Anxiety and Obsessive-Compulsive Disorder Notes

Anxiety

• Anxiety is a vague feeling of dread or apprehension in response to external or internal stimuli.

• It is different from fear, which is a feeling of being afraid or threatened by an identifiable stimulus representing danger.

• Anxiety is unavoidable and can serve positive functions.

• Anxiety disorders involve excessive anxiety with behavioral, emotional, cognitive, and physiologic responses.

Stress

• Stress is the wear and tear that life causes on the body.

• It occurs when a person has difficulty dealing with life situations, problems, and goals.

Stages of Reaction to Stress

• Alarm reaction stage

• Resistance stage

• Exhaustion stage

• These stages constitute the General Adaptation Syndrome.

Levels of Anxiety

Mild

• Sensation that something is different, requiring special attention.

• Sensory stimulation increases.

• Attention is focused to learn, solve problems, think, act, feel, and protect oneself.

• Individual is motivated.

Moderate

• Feeling that something is definitely wrong.

• Nervousness or agitation.

• Can still process information, solve problems, and learn new things with assistance.

• Concentration is difficult but can be redirected.

Severe

• Trouble thinking and reasoning.

• Muscles tighten, vital signs increase, pacing, restlessness, irritability, and anger.

• Use of emotional and psychomotor means to release tension.

Panic

• Fight, flight, or freeze responses.

• Increased vital signs, enlarged pupils.

• Cognitive process focuses on the person’s defense.

Working with Anxious Clients

• Be aware of the nurse’s own anxiety level.

• Assess the person’s anxiety level.

• Use short, simple, easy-to-understand sentences.

• Lower the person’s anxiety level to moderate or mild before proceeding with anything else.

• Use a low, calm, soothing voice.

• Ensure safety during a panic level.

• Consider short-term use of anxiolytics.

Anxiety Disorders

• Agoraphobia (with or without panic disorder)

• Panic disorder

• Specific phobia

• Generalized anxiety disorder (GAD)

Epidemiology of Anxiety Disorders

• Most common psychiatric disorders in the U.S.

• More prevalent in women.

• Prevalent in people younger than 45 years who are divorced or separated.

• More common in persons of lower socioeconomic status.

• Onset and clinical course are variable.

Related Disorders

• Selective mutism

• Anxiety disorder due to a general medical condition

• Substance-induced anxiety disorder

• Separation anxiety disorder

Etiology of Anxiety Disorders

Biological Theories

• Genetic theories suggest an inherited component.

• Neurochemical theories indicate that neurotransmitters (GABA, NE, and serotonin) may be dysfunctional.

Psychodynamic Theories

• Intrapsychic/psychoanalytic theories focus on overuse of defense mechanisms.

• Interpersonal theory (Sullivan, Peplau) suggests anxiety results from problems in interpersonal relationships.

Behavioral Theory

• Anxiety is a “learned” behavioral response.

Cultural Considerations

• Each culture has rules for expressing and dealing with anxiety.

• Asian cultures often express anxiety through somatic symptoms (headaches, backaches, fatigue, dizziness, and stomach problems).

• Hispanics may experience high anxiety manifesting as sadness, agitation, weight loss, weakness, and heart rate changes.

Treatment

• Combination of medication (anxiolytics and antidepressants) and therapy.

• Cognitive–behavioral therapy (CBT):

  • Positive reframing (turning negative messages into positive ones).

  • Decatastrophizing (making a more realistic appraisal of the situation).

  • Assertiveness training (learning to negotiate interpersonal situations).

Age-Related Considerations

• Late-life anxiety disorders are often associated with another condition, such as depression, dementia, physical illness, or medication toxicity or withdrawal.

• Phobias, particularly agoraphobia and generalized anxiety disorders (GAD), are the most common late-life anxiety disorders.

• Panic attacks are less common, often related to other illness

• Ruminative thoughts

• The treatment of choice for anxiety disorders in the elderly is SSRI antidepressants.

Tips for Managing Stress

• Keep a positive attitude and believe in yourself.

• Exercise regularly.

• Eat well-balanced meals.

• Limit intake of caffeine and alcohol.

• Get enough rest and sleep.

• Set realistic goals and expectations.

• Learn stress management techniques.

• Effective management, not total elimination of anxiety, is the goal.

Mental Health Promotion

• Anxiety can be a warning of not dealing with stress effectively.

• "Positive events" can be stressful as well.

• Managing the effects of stress and anxiety is important to health.

• Medication is important to relieve excessive anxiety but does not solve the problem entirely.

Panic Disorder

• Panic attacks involve 15- to 30-minute episodes of intense, escalating anxiety with emotional fear and physiologic discomfort.

• Panic disorder is diagnosed when the person has recurrent, unexpected panic attacks followed by at least 1 month of persistent concern or worry about future attacks.

• Discrete episodes of panic often with no stimulus for panic response

• Half of people with panic disorder have agoraphobia

• Primary, secondary gain

• Avoidance behavior

• Increased risk for suicidality

Treatment

• Cognitive-behavioral techniques

• Deep breathing and relaxation

• Medications:

  • Benzodiazepines

  • SSRI antidepressants

  • Tricyclic antidepressants

  • Antihypertensives (clonidine, propranolol)

Nursing Process Application for Panic Disorder

Assessment

• Hamilton Rating Scale for Anxiety (14.1)

• History

• General appearance and motor behavior (automatisms)

• Mood and affect (depersonalization, derealization)

• Thought processes and content (disorganized thoughts, loss of rational thinking)

• Sensorium and intellectual processes (confusion, disorientation)

• Judgment and insight

• Self-concept (self-blaming, consumed with worry)

• Roles and relationships (avoidance of others)

• Physiological and self-care concerns (sleeping, eating)

Actions

• Promoting safety and comfort

• Using therapeutic communication

• Managing anxiety

• Providing client and family education

Phobias

• A phobia is an illogical, intense, persistent fear of a specific object or social situation that causes extreme distress and interferes with normal life functioning.

Onset and Clinical Course

• Specific phobias usually occur in childhood or adolescence.

• Specific phobias that persist into adulthood are lifelong 80% of the time.

Treatment

• Psychopharmacology (see table14.3)

• Behavioral therapies:

  • Positive reframing

  • Assertiveness training

  • Systematic desensitization

  • Flooding

Generalized Anxiety Disorder (GAD)

• Excessive worry and anxiety that is unwarranted more days than not (50% of the time for 6 months or more).

• Symptoms include uneasiness, irritability, muscle tension, fatigue, difficulty thinking, and sleep alterations.

• Buspirone and SSRI or SNRI antidepressants are the most effective treatments.

Community-Based Care

• Treatment settings include family practitioner or advanced practice nurse, physician offices, psychiatric clinical specialists, psychologists, or other mental health counselors.

• Referral to community resources such as anxiety disorder groups or self-help groups.

Self-Awareness Issues

• Nurses need to understand how and why anxiety behaviors work.

• Nurses are as vulnerable as others to stress and anxiety.

• Everyone occasionally suffers from stress and anxiety.

• Avoid trying to “fix” the patient’s problem.

• Use techniques to manage stress and anxiety in personal life.

Obsessive-Compulsive Disorder (OCD)

• Classified as an anxiety disorder but with unique manifestations in the way patients attempt to decrease or control their anxiety.

Key Features

• Obsessions = recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses.

• Compulsions = ritualistic or repetitive behaviors that a person carries out continuously in an attempt to decrease/neutralize anxiety.

Common Compulsions

• Checking rituals

• Counting rituals

• Washing/scrubbing

• Praying/chanting

• Touching/rubbing/tapping

• Ordering (arranging and rearranging)

• Exhibiting rigid performance

• Having aggressive urges

Diagnosis

• Diagnosed once thoughts or behaviors consume the person to the point where they interfere with personal, social, and/or occupational functioning.

• The person realizes that the thoughts/behaviors are unreasonable but cannot stop/control them.

Onset

• Can start in early childhood; in females, more commonly begins in the 20s.

• Periods of waxing and waning symptoms over a lifetime.

• Differences exist in early-onset and late-onset OCD.

Related Compulsive Disorders

Self-Soothing Behaviors

• Excoriation (skin picking)

• Onychophagia (nail biting)

• Trichotillomania (hair pulling)

Reward-Seeking Behaviors

• Kleptomania (compulsive stealing)

• Oniomania (compulsive buying)

• Hoarding (excessive acquisition)

• Pyromania (fire setting)

Disorders of Body Appearance

• Body dysmorphic disorder (preoccupation with slight or even imagined physical imperfection).

• Body identity integrity disorder (feeling alienated from a part of the body to the extent of seeking amputation of the identified body part).

Etiology of OCD and Related Disorders

• Cognitive model focuses on childhood and environment experiences.

• Heredity: Complex network of several genes may contribute to the genetic risk for OCD.

Cultural Considerations

• Fairly similar or universal internationally; variation in symptom expression or beliefs about symptoms.

• Highly religious individuals may have a heightened sense of personal guilt.

• In some cultures, patients with OCD believe in a supernatural cause.

• Pharmacologic treatment varies a great deal.

Treatment of OCD

Medications

• First line: SSRI antidepressants (fluvoxamine, Sertraline)

• Second line: SNRI (venlafaxine)

• Treatment-resistant OCD: Second-generation antipsychotics (risperidone, aripiprazole)

Behavior Therapy

• Exposure Therapy: Deliberately confronting situations and stimuli that the client usually tries to avoid.

• Response Prevention: Delay or avoid performing the rituals. Learn to tolerate the thoughts and anxiety.

Nursing Process Application for OCD

Assessment

• Yale-Brown Obsessive–Compulsive Scale

• History

• General appearance, motor behavior (tense, anxious; embarrassment)

• Mood, affect (overwhelming anxiety)

• Thought process, content (obsessions out of nowhere)

• Judgment, insight (obsessions as irrational but unable to stop them)

• Self-concept (powerlessness, low self-esteem)

• Roles, relationships

• Physiologic, self-care considerations (sleeping problems)

Outcome Identification

• The client will:

  • Complete daily routine within realistic time frame

  • Demonstrate effective use of relaxation techniques

  • Discuss feelings with others

  • Demonstrate effective use of behavior therapy techniques

  • Spend less time performing rituals

Client/Family Teaching

Client

• Define OCD and assist in recognizing patient’s symptoms

• Review importance of talking openly

• Emphasize medication compliance

• Behavioral techniques

• Tolerating anxiety

Family

• Teach to avoid giving advice

• Teach to avoid trying to “fix” the problem

• Patience

• Monitoring anxiety levels among family members

• Taking breaks

Self-Awareness Issues with OCD

• Need to understand how and why OCD behaviors work.

• OCD is a chronic condition involving bizarre thoughts/behaviors.

• OCD treatment is dependent upon meds, daily structure, and long-term behavior therapy.

• Avoid trying to “fix” the patient’s problem.