NCM 0117 — 05 ANXIETY DISORDERS, OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

ANXIETY

○ Vague feeling of dread or apprehension

○ A response from an internal or external stimuli that has a behavioral, emotional, cognitive and physical symptom

ANXIETY

Considered normal when it is appropriate to the situation and dissipates when the situation resolves

ANXIETY DISORDERS

Refers to a group of disorders that share features of excessive fear and anxiety and related behavioral disturbances

ANXIETY DISORDERS

Conditions that arise when the person's anxiety no longer functions to signal danger or a motivation for needed change but significantly impairs the functioning of the individual

anxiety disorders

When we refer to __, there's already:

○ Maladaptive coping

○ Affected ADLs

○ Problems with emotional, occupational, and social

Alarm Stage

● Stress prepares the potential defense needs

Resistance Stage

● Essentially the Fight-or-Flight Response

● Blood shunted to areas needed for defense

Exhaustion Stage

● Occurs when the person has responded negatively to anxiety and stress: body stores are depleted, or the emotional components are not resolved

Mild Anxiety

● A sensation that something is different and warrants special attention

● Often motivates people to engage in a goal-directed activity

● Produces a slight arousal state that enhances perception, learning and productive abilities

Moderate Anxiety

● A disturbing feeling that something is definitely wrong; the person becomes nervous or agitated

Moderate Anxiety

● Person has narrowed perceptual field; focuses only on immediate concerns

● Increases the client's arousal state to a point where the person expresses feeling of tension, nervousness and concern

Severe Anxiety

● Perceptual field is further reduced

● Has trouble thinking and reasoning

● Consumes most of the person's energies and requires interventions

Severe Anxiety

● Person is unable to focus what is really happening

● Focuses only on one specific detail of the situation generating anxiety

Panic

● Associated with awe, dread, terror

● Person is unable to do things even with direction; still needs a stimulus to act and for anxiety to escalate

Panic

● The emotional-psychomotor realm predominates with accompanying fight, flight, or freeze responses

● An overpowering frightening level of anxiety

● May cause seizure, hyperventilation, convulsions or fainting

Gamma Aminobutyric Acid

● An inhibitory neurotransmitter, is dysfunctional in clients with Anxiety Disorders

● Reduces cell excitability and rate of neuronal firing

Benzodiazepines (Anxiolytic)

makes GABA receptors more sensitive to decreased GABA levels

Tricyclic Antidepressant

decreases the activity of the locus ceruleus (part of the brain/receptor responsible for fight and flight response)

Harry Stack Sullivan's Interpersonal Theory

● Viewed anxiety as being generated from problems in interpersonal relationship

Hildegard Peplau

● Humans exist in interpersonal and physiological reals, thus the nurse can better help the client achieve health by attending to both areas

● Interpersonal communication techniques to develop and nurture nurse-client relationship and provide care

Behavioral Theories

● View anxiety as being learned through experiences

● Begins with the attachment of pain to a stimulus = proceeds to generalizations to similar objects or situations

Asian culture

anxiety often expressed through somatic symptoms (fever, diarrhea, etc); koro

Hispanic clients

susto (high anxiety as sadness, agitation, weight loss, weakness, heart rate changes) believed to be caused by supernatural spirits or bad air from dangerous placed and cemeteries invading body

GENERAL ANXIETY DISORDER (GAD)

Persistent and excessive anxiety and worry about various domains, including work and school performance that the individual finds difficult to control

GENERAL ANXIETY DISORDER (GAD)

○ Restlessness or feeling keyed up or on edge

○ Being easily fatigued

○ Difficulty concentrating or mind going blank

○ Irritability

○ Muscle tension

○ Sleep disturbance

6 months

GAD DSM-V

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least __, about a number of events or activities (such as work or school performance)

BENZODIAZEPINES: short-term

○ GABA channels admit the anion chlorine, which hyperpolarizes the cell, decreasing the effect of norepinephrine ○ Greatly inhibitory

7th—10th day

BENZODIAZEPINES: short-term

Therapeutic effect is usually seen on the __ of continued use; should be taken only within 2-4 weeks

Taper when discontinuing (to prevent sudden drop of therapeutic levels on the blood)

● To prevent withdrawal symptoms

Important nursing consideration for Benzodiazepines

Dizziness, sedation

Side effects of Benzodiazepines

Positive Reframing

● Turning negative messages into positive messages

● GOAL: Address negative self talk

Decatastrophizing

Involves the therapist use of questions to realistically appraise the situation

Assertiveness Training

● Involves using "I" statements to identify feelings and to communicate concerns or needs to others

● Learn to negotiate interpersonal situations

Implosion Therapy

Form of behavior therapy involving intensive recollection and review of anxiety-producing situations or events in a patient's life in an attempt to develop more appropriate responses to similar situations in the future

Transcendental Meditation

● Use of a mantra

● Practiced for 15- 20 mins twice per day while sitting while one's eyes are close

PANIC ANXIETY DISORDER

● Refers to recurrent unexpected panic attacks

● experiences the emotional and psychological responses without the stimulus

PANIC ATTACKS

○ Abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of a list of 13 physical and cognitive symptoms occur

SNS manifestations are heightened such as increased RR, HR, etc.

Why do we give anti-hypertensives (Propranolol, Clonidine) during panic attacks?

PHOBIC ANXIETY DISORDER

● Condition that conjures intense, irrational fear in response to an external object, activity or situation

● May be classified as either specific or social phobia

PHOBIC ANXIETY DISORDER

● The anxiety is experienced when the person comes in contact with the dreaded object/situation/event

● The feeling persists even though phobic individuals recognize that they are irrational

PHOBIA

Anticipation of a future threat

Associated with muscle tension and vigilance in preparation for future danger and cautious avoidant behaviors

SPECIFIC PHOBIA

ENVIRONMENTAL

○ Parental overprotectiveness ○ Parental loss and separation ○ Physical and sexual abuse

○ Negative or traumatic encounters with feared object or situation (not as always)

SOCIAL PHOBIA

● TEMPERAMENTAL

○ Behavioral inhibition

○ Fear of negative evaluation

● ENVIRONMENTAL

○ Childhood maltreatment and adversity

DSM IV TR: Phobic Disorders

● Client has marked, persistent, excessive or unreasonable fear, cued by the presence or anticipation of a specific object or situation

● Exposure to the object almost causes immediate anxiety, which may be situationally bound or predisposed to panic attack

DSM IV TR: Phobic Disorders

● Client recognizes the fear is excessive or unreasonable

● Client avoids phobic stimulus or endure it with intense distress

● The disturbance impairs social, occupational, or other areas of functioning

AGORAPHOBIA

fear of being in public or open spaces, or situations in which escape might be difficult or help might not be available

SOCIAL PHOBIA

fear of being humiliated, scrutinized or embarrassed in public

SPECIFIC PHOBIA

illogical, intense, and permanent fear of a specific object or situation that is not either of the above which causes extreme distress and interferes with normal functioning

Specific Phobia

Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging

DSM-V: Specific Phobia

The phobic object or situation almost always provokes immediate fear or anxiety

The phobic object or situation is actively avoided or endured with intense fear or anxiety

DSM IV TR: Social Anxiety Disorder (Social Phobia)

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.

DSM IV TR: Social Anxiety Disorder (Social Phobia)

The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated

Social situations always provoke fear or anxiety

Systematic Desensitization (PHOBIA)

The therapist progressively exposes the client to the threatening object in a safe setting until the client's anxiety decreases

Gradual exposure of the client to varying levels of the object to treat anxiety: Word → picture → video → zoo → hold snake

Flooding/Implosion Therapy

A form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object until it no longer produces anxiety

OBSESSIVE-COMPULSIVE DISORDER

Presence of obsessions, compulsions, or both:

True

True / False

Anxiety is always present with OCD

Obsessions (thoughts)

● Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress

● The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion)

Compulsions (behavior)

● Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

Compulsions (behavior)

● The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

time or frequency

OCD

Provide time to perform rituals ○ Lessen the __and redirect patient to another activity

BODY DYSMORPHIC DISORDER

● Formerly known as dysmorphophobia

● Preoccupation with one or more perceived defects or flaws in their physical appearance, which is believed to look ugly, unattractive, abnormal, or deformed

BODY DYSMORPHIC DISORDER

Has been associated with executive dysfunction and visual processing abnormalities, with a bias for analyzing and encoding details rather than holistic aspects of visual stimuli

BODY DYSMORPHIC DISORDER

Individuals with this disorder tend to have a bias for negative and threatening interpretations of facial expressions and ambiguous scenarios

BODY DYSMORPHIC DISORDER

At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns

HOARDING DISORDER

● The essential feature is persistent difficulties discarding or parting with possessions, regardless of their actual value

● The difficulty refers to any form of discarding, including throwing away, selling, giving away, or recycling

HOARDING DISORDER

● The main reasons given for these difficulties are the perceived utility or aesthetic value of the items or strong sentimental attachment to the possessions

● Some individuals feel responsible for the fate of their possessions and often go to great lengths to avoid being wasteful

HOARDING DISORDER

● TEMPERAMENTAL

○ Indecisiveness is a predominant feature

● ENVIRONMENTAL

○ Presence of stressful and traumatic event prior to the episode of hoarding

● GENETIC AND PHYSIOLOGICAL

○ Hoarding behavior is familial

HOARDING DISORDER

The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use.

TRICHOTILLOMANIA (Hair Pulling Disease)

● The essential feature is the recurrent pulling out of one's own hair

○ The act of hair pulling may occur from any region of the body in which hair grows

TRICHOTILLOMANIA (Hair Pulling Disease)

○ The most common sites are the scalp, eyebrows, and eyelids

○ Less common sites are axillary, facial, pubic, and peri-rectal regions

TRICHOTILLOMANIA (Hair Pulling Disease)

Hair pulling may occur in brief episodes scattered throughout the day or during less frequent but more sustained periods that can continue for hours, and such hair pulling may endure for months or years

EXCORIATION (Skin Picking Disease)

● The essential feature of excoriation disorder is recurrent picking at one's own skin

○ Most commonly picked sites are the face, arms, and hands but many individuals pick from multiple body sites

skin lesions

The criterion requires that skin picking leads to __ although individuals with this disorder often attempt to conceal or camouflage