anxiety and obsessive compulsive disorders

Normal vs. abnormal anxiety 

Biological and cognitive manifestations of anxiety: 

• Biological: fatigue, sleep disturbance, appetite disturbance, somatic symptoms: pain, GI, CV, substance use: caffeine, nicotine, alcohol, cocaine, amphetamines 

• Psychological: mood changes, cognitive distortions: perseveration, catastrophizing, helplessness, all or nothing thinking, poor self-esteem, changes in concentration 

• Cognitive: poor focus, trouble making decisions 

Similarities and differences between anxiety disorders 

Obsessions vs. Compulsions: 

• Obsessions: persistent and distressing thoughts, images or impulses that are not desired but are overpowering and produce anxiety 

  • Attempts to ignore, suppress, or neutralize them with some other thought or action 

  • Recognizes as a product of own mind 

• Compulsions: repetitive behaviors or mental acts that the person feels they must do in response to the obsession, or according to rigid rules 

  • Done to prevent or reduce stress or to prevent a dreaded event from occurring 

  • Either unconnected in a realistic way to what they were intended to help or are obviously excessive 

etiology

• Biological: genetics, HPA axis dysfunction, limbic system dysfunction, neurotransmitter imbalance (serotonin, norepinephrine, GABA) 

• Psychological: classical conditioning, maladaptive thought patterns 

• Sociological: trauma exposure, caregiver anxiety 

Prioritization 

• Maintain safety and prevent suicide/self-harm  

• Minimize physical impact of anxiety; physical manifestations (ie: impaired skin integrity from excessive handwashing) 

• Minimize cognitive impact of anxiety and provide psychoeducation; psychosocial manifestations 

Nursing interventions 

• Therapeutic communication; adjust information/education to current anxiety level; have a calm demeanor 

• Mindfulness interventions; model and practice mindfulness techniques 

• Lifestyle modifications (ie: sleep hygiene); encouraging physical activity 

• Exposure; adjust the environment 

pharm treatment:

SSRIs/SNRIs, Buspirone, Benzos

SSRIs/SNRIs (daily) 

Buspirone (daily): 

• Mech of action: serotonin receptor partial agonist 

• Side effects: dizziness, headache, nausea 

• Adverse reactions: serotonin syndrome 

• Major DDI: other serotonergic drugs 

• Contraindications: recent MAOI use 

• Patient education: multiple daily doses 

Benzodiazepines: 

• Mech of action: GABA agonist 

• Ex: alprazolam (xanax), clonazepam (klonopil), diazepam (valium), lorazepam (ativan), chlordiazepoxide (librium) 

• Side effects: sedation, ataxia (loss of muscle coordination, causing clumsy movements), slurred speech, poor concentration, amnesia, confusion 

• Adverse reactions: respiratory depression 

• Major DDI: other CNS depressants, opioids, alcohol 

• Contraindications: active substance use disorder, dementia, delirium 

• Patient education: potential for dependence, avoid alcohol, do not drive or use machinery, avoid abrupt cessation, risk of memory impairment with long-term use 

Lifespan considerations - peds

• Normal periods of anxiety throughout development; ie. Separation anxiety in infants and toddlers 

• Fewer symptoms for diagnosis 

• Somatic symptoms are more common 

• Avoid benzodiazepines 

Lifespan considerations - childbearing

• Consider normal anxiety vs postpartum anxiety 

• SSRIs are generally safe 

• Avoid benzodiazepines in pregnancy/lactation 

lifespan considerations - older adult

• Anxiety disorders generally decrease with age 

• Avoid benzodiazepines 

• Consider medical or medication-induced for anxiety