Mediating Anxiety, Fear, and Pain in the Wound Clinic Setting

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

Medication is not considered to be the cure for anxiety disorders, only a way of reducing an individual’s anxiety to a point where they can more effectively receive psychotherapy.9 Cognitive-behavioral therapy (CBT) is the “psychotherapy (treatment) of choice” 8 for GAD, specific phobias, and panic disorders. The cognitive aspect of the therapy focuses on helping individuals change the thoughts and beliefs that support their fears, and the behavioral aspect assists individuals in changing their reaction to anxiety-provoking situations. CBT therapy includes the incorporation of breathing and relaxation skills (including progressive muscle relaxation, meditation, and biofeedback), along with exposure techniques aimed to allow the patient to desensitize himself or herself from the fearful situation that triggers their anxieties.10

Implications for the Wound Care Clinic
Anxiety related disorders are considered to be “the most common psychiatric disorders in America,”10 affecting 40 million individuals or 18% of the population.9 To date, however, no studies have addressed the prevalence, development, and course of separate anxiety disorders with wound patients and their associated pain. We do understand that anxiety, fear, and stress contribute to how patients perceive wound-related pain. What we frequently don’t see is how anxiety affects our patients when they leave the clinic. Remember neither anxiety nor pain stop at the door, so address your patient’s anxiety for its own sake as well as for its effect on perceptions of pain. n

Matthew Livingston, R.N., B.S.N., C.W.S., A.C.H.R.N, Author of the Scottsdale Wound Management Guide, HMP Communications. He has experience as an inpatient and outpatient wound management nurse (including hyperbarics) in the Phoenix, Arizona area. He designs web-based wound education sites including woundblog.com and woundadvice.com.