Anxiety and Obsessive-Compulsive Disorders PDF

Anxiety and ObsessiveCompulsive Disorders Bryan R. Hansen, PhD, RN, APRN-CNS, ACNS-BC Tamar U. Rodney, PhD, RN, PMHNP-BC Emma Mangano, DNP, PMHNP-BC More than numbers • >3X more likely • Jan-June,2019: 8.2 % • May 7-12, 2020: 30.0% Twenge, JM, Joiner, TE. U.S. Census Bureau‐assessed prevalence of...

Anxiety and ObsessiveCompulsive Disorders Bryan R. Hansen, PhD, RN, APRN-CNS, ACNS-BC Tamar U. Rodney, PhD, RN, PMHNP-BC Emma Mangano, DNP, PMHNP-BC More than numbers • >3X more likely • Jan-June,2019: 8.2 % • May 7-12, 2020: 30.0% Twenge, JM, Joiner, TE. U.S. Census Bureau‐assessed prevalence of anxiety and depressive symptoms in 2019 and during the 2020 COVID‐19 pandemic. Depression and Anxiety. 2020; 1– 3. https://doi.org/10.1002/da.23077 Objectives • Assess patients' level of anxiety. • Compare and contrast the four levels of anxiety in relation to perceptual field, ability to problem solve, and physical and other defining characteristics. • Analyze coping resources and coping mechanisms related to patient anxiety level. • Identify defense mechanisms and consider one adaptive and one maladaptive (if any) use of each. • Describe the function of defense mechanisms. • Apply nursing interventions for patients experiencing each level of anxiety. • Design a patient education plan designed to help patients cope with anxiety. Anxiety • Anxiety—apprehension, uneasiness, uncertainty, or dread from real or perceived threat • Fear—reaction to specific danger • Anxiety responses – Fight – Flight – Freeze Levels of Anxiety 1. Mild Alert, “good anxiety” – 2. Increased perceptual field Moderate: Focus immediate concerns – 3. Selective perceptual field Severe: Behavior aimed at relieving anxiety – 4. Decreased perceptual field Panic: Impaired communication, irrational thoughts, disturbed behaviors – Distorted perceptual field Audience Response Question Anita, 34, is shopping with her 5-year-old daughter in a large, busy urban mall when she suddenly realizes the child is missing. Which level of anxiety would likely result? A. Mild B. Moderate C. Severe D. Panic Audience Response Question Anita, 34, is shopping with her 5-year-old daughter in a large, busy urban mall when she suddenly realizes the child is missing. Which level of anxiety would likely result? A. Mild B. Moderate C. Severe D. Panic Audience Response Question • What behaviors might Anita be exhibiting that would indicate paniclevel anxiety? – Seeing and grasping information efficiently and quickly to make problem solving more effective – Voice tremors, perspiration, and headache – Dazed, confused, with automatic behaviors aimed at reducing anxiety – Running, shouting, and screaming Defenses Against Anxiety • Defense mechanisms (psychological identity armor) – Automatic coping styles – Protect people from anxiety – Maintain self-image by blocking • Feelings • Conflicts • Memories – Can be healthy or unhealthy Case Study Anita finds her little girl, Hillary, close by, looking at kittens in a pet supply store window, and is obviously relieved. “I feel sick to my core,” she says. “I thought for sure my panic attacks were coming back for good.” Anita has, in the past, frequently experienced sudden feelings of impending doom, in which “I feel like I am losing my mind or having a heart attack. They started when I was a teenager.” Clinical Picture • Generalized anxiety disorder (Uncontrolled anxiety in all areas life) – Excessive worry that lasts for months • Social anxiety disorder (People avoidance) – Severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others Clinical Picture • Separation anxiety disorder – Developmentally inappropriate levels of concern over being away from a significant other • Panic disorder – Panic attacks Clinical Picture (Cont.) • Phobia (Contact avoidance) – Agoraphobia • Excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing – Specific phobias Clinical Picture (Cont.) • Other anxiety disorders – Substance-induced anxiety disorder – Anxiety due to a medical condition Case Study Anita recalls the height of her struggles with panic disorder: “My attacks would come out of the blue—usually when I had already been super depressed for a while. They were so bad that I started being more afraid of the panic attack itself, and sometimes I’d just stay home from stuff I usually really liked, like the high school football games and even slumber or birthday parties because I was afraid of having an attack in front of everybody.” Obsessive-Compulsive Disorders • Obsessions (Intrusive thought) – Thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind • Compulsions (Response to intrusive thought) – Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety Obsessive-Compulsive Disorders (Cont.) • Obsessive-compulsive disorder • Body dysmorphic disorder • Hoarding disorder • Hair pulling and skin picking disorders • Other compulsive disorders Audience Response Question A patient complains of frustration with his impulse to use tissues “to touch or grab anything and everything around me. I just feel clean and safe doing it that way, but sometimes if I don’t have a tissue, I can barely stand to open a door.” This patient appears to have which anxiety problem? A. Panic disorder B. Generalized anxiety disorder C. Posttraumatic stress disorder D. Obsessive-compulsive disorder Audience Response Question A patient complains of frustration with his impulse to use tissues “to touch or grab anything and everything around me. I just feel clean and safe doing it that way, but sometimes if I don’t have a tissue, I can barely stand to open a door.” This patient appears to have which anxiety problem? A. Panic disorder B. Generalized anxiety disorder C. Posttraumatic stress disorder D. Obsessive-compulsive disorder Anxiety Disorders • Epidemiology • Comorbidity • Etiology – Biological • Genetics – Neurobiological • The fear network Application of the Nursing Process • Assessment – General assessment of symptoms – Self-assessment – Assessment guidelines: anxiety and obsessive-compulsive disorders • Nursing diagnosis • Outcomes identification • Planning Assessment • Sound physical and neurological exam • Determine source of anxiety (primary vs. secondary) • Determine current level of anxiety • Assess for potential self-harm • Complete psychosocial assessment – Ask patient about causes they can identify • Self-assessment Planning • Patients do not usually require inpatient admission • Planning involves selecting community-based interventions • Encourage active participation in planning to increase positive outcomes • Patient experiencing severe levels may not be able to participate in planning Application of the Nursing Process • Implementation • Mild to moderate levels of anxiety • Severe to panic levels of anxiety (Island of safety) • Counseling • Teamwork and safety • Promotion of self-care activities Case Study Anita recalls the help she experienced when she was treated in adolescence for panic disorder. “I remember my dad anxiously driving me to the emergency room, while my mom sat in the back seat and held me, just trying to keep me calm. My dad gripped the wheel like he was afraid we’d go right off the road.” Case Study (Cont.) “When we got to the hospital, I remember a nurse came right out to the car and opened my door. She didn’t grab me or anything. She just said, ‘Hi Anita. My name is Betsy, and I understand from your mom’s phone call that you are having a panic attack. I’m here to help you get through it.’ “Then she held out her hand. I’ve always felt like Betsy saved me that night.” Audience Response Question Which was probably the most helpful thing Betsy did for Anita that night? A. Left her by herself in a quiet, dark space to calm down. B. Stayed with her and kept up a steady stream of talk—about anything at all—to distract and soothe her. C. Introduced her to a bright, pleasant game with other patients her age to create a much-needed distraction from worry. D. Stayed with her in a quiet spot and listened. Audience Response Question Which was probably the most helpful thing Betsy did for Anita that night? A. Left her by herself in a quiet, dark space to calm down. B. Stayed with her and kept up a steady stream of talk—about anything at all—to distract and soothe her. C. Introduced her to a bright, pleasant game with other patients her age to create a much-needed distraction from worry. D. Stayed with her in a quiet spot and listened. Case Study: Discussion Suppose you are a nurse or social worker on duty when a child goes missing, but—unlike Anita’s child—is not immediately found. The police arrive on the scene, the parent is questioned and as the search intensifies, you are asked to remain with, and take care of, the anxious parent. What would be some appropriate interventions for helping a parent experiencing panic-level anxiety? Implementation • Pharmacological interventions – Antidepressants – Anti-anxiety drugs – Other classes • Psychobiological interventions • Integrative therapy • Health teaching Advanced Practice Interventions • Cognitive therapy • Behavioral therapy – Relaxation training – Modeling – Systematic desensitization – Flooding – Response prevention – Thought stopping – Cognitive-behavioral therapy Evaluation • Is the patient experiencing a reduced level of anxiety? • Does the patient recognize symptoms as anxiety-related? • Does the patient continue to display signs and symptoms such as obsessions, compulsions, phobias, worrying, or other symptoms of anxiety disorders? If still present, are they more or less frequent? More or less intense? Evaluation (Cont.) • Is the patient able to use newly learned behaviors to manage anxiety? • Does the patient adequately perform self-care activities? • Can the patient maintain satisfying interpersonal relations? • Is the patient able to assume usual roles? References • Keltner, N. L., & Steele, D. (2018). Psychiatric nursing. St. Louis, MO: Elsevier/Saunders :Chapter 27: Anxiety and obsessive-compulsive disorders. St. Louis, MO: Elsevier Saunders.