NURS 471 - Chapter 15: Anxiety and Obsessive-Compulsive Disorders

Mild anxiety

o Everyday problem-solving leverage

o Grasps more information effectively

o Physical symptoms: slight discomfort, restlessness, irritability, or mild tension-relieving behaviors (

o Ex: diving a car on clear road, enough anxiety to stay focused

Mild tension-relieving behaviors

nail biting, foot or finger tapping, fidgeting)

Moderate anxiety

o Selective inattention

o Clear thinking hampered

o Problem solving not optimal

o Sympathetic nervous system symptoms begin

§ Tension, increased HR and RR, perspiration, and mild somatic symptoms (e.g., gastric discomfort, headache, urinary urgency). Voice tremors, and shaking

o Ex

§ Lots of traffic, tend to focus on the task at hand and not on other things

§ Can follow instructions but struggle with teaching/attention

Severe anxiety

o Perceptual field greatly reduced

o Difficulty concentrating on environment

o Confused and automatic behavior

o Critical thinking is not possible

o Somatic symptoms increase

§ headache, nausea, dizziness, insomnia, trembling, pounding heart, hyperventilation and a sense of impending doom or dread.

o Ex

§ Dust storm, cannot see what is front of you

§ Cannot crucially think about anything

Panic

o Markedly disturbed behavior—running, shouting, screaming, pacing

o Unable to process reality; impulsivity

Interventions for Mild to Moderate Levels of Anxiety

Help the patient identify anxiety. "Are you comfortable right now?"

Anticipate anxiety-provoking situations.

Use nonverbal language to demonstrate interest (e.g., lean forward, maintain eye contact, nod your head).

Encourage the patient to talk about feelings and concerns.

Avoid closing off avenues of communication that are important to the patient. Focus on the patient's concerns.

Ask questions to clarify what is being said. "I'm not sure what you mean. Give me an example."

Help the patient to identify thoughts or feelings before the onset of anxiety. "What were you thinking right before you started to feel anxious?"

Encourage problem solving with the patient.

Help the patient to develop alternative solutions to a problem through role-play or modeling behaviors.

Explore behaviors that have worked to relieve the patient's anxiety in the past.

Provide outlets for working off excess energy (e.g., walking, playing ping-pong, dancing, exercising).

Interventions for Severe to Panic Levels of Anxiety

Maintain a calm manner.

Always remain with the person experiencing an acute, severe, or panic level of anxiety.

Minimize environmental stimuli. Move to a quieter setting, and stay with the patient.

Use clear and simple statements and repetition.

Use a low-pitched voice; speak slowly.

Reinforce reality if distortions occur (e.g., seeing objects that are not there or hearing voices when no one is present).

Listen for themes in communication.

Attend to physical and safety needs when necessary (e.g., need for warmth, fluids, elimination, pain relief, family contact).

Because safety is an overall goal, physical limits may have to be set. Speak in a firm, authoritative voice: "You may not hit anyone here. If you can't control yourself, we will help you."

Provide opportunities for exercise (e.g., walk with nurse, punching bag, ping-pong game).

When a person is constantly moving or pacing, offer high-calorie fluids.

Assess need for medication or seclusion after other interventions have been tried and have been unsuccessful.

What are the positives of mild anxiety?

"A person experiencing a mild level of anxiety sees, hears, and grasps more information, and problem solving becomes more effective"

o Panic - what actions do you take?

Person may not be in control

goal: safety for patient/others and meet physical needs

interventions:

Ground them

Food/water

Quiet environment

Potentially restraints/seclusions

meds: ?

Altruism

a largely unconscious motivation to feel caring and concern for others and act for the well-being of others.

Compensation

used to counterbalance perceived deficiencies by emphasizing strengths.

Conversion

the unconscious transformation of anxiety into a physical symptom with no organic cause.

Denial

involves escaping unpleasant, anxiety-causing thoughts, feelings, wishes, or needs by ignoring their existence.

Displacement

the transference of emotions associated with a particular person, object, or situation to another nonthreatening person, object, or situation.

Dissociation

is a disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself.

Identification

is attributing to oneself the characteristics of another person or group. This may be done consciously or unconsciously.

Intellectualization

is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing.

Projection

refers to the unconscious rejection of emotionally unacceptable features and attributing them to others.

Rationalization

consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.

Reaction formation

is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite emotion or behavior.

ReGression

is reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been exhibited previously.

RePression

is an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness.

Splitting

is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.

Sublimation

is an unconscious process of transforming negative impulses into less damaging and even productive impulses

Suppression

is the conscious decision to delay addressing a disturbing situation or feeling. For example, Jessica has studied for the state board examination for a week. She says, "I won't worry about paying my rent until after my exam tomorrow."

Undoing

when a person makes up for a regrettable act or communication.

Conversion: Adaptive and Maladaptive ex

Adaptive Use: No example. Almost always a pathological defense

Maladaptive Use: A man becomes blind after seeing his wife enter a hotel room with another man.

Projection: Adaptive and Maladaptive ex

Adaptive Use: No example. This is considered an immature defense mechanism.

Maladaptive Use: A woman who has repressed an attraction toward other women refuses to socialize. She fears that another woman will come on to her.

Splitting: Adaptive and Maladaptive ex

Adaptive Use: No example. Almost always a pathological defense.

Maladaptive Use: A 26-year-old woman initially values her acquaintances yet invariably becomes disillusioned when they turn out to have flaws.

Regression: Adaptive and Maladaptive ex

Adaptive Use: A 4-year-old boy with a new baby brother temporarily starts sucking his thumb and asking for a baby bottle.

Maladaptive Use: A man who loses a promotion starts complaining to others, hands in sloppy work, misses appointments, and comes in late for meetings.

Displacement: Adaptive and Maladaptive ex

Adaptive Use: A child yells at his teddy bear after being picked on by the school bully.

Maladaptive Use: A child who is unable to acknowledge fear of his father becomes fearful of animals.

Panic Disorder

Panic attacks along with fear of having another panic attack

Panic Disorder: Key assessment findings

Panic attacks are a key feature, so bad normal function is compromised; unpredictable

Begin to fear the fear

Physical: hyperthyroidism, dizziness, cardiac arrhythmias, asthma, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome.

Agoraphobia

Excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing

Agoraphobia: Key assessment findings

· Avoidant tendencies

· Adverse childhood experiences and stressful life events are associated with the development of agoraphobia

· May start as another fear disorder

Separation Anxiety Disorder

Developmentally inappropriate levels of concern over being away from a significant other

SAD: assessment findings

· Fear that something will happen to someone they are close to

· sleep disruptions and nightmares due to intense anxiety

· The separation anxiety is often manifested in physical symptoms, such as gastrointestinal disturbances and headaches.

· Adult symptoms: harm avoidance, worry, shyness, uncertainty, fatigability, and a lack of self-direction. Fear of separation is accompanied by a significant level of discomfort and disability that impairs social and occupational functioning.

· Physical or sexual assault can cause condition

Generalized Anxiety Disorder (GAD)

Excessive worry that lasts for months

GAD: assessment findings

· Excessive worry

· Sleep disturbances common

· Often comorbidity with major depressive

Phobias: assessment findings

· Phobias compromise a person's daily functioning, and phobic people go to great lengths to avoid the feared object or situation.

· Complications due to self medication with drugs/ETOH

Obsessions

Thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind

Compulsions

o Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety

Obsessive-Compulsive Disorder

symptoms that occur on a daily basis and may involve issues of sexuality, violence, contamination, illness, or death. Pathological obsessions or compulsions cause marked distress to individuals who often feel humiliation and shame regarding these behaviors.

Obsessive-Compulsive Disorder: types

· Obsessive-compulsive disorder

· Body dysmorphic disorder

· Hoarding disorder

· Hair pulling (trichotillomania) and skin picking (excoriation) disorders

· Other compulsive disorders

Benzodiazepines

most commonly used because they have a quick onset of action

-monitor for side effects of benzodiazepines including sedation, ataxia and decreased cognitive function

-not recommended for pts with substance use, or elderly people due to increase risk for delirium falls and fractures

antidepressants to tx anxiety

SSRI first line of defense in most anxiety and obsessive compulsive related disorders

-paxil is calmingprozac and zoloft are activating and can increase anxiety initially

drugs for GAD (4 types, 8 total)

SSRIs: escitalopram (Lexapro), paroxetine (Paxil)

SNRIs: Venlafaxine (Effexor), duloxetine (Cymbalta)

Benzodiazepines: alprazolam (Xanax), lorazepam (ativan), diazepam (valium)

other: buspirone (Buspar)

drugs for panic disorder (3 types, 6 total)

SSRIs: paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft)

SNRIs: Venlafaxine (Effexor)

Benzodiazepines: alprazolam (Xanax), clonazepam (Klonopin)

drugs for social anxiety (2 types, 3 total)

SSRIs: paroxetine (Paxil), sertraline (Zoloft)

SNRIs: Venlafaxine (Effexor)

Patient and Family Teaching: Antianxiety drugs (Box 15.2)

1. Caution the patient about the following:

- Not to change the dose/frequency of medication w/o consulting

- These meds may make it unsafe to handle mechanical equipment (e.g., cars, saws, and machinery).

- Avoid using with EOTH

-Avoid caffeine: lowers effect

Review prescription meds [+ doses] that may cause/increase anxiety (e.g., thyroid hormones, steroids, decongestants).

2. Discuss with the prescriber the risks to the fetus and the risk of untreated anxiety disorders should pregnancy occur or be considered.

3. Discuss breastfeeding

4. Teach the patient that:

- Quitting a benzodiazepine after the first month of daily use may cause withdrawal symptoms

- Medications should be taken with or shortly after meals or snacks to reduce GI discomfort.

- Drug interactions can occur [listed in chapter; p. 283]

NEED TO GET

anxiety meds

§ What route are they given?

§ How long do they take to work?

§ Which could be given as needed (PRN) in a crisis/psychiatric emergency situation versus on an ongoing basis?

· Buspar (buspirone)

· Ativan (lorazepam)

· Elavil (amitriptyline)

· Lexapro (escitalopram)

· Vistaril/Atarax (hydroxyzine)

Exposure and Response Prevention

first line CBI intervention used for obsessive compulsive behaviors

exposed to stimuli that triggers OCD s/s

teaches that anxiety dose go away even when compulsion is not completed.

Flooding

[Exposure and Response Prevention on crack]

gives lots and lots of undesirable stimuli with the goal of extinguishing anxiety response

Cognitive Behavioral Therapy

Addressing distorted thoughts

-cognitive restructuring, psychoeducation, breath restraining and muscle relaxation, teaching of self monitoring for panic and other symptoms, real life exposure to feared objects/situations

-idea that people overestimate the danger and underestimate their ability to handle them