anxiety and OCD

SSRIs

• fluoxetine

• ecitalopram

• fluvoxamine (OCD)

• sertraline

• paroxetine

SNRIs

• duloxetine

• venlafaxine

benzodiazepines

• clonazepam

• alprazolam

• lorazepam

• diazepam

anxiolytics

buspirone

tricyclic antidepressants

clomipramine (OCD)

antihistamines

hydroxyzine

beta blockers

propranolol

propranolol and hydroxyzine

used in addition to another medication

anxiety

feeling of apprehension, uneasiness, uncertainty, or dread resulting from real or perceived threat

• individual experiences physical, emotional, cognitive, and behavioral symptoms

• normal anxiety is necessary for survival → basic evolutionary response to impending doom; “fight or flight response”

fear

response to threats here and now

levels of anxiety

• mild

• moderate

• severe

• panic

mild anxiety

• occurs in normal experience of everyday living

• adaptive and can provide motivation for survival

perceptual field of mild anxiety

• heightened perceptual field

• person sees, hears, and grasps more information

• observations are sharper

• focus is flexible and is aware of anxiety

ability to problem solve with mild anxiety

• able to work effectively toward a goal and examine alternatives

physical or other characteristics of mild anxiety

• slight discomfort

• attention seeking behaviors

• restlessness

• easily startled

• irritability or impatience

• mild tension relieving behavior (fidgeting)

perceptual field of moderate anxiety

• narrowed perceptual field; some details are excluded from observation

• sees, hears, and grasps less of what is going on or information

• focuses on source of anxiety

• less able to pay attention

ability to problem solve with moderate anxiety

• able to solve problems but not at optional level

• still able to follow directions

physical or other characteristics of moderate anxiety

• sympathetic nervous system symptoms begin

• may experience tension, pounding heart, increased pulse and rr, perspiration, and mild somatic symptoms (headache, urinary frequency, backache, insomnia)

• voice tremors, poor concentration and shaking may be noticed

perceptual field of severe anxiety

• greatly reduced and distorted perceptual field

• focuses on details or one specific detail

• attention is scattered

ability to problem solve with severe anxiety

• problem solving feels impossible

• unable to see connections between events or details

• person may be dazed and confused

physical or other characteristics of severe anxiety

• behavior is automatic and aimed at reducing or relieving anxiety

• feelings of dread

• confusion

• purposeless activity

• sense of impending doom

• more intense somatic complaints (chest discomfort, dizziness, nausea, sleeplessness)

• diaphoresis

• withdrawal

• loud and rapid speech

• threats and demand

panic anxiety

most extreme level of anxiety

perceptual field of panic

• unable to process what is going on in environment

• focus is lost; may feel unreal (depersonalization) or that the world is unreal (derealization)

ability to problem solve with panic

• completely unable to process what is happening

• disorganized or irrational reasoning

physical or other characteristics of panic

• experience of terror

• immobility, severe hyperactivity, or flight

• unintelligible communication or inability to speak

• amplified or muffled sounds

• somatic comlaints increase (numbing or tingling, SOB, dizziness, chest pain, etc)

• severe withdrawal

• hallucinations and/or delusions

• likely out of touch with reality

defenses against anxiety

• automatic coping styles that protect people from anxiety

• enables individuals to maintain self-image by blocking

  • feelings

  • conflicts

  • memories

• can be healthy or unhealthy

• not always apparent to individual using them

defense mechanisms

• altruism (selfless)

• compensation (emphasize strengths)

• conversion (converted to physical strengths)

• denial

• displacement (put somewhere else)

• dissociation

• identification (adopts characteristics of another person)

• intellectualization (use facts instead of feelings)

• projection

• rationalization (logical but false explanations to justify)

• reaction formation (opposite reaction to true feelings)

• regression

• repression

• splitting (divides into good and bad)

• sublimation (negatives turn into positives)

• suppression 

• undoing (cancel out)

adaptive (healthy) defense mechanisms

• problem solving

• talking

• crying

• sleeping

• exercising

• deep breathing

• imagery

• relaxation

maladaptive (unhealthy) defense mechanisms

• blaming

• negative self talk

• obsessive compulsive behaviors

• aggressive acting out behaviors

• withdrawal

• excessive eating, drinking, spending, gambling, drug use, sexual activity

anxiety disorders

• separation anxiety disorder

• generalized anxiety disorder (GAD)

• social anxiety disorder (SAD)

• panic disorder

specific phobias

agoraphobia

obsessive compulsive disorders

• obsessive compulsive disorder (OCD)

• body dysmorphic disorder

• hoarding disorder

• trichotillomania

• excoriation disorder

systematic desensitization

• gradually exposed to feared object or anxiety provoking situation through a series of steps from least frightening to most frightening

• taught to use relaxation techniques at each step when anxiety becomes overwhelming

flooding

• exposed to large amount of an undesirable stimulus in a controlled environment

• learns through prolonged exposure that survival is possible, and anxiety diminishes

goals of CBT for anxiety and OCDs

• gain insight into what is causing anxiety

• learn new responses to irrational thinking

• reduce anxiety response

CBT for anxiety and OCDs include

• cognitive restructuring

• psychoeducation

• real life exposure to feared objects or situations

• breath restraining and muscle relaxation

• teaching of self monitoring for panic and other symptoms

non-pharmacological treatment

• promotion of self care activities

• deep breathing exercises

• physical exercise

• progressive muscle relaxation

• mental imagery

• meditation

• biofeedback

epidemiology of anxiety disorders

• one of the most common mental health disorders

• chronic and persistent illness

• affects all ages and genders

• highly treatable

• rarely ned hospitalization unless they are suicidal

separation anxiety disorder

• exhibit developmentally inappropriate levels of concern over being away from significant other

• fear that something horrible will happen to other person and that it will result in permanent separation

• normal part of infant development (onset at 8 months, peak at 18 months)

• distracts from normal activities and causes sleep disruptions

• often manifests as somatic complaints

separation anxiety disorder in adults

• typically diagnoses before age of 18, after about 1 months of symptoms

• subjects of attachment (parent, spouse, child, friend)

• fear of separation and significant level of discomfort and disability that impairs social and occupational functioning

• environmental stresses often bring about symptoms 

• no FDA approved medication

  • treated with CBT and addition of SSRIs if CBT alone isnt working

generalized anxiety disorder (GAD)

• one of the most common mental health disorders

• possible genetic predisposition

key pathological feature of GAD

• excessive and persistent worry that is out of proportion to events or situations

• may be accompanied by restlessness, difficulty concentrating, irritability, muscle tension, and sleep disturbances

clinical manifestations of GAD

• chronic with fluctuating symptom severity

• due to worry, significant amounts of time are spent in preparing for or doing activities

• symptoms cause distress or impairment that it interferes with daily life and relationships

• may exhibit mild depressive symptoms

• often present in a primary care setting with somatic complaints including muscle aches, soreness, and GI disturbances

treatment for GAD

• CBT

• pharmacotherapy

pharmacotherapy for GAD

• SSRIs (escitalopram, paroxetine)

• SNRIs (venlafaxine, duloxetine; only ages 7-17)

• benzodiazepines (short-term; try not to give all the time)

• buspirone

• antihistamines (hydroxyzine)

• anticonvulsants

• beta blockers (propranolol)

social anxiety disorder (SAD)

• severe anxiety or fear of social situations where they may be criticized or be evaluated negatively by others

  • fear of public speaking most common

  • may worry for days or weeks before dreaded situation

• withdraw from situations or experience intense discomfort

  • if unable to avoid, they endure situation with intense anxiety and emotional distress

• may interfere with work, school, and other ordinary activities and can make it hard to make and keep friends

treatment for SAD

• CBT

• systematic desensitization

• mindfulness and relaxation techniques

• pharmacotherapy

pharmacotherapy for SAD

• SSRIs (paroxetine, sertraline)

• SNRIs (venlafaxine)

• benzodiazepines (short term)

• antihistamines, anticonvulsants, beta blockers

  • added is first course treatment ineffective

54321 technique

• 5 things you can see

• 4 things you can touch

• 3 things you can hear

• 2 things you can smell

• 1 thing you can taste

specific phobias

individual experiences extreme anxiety when they anticipate exposure or are exposed to feared stimulus

• negative or traumatic experiences with the feared objects or situations lead to fear

• interfere with daily functioning

  • go to great lengths to avoid feared object or situation

five main categories of phobias

• animals 

• natural environment 

• blood injection types

• situational type

• other (do not fit in other categories)

agoraphobia

• most severe and persistent specific phobia

• intense and excessive anxiety or fear about being in places or situations from which escape might be difficult, embarrassing, or where help might not be available

• feared places are avoided to control anxiety

situations commonly avoided with agoraphobia

• being alone outside

• being alone at home

• traveling in car, bus, plane 

• being on bridge

• riding in an elevator

• being in a crowd

treatment for specific phobias

• CBT

• systematic desensitization

• pharmacotherapy

pharmacotherapy for specific phobias

• no FDA approved meds

• SSRIs and SNRIs

• antihistamines, anticonvulsants, and beta blockers added if first line treatment is ineffective

panic disorder

chronic condition with recurrent and unpredictable panic attacks

key features of panic disorder

• sudden onset of extreme apprehension or fear usually associated with feelings of impending doom

• occur out of the blue and are extremely intense; last for minutes then subside

• begin to fear the fear; fear future episodes

characteristics of panic disorder

• chest pain, racing heart rate

• sweating, trembling, shaking

• SOB, feelings of smothering or choking

• nausea and/or abdominal pain

• dizziness and unsteady gait

• chills

• fear of losing control

• fear of dying

treatment for panic disorder

• CBT

• pharmacotherapy

pharmacotherapy for panic disorder

• SSRIs (fluoxetine, paroxetine, sertraline)

• SNRIs (venlafaxine)

• benzodiazepines (short term)

caring for individual experiencing panic attack

• considered in crisis

• rule out medical causes (cardiac event)

• stay with individual

• reassure them that you will not leave

• give clear directions

• assist individual to environment with minimal stimulation

• administer PRN anxiolytic medications

recognize and analyze clues

• physical, neurological exam and psychosocial assessments

• potential for self harm or suicide

• current coping strategies (what has helped in past)

• cultural, ethnic, and social backgrounds

prioritize hypotheses

• risk for self harm or suicide

• anxiety

• fear

• social isolation

• impaired coping

generate solutions

encourage active participation if possible

take action

determine level of anxiety they are experiencing or is this an anxiety disorder

action for mild to moderate

• help individual identify anxiety, thoughts/feelings prior to onset, and anticipate provoking situations

• provide calm presence, empathize, and recognize individuals distress

• encourage individual to talk about feelings/concerns

• listen and focus on individuals feelings/concerns

• ask open ended questions, give broad openings, and use exploring and seeking clarification types of questions

• use nonverbal therapeutic communication to demonstrate interest

• encourage problem-solving

• assess past coping strategies and assist in developing alternative coping strategies

• provide outlets for working off excess energy

action for severe to panic

• safety is priority, always remain with individual

• maintain calm manner, use clear simple statements and repeat if necessary, use low pitched voice and speak slowly

• move individual to quiet environment with minimal stimulation

• reinforce reality of distortions are present

• assess need for medication

• assess risk for suicide

take action

• implement treatment modalities

• promote self care

evaluate outcomes

• no self harm or SI

• reduction in anxiety

• improved socialization

• improved coping

obsessive compulsive disorders

• obsessive compulsive disorder

• body dysmorphic disorder

• hoarding disorder

• trichotillomania disorder (hair pulling)

• excoriation disorder (skin picking)

obsessions

thoughts, impulses, or images that persist and recur so they cannot be dismissed from mind despite attempts to do so

• often seem senseless to individual who experiences them

• cause severe anxiety

compulsions

ritualistic behaviors individuals feel driven to perform to reduce anxiety or prevent an imagined calamity or disaster

• performing compulsive behavior temporarily reduces anxiety but act must be repeated again and again

obsessive compulsive disorder

• pattern of unwanted obsessions that lead to compulsions that cause significant distress, humiliation, and shame

• time consuming and interferes with daily routines, activities, and relationships

• stress can increase OCD symptoms

treatment for OCD

• may not result in cure, may help bring symptoms under control

• may need long-term, ongoing or more intensive treatment

• CBT

• deeb brain stimulation

• transcranial magnetic stimulation

• pharmacotherapy

pharmacotherapy for OCD (adults)

• SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine)

• TCAs (clomipramine)

• antipsychotics may be added to reduce severe symptoms

pharmacotherapy for OCD (children)

• SSRIs (fluoxetine 7-17, fluvoxamine 8-17, sertraline 6-17)

• TCAs (comipramine 10-17)

body dysmorphic disorder

preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

• time consuming, difficult to control and may lead to embarrassment, shame, anxiety, disgust, and depression

• compulsive behaviors include checking mirror, camouflaging, excessive grooming, reassurance seeking or mental acts

treatment for body dysmorphic disorder

• chronic; resonse to treatment is limited; high risk for suicide

• no FDA approved medications

  • SSRIs and CBT considered first line treatments

• alternative therapies - biofeedback, meditation, relaxation techniques

hoarding disorders

persistent difficulty with accumulation and discarding or parting with possessions, regardless of value

• causes clinically significant distress or impairment in social, occupational, or other areas of functioning

• safety is major concern

• no FDA approved medications

  • SSRIs and CBT

trichotillomania

recurrent hair pulling

• pain from pulling reduces anxiety

• causes clinically significant distress or impairment in social, occupational, or other areas of functioning

treatment for trichotillomania

• habit reversal therapy

• acceptance and commitment therapy

• CBT

pharmacotherapy for trichotillomania

• no FDA approved meds

• SSRIs

• TCA (clomipramine)

excoriation disorder

recurrent sin picking resulting in skin lesions; can also be rubbing, squeezing, lancing, or biting

• some engage to deal with stress and relieve anxiety, others may engage without thinking about it

• causes clinically significant distress or impairment in social, occupational or other areas of functioning

treatment for excoriation disorder

• habit reversal therapy

• acceptance and commitment therapy

• CBT

• pharmacotherapy

pharmacotherapy for excoriation disorder

• no FDA approved meds

• SSRIs

• anticonvulsants

recognize and analyze cues

• individuals with OCDs rarely need hospitalization unless there are suicidal or have compulsions that cause injury

• physical assessment and psychosocial assessments

• additional assessments

  • potential for self harm or suicide

  • current coping strategies; what has helped in past

prioritize hypotheses

• risk for self harm or suicide

• impaired skin integrity

• anxiety

• disturbed body image

• social isolation

• impaired coping

generate solutions

• encourage active participation

• often resistant to addressing dysfunctional behaviors; most will discuss how illness has affected their lives

take actions

• implement and monitor safety precautions

• implement treatment modalities

• promote self care

evaluate outcomes

• no self harm or SI

• improved skin integrity

• reduction in anxiety

• improved body image

• improved socialization

• improved coping

• improved self esteem