Anxiety, Somatoform, & OCD (NUR 322)

Anxiety

Vague feeling of dread or apprehension; it is a response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms

Anxiety Disorders

Group of conditions that share a key feature of excessive anxiety with ensuing (1) behavioral, (2) emotional, (3) cognitive, and (4) physiological responses; diagnosed when anxiety becomes chronic and permeates major portions of life

Stress

Wear and tear that life causes on the body

General Adaptation Syndrome

Physiological aspects of stress characterized by three stages: (1) alarm reaction, (2) resistance, and (3) exhaustion; identified by Hans Selye (endocrinologist)

3 Stages of Stress Reaction (General Adaption Syndrome)

1.) Alarm Reaction → preparation for defense

2.) Resistance → blood shunted to areas needed for defense

3.) Exhaustion → body stores are depleted; emotional components are unresolved

Alarm Reaction Stage

First stage of general adaptation syndrome; body is stimulated to send messages from the hypothalamus to the glands (i.e. adrenal gland) and organs (i.e. liver) to prepare for potential defense

Resistance Stage

Second stage of general adaptation syndrome; digestive system reduces function to shunt blood to areas needed for defense; RR, HR, and contractility ↑; adaptation to stress causes glands/organ response to abate

Exhaustion Stage

Third stage of general adaptation syndrome characterized by negative response to anxiety/stress; body stores are depleted or emotional components are unresolved, causing continual arousal and ↓ reserve capacity

4 Levels of Anxiety

1.) Mild → wide perceptual field; sharpened senses; ↑ motivation and sensory stimulation; “sensing something is different”

2.) Moderate → narrowed perceptual field (immediate task); nervousness/agitation; selective attention/difficulty concentrating; able to be redirected; “feeling something is definitely wrong”

3.) Severe → perceptual field reduced to single/scattered details; trouble thinking/reasoning; irritable/angry; muscle tighten; ↑ vital signs

4.) Panic → perceptual field recued to self; fight, flight, or freeze; cognitive processes focused on defense; dilated pupils; ↑ vital signs

Diazepam (Trade Name, Class, Adverse Effects, Implications)

Trade Name: Valium

Class: Anxiolytics, Benzodiazepines

Adverse Effects: Dizziness/clumsiness, sedation, blurred vision, sexual dysfunction, anticholinergic effects, high potential for misuse/dependence

Implications: Avoid concurrent CNS depressants (i.e. antihistamines, alcohol), avoid caffeine, caution with potentially hazardous activities, rise slowly, adequate hydration, do not stop abruptly

Alprazolam (Trade Name, Class, Adverse Effects, Implications)

Trade Name: Xanax

Class: Anxiolytics, Benzodiazepines

Adverse Effects: Dizziness/clumsiness, sedation, blurred vision, sexual dysfunction, anticholinergic effects, high potential for misuse/dependence

Implications: Avoid concurrent CNS depressants (i.e. antihistamines, alcohol), avoid caffeine, caution with potentially hazardous activities, rise slowly, adequate hydration, do not stop abruptly

Chlordiazepoxide (Trade Name, Class, Adverse Effects, Implications)

Trade Name: Librium

Class: Anxiolytics, Benzodiazepines

Adverse Effects: Dizziness/clumsiness, sedation, blurred vision, sexual dysfunction, anticholinergic effects, high potential for misuse/dependence

Implications: Avoid concurrent CNS depressants (i.e. antihistamines, alcohol), avoid caffeine, caution with potentially hazardous activities, rise slowly, adequate hydration, do not stop abruptly

Lorazepam (Trade Name, Class, Adverse Effects, Implications)

Trade Name: Ativan

Class: Anxiolytics, Benzodiazepines

Adverse Effects: Dizziness/clumsiness, sedation, blurred vision, sexual dysfunction, anticholinergic effects, high potential for misuse/dependence

Implications: Avoid concurrent CNS depressants (i.e. antihistamines, alcohol), avoid caffeine, caution with potentially hazardous activities, rise slowly, adequate hydration, do not stop abruptly

Clonazepam (Trade Name, Class, Adverse Effects, Implications)

Trade Name: Klonopin

Class: Anxiolytics, Benzodiazepines

Adverse Effects: Dizziness/clumsiness, sedation, blurred vision, sexual dysfunction, anticholinergic effects, high potential for misuse/dependence

Implications: Avoid concurrent CNS depressants (i.e. antihistamines, alcohol), avoid caffeine, caution with potentially hazardous activities, rise slowly, adequate hydration, do not stop abruptly

Buspirone (Trade Name, Class, Adverse Effects, Implications)

Trade Name: BuSpar

Class: Anxiolytics, Nonbenzodiazepines

Adverse Effects: Dizziness, restlessness/agitation, drowsiness, weakness, paradoxical excitement/euphoria, nausea/vomiting

Implications: Rise slowly, caution with potentially hazardous activities, take with food, report persistent restlessness/agitation or excitement/euphoria

2 Neurotransmitters Correlated with Anxiety

1.) GABA

2.) Serotonin

Positive Reframing

Cognitive-behavioral therapy (CBT) strategy for anxiety; turning negative messages into positive ones

Decatastrophizing

Cognitive-behavioral therapy (CBT) strategy for anxiety; making more realistic appraisal if situation

Assertiveness Training

Cognitive-behavioral therapy (CBT) strategy for anxiety; learn to negotiate interpersonal situations

Age-Related Considerations for Anxiety Disorders

Conditions seen in children…

i.) Selective mutism

ii.) Separation anxiety

iii.) Social anxiety disorder (can persist into adulthood)

Conditions seen in later life…

i.) Phobias most common

ii.) Panic attacks less common

iii.) Ruminative thoughts

iv.) SSRIs and antidepressants are the treatment of choice

6 Types of Anxiety Disorder

1.) Agoraphobia

2.) Panic Disorder

3.) Specific Phobia

4.) Social Anxiety Disorder

5.) Generalized Anxiety Disorder (GAD)

6.) Panic Disorder

Panic Disorder

Type of anxiety disorder composed of discrete episodes of panic attacks; diagnosed when the patient has recurrent/unexpected panic attacks, followed by at least 1 month of persistent concern about future attack; most have no environmental trigger

What percentage of those with panic disorder suffer from accompanying agoraphobia?

50%

Panic Attack

15 to 30 minutes of rapid, intense anxiety that causes great emotional fear and physiological discomfort; patient usually displays four or more indicative signs/symptoms

12 Panic Attack Signs/Symptoms

1.) Palpitations

2.) Sweating

3.) Tremors

4.) Shortness of breath

5.) Sense of suffocation

6.) Chest pain

7.) Nausea

8.) Abdominal distress

9.) Dizziness

10.) Paresthesia

11.) Chills

12.) Hot flashes

10 Assessment Findings of Panic Disorder

1.) Screening → Hamilton score of 1-4 (mild to grossly disabling)

2.) History → prior diagnosis; record/report of panic attacks

3.) Appearance/Behavior → automatisms (unconscious mannerisms)

4.) Mood/Affect → anxious, serious, tense, sad; depersonalization, derealization

5.) Though Processes/Content → disorganized; loss of rational thinking

6.) Sensorium/Intellectual Processes → confusion, disorientation

7.) Judgement/Insight → lack of sound judgement; insight absent until educated

8.) Self-Concept → self-blaming, consumed with worry

9.) Roles/Relationships → avoidance of others

10.) Physiological/Self-Care Concerns → sleeping, eating

Phobia

Illogical, intense, and persistent fear of a specific object or social situation that causes extreme distress and interferes with normal functioning; disproportionate emotional response or reaction to situation/circumstance

Phobias usually result from past negative experiences. TRUE or FALSE?

FALSE

3 Categories of Phobias

1.) Agoraphobia → fear of being outside

2.) Specific Phobia → irrational fear of a particular object or situation)

3.) Social Phobia → anxiety provoked by certain social or performance situations; severely anxious to the point of panic/incapacitation

5 Categories of Specific Phobias

1.) Natural Environmental Phobias → fear of storms, water, heights, or other natural phenomena

2.) Blood-Injection Phobias → fear of seeing one’s own or other’s blood, traumatic injury, or an invasive medical procedure (i.e. injection)

3.) Situational Phobias → fear of being in a specific situation such as on a bridge or in a tunnel, elevator, small room, hospital, or airplane

4.) Animal Phobia → fear of animals or insects (usually specific type) that develops in childhood and can continue through adulthood; cats/dogs most common

5.) Other Types → any specific phobia not subdivided

What periods of development do phobias usually occur? What is significant about specific phobia that persist into adulthood?

Childhood or adolescence; 80% of persistent phobias are lifelong

Systematic (Serial) Desensitization

Therapist progressively exposes the client to the threatening object in a safe setting until the client’s anxiety decreases; behavioral therapy strategy often used to treat phobias

Flooding

Form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety; commonly used to treat phobias

Generalized Anxiety Disorder (GAD)

Disorder characterized by excessive worry and feeling highly anxious at least 50% of the time (6+ months); unable to control focus on worry, the patient experiences three or more indicative sings/symptoms

6 GAD Signs/Symptoms

1.) Uneasiness

2.) Irritability

3.) Muscle tension

4.) Fatigue

5.) Difficulty thinking

6.) Sleep alterations

Obsessions

Recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that cause marked anxiety and interfere with interpersonal, social, or occupational function; patient knows these thoughts are excessive or unreasonable but believes they have no control over them

Compulsions

Ritualistic/repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety; the theme of the ritual is usually associated with that of obsession (i.e. repetitive handwashing when obsessed with contamination)

Obsessive Compulsive Disorder (OCD)

Diagnosed when obsessions/compulsions consume the patient or are compelled to act out the behaviors to an extent that interferes with personal, social, and occupational functions

5 Disorders Related to OCD

1.) Self-Soothing Behaviors → excoriation (dermatillomania), trichotillomania, onychophagia (chronic nail-biting)

2.) Body Dysmorphic Disorder (BDD) → preoccupation with an imagined/slight defect in physical experience that causes significant distress/interference

3.) Hoarding Disorder → progressively characterized by excessive acquisition of things, cluttered living spaces (uninhabitable), and significant distress/impairment

4.) Reward-Seeking Behaviors → kleptomania (stealing), oniomania (buying)

5.) Body Identity Integrity Disorder (BIID) → feeling “overcomplete” or alienated from a part of their body and desire amputation

Cognitive Model of OCD

Focuses on childhood and environmental experiences of growing up and serves to partially explain the etiology of OCD; describes the patient’s thinking as (1) believing one’s thoughts are overly important (“If I think it, it will happen”) and a need to control them, (2) perfectionism and the intolerance of uncertainty, and (3) inflated personal responsibility (from a strict moral/religious upbringing)

8 OCD Assessment Findings

1.) Screening → positive answers to questions r/t obsessions/compulsions

2.) History → prior diagnosis, report of overwhelming obsessions/compulsions

3.) General Appearance/Behavior → tense, anxious/worried, fretful; unremarkable or immobilized by thoughts

4.) Mood/Affect → overwhelming anxiety

5.) Thought Processes/Content → describe obsessions as rising out of nowhere

6.) Judgement/Insight → recognizes obsessions as irrational but unable to stop them)

7.) Roles/Relationships → difficulty fulfilling roles; less available to family/friends

8.) Physiological/Self-Care Concerns → sleeping problems, appetite/weight changes

Psychosomatic

Term used to convey the connection between mind (psyche) and body (soma)

Hysteria

Multiple (dramatic) physical complaints with no organic basis

Somatization

Transference of mental experiences/states into bodily symptoms; Freud proposed that unexpressed emotions can be converted into physical symptoms

3 Central Features of Somatization

1.) Physical complaints suggest major medical illness but have no demonstratable organic basis.

2.) Psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the symptoms.

3.) Symptoms or magnified health concerns are not under the client’s conscious control.

4 Types of Somatic Disorders

1.) Somatic Symptom Disorder → characterized by one