Anxiety: a concept analysis

Abstract Anxiety is often mentioned in people’s daily life, especially in the field of medicine and psychology. For nursing, a clear understanding of anxiety is conducive to clinical nursing practice and research. Under the guidance of the Walker and Avant method, this article conducts a concept analysis of anxiety that provides a comprehensive and rounded analysis of anxiety and helps nurses gain a better understanding of anxiety.


Introduction
Nowadays, anxiety is very common because the social environment is consistently changing and the pace of modern life is soaring. Statistics indicate that there are considerable number of people who are experiencing anxiety all over the world, and the number keeps growing. [1][2][3] Anxiety can occur in many situations, sometimes it is mild and disappears in a short time, but sometimes it can last for a long time and become so severe that it can cause body and mental dysfunctions. 4 In the medical field, patients are more likely to experience anxiety due to illness, which sometimes can affect patient outcomes. 5 As care providers, nurses should have a clear understanding of anxiety to maintain people's bodies and minds in the best conditions. In this study, a concept analysis of anxiety was conducted by using the Walker and Avant method. 6 The defining attributes of anxiety were first extracted from the literature to form a new definition of anxiety, and then a model case and a contrary case were given to further explain this definition. The antecedents and the consequences of anxiety were illustrated after that and followed by the empirical referents of anxiety in the end.

Anxiety in the literature
An advanced search strategy was used to locate the relevant literature in the PsycARTICLES database. Key terms were "anxiety" in title field, "concept" in all text field, and "definition" in all text field, then combined them with the Boolean, and 89 English full texts articles were found during 2007 and 2018 in the end. More information was needed after filtering these articles. Therefore, Google was also searched with the key term stomach upsets, lack of sleep, diarrhea, and muscle aches. Psychological responses may involve selfdoubt, self-soothing, egocentric view, raising apprehension, and psychological avoidance. 1 These reactions often disturb people's normal lives and make them hard to cope with daily lives, and that is why they are non-adaptive. 1,14

Operational definition
Anxiety is an uneasy personal feeling and manifests as non-adaptive physical and mental reactions when people have intrusive thoughts about uncertain future.

Model case
Andy, 31-year-old, is a successful businesswoman in a transnational corporation. She is smart and pretty and she has a steady boyfriend. Everybody respects and admires her. However, in this year's physical examination, she was found to have breast lumps and lumpectomy was suggested. She was hospitalized and surgery was arranged. Since then, she began to experience anxiety because she was worried about her illness and surgery.
An uneasy personal feeling: She felt sad, nervous, and afraid. Intrusive thoughts about uncertain future: She kept thinking what if there were some accidents during the surgery? What if the lumps were malignant so that her entire breast needed to be removed? Will her colleagues treat her as before after the surgery? Will she still be charming to her boyfriend after the surgery? These thoughts just came up and stuck in her mind.
Non-adaptive physical and mental reactions: She suffered from headache, loss of appetite, and insomnia. She was often unreasonably mad at her boyfriend. The nurses encouraged her to communicate with the staff and the wardmates. However, she refused to talk about her feelings and concerns to the nurses and avoided meeting other patients. She was in a state of psychological avoidance and self-abasement. She could not live a normal life as before.

Contrary case
Andy, 31-year-old, is a successful businesswoman in a transnational corporation. She is smart and pretty and she has a steady boyfriend. Everybody respects and admires her. However, in this year's physical examination, she was found to have breast lumps and lumpectomy was suggested. After she was hospitalized, she was optimistic and felt lucky to have discovered the problem in the early stage (no uneasy personal feeling). She cooperated with the doctors and nurses actively "anxiety," and the latest and most relevant resources were selected. Besides, references in these articles were considered to add information.
According to Cambridge English Dictionary, anxiety is defined as "an uncomfortable feeling of nervousness or worry about something that is happening or might happen in the future." 7 In the literature, Bouras and Holt 8 pointed out that when individuals subjectively think that some dangers may befall them, anxiety shows up as uncomfortable and worry feelings. Kring, et al. 9 stated that anxiety comes from people's anticipation, such as the impending death. In recent years, anxiety is still a heated topic among many organizations. American Psychiatric Association 10 asserts that anxiety is different from fear because fear is the response to the real threat while anxiety is about the imaginary threat. American Psychological Association (APA) 11 states that "anxiety is an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure," while Anxiety Centre 12 thinks anxiety is "a state of apprehension, uncertainty and fear resulting from anticipation of a realistic or fantasized threatening event or situation, often impairing physical and psychological functioning." At the same time, Beyondblue 1 pointed out that anxiety is when the feeling of worry keeps ongoing and makes people hard to cope with daily lives.

Defining attributes
Collected and generalized from all the information in the literature, the defining attributes of anxiety are: an uneasy personal feeling, intrusive thoughts about uncertain future, and non-adaptive physical and mental reactions.
The first attribute is an uneasy personal feeling, such as tension, apprehension, dread, and concern. 8,9,11 Healthline 4 and Mayo Clinic Store 13 list some feelings, such as nervous, tension, worry, and restlessness. These feelings are personal and subjective.
The second defining attribute is intrusive thoughts about uncertain future. 9,10,12 Because of the uncertainty of future, some people always think that what if something bad happened to them and these thoughts just invade and stuck in their minds and induce anxiety. For example, a straight-A student can feel very anxious and nervous before every exam because of his thought that what if he failed to do well in the exams and disappointed others. Healthline 4 describes these thoughts as "intrusive thoughts".
The third one is non-adaptive physical and mental reactions. 1,11,13,14 APA 11 and Mayo Clinic Store 13 gives some prevalent physical symptoms among many anxiety patients, which include headaches, loss of appetite, and was ready for the surgery (no intrusive thoughts about uncertain future). She got along well with others and it seems like that she just changed a place to live (no non-adaptive physical and mental reactions).

Antecedents
There are many antecedents to anxiety. The first is genetic factors. 1,15 Beyondblue 1 stated that genetic predisposition toward anxiety can be concealed in the person who experiences anxiety and runs in his family. Maisel 15 pointed out that if someone's parents have an anxiety disorder, then this person can easily experience anxiety than others. The second is psychological factors which can be divided into personality and cognitive distortions. Certain personality traits, such as neuroticism and pessimism, are risk factors to anxiety. 10,16 Cognitive distortions are related to brain dysfunction such as overgeneralizing and catastrophizing. Anxiety occurs when people do not have a proper and reasonable perception. 17 Besides, some drugs may have anxiety as their side effects mainly because these drugs can affect certain neurotransmitters, which in turn affect brain function. 18 Last but not least, there are stressful life events such as work and study stress, abuse, poverty, illness, pregnancy, death or loss of a loved one, and so on. 1,13 For example, in poverty-related conditions, people are more likely to experience anxiety; patients can be very anxious about whether their illnesses are getting better or worse. All these can be very stressful for some people and cause anxiety in them.

Consequences
The consequences of anxiety depend on what individuals do to deal with anxiety. People's behaviors toward anxiety can be divided into positive and negative. If people take positive adaptions toward anxiety, detect and deal with it in the early stage, it will promote personal growth as well as physical and mental development. 19,20 On the contrary, if people act out negative behaviors, allow it reach the last stage and out of control, anxiety can affect both physical and psychological health and even lead to body and mental dysfunction. 21 Outcomes, such as irregular life and abuse of drugs and alcohol, will damage the bodies. When anxiety developed into anxiety disorders, it will impair mental health, the worst can be mental breakdowns which cause suicides. Beyondblue 1 proved this statement by listing some outcomes like suicides in young people and men as well as depression in the elderly and pregnant women. The consequences of anxiety are consistent in the literature: positive or negative behavior change, personal growth, and physical or mental illness.

Empirical referents
Anxiety is an emotion that cannot be directly measured. However, many measuring instruments can help people measure anxiety. Hamilton Anxiety Scale has a long history, but it cannot distinguish anxiety from depression well because this scale has some overlaps with its depression scale. 22 Hospital Anxiety and Depression Scale is mostly used in hospitals for doctors to detect their patients' levels of anxiety. 23 It is good at detecting general anxiety but does not adequate to detect anxiety disorders. 24 State Trait Anxiety Inventory (STAI) and Beck Anxiety Inventory (BAI) are widely used in clinical and research areas today. STAI focuses on the degree of anxiety under a special stressor. Although it has poor validity in its T-Anxiety subscale 24 , STAI is comprehensive and widely used in many research studies all over the world. However, BAI avoids overlapping with depressive symptoms but pays more attention to somatic symptoms, so it is not very valid among young people. 24,25 From the author's perspective, STAI might be the most suitable scale to measure anxiety. It measures anxiety from two angles: state and trait. State-Anxiety is an emotion experience under a certain time or a certain situation, while Trait-Anxiety refers to the tendency that a person will experience anxiety. 26 Thus, STAI is more effective and comprehensive compared with others. It can be used not only in many occupational populations but also in testing the curative effects of psychological interventions and drugs. As every anxiety scale has its limitations, nurses should choose the most suitable one or even combine them to achieve a better assessment of anxiety according to the clinical practice situations.

Conclusions
In this article, we described that anxiety is an unpleasant emotion caused by intrusive thoughts and depicts through physical and psychological responses. Besides, it has many antecedents and different consequences. Many scales can be used as tools to measure anxiety. A thorough understanding of anxiety is achieved through this concept analysis, which is beneficial for nurses doing further studies about its types or anxiety disorders as well as improving quality care in practice and applying it to related researches.

Ethical approval
Ethical issues are not involved in this article.

Conflicts of interest
There are no conflicts of interest.