Anxiety, OCD, and Related Disorders

Epidemiological Data risk factor

• Anxiety disorders are the most common mental ilness in the U.S.

• Lifetime prevalence: more than 25% of the population between 13 and 18 years old are affected by an anxiety disorder.

• Persons assigned female at birth appear to be twice as likely to develop an anxiety related disorder than persons assigned male at birth.

• Personality traits and overall physical health contribute

• OCD prevalence: Lifetime 2.3%; affects both children and adults.

• Gender: Anxiety and OCD are more common in females, though OCD often appears earlier in males.

• Serotonin imbalance – SSRI’s successful for

• Onset: Often begins in adolescence or early adulthood.

Compulsions

• Excessive handwashing, counting, checking locks

ex: Excessive handwashing, counting, checking locks

Obsessions

• Persistent, intrusive, unwanted thoughts or urges that cause anxiety

They are done by the client to decrease the anxiety.

Examples:

Fear of germs, harm, or making a mistake

Anxiety overview

• Anxiety is a normal human response to stress or threat.

• It becomes a disorder when the frequency, intensity, and duration interfere with daily functioning.

• Anxiety serves an adaptive purpose but becomes maladaptive when persistent or excessive.

• Common triggers: stress, illness, certain medications, and poor self-care.

Anxiety Psychological Manifestations

• Feeling apprehensive or nervous

• Restlessness

• Irritability

• Anticipating the worst result

• Watching for what causes anxiety

• Avoidance of cause: The person avoids the situation

Anxiety Physiological manifestations

• increased HR,RR

• Sweating, fatigue/exhaustion

• Cant concentrate

• Upset GI, cant sleep

Mild Anxiety

• restless, seeking attention, requires reassurance, sweating, mild nausea, shaking

• Perceptual field – heightened awareness

• Cognitive – clearer and more focused, sense becomes more elevated, can learn

Moderate Anxiety

• On edge, easily frustrated, unable to sleep, uncontrollable worry, jitteriness

• Perceptual field – field narrows

• Cognitive – difficulty concentrating, can be focused by someone else to

problem-solve

Severe Anxiety

• Head/stomach aches, shaking, frequent urination, reduces functioning, distress, irritable

• Perceptual field – greatly reduced, awareness only on stressor, feeling of doom

• Cognitive – can’t focus on problem, even with someone helping

Panic

• at risk for self-harm

• Palpitations, VS increased, trembling,

SOA/smothering/hyperventilating, chest pain, dizzy/faint, chills or hot, parasthesias (N & T), derealization, fear of dying

• Perceptual field – focused on loss of control, fear of dying

• Cognitive – cannot learn or process

Nursing Interventions (Mild Anxiety to Moderate Anxiety)

• Self-care strategies - Encourage to divert anxiety energy to learning about it.

• Encourage to talk through the anxiety

• Encourage nutritional planning

• Focus on breathing, deep, slow, abdominal breaths – five seconds, “letting go”

• Progressive muscle relaxation

• After - Focus on the experience and describe it fully

• Identify the generalizations about the anxiety

• Evaluate reaction and how interventions worked after

Severe Anxiety and Panic (Nursing interventions)

• Stay with the patient

• Be direct and use few words

• Do not touch the person

• Use of relief measures from above but they may not be able to focus and participate: Abdominal breathing, Progressive muscle relaxation

• Encourage to talk about their random ideas

• Allow pacing and walking – encourage physical activity

Separation Anxiety

• Excessive fear of being away from attachment figures

• nightmares 

• scared to leave who they are attached to. 

Selective mutism

• Inability to speak in social situations despite ability to speak elsewhere

• Not able to speak during school even when spoken to

  • Affects achievement academically or socially

  • Interferes with regular communication

Phobias

• Intense fear of a specific object or situation

• Exposure Therapy

• Are often present in anxiety disorders but may also develop into a specific phobia disorder

Social Anxiety Disorder

Fear of embarrassment or judgment in social settings

• Tx: SSRIs, short-term benzodiazepines

Agoraphobia

• Fear of public spaces, crowds, or leaving home alone, public transportation

• The result of this disorder is avoiding the situation or requiring others to navigate the situation.

• Implosive Therapy

Panic Disorder

• Recurrent, unpredictable panic attacks and fear of recurrence,

•CBT – FIRST-LINE for panic disorder.

Extreme, overwhelming form of anxiety often experienced when an

individual is placed in a real or perceived life-threatening situation

• Diagnostic Criteria- recurrent panic attacks, one month of dysfunction,

not related to substance or other diagnosis, has target symptoms

• Fluoxetine, sertraline, and imipramine are used to treat panic disorder.

Generalized Anxiety Disorder (GAD)

• Chronic, excessive worry lasting ≥6 months, difficult to control unspecified reason for anxiety, interferes with life (Fatigue, sleep disturbance, restless, irritable, muscle tension, diff concentrating/blank

• Mild depressive symptoms common – dysphoria

  • Somatic complaints – headache, GI problems

Nursing Care similar to Mild to Moderate Anxiety

• Focus on coping strategies and targeting specific areas of anxiety

• Buspirone – tx anxiety & depressive symptom

• SSRI’s

Recovery-Oriented Care for Persons with Anxiety Disorders

• Teamwork and Collaboration: Nurses, Providers, CSW’s, and counselors

• Systematic Desensitization – exposure to least feared to most feared

situations.

• Implosive Therapy – panic d/o and agoraphobia, guided imagery to make

the patient feel the anxiety while safe

• Exposure Therapy – phobias – expose to the anxiety-provoking situation to desensitize.

• Safety Priority

Panic Disorder: Emergency Care

• Stay with the patient

• Reassure him or her that you will not leave

• Give clear, concise directions

• Assist the patient to an environment with minimal stimulation

• Walk or pace with the patient

• Administer PRN anxiolytic medications

• Afterward, allow the patient to vent his or her feelings

OCD Diagnostic Criteria

• Presence of obsessions or compulsions

-Experiencing a pattern of uncontrollable obsessive thought and associated compulsive behaviors or rituals

• Patient recognition that thoughts and actions are unreasonable or excessive

• Thoughts and rituals causing severe disturbance in daily routines, relationships, or occupational function; time consuming, taking longer than 1 hour a day to complete

Recovery-oriented Care for Persons with OCD

• Monitor skin integrity (handwashing, picking).

• Medications

• Most common is SSRI’s (Can use many, Fluvoxamine is specific to OCD), CBT,

Exposure & Response Prevention (ERP),

• Clomipramine (TCA) functions as an SNRI

• If no response, may use:

• CBT, ERP

• Electroconvulsive Therapy (ECT)

• Transcranial Magnetic Stimulation (TMS)

• Psychosurgery – create lesions (brakes for the brain)

• Safety Issue – Suicide risk r/t OCD and depression

Body dysmorphic disorder

• Persistent preoccupation with perceived defects or flaws in one’s appearance.

• Mirror checking, Excessive grooming, Skin picking, Seeking reassurance about look

• CBT 

Hoarding and Trichotillomania

• hoarding: CBT

• Demonstrating a persistent difficulty or inability to discard or part with possession, CBT

• Trichotillomania: Pulling out hair 

• Olanzapine and Clomipramine, CBT, habit revers

Excoriation disorder

-Pattern of behavior defined by the recurrent picking at one’s skin, resulting in lesions

-CBT, ACT, SSRI’s, Topiramate, Cold compress, antihistamines

tx: Pharmacological 

Selective serotonin reuptake inhibitor (SSRI) antidepressants – first line

• Paroxetine (Paxil)

• Sertraline (Zoloft)

• Escitalopram (Lexapro)

• Citalopram (Celexaa)

Assessment (Recognize Cues)

• Observe manifestations: restlessness, irritability, trembling, sweating, fatigue, difficulty concentrating, sleep problems.

• Identify variables that make anxiety worse or better (triggers, coping methods).

• Ask about physical causes (thyroid problems, low blood sugar, heart issues, medications, substance use).

• Gather family history of anxiety or OCD.

• Determine which symptoms are most distressing to the client.

• Assess client’s awareness and readiness for help.

• For OCD: ask about obsessions, compulsions, time spent on rituals, and how it affects daily life.

• Screen for suicidal thoughts (OCD and panic disorder increase suicide risk).Screening Tools (from slides):

  • Hamilton Anxiety Scale (HAM-A)

  • Self-report tools for anxiety (not very reliable for panic attacks)

  • Rating scales to track symptom improvement

Analysis (Diagnoses / Prioritize Problems)

Common nursing diagnoses:

• Anxiety related to perceived threat or stressor

• Ineffective coping related to anxiety or fear

• Risk for self-harm (especially with panic disorder and OCD)

• Impaired skin integrity (from excessive handwashing or skin picking)

• Disturbed sleep pattern

• Social isolation related to fear or embarrassment

Priority:

• Safety first → risk for self-harm or panic-level anxiety.

• Then address coping and problem-solving skills.

Planning (Generate Solutions)

• Create plan with the client and care team.

• Goals should be Specific, Measurable, Achievable, Relevant, and Time-bound (SMART).

  • Example: “The client will verbalize two effective coping techniques by the end of the shift.”

• Focus on reducing symptoms and improving ability to function.

• Prioritize safety, coping, and recovery goals.

Implementation (Take Action)/ Evaluation (Determine Outcomes)

• Has the client remained safe and free from injury?

• Has anxiety level decreased after interventions?

• Is the client using coping techniques effectively?

• Is the client able to function in daily life (socialize, sleep, work, eat)?

• For OCD: Has time spent on rituals decreased?

• Are physical symptoms (heart rate, GI upset) reduced?

• Are medications taken as prescribed?

• Does the client verbalize improved sense of control and hope?