ANXIETY AND OBSESSIVE-COMPULSIVE DISORDERS CHAPTER 15 OBJECTIVES • Compare and contrast the four levels of anxiety in relation to perceptual field, ability to problem solve, and other defining characteristics. • Identify defense mechanisms and consider one adaptive and one maladaptive (if any) use of each. Anxiety—apprehension, uneasiness, uncertainty, or dread from real or perceived threat ANXIETY Fear—reaction to specific danger Normal anxiety— necessary for survival Mild anxiety LEVELS OF ANXIETY • Everyday problem-solving leverage • Grasps more information effectively Moderate anxiety • • • • Selective inattention Clear thinking hampered Problem solving not optimal Sympathetic nervous system symptoms begin Severe anxiety LEVELS OF ANXIETY (CONT.) • Perceptual field greatly reduced • Difficulty concentrating on environment • Confused and automatic behavior • Somatic symptoms increase Panic • Markedly disturbed behavior— running, shouting, screaming, pacing • Unable to process reality; impulsivity 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 panic-level anxiety? A. Seeing and grasping information efficiently and quickly to make problem solving more effective B. Voice tremors, perspiration, and headache C. Dazed, confused, with automatic behaviors aimed at reducing anxiety D. Running, shouting, and screaming • Defense mechanisms • Automatic coping styles • Protect people from anxiety • Maintain self-image by blocking DEFENSES AGAINST ANXIETY • Feelings • Conflicts • Memories • Adaptive • Lowers anxiety for acceptable achievement of goals • Maladaptive • Overuse of immature defenses OBJECTIVES • Describe clinical manifestations of separation anxiety disorder, specific phobia, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder. • Identify risk factors that may contribute to anxiety disorders. 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.” Separation anxiety disorder • Developmentally inappropriate levels of concern over being away from a significant other CLINICAL PICTURE Specific phobias • Persistent irrational fear of a specific object, activity or situation that leads to a desire for avoidance Social anxiety disorder • Severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others CLINICAL PICTURE (CONT.) • Panic disorder • Panic attacks: abrupt surge of intense fear or intense discomfort that reaches a peak within minutes • Agoraphobia • Excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing Generalized anxiety disorder CLINICAL PICTURE (CONT.) • Excessive worry that lasts for months Other anxiety disorders • Selective mutism • Substance-induced anxiety disorder • Anxiety due to a medical condition Genetic RISK FACTORS Biological Psychological Cultural 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.” AUDIENCE RESPONSE QUESTION What level of anxiety could actual be a good thing on the day of a nursing exam? A. Mild B. Moderate C. Severe D. Panic OBJECTIVES Formulate four priority nursing diagnoses that can be used in caring for a patient with an anxiety disorder. Propose realistic outcome criteria for a patient an anxiety disorder. Assessment APPLICATION OF THE NURSING PROCESS • General assessment of symptoms • Self-assessment • Assessment guidelines: anxiety Nursing diagnosis Outcomes identification Planning • Sound physical and neurological exam • Determine source of anxiety (primary vs. secondary) ASSESSMENT • Determine current level of anxiety • Assess for potential self-harm • Complete psychosocial assessment • Ask patient about causes they can identify • Self-assessment NURSING DIAGNOSES AND OUTCOME IDENTIFICATION • Anxiety & Fear • Self-monitors intensity; uses reduction techniques • Difficulty coping • Identifies ineffective and effective patterns; asks for assistance and information; modifies as needed • Impaired socialization & low selfesteem • Self-monitors anxiety and desire for avoidance; uses techniques to reduce anxiety to maintain role performance 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 OBJECTIVES Describe five basic nursing interventions for patients with anxiety disorders. Discuss the classes of medications used to treat anxiety disorders. Describe psychological therapies for anxiety disorders. • Implementation APPLICATION OF THE NURSING PROCESS Mild to moderate levels of anxiety Severe to panic levels of anxiety • Counseling • Health teaching and health promotion • Teamwork and safety • Promotion of self-care activities • Is the patient experiencing a reduced level of anxiety? • Does the patient recognize symptoms as anxiety-related? EVALUATION • 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? Is the patient able to use newly learned behaviors to manage anxiety? EVALUATION (CONT.) Does the patient adequately perform self-care activities? Can the patient maintain satisfying interpersonal relations? Is the patient able to assume usual roles? Anita recalls the help she experienced when she was treated in adolescence for panic disorder. CASE STUDY “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 the thing Betsy did next saved me that night.” AUDIENCE RESPONSE QUESTION Which was probably “the thing Betsy did next” that helped 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? Biological: Pharmacotherapy TREATMENT MODALITIES • Antidepressants • Anti-anxiety drugs • Other classes Integrative medicine Psychological therapies • Behavioral therapy • Cognitive-behavioral therapy • Biological: Pharmacotherapy • SSRIs and SNRIs TREATMENT MODALITIES • Antianxiety drugs • Other categories • Children & adolescents Integrative Medicine PSYCHOLOGICAL THERAPIES • Behavioral therapy • Modeling • Systematic desensitization • Flooding • Thought stopping Cognitive-behavioral therapy OBJECTIVES Describe clinical manifestations of obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder. Identify risk factors that may contribute to obsessivecompulsive disorders. Anton comes to the behavioral health clinic, asking for help. CASE STUDY “I know this sounds weird,” he tells the nurse, ”but I have to carry tissues with me everywhere. If I don’t have a pocket packet of tissues, even if I am late for work, I have to turn around and go back home. I mean, I was late for my own wedding rehearsal and dinner, and I thought my fiancée was going to break up with me for that. But I had to have those tissues.” OBSESSIVECOMPULSIVE DISORDERS Obsessions Compulsions Thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety OBSESSIVECOMPULSIVE DISORDERS (CONT.) • DSM-5 Criteria for ObsessiveCompulsive Disorder • Obsessions, compulsions or both • Not due to a substance or condition • Not explained by another psychiatric disorder • Time-consuming (in excess of 1 hour per day) • Obsessive-compulsive disorder OBSESSIVECOMPULSIVE DISORDERS (CONT.) • Body dysmorphic disorder • Hoarding disorder • Trichotillomania (hair pulling) disorder • Excoriation (skin picking) disorder • Body Dysmorphic Disorder • False assumptions about appearance OBSESSIVECOMPULSIVE DISORDERS (CONT.) • Fear of rejection • Perfectionism • Hoarding Disorder • Obsessive accumulation of objects • Letting go of any item is painful • Collecting has consumed life; individual is alienated • Trichotillomania and Excoriation Disorder OBSESSIVECOMPULSIVE DISORDERS (CONT.) • Body-focused repetitive behaviors • Hair pulling (trichotillomania) • Skin picking (excoriation disorder) • Excoriation: picking at skin on face, head, cuticles, back, limbs, hands and feet to point of damage • Other Compulsive Disorders • Medication- or substance-related • Medical condition-related Child abuse & trauma RISK FACTORS FOR OCD Post-infectious autoimmune syndrome. Genetics: First-degree relatives = twice the risk Comorbidity with anxiety disorders, eating disorders, and/or tic disorder CASE STUDY When asked if he can expand on why he feels a need to carry tissues everywhere, Anton says, “I need them to open doors and clean dishes when I don’t eat at home. Whether it’s a door knob or a fork or dish in a restaurant, I swipe it three times with three different tissues—1-23—like that. I don’t feel safe without doing that. Sometimes if I don’t have a tissue, I can barely stand to open a door “But that’s not all. At work or in a meeting, if I sit down and don’t swipe the desk or table three times, I feel like it’s not going to go well.” AUDIENCE RESPONSE QUESTION Anton’s symptoms are most indicative of which disorder? A. Hoarding disorder B. Body dysmorphic disorder C. Generalized anxiety disorder D. Obsessive-compulsive disorder OBJECTIVES Formulate four priority nursing diagnoses that can be used in treating patients with obsessive-compulsive disorders. Propose realistic outcome criteria for patients with obsessive-compulsive disorder. Describe three basic nursing interventions used for patients with obsessivecompulsive disorders. OBJECTIVES (CONT.) Discuss the classes of medications used to treat obsessive-compulsive disorders. Describe psychological therapies for obsessivecompulsive disorders. Assessment • Self-assessment NURSING PROCESS Nursing Diagnosis • • • • • Anxiety Impaired skin integrity Disturbed body image Risk for self-destructive behavior Risk for impaired socialization, fear, difficulty coping, and chronic low self-esteem • Outcomes Identification • Reduced anxiety NURSING PROCESS (CONT.) • Improved skin integrity • Reduced self-destructive behavior • Improved body image • Improved socialization • Reduced fear • Improved coping • Improved self-esteem • Basic-Level Nursing Interventions • Promotion of self-care activities NURSING PROCESS (CONT.) • Monitor skin integrity for excoriation or trichotillomania disorder • Health teaching, including the importance of taking bathroom breaks • Monitor for urinary tract infections and create a regular schedule for the patient to use the bathroom NURSING PROCESS (CONT.) • Advanced Practice Nursing Interventions • Flooding • Cognitive-behavioral therapy • Exposure-and response prevention Biological Treatments • SSRIs for OCD (FDA-approved) • Others: Clomipramine (TCA), Venlafaxine (SNRI) TREATMENT MODALITIES • Some antipsychotics • None for: Body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation disorder • Exceptions: • SSRIs can be helpful in those disorders displaying obsessive-compulsive features in these other disorders • Surgical treatments TREATMENT MODALITIES (CONT.) • Gamma Knife: creates lesions to form a disconnect of overactive circuits • Deep brain stimulation (DBS): implanted pulse generator uses low-dose current to reduce symptoms Exposure and response prevention PSYCHOLOGICAL THERAPIES • First-line cognitive-behavioral intervention for obsessivecompulsive behaviors • Expose patient to triggers of OCD symptoms • Message: anxiety does subside even when the ritual is not completed Flooding • Expose patient to large amount of trigger to extinguish response CASE STUDY At first, Anton resists the idea of needing medication. He says, “I mostly wanted to discuss how to get a better handle on things with a therapist.” However, once the therapist connected well with Anton, he became willing to at least try paroxetine (Paxil), and now he is seeing small improvements in his levels of distress if he does not wipe the desk in front of him before a meeting. He still carries tissues for doorknobs and cutlery. AUDIENCE RESPONSE QUESTION As Anton begins to feel less anxious with the use of Paxil, his therapist sets out a plate, fork and glass on the table between them and asks Anton to challenge himself to rest his hand on one of these objects for the entire hour without using a tissue. This is an example of: A. Flooding B. Relaxation therapy C. Cognitive restructuring D. Exposure and response prevention
