Anxiety and Obsessive-Compulsive and Related Disorders
Anxiety, Obsessive-Compulsive, and Related Disorders: Comprehensive Study Notes
Introduction and Overview
Learning Objectives
Describe the impact of anxiety and obsessive-compulsive and related disorders on a client’s overall health.
Explore epidemiological and etiological risk factors contributing to these disorders.
Differentiate the clinical presentation of clients experiencing these disorders.
Explore the nurse's role in caring for clients with these conditions.
Apply the nursing process and clinical judgment functions when providing care.
Understanding Anxiety
Anxiety is a normal, common human response to stress, manifesting as feelings of worry, fear, or nervousness when stressed or threatened.
Temporary anxiety can be motivational, pushing individuals to perform or act.
However, persistent or excessive anxiety significantly interferes with daily functioning (APA, 2021).
Prevalence: Anxiety disorders are the most frequently diagnosed psychiatric disorders in the U.S., with approximately 30\% of adults reporting an anxiety disorder during their lifetime (NAMI, 2017).
When Anxiety Becomes a Disorder
Physiological expression of anxiety optimally serves an adaptive function to protect an individual from danger.
Anxiety transitions into a disorder when it interferes with an individual's ability to function normally.
This interference is characterized by:
Feelings of anxiety occurring at inappropriate times or in inappropriate situations.
An increase in the frequency of anxiety episodes.
The intensity of anxiety negatively affecting a person’s ability to function.
The duration of anxiety becoming increasingly prolonged.
The Anxiety Cycle
Stress: Initiates the cycle.
Cognitive Symptoms (Worry, Fear, Anxiety): Manifests as thoughts like "What will happen next?", "I can't do this.", "Only bad will come of this."
Physiological Symptoms: Dizziness, elevated heart rate, gastrointestinal (GI) distress, fast/shallow breathing, dry throat, beginning to sweat, and disrupted concentration.
Behavioral Responses (Fight, Flight, Freeze, Fawn):
Fight: Anger, frustration, aggression.
Flight: Avoidance behaviors, such as drinking alcohol.
Freeze: Inability to respond or act.
Fawn: Attempting to please others to avoid anxiety or stress.
Stress Response vs. Anxiety
Both share common physiological responses, including increased adrenaline, dry mouth, and sweating.
A stress response is typically proportionate to the actual stressor.
Anxiety, however, is a response to stress that can be either real or perceived.
Levels of Anxiety
Restless: Characterized by trouble sleeping, feeling overwhelmed, acting out, and being unsure what to do.
Panic: Involves feeling terror, exhaustion, and being unable to respond to stimuli.
Obsessive Compulsive Disorder (OCD) Explained
OCD is often precipitated by underlying anxiety.
It can be diagnosed in both children and adults.
Obsessions: These are persistent, recurrent thoughts or urges that are unwanted and become intrusive, causing significant distress. Examples include:
Thoughts about being harmed or harming someone else.
Fears for personal safety.
Excessive concern for cleanliness or germs.
Fear of offending a higher power or deity.
Fear of forgetting something important.
Worry about how tidy or neatly arranged items are.
Compulsions: These are repetitive behaviors that a client with OCD performs to lessen or prevent the anxiety brought on by their obsessions. Examples include:
Checking and rechecking that a door is locked repeatedly.
Performing handwashing in a ritualistic order.
Repeating specific words or phrases.
Hurting oneself, such as hair pulling (trichotillomania).
Counting objects, items, or actions.
Repeating an activity a specific number of times.
The obsessions and compulsions associated with OCD become time-consuming and significantly interfere with the client’s ability to perform daily tasks and maintain normal functioning.
Epidemiological and Etiological Risk Factors
Anxiety-Related Disorders
Anxiety disorders are the most common mental illness among adults in the United States (Anxiety & Depression Association of America, 2022a).
Research suggests a familial pattern, indicating a combination of heredity and learned responses to stress (Merck Manual, 2020).
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.
Transdiagnostic Nature of Anxiety
Anxiety is transdiagnostic, meaning it can coexist with or be seen in relation to various other conditions (APA, 2013), including:
Panic disorders
Trauma and stressor-related disorders
Depressive disorders
Substance use disorders
Somatic manifestations
Sleep-wake disorders
Eating disorders
Comorbidities
Anxiety and OCD frequently co-occur with a wide range of other medical and psychiatric conditions:
Stress-related disorders, including Posttraumatic Stress Disorder (PTSD)
Medical conditions such as pulmonary embolism, asthma, emphysema, stroke, myocardial infarction, cancer, sepsis, chronic pain, Irritable Bowel Syndrome (IBS), and delirium.
Mood disorders like major depressive disorder or bipolar disorder.
Obsessive-compulsive personality disorder.
Tic disorder.
Attention-deficit/hyperactivity disorder (frequently identified in children).
Oppositional defiant disorder.
Schizophrenia spectrum disorders.
Eating disorders.
Substance use disorders.
Obsessive Compulsive and Related Disorders Epidemiology
The 12-month prevalence rate for Obsessive Compulsive Disorder (OCD) in the United States is estimated at 1.2\%.
There is no single known cause for OCD.
People assigned female at birth are more prone to be diagnosed with OCD, although symptoms may appear earlier in people assigned male at birth.
Approximately 50\% of adults diagnosed with OCD experience severe impairment, resulting in a reduced ability to function (NIMH, 2019).
General Risk Factors for Anxiety and OCD
Brain chemistry imbalances.
Social influence and environmental factors.
Lifestyle factors.
Family background.
Genetic predisposition.
Childhood Experiences: ACEs and PCEs
Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs) both play a significant role in the development and course of anxiety and OCD.
PCEs, while protective, do not entirely cancel out the negative impacts of ACEs.
Nurses should assess for both ACEs and PCEs in clients.
Example ACE Risk Factors and Corresponding PCEs:
ACE Risk: Children and youth who do not feel close to their parents/caregivers and feel unable to discuss their feelings.
Correlating PCE: Families who create safe, stable, and nurturing relationships where children experience consistent family life, safety, care, and support.
ACE Risk: Children and youth with few or no friends.
Correlating PCE: Children who have positive friendships and peer networks.
ACE Risk: Families with inconsistent discipline and/or low levels of parental monitoring and supervision.
Correlating PCE: Families where caregivers engage in parental monitoring, supervision, and consistent enforcement of rules.
Distinguishing Anxiety and OCD Manifestations
Anxiety Disorders in General
Psychological Manifestations: Feeling apprehensive or nervous, restlessness, irritability, anticipating the worst outcome, watching for anxiety-provoking stimuli, and avoidance of anxiety causes.
Physiological Manifestations: Increased heart rate and respiratory rate, sweating, fatigue or exhaustion, difficulty concentrating, gastrointestinal (GI) disturbances, and sleep disruptions.
Specific Anxiety Disorders (in order of life cycle emergence)
Separation Anxiety:
Developmentally inappropriate and excessive fear or anxiety upon separation from attachment figures.
Reluctance to leave those they are attached to, and experiencing nightmares related to separation.
Selective Mutism:
Consistent failure to speak in specific social situations where speaking is expected (e.g., school).
Interferes with academic or social achievement and regular communication.
Phobias:
Experiencing marked fear and anxiety upon exposure to a specific object or situation.
Examples include fear of animals, heights, or blood.
Social Anxiety (Social Phobia):
Marked fear and anxiety upon exposure to social situations.
Thoughts often ruminate on being embarrassed, humiliated, rejected, or offending others.
Panic Attacks:
Experiencing distinct and extreme periods of physiological and psychological hyperarousal.
Usually unexpected and occurring for no apparent reason, leading to avoidance of situations, people, or events that may trigger an attack.
Associated with persistent worry about another attack occurring.
Agoraphobia:
Experiencing marked fear and anxiety related to travel or specific locations.
Examples include closed spaces (e.g., an elevator), open spaces (e.g., a park), or leaving home alone.
Results in avoiding the feared situation or requiring others to navigate it.
Obsessive Compulsive Disorders (General Manifestations)
Experiencing a pattern of uncontrollable obsessive thoughts and associated compulsive behaviors or rituals.
These behaviors often involve cleaning (e.g., washing hands excessively), ordering or counting objects or behaviors, or being preoccupied with taboo or forbidden thoughts.
Specific Obsessive-Compulsive Disorders
Body Dysmorphic Disorder (BDD):
Persistent preoccupation with perceived defects or flaws in one’s physical appearance.
Leads to repetitive behaviors such as mirror checking, excessive grooming, skin picking, or seeking reassurance about looks.
May be associated with a possible eating disorder.
Hoarding Disorder:
Demonstrating a persistent difficulty or inability to discard or part with possessions.
Differs from collecting in that symptoms result in an excess accumulation of possessions that clutter and overwhelm living areas, making them unusable.
Trichotillomania (Hair-Pulling Disorder):
A pattern of ritualized behavior defined by serially and intentionally pulling out one’s hair.
Behaviors are often triggered by boredom and/or anxiety.
The results of this behavior reduce tension and can lead to a form of gratification, pleasure, or a sense of relief.
Excoriation Disorder (Skin-Picking Disorder):
A pattern of behavior defined by the recurrent picking at one’s skin, resulting in lesions.
Physical manifestations are commonly found on the hands, face, arms, or multiple body sites.
Individuals may pick pimples, scabs, or previous picked areas of skin.
Extensive time daily is spent picking, and clients often attempt to cover the lesions with clothing or makeup.
Diagnostic Criteria (DSM-5)
Generalized Anxiety Disorder (GAD) Diagnostic Criteria (DSM-5)
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (e.g., work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three or more of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months):
Restlessness or feeling keyed up or on edge.
Being easily fatigued.
Difficulty concentrating or mind going blank.
Irritability.
Muscle tension.
Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder, contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
Obsessive-Compulsive Disorder (OCD) Diagnostic Criteria (DSM-5)
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. 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 are defined by (1) and (2):
1. 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.
2. 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. (Note: Young children may not be able to articulate the aims of these behaviors or mental acts).
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania; skin picking, as in excoriation disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder.
Interprofessional Team and Treatment Approaches
Treatment: Nonpharmacologic Strategies
Psychotherapy: Talk therapy specifically focused on the client’s anxiety.
Cognitive Behavioral Therapy (CBT): A psychotherapy approach that targets how the client thinks, behaves, and reacts to the causes and feelings of anxiety.
Cognitive Therapy: Similar to CBT, this approach focuses on identifying the cause of anxiety and eliminating thoughts that are distorted or unhelpful regarding anxiety or stressors.
Exposure Therapy: The client is gradually exposed to the underlying cause of anxiety they are avoiding (e.g., driving in traffic or riding in an elevator) to become more comfortable with the activity over time.
Support Groups: Groups that focus on sharing experiences and achieving goals related to anxiety management.
Complimentary-Integrative Approaches: Therapies focused on relieving anxiety in specific situations, such as during a medical procedure. These practices include:
Relaxation techniques (deep breathing, guided imagery, progressive body relaxation).
Hypnosis.
Massage therapy.
Mindfulness meditation.
Music therapy.
Lifestyle Management: Helping clients make better choices, including nutritional strategies (healthy diet), regular exercise, and avoiding excessive caffeine or substance use.
Treatment: Pharmacologic Strategies
Anxiolytics: Such as benzodiazepines (e.g., alprazolam).
Selective Serotonin Reuptake Inhibitor (SSRI) Antidepressants: (e.g., paroxetine).
Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) Antidepressants: (e.g., venlafaxine).
The Nurse's Role in Anxiety and OCD Care
Core Responsibilities
Providing equitable and sensitive care.
Demonstrating self-awareness.
Implementing client-centered care.
Focusing on prevention.
Engaging in comprehensive teaching.
Providing a wide range of support.
Self-Awareness
Implicit Bias: Unconscious discriminatory attitudes that can trigger negative reactions or fear, potentially creating disparities in care for specific groups (e.g., ethnic, racial, minority groups).
Stereotyping: Making assumptions based on previous experiences, such as interactions with individuals expressing anger.
Habit-Breaking Strategies (Narayan, 2019):
Recognize the inequitable effects of bias.
Commit to breaking biased habits.
Practice desired, unbiased behaviors.
Replace stereotypes with individualized understanding.
Practice mindfulness: focus on the present moment, take slow, deep breaths before entering a client's room, and become more deliberate in actions, paying attention to feelings and assumptions.
Client-Centered Care
Trauma-Informed Care: Assuming that everyone has struggles and demonstrating unconditional positive regard towards all clients.
Developing a strong therapeutic relationship.
Understanding and managing transference and countertransference phenomena.
Viewing the illness and its impact from the client’s unique perspective.
Prevention
While anxiety disorders may not be entirely preventable, the management of anxiety and learning effective coping strategies are essential.
These strategies appear to mitigate anxiety, reduce its progression to a disorder, and improve the client's quality of life (Carter, 2022).
The focus is on developing a meaningful life, which includes fostering good relationships, engaging in satisfying work, promoting personal growth, and maintaining a healthy living environment (MentalHealth.org, 2021).
Teaching
Specific Education: Provide education directly related to the client’s specific disorder.
Manifestation Recognition: Help clients recognize common clinical manifestations of their anxiety.
Management Strategies: Teach strategies for better management of their anxiety.
Treatment Plan: Explain the prescribed treatment and therapies based on the client’s plan of care.
Medication Education: Inform clients about medications, potential adverse effects, and what actions to take if adverse effects occur.
General Wellness: Educate on general physical health practices for wellness and recovery.
Resources: Provide information on available community resources and support groups.
When to Seek Provider Care: Advise clients on when to contact their provider:
When worry begins to interfere with function or relationships.
When worry becomes increasingly difficult to control.
Worry leading to thoughts of self-harm or suicide is a mental health emergency and requires immediate attention.
Teaching Principles:
Create a physical environment conducive to learning, reducing distractions or negative stimuli.
Use therapeutic communication, stripping away complicated medical jargon.
Ensure content is accurate and appropriate for the learner.
Offer more than one way of learning (reading, hearing, or seeing).
Ensure content is evidence-based.
Use the teach-back method to confirm client understanding.
Support Strategies
Active Listening: The nurse demonstrates, both verbally and non-verbally, engagement and genuine interest.
Therapeutic Communication: The nurse simplifies language, avoiding complicated and unnecessary medical jargon.
Modeling: When a client experiences panic, the nurse sits next to them and begins to breathe slowly and deeply, demonstrating calm.
Milieu (Therapy) Management: The nurse moves a client struggling with severe anxiety away from the nurse’s station to reduce overstimulation.
Anticipatory Guidance: The nurse educates the client on possible adverse effects of an antidepressant and offers practical strategies to minimize them.
Anti-Stigma Messaging: The nurse earnestly and constructively corrects a family member’s statement about the client’s anxiety being “all in their head.”
Triggers: The nurse assists the client in determining the cause of their worry and how they are responding to it.
Self-Management: The nurse educates the client to use mindfulness, deep breathing, or other techniques to reduce anxiety and increase relaxation.
Support: The nurse provides information regarding community support groups for individuals who have experienced trauma.
Applying the Nursing Process: Clinical Judgment Functions
Recognize Cues (Assessment)
Identify the manifestation(s) the client is exhibiting.
Determine variables that aggravate or alleviate manifestations.
Look for findings suggesting underlying physiological causes, such as:
Thyroid function tests.
Blood glucose levels.
Echocardiography.
Toxicology screening.
Identify manifestations most distressing to the client, both in the present and historically.
Assess client awareness of any family history relevant to their manifestations.
Determine what helped the client navigate similar manifestations in the past.
Evaluate the client’s readiness for change as it relates to engaging in treatment.
Assess the extent to which anxiety has affected the client’s ability to function.
Determine the intensity, duration, and distress of anxiety associated with each symptom.
Screening Tools for Anxiety and OCD:
Generalized Anxiety Disorder 7 (GAD-7) (Spitzer, Kroenke, Williams, & Lowe, 2006).
The Hamilton Anxiety Rating Scale (HAM-A) (Hamilton, 1959).
Screen for Child Anxiety Related Disorders (SCARED) (Birmaher et al., 1999).
Leibowitz Social Anxiety Scale (LSAS) (Heimberg et al., 1999).
Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983).
Penn State Worry Questionnaire (PSWQ) (Meyer, Miller, Metzger, & Borkovec, 1990).
Yale-Brown Obsessive Compulsive Scale (Y-BOCS) (Goodman et al., 1989).
Brief Obsessive-Compulsive Scale (BOCS) (Bejerot, 2014).
Analyze Cues/Prioritize Hypotheses
Always prioritize client safety first.
Then, target symptoms and stressors identified by the client as most important, focusing on:
Coping mechanisms.
Physical symptoms.
Problem-solving abilities.
Recovery goals.
Generate Solutions (Planning)
Create a comprehensive plan in collaboration with the client and the healthcare team.
The primary focus is on the reduction of clinical manifestations of the disorder and an improvement in the client’s ability to function.
Goals should be Specific, Measurable, Achievable, Relevant, and Time-bound (SMART).
Example SMART Goal: "The client will report a reduction in anxiety and acclimatize to therapeutic milieu within 8 hours of nursing intervention."
Take Action (Implementation)
Utilize therapeutic communication effectively.
Control the environment (milieu) to be supportive and safe.
Administer medications as prescribed.
Apply restraints and place the client in seclusion as ordered by the provider and warranted by the situation.
Seclusion and Restraints: These interventions require a specific prescription detailing:
The reason for the seclusion or restraint.
The authorized length of time for its application.
The type of restraints to be used.
The criteria needed for removal from seclusion or restraints.
Outcomes (Evaluation)
Specific outcomes are based on the client’s individualized plan of care and their prioritized problems.
Consider the following questions during evaluation:
Has the client remained free from injury or harm (both physically and psychologically)?
After reassessing the client, have the clinical manifestations of anxiety reduced?
Were the interventions implemented part of the original plan of care?
Was the client able to effectively use the prescribed strategy (such as deep breathing) as intended?