Anxiety, Obsessive-Compulsive, and Related Disorders PDF

**Chapter 18: Anxiety, Obsessive-Compulsive, and Related Disorders** **Anxiety is a feeling of discomfort, apprehension, or dread related to anticipation of danger, the source of which is often nonspecific or unknown.** - subjective response to a stressor Fear is related to the cognitive sense...

**Chapter 18: Anxiety, Obsessive-Compulsive, and Related Disorders** **Anxiety is a feeling of discomfort, apprehension, or dread related to anticipation of danger, the source of which is often nonspecific or unknown.** - subjective response to a stressor Fear is related to the cognitive sense of danger - Normal reaction to stress - Different levels - Relationship exists between anxiety and dysfunctional behaviors - Involve excessive fear or anxiety - Are among the most common psychiatric disorders - Frequently co-occur with other psychiatric disorders - Lifetime prevalence is 30% + - More common in females **Epidemiological Statistics** - Anxiety disorders are among the most common of all psychiatric illnesses - More common in women than in men - A familial predisposition probably exists **How Much Anxiety Is Too Much?** - When anxiety is out of proportion to the situation that is creating it - When anxiety interferes with social, occupational, or other important areas of functioning **Predisposing factors to anxiety, OCD, and related disorders** - Genetic factors - Dysfunction within limbic system & prefrontal cortex - Neurotransmitter dysfunction: serotonin, norepinephrine, GABA, dopamine, glutamate - Psychoanalytic/Psychodynamic Theories - Ego development is delayed and lacks ability to modulate anxiety - **Unconscious fears may be expressed in symbolic manner as phobias** - Underdeveloped ego leads to regression - Psychosocial Influences - Stressful situations and unmanaged stress - Learning Theory - Classic conditioning - Learned behavior, modeling - Passive and active avoidance - Cognitive Theory - Faulty, distorted thinking patterns precede maladaptive behaviors - Negative self-statement and irrational beliefs **Panic Disorder** - Assessment - Characterized by recurrent panic attacks, the onset of which are unpredictable and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort - May or may not be accompanied by agoraphobia - **Symptoms of panic attack** - **KNOW Shortness of breath, chest pain, or discomfort, palpitations, pounding heart rate, accelerated HR, intense apprehension, fear of terror, Fear of losing control or "going crazy" and Fear of dying** - Sweating, trembling, shaking - Nausea or abdominal distress - Dizziness, chills, or hot flashes - Numbness or tingling sensations - Derealization or depersonalization - **Medications for panic disorder ("i relieve panic in 3's → SSRI, SNRI, Benzos")** - Antidepressants: SSRI \[fluoxetine, paroxetine, sertraline\] & SNRI \[venlafaxine\] - Benzodiazepines: Lorazepam, diazepam, clonazepam - Used for panic attacks - **KNOW Education: Drowsiness and sedation, increases risk of respiratory depression (especially when paired with opioids and ETOH), potential for dependence, and educate them to take medication and take as prescribed** **Generalized anxiety disorder (GAD)** - **Characterized by persistent/chronic, unrealistic, and excessive anxiety and worry** - Causes impairment in social, occupational, or other important areas of functioning - Avoidance and procrastination behaviors - Most occur more days than not for **at least 6 months** - **KNOW s/s: May avoid activities/events that may result in negative outcomes, irritability, muscle tension, sleep disturbance, feeling keyed up or on edge, and excessive anxiety and worry for at least 6 months** - **In class examples:** - "Don has always been an excellent student and was valedictorian of his high school graduating class. Since starting college, he has been unusually worried about his academic performance. Lately, he has been unable to sleep, is irritable, has difficulty concentrating, and has begun experiencing nausea and vomiting due to worry that he will not do well academically." - **Tx modalities: psychopharmacology ("GAwD, we got to tx this with some BUSy ANTs (buspirone and antihistamines) and antidepressants")** - Medication for Generalized Anxiety Disorder (GAD) - **Antidepressants** - **KNOW SSRIs (escitalopram, paroxetine) or SNRIs (duloxetine, venlafaxine)** - TCAs (imipramine) - Other antidepressants - **Other medications** - **KNOW Buspirone \[takes 1 week or so to take w/ consistent use\]** - **KNOW Diphenhydramine or Hydroxyzine (antihistamines)** - Anticonvulsants (pregabalin, valproic acid, gabapentin) - Antipsychotics (quetiapine) **Phobias** - **Agoraphobia** - Fear of being in places or situations from which escape might be difficult or in which help might not be available - Using public transportation (e.g., automobiles, buses, trains, ships, planes) - Being in open spaces (e.g., parking lots, marketplaces, bridges) - Being in enclosed places (e.g., shops, theaters, cinemas) - Standing in line or being in a crowd - Being outside of the home alone - **Meds**: - Antidepressants: SSRI \[fluoxetine, paroxetine, sertraline\] & SNRI \[venlafaxine\] - Benzodiazepines: Lorazepam, diazepam, clonazepam - **In class examples:** - "Frances will not leave her home unless a friend or relative goes with her." - "Carol will go to church only if she can sit right near the door." - **Social anxiety disorder (social phobia)** - Excessive fear of situations in which the affected person might do something embarrassing or be evaluated negatively by others - Extreme concerns about being exposed to scrutiny in social or performance situation - **In class examples:** - "Sonja refuses to eat in a restaurant. She is afraid others will laugh at the way she eats." - "George never volunteers to speak in class. He is afraid his classmates will laugh at what he says." - **Medications for social anxiety disorder/social phobia "tx the social phobia with the Beta (beta blockers) and Clones (clonidine)"** - SSRI \[sertraline, paroxetine)/SNRIs (venlafaxine) - Beta blockers (propranolol, atenolol) - Antihypertensive \[clonidine\] - Antihistamines \[diphenhydramine, hydroxyzine\] - Benzodiazepines \[diazepam, clonazepam, lorazepam\] - **Specific phobia** - Fear of specific objects or situations that could conceivably cause harm, but the person's reaction to them is excessive, unreasonable, and inappropriate - Exposure to the phobic object produces overwhelming symptoms of panic - **Examples:** claustrophobia, arachnophobia, belonephobia - **In class examples:** - "Janet becomes panicky when she gets near a dog." - "Janie desperately wants to visit a foreign country with her friends, but b/c of her fear of needles, she has not been able to get the required immunizations." - "When Sally sees a spider on the floor, she screams and runs out the door." - Usually don't require medication **Anxiety Disorder Due to Another Medical Condition or Substance or Medication Induced** - Medical conditions that may produce anxiety s/s: - Cardiac, endocrine, thyroid, respiratory, & neurological conditions; Common with COPD - Substance or Medication Induced Anxiety Disorder - May be associated with intoxication or withdrawal from any of the following substances: - Alcohol, sedatives, hypnotics, or anxiolytics - Amphetamines or cocaine, Hallucinogens, Caffeine, Cannabis, Others **Obsessive-Compulsive Disorder (OCD)** - **KNOW Characteristics:** - **Recurrent intrusive thoughts that cause anxiety** - **Individual attempts to ignore or suppress thoughts** - **Repetitive behaviors are done in response to obsession** - **Behaviors or mental acts are done to prevent or reduce anxiety** - Assessment data - Recurrent obsessions and/or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment - Obsessions - **Recurrent thoughts, impulses, or images experienced as intrusive and stressful**, and unable to be removed by logic or reasoning - The obsessions cause anxiety and the compulsions are an attempt to alleviate the anxiety (notebook LM) - Compulsions - Repetitive ritualistic behavior or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded event or situation - Medications for OCD - **Antidepressants** - SSRIs (fluoxetine, paroxetine, sertraline, fluvoxamine) - TCAs (clomipramine) - **Other medications** - Atypical antipsychotics (risperidone, aripiprazole) - Buspirone - **OCD In class examples**: - "Patricia weighs and measures her food. Long after everyone else has finished eating, she is still calculating the caloric value of her food and remeasuring her portion." - "Everyday when Wanda gets home from work, she cleans her house. She has told her friends not to call her during this time, and if anything interferes with her cleaning, she becomes very upset and starts over from the beginning." - "Helen's boss has told her that if she is late for work one more time she will lose her job. Helen gets up early enough to be at work on time, but she just follows a specific routine of putting her apartment in order before she leaves the house. If one activity in her routine is interrupted, she must start over from the beginning. These delays and repatriation in her routine are causing her to be late for work." **Body Dysmorphic Disorder** - Assessment - Characterized by the exaggerated belief that the body is deformed or defective in some specific way - If true defect is present, the person's concern is unrealistically exaggerated and grossly excessive - Often has another comorbid mental disorder \[depression, psychotic disorders\] - Plastic surgeons screen for this disorder prior to surgeries - **In class example:** - "Virginia has some freckles across her nose and cheeks. She visits dermatologists regularly trying to find one who will "get rid of these huge, ugly spots on my skin." - Medication for body dysmorphic disorder - No FDA approved mediation - **Antidepressants** - SSRIs (citalopram, escitalopram, sertraline, fluoxetine, fluvoxamine) - TCAs (clomipramine) - **Other medications** - Atypical antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole) **Hair-Pulling Disorder (Trichotillomania)** - The recurrent pulling out of one's own hair that results in noticeable hair loss - Preceded by increasing tension and results in sense of release or gratification - No medications have demonstrated consistent benefits, may try SSRIs, TCA-clomipramine, mood stabilizers, antipsychotics, N-Acetylcysteine, inositol, naltrexone, memantine - **In class example:** - "The nurse asks Heather about the bald spots on her scalp. Heather replies that when she gets nervous, she feels better if she pulls on her hair." **Hoarding Disorder** - The persistent difficulty discarding possessions regardless of their value - there can be a need for excessive acquiring of items (by purchasing or other means) - Additionally, there can be a need for excessive acquiring of items (by purchasing or other means) - No FDA approved medications for this disorder, may try SSRIs/SNRIs, addition of an antipsychotic **Diagnosis/Outcome Identification** - Nursing diagnoses commonly associated with anxiety, OCD, and related disorders - Panic anxiety - Powerlessness - Fear - Social isolation - Ineffective coping - Ineffective role performance - Disturbed body image - Ineffective impulse control **Outcomes: The Patient** - Is able to recognize signs of escalating anxiety and intervene before reaching panic level - Is able to maintain anxiety at manageable level and make independent decisions about life situation - Functions adaptively in the presence of the phobic object or situation without experiencing panic anxiety - Verbalizes a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety - Is able to maintain anxiety at a manageable level without resorting to the use of ritualistic behavior - Demonstrates more adaptive coping strategies for dealing with anxiety than ritualistic behaviors - Verbalizes a realistic perception of his or her appearance and expresses feelings that reflect a positive body image - Verbalizes and demonstrates more adaptive strategies for coping with stressful situations **Planning/Implementation** - **KNOW Panic anxiety interventions** - **Remain calm, non threatening approach** - **Assist the pt to breathe into a small paper bag** - **Stay with patient** - **Give benzo PRN** - **Use simple words and brief messages** - Keep the immediate surroundings low in stimuli. - Teach the client signs of escalating anxiety. - Fear - Include the client in making decisions. - Encourage the client to explore underlying feelings. - Ineffective Coping - Initially meet the client's dependency needs. - Provide a structured schedule of activities. - Disturbed Body Image - Help client see THEIR view of their body image is distorted. - Involve client in activities that reinforce a positive sense of self. - Make referrals to support groups. - Ineffective Impulse Control - Convey a nonjudgmental attitude. - Practice stress management techniques. - Offer support and encouragement. **Client/Family Education** - Nature of the Illness - What is anxiety? To what might it be related? What is OCD? - What is body dysmorphic disorder? What is trichotillomania? - Symptoms of anxiety, OCD and related disorders - **Management of the Illness** - Medication management - Possible adverse effect - Length of time to take effect \[\~4 weeks\] - What to expect from the medication - Ex. benzo can lead to dependence & should be taken as PRN - Stress management \[mindfulness\] - Teach ways to interrupt escalating anxiety - Teach relaxation techniques (may utilize paper bag to help with breathing) - **Support Services:** Crisis hotline, Support groups, Individual psychotherapy **Treatment Modalities:** Individual psychotherapy, Cognitive behavioral therapy, Behavior therapy **Evaluation** - Evaluation of the effectiveness of the nursing intervention is measured by fulfillment of the outcome criteria **Treatment Modalities: Psychopharmacology** - Examples of **antianxiety** agents - Hydroxyzine (Vistaril) - antihistamine - Buspirone (Buspar) - takes a while to be effective - Alprazolam (Xanax), Chlordiazepoxide (Librium), Clonazepam (Klonopin), Diazepam (Valium), Lorazepam (Ativan) - Examples of **antihypertensive** agents - Propranolol (Inderal), Atenolol (Tenormin), and Clonidine (catapres) - Examples of **antidepressants** - Paroxetine (Paxil), Fluoxetine (Prozac), Sertraline (Zoloft), Fluvoxamine (Luvox), Escitalopram (Lexapro), Venlafaxine (Effexor), Duloxetine (Cymbalta), Clomipramine (Anafranil), and Amitriptyline (Elavil)