Anxiety and obsessive compulsive disorders

________- feeling of apprehension, uneasiness, uncertainty, or dread from a real or perceived threat, subjective feeling or emotional response to threatening situations

• vague sense of dread r/t unspecified or unknown danger

• a universal human experience, is among the most basic of emotions

anxiety

_______- a reaction to specific danger, person is aware of specific dreaded object or event

• body reacts in similar ways to fear and anxiety but anxiety affects at deeper level by invading core of personality and eroding feelings of self esteem and personal worth

fear

explain normal anxiety

• healthy rxn

• necessary for survival

• provides energy to carry out tasks of living and striving towards goals

• motivates ppl to make and survive change

• prompts constructive behaviors- studying, timeliness, prep for presentations

• increases mental focus/ problem solving

explain the physiological anxiety response

Sympathetic (fight or flight)

Adrenal glands stimulated to release NE.

Increase systolic BP, P, glycogenesis

Increase blood flow to muscle, brain &

heart

➢ Frequent urination ➢ Restlessness ➢ Increase HR, palpitations ➢ Increased BP ➢ Difficulty breathing, hyperventilation ➢ Sweating ➢ N&V, diarrhea ➢ HA 

explain mild level of anxiety

• alertness

• everyday problem solving leverage

• grasps more information effectively, heightened perception, awareness, sharp focus

• problem solving become more effective and increase learning happens here

• physical symptoms- slight discomfort, resltessness, irritability, mild tension releiving behaviors (nail biting, foot tapping, fidgeting)

explain moderate level of anxiety

• selective inattention

• grasps less info- only certain things in environment are sen/ heard only if pointed out

• clear thinking hampered

• learning and problem solving not optimal

• SNS symptoms begin- tension, pounding heart, increased RR, mild somatic symptoms (GI, HA, urinary urgency)

• can be constructive, may signal that something in persons life needs attention or is dangerous

explain the severe level of anxiety

• tunnel vision

• perceptual feild greatly reduced, blocking things out

• may focus on 1 particular detail or many scattered details

• difficulty concentrating on environment

• confused and automatic behavior aimed at reducing anxiety

• learning and problem solving are NOT possible at this level

• somatic symptoms increase

• palpitations, hyperventilation, sense of impending doom/ dread

explain the panic level of anxiety

• immobilization

• most extreme level with markedly disturbed behavior- running, shouting, screaming, pacing, withdrawal

• unable to process reality, distorted perceptions

• erratic, uncoordinated, and impulsive physical behavior

• possible hallucinations or false sensory perceptions

• can lead to exhaustion

• may feel unreal

▪ If patient’s anxiety is at severe or panic level, highest-priority short-term goals address both ____________.

▪ Make additional progress only after anxiety decreases 

safety and lowering anxiety level 

▪ Because anxiety is subjective, useful measure would be to ask patient to ____________; anxiety scales, physical symptoms, level of distress

rate level of anxiety from 1 to 10 

explain defense mechanisms for anxiety

Automatic coping styles

▪ Protect people from anxiety

▪ Maintain self-image by blocking:

Feelings

Conflicts

Memories

▪ Can be healthy or unhealthy – determined by the frequency,

intensity, and duration of use

▪ Adaptive- lowers anxiety for acceptable achievement of goals

▪ Maladaptive- overuse of immature defenses

explain anxiety disorders

▪ Individuals suffering from anxiety disorders use rigid, repetitive

and ineffective behaviors to control their anxiety

▪Experience a degree of anxiety that interferes with

Personal

Occupational

Social functioning

▪ Chronic anxiety disorders may increase the rate of CV system

related deaths

▪ Tend to be persistent and often disabling

explain separation anxiety disorder

▪ Developmentally inappropriate levels of concern over being away from a

significant other

▪Fear that something horrible will happen to the other person that will result in

permanent separation

▪So intense that it distracts sufferers from their normal activities and can cause

sleep disturbances and nightmares

▪Often manifested in physical symptoms such as GI disturbances and headaches

▪Can impair social and occupational functioning, does not respond well to CBT

▪Most commonly diagnosed before 18 y.o, females more affected

▪Can be genetically inherited or brought about by abuse or an environment

change

▪Can coexist with other disorders such as depression, bipolar, other anxiety d/o,

PTSD, OCD and personality d/o

explain specific phobias

▪ A persistent irrational fear of a specific object, activity, or situation that

leads to a desire for avoidance

▪Examples – spiders, dogs, heights, storms, water, blood, closed spaces,

tunnels, bridges, open spaces

▪Can be overwhelming and crippling with compromised daily functioning

▪Negative & traumatic experiences lead to fear

▪Usually recognizes fear as excessive

▪Can lead to self-medication with alcohol or drugs

▪Can lead to depression, anxiety, substance use, somatic symptom

disorder and a dependent personality disorder

explain agoraphobia

▪ Excessive anxiety or fear about being in places or situations from

which escape might be difficult or embarrassing or which help

may not be available

▪The feared places or situations are avoided in effort to control the

anxiety but the situations may be made more tolerable in the

company of another person

▪Common examples – being alone outside, being home alone,

traveling in a car, bus or plane, being on a bridge, riding in an

elevator

▪Strong genetic component, 61%

explain social anxiety disorder

▪ Severe anxiety or fear provoked by exposure to a social or a performance

situation that will be evaluated negatively by others

▪Examples – fear of saying something that sounds foolish in public, not

being able to answer questions in the classroom, looking awkward in

public

▪ Fear of public speaking is most common

▪ Are at risk for chronic social isolation and depression

▪Risk factors – childhood mistreatment, adverse childhood events

explain panic disorder

▪ Panic attacks – sudden onset of extreme apprehension or fear, usually

associated with feelings of impending doom

▪ Normal functioning is suspended, perceptual field is limited,

disordered thoughts, misinterpretation of reality may occur

▪ May become so preoccupied about future episodes of panic that they

avoid what could be pleasurable experiences “fear the fear”

▪Usually come “out of the blue”, are extremely intense and last for

minutes, may feel like they are “having a heart attack”

▪Symptoms – pounding heart, tachycardia, sweating, trembling, SOB,

feelings of choking, CP, nausea, dizziness, chills, paresthesia,

depersonalization or de-realization

▪May not be able to be calmed down immediately

explain generalized anxiety disorder

▪ Excessive anxiety and worry, out of proportions to the true impact of

events or situations

▪Common worries – inadequacy in interpersonal relationships, job

responsibilities, health of family members

▪Spends huge amounts of time preparing for activities, putting things off

and avoidance, impaired ADL’s

▪Sleep disturbance is common due to worry about the days events,

reviewing past problems and anticipating future difficulties

▪ Family and friends get overtaxed due to the person seeking continual

reassurance about meaningless details

▪Physiological: muscle tension, palpitations, SOB, ^B/P and pulse, dry

mouth, vasoconstriction, chills, nausea, Headaches

▪Affective: irritability, fatigue, disturbed sleep, fear of dying, helplessness

▪Behavioral: crying combativeness, rumination, agitation or inactivity…

▪Cognition: thought blocking, inattention, preoccupation, confusion….

▪Interventions – Counseling, Assess support systems, Monitor for defense

mechanisms, Coping Skills, Daily & PRN Medications, Relaxation

techniques,

▪DSM-5 criteria:

▪ Last for at least 6 months & associated with 3 of the following –

restlessness, easily fatigued, difficulty concentrating, irritability, muscle

tension, tension headaches, sleep disturbance

▪ Worry is difficult to control

▪ Symptoms cause distress in social, occupational or other important

areas of functioning

▪ Symptoms are not due to another medical diagnosis

_______ – condition in which children do not speak due

to fears of negative responses or evaluation, maybe only speak at

home around immediate family members

Selective Mutism

________ - symptoms of anxiety, panic attacks, obsessions and compulsions that develop with use of a substance (alcohol, cocaine, heroin, hallucinogens) • Very common to see anxiety occur with substance abuse 

Substance-induced anxiety disorder

what to assess for anxiety disorders

▪ Sound physical and neurological exam

▪ General assessment of symptoms, essential to determine

whether the anxiety is the primary problem, or secondary to

another source such as a medical diagnosis. EX) chest pain,

SOB

What has helped in the past? Subjective data

Rating Scales/Objective data

▪ A medical illness can initiate or exacerbate anxiety symptoms

▪Determine current level of anxiety (moderate, severe, panic)

▪Assess for self harm or suicide

▪Perform Psychosocial assessment

▪Self-assessment

will a pt in severe or panic anxiety be able to participate in planning?

no

nursing implementation for mild to moderate anxiety:

they are still able to solve problems but ability to concentrate is diminished, use of therapeutic communication, encourage the patient to talk about feelings and concerns, encourage problem solving, what has worked in the past? Speak slowly & calmly, using simple language 

nursing implementation for severe to panic levels of anxiety

unable to solve problems, provide for their safety, prevent exhaustion; guide them to a quiet environment; maintain calmness, speak slowly; stay with them; firm, short & simple statements; reinforce reality; monitor for dehydration; offer high calorie fluids or nutritious snacks; prn medications if needed 

nursing interventions for anxiety patients

Coping enhancement

Hope Inspiration

Self-Esteem Enhancement

Relaxation Therapy

Teach patients to recognize and reframe irrational thoughts

May need help with eating, drinking, getting dressed, grooming,

hygiene, elimination, and sleep, counseling, milieu therapy,

relaxation, community resources and support group information

pharmacological interventions for anxiety

Antidepressants – SSRI’s, SNRI’s

▪ Anti-anxiety drugs – benzodiazepines (quick onset but be careful with dependence), buspirone (takes 2-4 weeks to work)

▪ Other classes – beta-blockers, antihistamines, anticonvulsants, antipsychotics 

▪ Integrative therapy – herbal therapy and diet supplements

▪ Health teaching – relaxation exercise teaching, coping strategies, 

list advanced practice interventions for anxiety

o Cognitive therapy – cognitive restructuring

Identify negative beliefs and re-evaluate the situation realistically

Combines cognitive with behavioral therapies to reduce the anxiety

response

o Behavioral therapy-

Relaxation training

Modeling – role playing

Systematic desensitization – gradual exposure to phobia

Flooding – large amount of stimulus exposure

Response prevention – for compulsive behavior

Thought stopping – a negative obsession is interrupted

▪__________ – (impaired thought patterns)

Thoughts, impulses, or images that persist and recur, so that

they cannot be dismissed from the mind, often seem senseless

to the individual who experiences them

Obsessions

_____________ – (impaired adaptive capacity) Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety, performing the act temporarily reduces anxiety so must be repeated 

Compulsions

Obsessions & compulsions can exist independently of each other but _______________

most often occur together 

explain obsessive compulsive disorder (OCD)

▪ Can be mild to severe (daily)-

• Nagging doubts about a door being locked, rechecking the door, timeliness,

orderliness

• May involve issues of sexuality, violence, contamination, illness

▪ Rituals are time consuming and interfere with normal routines,

social activities, and relationships

▪ Strong genetic component

▪ High risk for suicide

▪ DSM-5 Criteria:

▪ Obsessions, compulsions or both

▪ Not due to a substance or condition

▪ Not explained by another psychiatric disorder

▪ Time-consuming (in excess of 1 hour per day

▪ Almost always allow the patient to perform ritualistic behavior

unless the behavior is unsafe

▪____________ – false assumption about appearance;

preoccupation with an imagined defective body part results in

obsessional thinking and compulsive behavior such as mirror

checking and camouflaging

▪ Perfectionism- Frequent concerns with skin, hair, nose, stomach, teeth, weight, body build, etc.

▪ Fear of Rejection- High risk for depression and suicide, common in people with history of abuse and

neglect

Body dysmorphic disorder

▪___________– purging un-needed items is extremely distressing/painful ▪Obsessive accumulation of objects ▪Collecting has consumed life; individual is alienated 

Hoarding disorder

__________ – one of the oldest psychiatric problems, used as a way to deal with stress or may be unaware (similar to engaging in cutting) 

Hair pulling (Trichotillomania)

▪__________– used as a way to deal with stress or may be unaware, can damage skin 

Skin picking disorders (Excoriation)

▪_______________–develop with the use of a substance or within 1 month of stopping a substance, EX) drugs used to treat Parkinson’s have been linked to gambling, excessive spending 

Substance-induced OC and related disorders

risk factors for anxiety and OC disorders:

▪Child abuse & trauma

▪Genetic – first degree relatives = twice the risk

▪Neurobiological – Serotonin, GABA, NE, Dopamine, Epinephrine

▪Psychodynamic Theories – (a review from Chapter 2)

Interpersonal theories – unmet needs, disapproval is experienced

Behavioral theories – anxiety is a learned response to specific stimuli

Cognitive theories – anxiety is caused by distortions in a persons thoughts

▪Cultural Considerations – symptoms of anxiety disorders vary

amongst cultures

▪Comorbidity with anxiety disorders, eating disorders, and/or tic

disorder

nursing interventions for OC disorders

▪Promotion of self-care activities

▪Monitor skin integrity for excoriation or trichotillomania disorder 

advanced practice nursing interventions for OC disorders

Flooding

▪Cognitive-behavioral therapy

Exposure-and response prevention

biological tx modalities for OC disorders

▪Biological Treatments

▪ SSRIs for OCD (FDA-approved)

▪ Others: Clomipramine (TCA), Venlafaxine (SNRI)

▪ Some antipsychotics

▪ None for: Body dysmorphic disorder, hoarding

disorder, trichotillomania, excoriation disorder

▪ Exceptions:

▪ SSRIs can be helpful in those disorders displaying obsessivecompulsive

features in these other disorders

surgical treatments for OC disorders

▪ Gamma Knife: creates lesions to form a disconnect

of overactive circuits

▪ Deep brain stimulation (DBS): implanted pulse

generator uses low-dose current to reduce

symptoms

list some psychological therapies for OC disorders

▪Exposure and response prevention

▪ First-line cognitive-behavioral intervention for obsessivecompulsive

behaviors

▪ Expose patient to triggers of OCD symptoms

▪ Message: anxiety does subside even when the ritual is not

completed

▪Flooding

▪ Expose patient to large amount of trigger to extinguish

response