14. ANXIETY AND OBSESSIVE-COMPULSIVE DISORDERS

LEARNING OBJECTIVES

  • Identify assessment data for patients with anxiety disorders.

  • Establish patient care priorities for developing a nursing care plan for patients with anxiety disorders.

  • Select interventions that promote:

    • Safety

    • Physiological functioning

    • Psychological functioning

    • Cognitive functioning

  • Provide information about illness management and relapse prevention for patient/family teaching regarding anxiety disorders.

  • Choose therapeutic communication techniques that foster a therapeutic relationship with patients experiencing anxiety.

ANXIETY

  • The phrase "My anxieties have anxieties" illustrates the recursion and complexity of anxiety relations.

  • Types of anxiety levels:

    • Mild Anxiety

    • Moderate Anxiety

    • Severe Anxiety

    • Panic

PHYSIOLOGICAL RESPONSE TO STRESS AND ANXIETY

  • Common physical responses include:

    • Frequent urination

    • Restlessness

    • Increased heart rate (HR) and palpitations

    • Increased blood pressure (BP)

    • Difficulty breathing, leading to hyperventilation

    • Sweating

    • Nausea and vomiting (N&V), diarrhea

    • Headache (HA)

COGNITIVE RESPONSE TO STRESS AND ANXIETY

  • Manifested through:

    • Impaired concentration and attention

    • Blocking of thought processes

    • Forgetfulness

    • Rumination (repetitive, often negative thoughts)

AFFECTIVE RESPONSE TO STRESS AND ANXIETY

  • Emotional responses can include:

    • Edginess and irritability

    • Tension and nervousness

    • Fear

    • Depression

    • Feelings of worthlessness

    • Anger

    • Anhedonia (inability to feel pleasure)

MILD ANXIETY

  • Characteristics:

    • Helps focus attention

    • Common in everyday circumstances

    • Sharpens senses

    • May manifest as nail biting, foot and hand tapping, and fidgeting.

MODERATE ANXIETY

  • Attributes:

    • Narrowed perceptual field

    • Diminished senses

    • Sympathetic nervous system response observed (e.g., pounding heart, increased respiratory rate, sweating)

    • May see voice tremors and shaking

    • Patient retains the ability to solve problems, though not optimally.

NURSING INTERVENTIONS FOR MILD AND MODERATE ANXIETY

  • Anticipate anxiety-provoking situations.

  • Help patients recognize their anxiety; patients may not readily identify what they feel as anxiety.

  • Employ nonverbal cues: Lean forward, maintain eye contact, and nod to show engagement.

  • Use a calm, reassuring verbal tone when communicating.

  • Inquire about past personal strategies the patient has found effective in alleviating anxiety.

  • The main objective is to decrease the patient's anxiety and prevent it from escalating to severe levels or panic.

SEVERE ANXIETY

  • Symptoms include:

    • Severely reduced perceptual field; patients may not be aware of surroundings.

    • Inability to focus on tasks individually.

    • Problem-solving skills and learning become nonviable.

    • Patients may display confusion.

    • Typical physical symptoms: headache, dizziness, insomnia, nausea, hyperventilation.

    • Patients often describe a sense of impending doom.

PANIC

  • Description:

    • Represents the most extreme level of anxiety experience.

    • Patients may lose touch with reality.

    • Symptoms may include hallucinations, crying out, or fleeing behavior.

    • Patients struggle to process their situations and may experience:

    • Shortness of breath

    • Chest pain

    • Palpitations

PANIC DISORDER

  • Defined as:

    • Recurring and unexpected panic attacks without a discernable cause.

    • Symptoms may mimic heart attack, causing extreme distress.

    • Panic attacks can last up to 10 minutes and may comprise:

    • Palpitations

    • Accelerated heart rate

    • Sweating

    • Trembling

    • Shortness of breath or sensations of choking

    • Chest pain

    • Nausea or gastrointestinal distress

    • Sudden chills or warmth

    • Dizziness or light-headedness

    • Feelings of derealization or depersonalization

    • Intense fear of dying.

  • Diagnosis of panic disorder requires recurrent attacks, with a minimum of four listed symptoms.

NURSING DIAGNOSIS FOR ANXIETY

  • Possible nursing diagnoses may involve:

    • Anxiety (Moderate, severe, panic)

    • Fear

    • Ineffective coping

    • Social isolation

    • Decisional conflict

    • Impaired skin integrity

    • Imbalanced nutrition

    • Sleep deprivation

    • Spiritual distress

INTERVENTIONS FOR SEVERE ANXIETY AND PANIC DISORDER

  • Attend to the physical and safety needs of patients as a top priority.

  • Teach deep breathing techniques, such as Square Breathing.

  • Use clear and simple language when communicating—for understanding.

  • Assist patients in recognizing that symptoms are panic-related and not indicative of a physical condition like heart attack.

  • Maintain a calm demeanor, using a low-pitched voice and slower speech patterns.

PHARMACOLOGICAL INTERVENTIONS FOR SEVERE ANXIETY AND PANIC DISORDERS

  • First-line medications include:

    • Selective Serotonin Reuptake Inhibitors (SSRIs):

    • Fluoxetine (Prozac)

    • Paroxetine (Paxil)

    • Sertraline (Zoloft)

    • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):

    • Venlafaxine (Effexor)

  • Benzodiazepines may be useful for severe anxiety and panic but carry a high addiction risk and should not be used long-term:

    • Alprazolam (Xanax)

    • Diazepam (Valium)

    • Lorazepam (Ativan)

ANXIETY DISORDERS

  • Defined by maladaptive coping mechanisms.

  • They interfere significantly with daily functioning and increase the risk of cardiovascular-related mortalities.

TYPES OF ANXIETY DISORDERS

  • Categories of anxiety disorders include:

    • Separation Anxiety Disorder

    • Specific Phobias

    • Social Anxiety Disorder

    • Panic Disorder

    • Generalized Anxiety Disorder

    • Obsessive-Compulsive Disorder (OCD)

    • Body Dysmorphic Disorder

    • Trichotillomania

SEPARATION ANXIETY DISORDER

  • A normal developmental occurrence in toddlers but may become a disorder when it is developmentally inappropriate.

  • More common in females and can create difficulties in adult relationships, often co-occurring with other mental health disorders.

SPECIFIC PHOBIAS

  • Defined as irrational fears toward specific objects, activities, or situations, leading to avoidance due to high anxiety levels.

  • Common specific phobias include:

    • Acrophobia (Fear of Heights)

    • Agoraphobia (Fear of Open Spaces)

    • Mysophobia (Fear of Germs or Dirt)

    • Claustrophobia (Fear of Closed Spaces)

    • Glossophobia (Fear of Public Speaking)

    • Hematophobia (Fear of Blood)

    • Nyctophobia (Fear of Darkness)

SOCIAL ANXIETY DISORDER

  • Characterized by anxiety stemming from social interactions, such as speaking publicly.

  • Patients fear negative evaluation or criticism.

  • Can lead to social isolation and an increased potential for substance abuse.

  • Common screening tool includes the Social Phobia and Anxiety Inventory.

  • Pharmacological interventions include:

    • Paroxetine (Paxil)

    • Sertraline (Zoloft)

    • Venlafaxine (Effexor)

GENERALIZED ANXIETY DISORDER (GAD)

  • Hallmarks of GAD include excessive worry about various life aspects—occupation, relationships, financial status, and health.

  • Relationships can suffer due to the constant need for reassurance and avoidance behaviors.

  • Screening tools include GAD-7.

  • DSM-5 diagnostic criteria specify that anxiety and worry must occur on most days for at least 6 months, with at least three of the following symptoms observed:

    • Restlessness

    • Feeling on edge

    • Easily fatigued

    • Difficulty concentrating

    • Irritability

    • Muscle tension

    • Sleep disturbances.

PHARMACOLOGICAL INTERVENTIONS FOR GAD

  • First-line treatments may include:

    • Escitalopram (Lexapro)

    • Citalopram (Celexa)

    • Venlafaxine (Effexor)

    • Duloxetine (Cymbalta)

    • Buspirone (BuSpar)

  • Second-line options may consist of:

    • Alprazolam (Xanax)

    • Diazepam (Valium)

NURSING INTERVENTIONS FOR ANXIETY DISORDERS

  • Focus on self-awareness due to the contagious nature of anxiety among patients.

  • Build a supporting, trusting relationship with the patient.

  • Ensure patient safety at all times.

  • Educate patients on effective coping skills and do not criticize their coping mechanisms.

  • Protect the patient's defenses as they help manage anxiety tolerance.

  • Avoid focusing on obsessive behaviors.

ADDITIONAL NURSING INTERVENTIONS

  • Maintain a calm manner and utilize a low-pitched voice.

  • Never leave a patient experiencing severe to panic-level anxiety alone.

  • Assess the patient continuously for suicidal ideation and self-harming behaviors.

  • Minimize environmental stimuli to reduce stressors.

  • Use clear, simple statements, and repeat as necessary if required for understanding.

  • Reinforce reality for patients showing distortions of perception (e.g., auditory or visual hallucinations).

OBSESSIVE-COMPULSIVE DISORDERS

  • Types of OCD:

    • Obsessive-Compulsive Disorder (OCD)

    • Body Dysmorphic Disorder

OBSESSIVE-COMPULSIVE DISORDER (OCD)

  • Description:

    • A disorder characterized by persistent obsessions (unwanted, intrusive thoughts) and compulsions (repetitive behaviors).

    • Common fears include:

    • Contamination

    • Checking behaviors

    • Fears of harming others

    • Ordering and arranging items

    • Aggressive thoughts

    • Unwanted sexual thoughts.

THE OCD CYCLE

  • Components of OCD are represented in a cycle:

    1. Obsessions: Unwanted, distressing thoughts, mental images, and doubts (often framed as "What if…" scenarios).

    2. Anxiety: Emotional responses may include distress, fear, worry, or disgust, characterized as a false alarm, causing the individual to feel the compulsion to perform a task.

    3. Compulsions: Behaviors performed to alleviate anxiety, such as checking or repeating certain acts.

    4. Relief: Temporary reduction of anxiety but leads to a recurrence of obsessions soon after.

BODY DYSMORPHIC DISORDER

  • A preoccupation with perceived flaws in physical appearance leading to:

    • Concealment efforts for perceived physical flaws.

    • Repetitive procedures such as surgeries.

    • Mirror checking and self-comparisons.

    • Heightened anxiety concerning perceived flaws.

DSM-5 CRITERIA FOR OBSESSIVE-COMPULSIVE DISORDERS

  • Diagnosis includes a combination of:

    • Presence of obsessions, compulsions, or both.

    • Obsessions or compulsions consuming more than one hour per day and causing significant distress in social, occupational, or other critical functioning.

    • Symptoms should not be attributed to substance abuse or other medications.

PHARMACOLOGICAL INTERVENTIONS FOR OCD

  • Medications effective for OCD include:

    • Fluoxetine (Prozac)

    • Fluvoxamine (Luvox)

    • Paroxetine (Paxil)

    • Sertraline (Zoloft)

    • Clomipramine (Anafranil)

THERAPIES FOR ANXIETY AND OCD

  • Various therapeutic options consist of:

    • Cognitive Therapy

    • Behavioral Therapy

    • Relaxation techniques (e.g., deep breathing and muscle relaxation)

    • Modeling therapy (therapist demonstrating behaviors, such as accompanying a client on an elevator)

    • Systematic Desensitization (gradual exposure to a feared stimulus while in a relaxed state)

    • Response Prevention (extending intervals between compulsive behaviors)

    • Thought Stopping (using physical cues or verbal prompts to interrupt negative thoughts)

    • Cognitive Behavioral Therapy (CBT) to address thought patterns and behaviors.