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Anger, Anxiety and Depression: Handling Difficult Emotions in Nursing Care

Submitted by on September 7, 2014 – 2:01 PM

depressed400Interestingly, very little is known about anger, anxiety and depression in Pakistan. Social stigmatization about mental illness is a major cause of this oblivion. Furthermore, it is an understudied topic due to multiple reasons. Statistics of WHO show that worldwide 121 million people are suffering from depression, 90 percent of mental health problems are anxiety and depression. By year 2020 , depressive disorders will be ranked 2nd in the world (Khowaja & Qureshi, 2004).


Health care professionals are also suffering more from mental Illness like anxiety and depression. While reviewing literature ,I found that 39 % of family practitioners in Karachi were suffering from anxiety and depression (Khowaja & Qureshi,2004) . Among these 51 % were females and 32 % were males, 81 % of them were smokers and 71 % were smoking as a coping mechanism to overcome anxiety and depression (khowaja & Qureshi 2004)


During my clinical rotations, I realized that most of the patients were suffering from depression and anxiety. Dealing with such a patient aggressive behaviors and anger episodes were common in them. Through all these observations, I found these problems interesting and it compelled me to learn more in detail about them and help out patients during my clinical.


In this paper, my aim is to understand psychological and biological perspectives of anger, anxiety and depression. Moreover this paper will provide a brief overview of anxiety disorders in the light of different clinical exposures and literature review .At the end I will discuss different ways to handle these patients.


Videbeck (2009) states “Anger is a normal human emotion in response to a real or perceived provocation. Anger results when a person is frustrated hurt or afraid. Handled appropriately and expressed assertively, anger can be a positive force that helps a person to resolve conflicts, solve problems and make decisions”. While looking into biological perspective of anger it also activates the fight and flight response of the sympathetic nervous system; in order, to prepare our body to handle any threat or dangerous situation to our body. Anger needs proper expression and if suppressed can create other problems later on. Some patients with anger show hostility and get physically aggressive which is a challenge for health care professionals (Videbeck, 2009).


During my last clinical at psychiatric ward I encountered a schizophrenic patient with anger and aggressive behavior. He had history of paranoid behaviors and physical aggression towards family and friend’s .He was paranoid toward staff, my colleagues and his friends .He also showed aggression toward his family members. We explained to the patient that we were there to care for him. We did a thorough assessment of his anger and anxiety.


Literature also suggests effective assessment, use of mood stabilizer medications, and interacting with patients in a holistic manner (Hollinworth, Clark, Harland, Johnson & Partington, 2005). After reviewing literature it was found that some early warning signs for anger and aggression in a patient are: getting hostile towards staff and friends, patients’ face may become reddish and may start clenching fists; changing position often and moving in a rough manner often indicate that the client is going from irritation towards anger and aggression (Videbeck, 2009). After identifying such a situation we can help the patient to calm down by involving him in activities like playing cards, discussing his interests and hobbies, helping patient in expressing anger in an appropriate manner, using assertive communication statements and discussing a solution for the conflict are all important steps in order to manage anger.


Furthermore, we should keep a proper distance with the patient, showing calmness to patient by showing correct posture, speech and maintaining accurate eye level. Moreover, our hands should be visible, identifying reason for anger and avoiding sudden movements which may turn the patient suspicious (Hollinworth, Clark, Harland, Johnson & Partington, 2005).


“Anxiety is a feeling of dread or apprehension, accompanied by specific thoughts and actions; it’s a response to external or internal stimuli that has behavioral, emotional, cognitive and physical aspects” (Videbeck, 2009). Anxiety to a certain level is normal and is good for our body to show a better efficiency. E.g.: Worrying about getting a new job, buying a new house or appearing in an interview. Anxiety provokes our sympathetic nervous system, initiates a fight and flight response and an increase in adrenaline which prepares our body for strange situations (Kuchel, 2009).


Going through literature review different levels of anxiety were found. For instance, mild anxiety arouses the person for an alarming situation and the person performs better. In moderate anxiety the person feels that something went wrong but still can mange the situation and can return to a healthy pattern. However, in sever or panic level of anxiety the person has poor cognitive skills, increased physiological response and poor coping capability (Videbeck, 2009). Neuro chemical theories suggest that anxiety disorders occur in imbalance of GABA and adrenaline (Vital et al, 2009).


On my clinical I came across a similar case. A 13 years old girl belonging to a far-flung area presented with chronic renal failure and dialysis dependent also suffered from panic level of anxiety due to her poor prognosis. She was restless, angry and irritable. Patient was assessed for contributing factors of anxiety. It was revealed that lack of knowledge and treatment outcome were the leading causes of patient anxiety. After literature review it was found that such patient requires an immediate attention and if left unnoticed ,can worsen the situation. Patient should be accompanied because if left alone patient’s anxiety will aggravate.


Furthermore, if patient is in panic anxiety he/she must be provided a safe and calm environment. Patient should be provided with anxiolytics. Zoya (2009) states that provide patient with other management modalities for anxiety like Cognitive behavioral therapy, reframing, decatastrophizing and assertive training.


“Mood disorders, also called affective disorders, on the other hand, are pervasive alteration in emotions that are manifested by depression, mania or both”(videback, 2009). These disorders greatly affect a person’s life, relation with family, friends and in the society. Depression is classified into three subcategories on the basis of symptoms found in them like long term sadness, anger, agitation, intolerance, decrease in energy marked tiredness, loss of concentration and slowed thinking process (Videbeck, 2009).


Firstly, in mild depressive episode two to three of the mentioned symptoms are present. Secondly, a moderate depressive episode comprises of four or more of the above mentioned symptoms. Thirdly, severe depressive episode without psychotic symptoms consists of several of the above symptoms along with loss of self-esteem and ideas of worthlessness. In this class of depression suicidal ideation and somatic symptoms are common.


According to International Statistical Classification of Diseases and Related Health Problems (2010) , in severe depressive episode with psychotic symptoms, patient has all the symptoms of the previous category along with hallucinations delusions , psychomotor retardation and there is a constant threat to the patient’s life from suicide, dehydration or starvation During my clinical rotation in Mental Health, I observed a patient of severe depression. He was very anxious when I was interviewing him. It was found that he had past psychiatric history of anxiety and depression. It was a relapse episode due to noncompliance to treatment modality. He had twice attempted suicide .

His major stressor was identified, which was loss in business. In his family counseling ,future plans for his job and treatment were discussed. Family was educated to assess the patient in preventing relapses of depression episode and long term treatment regimen. Client was encouraged to seek occupational therapies for instance; participating in group exercise activity, dance therapy and spending time in OT Room activities.

According to Hodes and Geralda, (2012) in depression we need to strictly follow step by step management. We should not start drugs for mild depression, we should start from cognitive behavioral and family therapy .If a patient is not responding to occupational therapies then we should go for anti-depressive medications like SSRIs . Electroconvulsive therapy should be the last option .Furthermore; we should also assess the patient for suicidal ideation (Vidbeck, 2009). In addition, adequate nutrition and hydration should be maintained; client’s environment should be maintained safe to prevent any attempt for suicide ,they should be encouraged for activities, and family should be taught about depression, its causes , management and treatment regime .

Now coming to the overall recommendation points; it is recommended that mass level steps should be taken to find out the different causes of anger, depression and anxiety in the society. Then we will go for management. First of all,sessions should be conducted on a societal level to reduce these problems. On individual level teaching should be given to clients in hospital settings.


Furthermore, we should have associations and clinics on anger, depression and anxiety management. Moreover, to overcome these problems in our society, it is recommended that vulnerable populations should be identified and teaching should be conducted on stress coping mechanisms. In addition, community health visitors should be properly trained to handle these patients. Also , support group should be built up for those who are at risk for depression and mass level awareness is needed about depression as well as its prevention at an early level and treatment regime of depression.


In short, I conclude my paper with these points that anger, anxiety and depressions are difficult emotions which are encountered at clinical setting by nurses and often it is challenging for them. Anger is a normal human emotion and needs appropriate handling. Health care professionals should know about the early warning signs of violence in an angry patient. They should learn proper skills for management of anger and violence. Anxiety is our body’s response to stress and it’s beneficial for our body up to some extent. It strengthens and prepares our body to handle any difficult situation.


Too much stress can be problematic for our mental health. So while dealing with such patients, they should be helped to release their stress and should be taught about coping mechanisms. Depression is a serious mental health problem which needs immediate attention. Many people become victims of these problems when they are unable to overcome their major stressors in life. Treatment is also difficult due to greater recurrence so we need early prevention of this disease. It also needs strict treatment compliance. As a nursing student, i now know what role i shall play while encountering such patients in the future.



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