Anxiety, OCD, and Trauma-Related Disorders

Anxiety and Related Disorders

• In the 2015 DSM, anxiety disorders were separated into:
  • Anxiety and related disorders
  • Obsessive-Compulsive Disorder (OCD) and related disorders
  • Stress-related disorders
• These three categories will be covered in the next exam.

Studying with Tables

• Creating tables can be a helpful study technique.
• Focus on identifying similarities and differences between disorders.
• All anxiety-related disorders have anxiety as a symptom, so focus on what sets them apart.

Anxiety Disorders

• Everyone experiences anxiety to some degree.
• It's important not to confuse normal traits with a diagnosable disorder.
• A condition is diagnosable when it is:
  • Very disruptive
  • Lasts for an extended period of time
  • Noticeable in the whole of one's life
• Medical reasons, drug use, or withdrawal must be ruled out before diagnosing a mental health condition.
• Anxiety traits are common, especially in stressful situations like nursing school.

Anxiety vs. Fear

• Fear is a legitimate response to a real threat.
  • Example: The "Miracle on the Hudson" survivor experienced fear when the captain announced the plane would land on the river.
• Anxiety is often a response that is out of proportion to the situation.

Levels of Anxiety

• Mild anxiety can be beneficial, increasing awareness and focus.
• Moderate to severe anxiety can impair learning and concentration.
• There is a "sweet spot" where anxiety is helpful.

Applying Anxiety Levels to Patient Care

• Avoid teaching patients when they are experiencing high levels of anxiety.
  • Example: A mother who just received a diagnosis of diabetes for her infant may be too anxious to learn about the condition immediately.
• Moderate anxiety:
  • Focus is possible but narrowed.
  • Someone with greater awareness may need to refocus the person.
  • Learning is not ideal.
• Severe and Panic-Level Anxiety:
  • No teaching is possible.
  • Use short statements and reassure safety.
  • People may act irrationally.

Avoidance

• Avoidance is a key concept in anxiety disorders, OCD, and post-traumatic stress.
• People often avoid situations that trigger anxiety.
• Example: Choosing a written project over a presentation to avoid public speaking.
• Avoidance can worsen anxiety in the long run because the brain is not taught that the situation is not threatening.

Animal Studies on Avoidance

• Dogs were placed in a container where they received shocks after a light turned on.
• The dogs learned to jump to the other side to avoid the shock.
• Even when the shock was removed, the dogs continued to avoid the side where the light turned on.
• This demonstrates how avoidance can be a learned response.
• Learned helplessness: Some dogs gave up trying to avoid the shock.

Levels of Anxiety

• Mild anxiety is the only beneficial level.
• It increases the ability to perform, awareness, focus, and learning.
• Moderate anxiety impairs learning and concentration.
• Severe anxiety causes decreased perceptual field, inability to complete tasks, and ritualistic behaviors.
• Panic level anxiety is essentially a panic attack.

Panic Level Anxiety

• Panic disorder involves discrete episodes of panic-level anxiety.
• During escalating anxiety teaching moments must be approached when a person is calmer.
• It is better to teach grounding techniques -- deep breathing, meditation, recognizing escalating signs -- before acute panic happens.
• Anxiolytics (benzodiazepines) can be effective, especially if given intravenously.
• Panic attacks typically last 15-30 minutes.
• Medication can help in the moment, but it may not be therapeutic in the long run if it encourages avoidance.
• It's not helpful to send patients home with a lot of Ativan because it is habit-forming and can encourage overuse.

Panic Attacks

• Panic attacks are isolated in time and have a limited duration due to the body's physiological limitations.
• Severe anxiety and panic exist on a continuum.
• Treatment involves staying with the person, reassuring safety, and reducing stimulation.
• Keep the patient safe from hurting themselves or seeing threats that are not there.

Types of Anxiety Disorders (for testing)

• Panic disorder
• Agoraphobia
• Specific phobias
• Social anxiety disorder (social phobia)
• Generalized anxiety disorder
• Separation anxiety disorder
• Rule out substance/medication-induced anxiety or medical reasons (e.g., MI).

Panic Disorder

• Panic disorder involves separate episodes of panic-level anxiety.
• Panic attacks are recurrent and, often, unpredictable.
• A person might experience a panic attack and begin to think: "I am not getting on a bus again because that might happen again."
• Panic disorder is highly associated with agoraphobia.
• Agoraphobia: "The fear of not being able to get out of an open space or a business or somewhere outside of basically, you leave your home, you're afraid that something bad will happen to you."
• As panic attacks recur, even feeling one's heart rate increase can trigger another panic attack.
• Panic episodes last 15-30 minutes, with intense escalating anxiety that eventually subsides.

Symptoms of a panic attack

• Pounding heart
• Increased heart rate
• Sweating
• Trembling
• Shortness of breath
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness or lightheadedness
• Paresthesia (pins and needles)
• Derealization (out-of-body experiences)
• Fear of losing control or going crazy
• Fear of dying

What's Happening in a Panic Attack

• The body becomes its own corset.

• Exist as a single force, a swing without gravity soars to a terrifying height.

• The outlines of people and things dissolve.

• The body's perception of danger is enough to trigger the response we would have to a real threat and then some.

• At its core, a panic attack is an overreaction to the body's normal physiological response to the perception of danger.

• This response starts with the amygdala, the brain region involved in processing fear.

• When the amygdala perceives danger, it stimulates the sympathetic nervous system, which triggers the release of adrenaline.

• Adrenaline prompts an increase in the heart and breathing rate to get blood and oxygen to the muscles of the arms and legs.

• This also sends oxygen to the brain, making it more alert and responsive.

• During a panic attack, this response is exaggerated well past what would be useful in a dangerous situation, causing a racing heart, heavy breathing, or hyperventilation.

• The changes to blood flow cause lightheadedness and numbness in the hands and feet.

• A panic attack usually peaks within ten minutes.

• Then the prefrontal cortex takes over from the amygdala and stimulates the parasympathetic nervous system.

• This triggers the release of a hormone called acetylcholine that decreases the heart rate and gradually winds down the panic attack.

• Panic attacks can be part of anxiety disorders like PTSD, social anxiety disorder, OCD and generalised anxiety disorder.

• Recurring panic attacks, frequent worry about new attacks and behavioural changes to avoid panic attacks can lead to a diagnosis of a panic disorder.

Treatment

• The two main treatments for panic disorder are antidepressant medication and cognitive behavioral therapy, or CBT.
• Both have about a forty percent response rate, though someone who responds to one may not respond to the other.
• However, antidepressant medications carry some side effects, and fifty percent of people relapse when they stop taking them.
• CBT, meanwhile, is more lasting with only a twenty percent relapse rate.
• The goal of CBT treatment for panic disorder is to help people learn and practice concrete tools to exert physical and in turn mental control over the sensations and thoughts associated with a panic attack.
• CBT begins with an explanation of the physiological causes of a panic attack, followed by breath and muscle exercises designed to help people consciously control breathing patterns.
• Next comes cognitive restructuring, which involves identifying and changing the thoughts that are common during attacks, such as believing you'll stop breathing, have a heart attack or die, and replacing them with more accurate thoughts.
• The next stage of treatment is exposure to the bodily sensations and situations that typically trigger a panic attack. The goal is to change the belief through experience that these sensations and situations are dangerous.

Helping Someone During a Panic Attack

• Helping people understand what's actually happening during a panic attack and reassuring them that they'll be okay is helpful.
• Treatment is always exposure to what they are avoiding.
• Teach them things while they are somewhat calm.
• Use grounding, deep breathing

Medications

• Anxiolytics (Ativan, Valium) can help quickly, especially if given intravenously, but reassurance is helpful
• Beta blockers can reduce the intensity of heart contractions.
• SSRIs (antidepressants) are used as long-term treatment.

Relaxation Techniques

• Teach patients relaxation techniques when they are calm.
• Encourage regular practice, not just during moments of anxiety.

Phobias

• Phobias are specific fears that are disproportionate to the actual danger.
• Examples: Snakes, spiders, public speaking.
• Social phobia (social anxiety disorder): Fear of being judged by others.
• Because of this fear, what do they do??? -- They avoid it.
• People with phobias may have panic level anxiety when exposed to the feared object or situation.

Types of Phobias

• Natural/environmental (e.g., large bodies of water, heights).
• Blood/injection/injury (associated with biphasic response).
• Situational (e.g., public speaking).
• Animal.
• Anything can be a phobia.

Agoraphobia

• Highly comorbid with panic disorder.
• Fear of being alone in public spaces or somewhere difficult to escape or without help.

Social Phobia (Social Anxiety Disorder)

• Avoidance of situations where others may criticize them.
• Can interfere with development.
• Predisposes individuals to depression and substance abuse.

Treatment for phobias and anxiety

• Exposure.
• Cognitive behavioral therapy.
• Deep breathing, reassuring nothing bad will happen.
• Systematic desensitization
  • Skills first, then systematic desensitization.
  • Systematically expose a person to a low level anxiety-provoking situation and grow from there.
• Implosion therapy (flooding): Should be done with a trained therapist.

Generalized Anxiety Disorder

• Chronic symptoms.
• A person worries most of the time (at least half the time for 6 months at a time)

Clinical Manifestations

• Restlessness
• Uptightness and muscle tension
• Fatigue
• Impaired concentration
• Irritability
• Sleep disturbance
• Social and occupational impairment
• Rule out medication/substance or biological/medical cause.
• Because it's generalized the worrier all the time they have exhausting days.

Treatment for generalized anxiety disorder

• Educate about medications.
• SSRIs (first choice).
• Other antidepressants.
• Benzodiazepines (anxiolytics) - use with caution.
• Teach diet, nutrition and time management to assist with general overall health.

Cognitive Behavioral Therapy (CBT) Basics

• Reframe thoughts and identify more positive alternatives.
• Differentiate between rational and irrational worries.
• Teach relaxation techniques.

CBT Techniques for GAD

• Schedule worry time.

• Engage in pleasurable activities.

• Help people change negative thinking by recognizing that their excessive worry is not doing any good; it's maladaptive.

• Help them stop negative thoughts; recognize that, stop them.

• Face situations that provoke worry. That's exposure.

Separation Anxiety Disorder

• Excessive fear or anxiety from being separated from a caregiver.
• Typically affects preschool or school-age children.
• Not diagnosed if age-appropriate (e.g., normal stranger anxiety in a toddler).

Clinical Manifestations

• Fear that something bad will happen to themselves or their caregiver.
• Tantrums when separation is anticipated.
• Somatic complaints (stomach aches, headaches).
• Refusal to go places or shadow caregiver.
• Worries about harm coming to themselves or their attachment figure.
• Reasonable social skills (if this is the primary condition).

Treatment

• Create a calm environment, reduce stress.
• Reassure the child that they will be safe and that the caregiver will be safe.
• Teach skills like deep breathing.
• Explore the child's fears and when it started (addressing that directly).
• Involve the family in treatment.
• Systematic desensitization: Gradually expose the child to separations.

Review of Anxiety Disorders

• Levels of anxiety: Mild, moderate, severe, panic.
• Agoraphobia and social anxiety disorder: Treatment will be exposure/systematic desensitization because it's a phobia.
• Clinical manifestations.
• Treatment measures.
• Nursing care.

Key Treatment Principles

• Always teach skills first, then exposure.
• SSRIs and other antidepressants.
• Anxiolytics used sparingly.
• Cognitive behavioral therapy.

Test Question

• "The patient has panic disorder. What somatic symptoms does the nurse expect to occur?"

• Fear of dying? No (psychological).

• Palpitations? Yes.

• Sensations of choking? Yes.

• Numbness or tingling? Yes.

OCD and Related Disorders

• OCD, Hoarding, and Body Dysmorphic Disorders.

OCD and Related Common Traits

• Typically have an obsessive thought that's recurrent and unwanted.
• When this thought happens image comes to their mind or an impulse to do something causes marked anxiety.
• Typically the thought happens, the behavior follows.
• The thought happens > anxiety > Compulsive behavior to lower anxiety.

OCD insight

• A person with OCD, obsessive compulsive disorder itself, usually has at least fair insight.

Key Points

• Insight is a good thing.
• The more the insight, the better the prognosis.
• The better the likelihood that people will get help.
• The obsession is more on the mental side, the compulsions more on the behavioral.

OCD Related Disorders.

• OCD is on testing
• Hoarding disorder on testing.
• Body dysmorphic disorder is on testing.
• Anything about trichotillomania or excoriation is just what they are.

Clinical manifestations with trichotillomania and excoriation disorder

• Trichotillomania -- anxiety is reduced by pulling your hair.
• Excoriation -- anxiety is reduced by picking at their skin.
• Always rule out a biological medical reason for those symptoms before we're gonna assume that it's a psychological disorder

Facts about OCD

• Equally found between men and women.
• Can begin in childhood, but usually it's adolescence.
• They'll perform the ritual to temporarily reduce anxiety.
• They'll call it a disorder that's diagnosable if it's significantly impacting life which typically DSM says, it's taking at least an hour of their day or more to do the compulsion.
• It's causing significant social and occupational impact.

Reinforcement of Coping

• Thaw the germ -- I touched it.
• My anxiety just grows.
• Anxiety just grows.
• What does my anxiety do???
• Comes down.
• So, what did I just do???
• I just reinforced that washing my hands makes me feel better.

Important point -- Avoidance

• Avoidance is the anxiety.
• Exposure is gonna be to try to separate that thought and behavior when we get into treatment for it.

Taboo Thoughts

• With OCD in order to protect your family and yourself from things that you do not want to happen, such as walking on a crack or running over someone, you might do things such as checking things 3 or 4 and even more times just to make sure that it does not happen.

Some Categories for checking the compulsive thoughts:

• Something harm or aggression.
• Contamination fears.
• osymmetry
• There must be an exact pattern, with little to no exceptions.
• Taboo thoughts.

OCD related Treatment.

• SSRI's are still the medical treatment of choice and at high doses.
• Plus, high dose for whatever reason higher dose antidepressants are the treatment for OCD and related conditions that's important to know.
• But before we're gonna expect somebody to live with that anxiety and be and it was exposure of that anxiety, we gotta do something first, that's that's always the truth when it comes to anxiety conditions.
• So early in treatment teach relaxation techniques, deep breathing, meditation, thoughts, stopping exit, looking what's, like, anxiety causing in their life, things like that.

CBT and Treatment of Choice for OCD

• They do ERTT, exposure and response prevention therapy.
• ERTT > Exposure to anxiety with a non-response pattern that leads to stopping/ redirecting behaviour.
• You get to text her at eight in the morning and at eight at night that's it. .

CBT principles with OCD patients.

• They make sure and prioritize that they teach patients the ability to recognize the signs of increasing anxiety and how to address them properly.
• Then to get a list of personal triggers, these should be ranked in order, that way CBT treatment can be done strategically in a way that the patient has success and grows their confidence.
• The repetitive exposure is important, that way the education is effective and that they are more likely to move beyond a bad event, or situation.
• Is also important that the CBT exercises are done at times during the patients schedule that help them reduce the performance of behaviors that relate to their OCD.

Always remember that with OCD the goal has to be that it gets treated early and that the patients have positive affirmation that they can progress beyond the triggers.

Some Points to Take

• The behavioral cognitive therapy of choice for OCD.
• Is this systematic desensitization??? No. That is for phobias and separate anxiety.

Hoarding Disorder

• Hoarding related things are classified as traits such as:
• Hoarding involves excessive acquisition and inability to get rid of things.
• So they, they acquire things that are pretty much useless.
• Have this affinity for things that's usually not related to the actual usefulness of the thing.
• So they'll value pay like, toilet paper rolls because of the shape or the color or the texture.
• They keep all these paper towel and toilet paper rolls and they store those together.
• Newspapers and mail with anything that is paper.
• When they hold on to their things and somebody they dwarf somebody's efforts in getting rid of it, their anxiety comes down. And when they go to a yard sale and they pick up some things their anxiety comes down.
• It becomes an environmental danger to a point that a health department gets called to the individuals home so that the situation can be assessed. The person is at that point more comfortable knowing that the house is going to condemn then getting rid of any thing that they have.

The classic profile that involves hoarding is:

• The behaviors experiences, and all those of the patient are dramatically different is a combination to many things: excessive levels of acquisition
  • Compulsively acquiring free things.
  • Excessive, hard time getting rid of anything.

It must be addressed that most of the patients that hoard are unable to throw away or to intend to make an effort to get rid of anything.

With hording, it must equally be realized what are the main facts that lead to a behavior:

The key of the facts comes down to being both the fact that the patient cant say NO to the fact that they want something, but not just that, also the fact that they cant have something thrown away, regardless if the object is worth anything or not. Also the fact in what that patient considers to be in a condition of order is completely different of the reality the situation is in.

Hoarding Insight - the things to do.

• build trust, show caring attitude, respect. And try to be non-judgmental.
• Help them share their feelings about hoarding, give show them empathy.
• Then we'll discuss the potential consequences the health department coming, dangers, rodents, children. And pets in danger, losing your family, losing your home, losing your job. Teach them ways they can make their home safer methods to reduce anxiety, encourage the family to help, and you probably will have to bring in some community help.

Hoarding and CBT

• identify challenging thoughts beliefs help and resist the urge
  to get more items.
• reduce isolation and increase opportunities and meaningful
  activities. Is gonna show them to you video.

Body dyphsormic disorder

• Is an ODC
  • the last ODC one.
• The main focus BDD is for next class.