Mediating Anxiety, Fear, and Pain in the Wound Clinic Setting
- Mon, 12/14/09 - 12:59pm
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Wound clinics often manage care for individuals who suffer from anxiety-related stress. For those individuals, the experience of having a wound often transcends the wound clinic and affects their day-to-day life. It is common for individuals with psychological disorders, such as generalized anxiety disorder; to have anxious thoughts days before their wound care appointment. Often these individuals dwell on questions that lead them into a spiral of anxious thought. These thoughts, no matter how unrealistic, become real. Initially, patients may think things like:
How will I afford this?
Will I lose my leg?
Will I experience pain?
These quickly escalate into thoughts like: I will go broke, I will lose my leg, and I will have pain during my next visit to the wound clinic.
Patients who develop feelings of fear and emotional distress also form identifiable maladaptive physiological and psychological responses1 (See Table 1). These anxiety-related responses directly affect how these individuals perceive their wound. Anxiety is correlated with increased self-reports of wound-based pain2,3. also found that “the higher the anxiety before dressing change, the higher the anticipatory level of pain and the more intense the pain expressed during the procedure” Woo et al.4
Starting a Dialog with the Patient
Prior to dressing changes and wound management related procedures, patients deal with the anxiety related to the fears of pain and lack of control. Clinicians can help reduce anxiety by meeting with the patient and discussing the patient’s concerns. provide useful non-pharmacological recommendations for reducing patient fear, anxiety, and pain. The pre-dressing removal and procedural anxiety reduction strategies include.Woo et al 5:
1. Inviting patient involvement.
Ask the patient to describe their sensations during the last dressing change (eg, does it hurt a little or a lot?). Try and separate what type of pain the patient is experiencing. Is it acute pain that is very intense, but only lasts a short period of time? Or is the patient experiencing long-lasting pain throughout the day? Ask them what has been successful in reducing their pain in the past (including improving environmental conditions, pain medications, or adjunct pain therapy).
2. Reducing anxiety by creating a sense of patient control.
Reassure the patient that you will be sensitive to their needs during debridement and dressing changes. Incorporate time-out procedures. Time-outs allow the patient to regulate how much pain they can tolerate at one time and give patients breaks as needed. Ask the patient how you can best reduce environmental stimuli to help reduce anxiety levels. Consider discussing several adjunct pain reduction strategies.
3.Providing ongoing education.
Talk with the patient about how incorporating non-pharmacological and pharmacological strategies can help reduce wound and dressing removal related pain. Focus on providing education that not only highlights the patient’s etiology-related condition, but how the dressings and treatments can benefit or resolve that condition.
What to Consider if the Patient Remains Highly Anxious
In order to treat highly anxious patients, it is important to understand the variations of anxiety-related conditions. There are four types of anxiety disorders that are common in the wound clinic environment. One of the more common types of anxiety is generalized anxiety disorder (GAD) which is an “excessive anxiety and worry that occurs more days than not … about a number of events or activities.”6 The recommendations above often successfully address an individual’s mild to moderate fears or concerns. If pharmaceutical help is needed (For irresolvable fear and anxiety), Benzodiazepine is the front line medication for the initial treatment of general anxiety disorders (specifically: Xanax, Valium, and Ativan). Selective serotonin reuptake inhibitors are also indicated by the FDA for the treatment of generalized anxiety including: Paxil and Lexapro.
Other Types of Anxiety Disorders Include6:
1. Anxiety caused by a general medical condition (See Table 2), like hypoglycemia, cardiac arrhythmias, and chronic obstructive pulmonary disease. Anxiety in this circumstance can be resolved by treating the medical disorder.
2. Specific phobias, which are excessive or unreasonable fears, cued by objects or events common in the wound clinic environment including: scalpels, blood, needles, and medical procedures (including debridement). Cognitive behavioral therapy is best at resolving specific phobias and benzodiazepines are often used to mediate these phobias prior to exposure.
3. Panic disorders involving recurrent unexpected panic attacks (See Table 3). Cognitive behavioral therapy is a beneficial treatment for this condition. Specific medications in the benzodiazepine family (Xanax & Klonopin) and SSRI family (Zoloft, Paxil CR, Paxil, & Prozac) are indicated by the FDA for the treatment of panic disorders.7
The advantage of benzodiazepine in the clinical setting is that they can be effective within 30 minutes. For wound care patients with wounds that will require multiple weeks of treatments consider, starting Benzodiazepines and SSRI’s together. This provides a bridge from the fast acting benzodiazepines to the SSRI’s that generally take up to four weeks to be effective.7 At that point weaning the benzodiazepines should be considered as long-term use of benzodiazepines lead to an increased incidence of side effects and dependence.8
1. Johnson, S. Therapist’s guide to clinical intervention, second edition, 2004. Academic Press: London.
2. Woo KY. Meeting the challenges of wound-associated pain: anticipatory pain, anxiety, stress, and wound healing. Ostomy Wound Manage. 2008;54(9):10-12.
3. Feeney SL. The relationship between pain and negative affect in older adults: anxiety as a predictor of pain. J Anxiety Disord. 2004;18(6):733-44.
4. Woo, K., Sadavoy, J., Sidani, S., Maunder, R., & Sibbald, R. The relationship between anxiety, anticipatory pain, and pain during dressing change in the older population. Presented at the CAWC Annual Conference. London, Ontario. November 1-4, 2007.
5. Woo KY, Harding K, Price P, Sibbald G. Minimising wound-related pain at dressing change: evidence-informed practice. Int Wound J. 2008;5(2):144-57.
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Forth Edition, Text Revision. Washington, DC, American Psychiatric Association.
7. Antony, M. & Norton, P. The anti-anxiety workbook. The Guilford Press: New York, New York.
8. Sibell, D. & Kirsch, J. The 5-minute pain consult. Lippincott Williams & Wilkins, Philadelphia, Pennsylvania, 2007.
9. National Institute of Mental Health. Anxiety disorders. Science Writing, Press, & Dissemination Branch: Bethesda, MD
10. Stuart, G. & Laraia, M. Principles and practice of psychiatric nursing, 8th edition. Elsevier Mosby: St. Louis, Missouri.
This is a rather insightful article, since it encourages physicians to be attentive to their patient’s mental health in order to achieve best results in wound treatment. As a long time anxiety sufferer, I can personally attest to the fact that anxious thoughts can really put a burden on procedures that might otherwise be effortless for both the patient and doctor. Anyway, here’s a simple anxiety quiz which I’ve found quite revealing. Anyone who thinks they may be having anxiety issues should really take this quiz… it certainly won’t hurt!
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