrating, and sustaining attention. It may manifest in occupational patterns by disrupting habits and routines and diminishing roles, or in the case of infants or children, preventing development of habits, routines, and roles. Anxiety may interrupt occupational performance skills; in the case of infants and children, it may prevent acquisition of occupational performance skills.

 

Common general occupational therapy assessments³ that are interviews are the Canadian Occupational Performance measure (COPM), and the Occupational Performance History Interview-II (OPHI-II). The COPM is a more unstructured interview that allows the client to prioritize problems and interventions. The OPHI-II is a semi-structured interview, providing more structure through specific questions that are grounded in the Human Occupation model.

 

Surveys also highlight the occupational interests and roles of an individual.³ The Occupational Self-Assessment (OSA) and Role Checklist are commonly used surveys that help the client get an idea of their most valued occupations and roles, as well as their satisfaction with those occupations and roles. Semantic differential function and self-assessment questionnaires also quickly assess how a person perceives the extent that anxiety interferes.³ An example of items from the Function Questionnaire is —

 

The extent to which my social life is impaired because of anxiety (going out with friends, dating, outings, entertaining, etc).

 

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