Anxiety and Obsessive-Compulsive Disorders
Objectives:
 Differentiate between Anxiety, OCD and related disorders
 Develop priority nursing interventions for anxiety, OCD and related disorders
 Determine priority client education and safety concerns of anxiety medications
 Identify side effects psychotropic drugs versus symptoms of mental illness





Anxiety Disorders
Anxiety or fear is excessive or out of proportion to the situation causing it.
Interfere with the ability to work, relationships, and physical functioning.
Most common of all psychiatric disorders
Differentiated by the situations or objects that provoke anxiety, fear, or avoidance behaviors
Major neurotransmitters involved serotonin, decreased GABA, increased norepinephrine.
Panic Disorder
At least 1panic attack followed by 1 month or more of worry about future attacks.
 Severity and frequency of attacks vary.
 Onset rapid, unpredictable, and intense
 4 or more symptoms:
Palpitation, SOB, choking sensation, chest pain, nausea, feeling of dying or insanity, chills or hot
flashes, paresthesia, derealization (feeling of unreality) or depersonalization (being detached from
oneself), sleep disturbances
 Attacks do not occur immediately before or after exposure to a situation that causes anxiety as in
specific phobia but can become associated with situations
 Not triggered when a person is a focus of attention as in social anxiety
 Nervousness and apprehension between attacks
 May have depression
 Begins in early adulthood
 Prognosis excellent with early treatment
 Agoraphobia can occur with Panic Disorder
 FDA treatment SSRIs
General Anxiety Disorder (GAD)
Uncontrollable, chronic, unrealistic, and excessive anxiety and worry about several events or activities
that are difficult to control (generalized not specific) during most of the day for at least 6 months.
Symptoms could include:
 Procrastination
 Avoidance of stressful activities/events
 Muscle tension, restlessness or feeling “on edge”
 Feel hopeless and frustrated.
 Can be associated with depressive symptoms
Separation Anxiety Disorder
Lasts 6 months or more excessive fear or anxiety when separated from home or an individual which the
client is emotionally attached
 Anxiety is more than what is expected for the individual’s developmental level.
Page 1
Anxiety and Obsessive-Compulsive Disorders


Lasts 4 weeks in children and adolescents
Attachment figures may include the children of adults with separation anxiety disorders
 Symptoms include HA, N/V, and sleep disturbances.
 Does not provide pleasure or gratification
Anxiety Disorder due to General Medical Condition
 Generalized anxiety symptoms, panic attacks or obsessions or compulsion
 Symptoms are the direct physiological result of general medical conditions such as
o Cardiac conditions such as MI, CHF, or mitral valve prolapse
o Endocrine disorders such as hypoglycemia, hyper/hypothyroidism, pheochromocytoma
o Respiratory conditions such as COPD, pulmonary embolism
o Neurological conditions such as neoplasms, complex partial seizures











Substance Induced Anxiety Disorder
Major anxiety symptoms in excessive of those usually associated with the direct physiological
effects of a substance either from current use or from withdrawal
Examples include alcohol, sedatives, anxiolytics, amphetamines, cocaine, hallucinogens, caffeine
Nursing Interventions for All Anxiety and Related Disorders
Establish rapport with client
Reassure of safety and security
Maintain a calm approach
Structure environment so client can stay focused
Assess level of anxiety and follow the interventions under anxiety handout
Allow client to determine amount of stress they can handle at first.
Once anxiety is at an acceptable level use (mild to moderate -use interventions in anxiety level
handout)
o Cognitive Behavior Therapy (CBT)-positive reframing, decatastrophizing, and assertiveness
training
Phobic Disorders
Persistent chronic irrational fear in the presence or anticipation of a specific object, activity, or
situation resulting in intense anxiety that worsens or spreads if untreated
May recognize the fear is irrational but feel powerless to control it.
Agoraphobia
The true fear is separation from a source of security.
 Fear or anxiety about 2 or more of the following 5 situations for 6 months or more
o Using public transportation
o Being in open/enclosed spaces
o Standing in line or being in a crowd
o Being outside of the house alone
o Believe something terrible will happen and no escape
Page 2
Anxiety and Obsessive-Compulsive Disorders





This leads to avoidance
Usually occurs in 20s and 30s
Most resistant to treatment of all phobias
Does not involve only social situations
Not related to obsessions, perceived defects in physical appearance or reminders of trauma or fear of
separation
Social Anxiety Disorders
Excessive fear of situations lasts 6 months or more in which a person may be embarrassed or evaluated
negatively by others such as performing in front of others, social interactions, or being observed
 Exposure to the situation results in panic, anxiety or fear with sweating, tachycardia, and dyspnea.
 Symptoms start in late childhood or early adolescence stage.
 Usually only avoid one or two situations
 Self -help techniques include mental rehearsing and visual imagery.
Specific Phobia Disorder
Persistent excessive, inappropriate, and unreasonable fear in the presence of or anticipating an encounter with
a specific object or situation that could cause injury.
 Reactions are excess and inappropriate.
 Symptoms of exposure to phobic object includes palpations, sweating, dizziness, and difficulty breathing
 May have fears of losing control, panicking, or fainting when exposed to object
 Types include
o Animal type
o Natural environment-heights, storms, water
o Blood-injection-injury type
Specific phobias can begin at any age (sometimes in childhood only to reappear in 20s)











Nursing Interventions for Phobias
Initially, do not force anxious client to confrontation avoided situations or phobic objects, allow
client to determine amount of stress they can handle at first
Do not reinforce phobia (do not focus on phobic behaviors)
Explore client’s perception of the threat to physical integrity or threat to self-concept.
Once anxiety at acceptable level discuss the situation with client to recognize the aspects that cause
feat that can be changed and those that cannot
Provide structure in the day
Include client in decision making related to alternate coping strategies
If client wants to work on elimination of fear (example leaving home alone) can use
o Systematic Desensitization-expose the client to a hierarchy of feared items in a situation and
gradually expose the client in a safe environment while using relaxation techniques
o Flooding- Rapid desensitization, no relaxation techniques used
o Cognitive Behavioral therapy (CBT)- cognitive restructuring
Assist the client to function in the situation or event without experiencing panic
Instill hope and enhance self-esteem
Encourage client to explore underlying feelings that contribute to irrational fears
Expressing feelings result in more adaptive coping abilities
Page 3
Anxiety and Obsessive-Compulsive Disorders









Obsessive-Compulsive Disorders (OCD)
Compelled to perform rituals to avoid an extreme increase in anxiety
Experience recurrent obsessions or compulsions or both that are severe enough to be timeconsuming (take more than 1 hour a day), causing distress or significant impairment
Obsessions: inappropriate, unwanted, intrusive, persistent ideas, thoughts, impulses or images that
cause marked anxiety or reoccurring disturbing thoughts
Compulsions: uncontrolled persistent act/behavior ritualistic in nature that do not provide pleasure
or gratification such as repetitive hand washing, constant straightening of things or mental acts such
as praying or counting silently to relieve fear connect to obsession that result in difficulty meeting
self-care needs
Ritualistic actions often performed in the home and not readily apparent to others
Depression and substance abuse associated with OCD
Five categories-washers, checkers, doubters and sinners, counters and arrangers, and hoarders.
Common defense mechanisms are undoing, isolation, displacement and reaction formation.
Chronic in nature but waxes and wanes
Body Dysmorphic Disorder
Preoccupation with an exaggerated or imagined belief that the body is deformed or defective in some
specific way not related to concerns of body fat or weight
 Most complaints regard face or head
 A defect may be present, but it is exaggerated and causes excess concern
 Results in repetitive behaviors (such as checking a mirror) or mental acts (comparing self with
others) in response to preoccupation
 Cognitive restructuring to change irrational thoughts may reduce preoccupation with thoughts
 Depressive symptoms and OCD personality disorder are common.
Hoarding Disorders
Persistent difficulty discarding or parting with possessions due to a perceived need to save the items
regardless of actual value resulting in functioning distress.
 May result in excessive acquisition.
 Results in social and occupational impairment and possible unsafe living conditions
 More men than women affected, severity increases with age
Trichotillomania (Hair Pulling Disorder)
Recurrent pulling out of hair resulting in hair loss
 Impulse is preceded by increased tension and results in a sense of release or gratifications from
pulling out hair on the scalp, eyebrows, and eyelashes
Excoriation Disorders (Skin picking)
Recurrent picking of skin resulting in scabs and scars
 Impulse is preceded by increased tension and results in a sense of release or gratifications from
picking skin
Examples of Responses to Anxiety and Related Disorders and OCD
Page 4
Anxiety and Obsessive-Compulsive Disorders














Fear
Powerlessness
Anxiety
Social Isolation
Ineffective Coping
Ineffective Impulse Control
Ineffective Role Performance
Disturbed Body Image
Nursing Interventions for OCD Disorders
Initially allow ritualistic behaviors, be nonjudgmental, noncritical till anxiety at acceptable level
 Initially meet dependency needs but encourage independent behaviors with positive reinforcement
o Gradually eliminate time allotted for ritualistic behavior as client becomes involved in treatment
by providing structured activities including time for completion of rituals
o Assist client to complete daily activities and routines within agreed upon time limits
Support client in the exploration of the meaning and purpose of the behavior
Give positive reinforcement and support for nonritualistic behavior
Encourage recognition of situations that provoke anxiety (triggers), obsessive thoughts that result in
ritualistic behavior. Explain ways of interrupting the thoughts and ritualistic patterns
o Thought stopping-interrupt obsessive thoughts by saying “Stop” aloud or silently
o Relaxation techniques-people OCD have difficulty sleeping relaxation techniques may improve
sleeping
o Cognitive restructuring-reconstruct dysfunctional thoughts, identify the automatic thoughts then
the connection between the thoughts and the emotions felt and behaviors
o Physical activity
Once anxiety decreases refer to or plan groups related to stress management, recreational, social
skills and codependency.
Exposure and Response Prevention (ERP)- involves exposure to the feared stimuli (exposure )
and simultaneous prevention of the ritual that is typically performed in the face of the anxietyprovoking stimuli or obsession (response prevention), focuses on preventing the client from
performing a compulsive behavior with the intent the anxiety will decrease. Client becomes aware it
takes less time to let the anxiety decreased then to perform the ritual.
Nursing Interventions for Disturbed Body Image
Assess client’s perceptions
If there is an actual change in structure or function of body encourage client to progress through
stages of grief
Realize exaggerated image is real to client but:
o Correct inaccurate perceptions or distortions in a matter-of-fact nonthreatening manner
o Withdraw attention when preoccupation with distorted image persists
Provide positive reinforcement for client’s expressions of realistic body image
Nursing Interventions for Hair Pulling or Skin Picking
 Support client in her effort to stop hair pulling or hair pulling
 Ensure a nonjudgmental attitude is maintained and criticism of behavior is avoided
 Habit Reversal Training (HRT)
o Awareness training-recognize urges, thoughts or sensations that precede hair pulling
Page 5
Anxiety and Obsessive-Compulsive Disorders
o Complete response training where the client learns to substitute another response to the urge to
pull their hair. Example putting hands into fist or hold something in their hand so they cannot pull
hair
o Social support -encourage family to participate and offer positive feedback
 Practice stress management techniques
 Offer support and encouragement when setbacks occur. Important not to quit










Non-pharmacological Treatment Anxiety Related and Obsessive-Compulsive Disorders
Individual psychotherapy
o Stress the importance of maintaining contact with community and supportive organizations
o Describe time management techniques such as “to do lists”
o Discuss positive coping strategies
Cognitive Behavior Therapy most successful
o Reduce anxiety responses by altering cognitive distortions
o Try identifying individual’s negative appraisals that produce self-doubt, negative evaluations, and
negative predictions techniques include cognitive reframing, decatastrophizing, assertiveness
training, and thought stopping
 Brief and time limited
 Structured and focused
Behavior Therapy
o Relaxation therapy-progressive relaxation, mental imagery, meditation
o Systematic desensitization
o Implosion (flooding)
o Reciprocal inhibition
o Modeling
o Self-exposure therapy
o Exposure and Response Prevention (ERP)
o Habit-Reversal therapy (HRT)
Stress Management
Marital and Family Therapy
Supportive Services including crisis hotlines and support groups
Psychopharmacology
Psychotropic drugs - chemicals that affect the brain and nervous system altering feelings, emotions, and
consciousness. Not intended to “cure” mental illness, only relieve physical and behavioral symptoms
Produce changes in cell function in the central nervous system (CNS), which permit new behaviors
Most psychotropic drugs produce effects by altering the synaptic concentration of dopamine,
acetylcholine, norepinephrine, serotonin, histamine, GABA or glutamate.
Effects result from receptor antagonists (interfering with an action) or agonist (mimicking an action) thus
interfering with neurotransmitter release or inhibition of enzymes.
Major Classifications of Psychotropic Drugs
Anxiolytics (antianxiety) agents
Mood Stabilizers
Antidepressants
Antipsychotics
Antihistamines
Page 6
Anxiety and Obsessive-Compulsive Disorders
Antianxiety (Anxiolytics) Agents
Benzodiazepines
Action: Binds to BZ receptor on GABA, enhances the inhibitory effect of GABA in CNS by increasing the
affinity of the GABA receptors for GABA, works quickly, use short term, narrow margin of safety,
overdose potential
Uses: relieve anxiety, produced sedation, GAD and Panic disorders, seizure disorders, sleep disorder,
alcohol withdrawal, muscle spasm, induction anesthesia and prior to surgery
Side effects: lightheadedness, motor impairment (ataxia), amnesia, GI upset, and memory impairment,
confusion, dependency with long-term use
Toxicity IV: respiratory depression, hypotension, cardiac arrest
Flumazenil (Romazicon) reverses the sedation and adverse effects of benzos
Paradoxical response: paradoxical (increased agitation or anxiety)
Withdrawal: Need to taper drugs otherwise delirium, insomnia, diaphoresis, tremors, lightheadedness and
seizures, life threatening
Contraindications: Pregnancy, sleep apnea, respiratory depression, glaucoma, suicidal tendencies
Use cautiously: liver disease, Substance Use Disorder,
Client education:
Do not discontinue abruptly. Take with food, do not crush or chew, discuss potential for dependency, do
not use with alcohol, CNS depressants, avoid hazardous activities driving etc.
Decreased effectiveness with cigarette smoking and caffeine consumption
Increased effectiveness when mixed with alcohol, barbiturates, narcotics, antipsychotics, antidepressants
and antihistamines, cimetidine (Tagamet), disulfiram (Antabuse) and herbal remedies like Kava Kava and
valerian
Nursing Considerations: Adjunct to Psychotherapy
Diazepam (Valium), midazolam (Versed), lorazepam (Ativan) work fast and wear off quickly so effective
for panic attacks and status epilepticus because out of the liver (OTL) quickly
Chlordiazepoxide (Librium), clonazepam (Klonopin) used for long-term management panic disorder and
alcohol withdrawal (prophylaxis delirium tremens
Poor metabolizers of CYP3A4 at risk for increased respiratory depression, torsade de pointes,
hallucinations, increase sedation
Atypical Nonbarbiturate Buspirone (Buspar)
Action: Thought to bind to serotonin and dopamine receptors, less sedating, less dependency, response is
slow slag time of 10 to 14 days full results 2-6 weeks, not for prn use
Uses: GAD first line treatment
Side Effects: dizziness, HA, lightheadedness, nausea, agitation
Contraindications: Pregnancy breast feeding, do not use concurrently with MAOIs or 14 days before or
after as causes hypertension, do not take with grapefruit juice, erythromycin, St John’s Wort
Use cautiously: Older adults, liver or renal dysfunction
Client Education: Take with meals, take same time each day, Effects do not happen immediately,
Tolerance, dependency, and withdrawal not an issue, does not interfere with activities like benzos. Do not
take with grapefruit juice as decreases drug metabolism. Do not use with erythromycin
Select Serotonin Reuptake Inhibitors
Action: Inhibits serotonin reuptake (5HT), does not block reuptake of dopamine and norepinephrine, up to
Page 7
Anxiety and Obsessive-Compulsive Disorders
4 weeks to client sees full therapeutic effects
Uses: Panic and PTSD
Paroxetine (Paxil): GAD, OCD, Social Anxiety Disorder, PTSD, Depression, Adjustment Disorders,
Phobias
Sertraline (Zoloft): GAD, Panic Disorder, OCD, Social Anxiety Disorder, PTSD, Phobias
Fluoxetine (Prozac): Panic Disorder, OCD, PTSD, Social Anxiety Disorder, Body Dysmorphic Disorders
Escitalopram (Lexapro): OCD, GAD, PTSD, social anxiety disorder
Fluvoxamine (Luvox): OCD, Social Anxiety Disorder, Panic, PTSD
Side Effects: Early: dry mouth, nausea, diarrhea, fatigue, tremor, drowsiness that usually subside
Late: Weight gain, HA, and sexual dysfunction
Also: GI Bleeding in clients with history of GI bleed or taking anticoagulants, hyponatremia if taking
diuretics, bruxism (grinding teeth),
Withdrawal: Taper medications slowly
Contraindications: pregnancy, client taking MAOIs, TCAs, alcohol
Liver and renal disease, seizure disorder or GI bleeding, use with caution if client has Bipolar as may switch
to mania
Client Education: Take with food, Instruct client concerning early and late side effects, report sexual
dysfunction can modify dose, medication holiday or switch drugs, Monitor weight, eat a well-balanced diet,
exercise, report signs of GI bleeding, obtain baseline sodium and monitor periodically, report bruxism to
physician can use buspirone, mouth guard or switch medication to treat, advise client not to suddenly stop
SSRIs.
Interactions: Use of MAOIs, TCAs, and St John’s Wort increase risk of serotonin syndrome, Warfarin and
SSRIs increased warfarin levels so check PT, INR levels, SSRIs with TCA and Lithium increase TCA and
Lithium levels,
SSRIs and NSAIDs and anticoagulants suppress platelet aggregation leading to bleeding monitor signs of
bleeding
 Serotonin Syndrome: Increase level of serotonin usually resulting from taking other medications that
also increase serotonin levels.
Signs and symptoms are agitation, confusion, difficulty concentrating, anxiety, hyperreflexia, fever,
diaphoresis, hallucinations, tremors, incoordination starts 2 hours to 3 days after starting new drug, resolves
after stopping the drug.
Muscle relaxants that block serotonin decrease the symptoms
 Serotonin syndrome with any drug that increases serotonin
o Immediately discontinue mediation
o Prescribe medications to block serotonin receptors such as cyproheptadine (Periactin) an
antihistamine and serotonin blocker
o Monitor vital signs, provide safety to prevent injury with muscle hyperreflexia and change in
mental status, tepid bath and cooling blankets for temperature regulation, monitor I & O
o Severe serotonin syndrome requires supportive care first with benzodiazepines, agents to
control hypertension/tachycardia, and sometimes airway management
o if untreated may progress to seizures, coma, hypertension, arrhythmias, DIC, (disseminated
intravascular coagulation), rhabdomyolysis, metabolic acidosis, renal failure
 SSRIs increase effects of buspirone and digoxin
Serotonin Norepinephrine Reuptake Inhibitors SNRIs
Action: Inhibit the reuptake of serotonin and norepinephrine and minimal inhibition of dopamine
Venlafaxine (Effexor SR), Duloxetine (Cymbalta), Desvenlafaxine (Pristiq)
Page 8
Anxiety and Obsessive-Compulsive Disorders
Uses: Major Depressive Disorders, GAD and Panic Disorders
Side effects: dry mouth, HA, nausea, agitation, sleep disturbances
Also: Hyponatremia in older adults taking diuretics, anorexia resulting in weight loss, hypertension, sexual
dysfunction
Contraindications: Pregnancy, MAOIs, alcohol, Duloxetine should not be used in those with hepatic
disease or those that drink alcohol
Client Education: Do not abruptly stop taking drug or will have withdrawal symptoms should be tapered,
SNRIs should be taken with food. Take daily to keep up therapeutic levels, takes up to 4 weeks to get
therapeutic effects, do not drink with Duloxetine.
Select Antihypertensives
Action: Depends on the type of antihypertensive but calms the CNS system and decreases the physical
symptoms of anxiety such as tremors, diaphoresis, and tachycardia.
Beta Blockers such as Propranolol (Inderal) with SSRIs
Centrally acting alpha blockers such as Prazosin (minipress)
Centrally acting alpha-agonist hypotensive agents: Clonidine (Catapres)
Uses: Panic disorder, Social Anxiety Disorder, Prazosin -PTSD
Side effects: hypotension, dry mouth, sedation. Propranolol can cause insomnia, hallucinations, impaired
metabolism of other drugs and/or lethargy or depression.
Client Education: : Monitor B/P, hard candy for dry mouth
Select Antihistamines
Action: Acts as CNS depressant at a subcortical level, blocks the H1 receptors for histamine
Uses: Hydroxyzine (Vistaril, Atarax), diphenhydramine (Benadryl) treat lower levels of anxiety and have
no physical dependence. Not as effective as benzos
Side effects, sedation and substantial weight gain causing possible insulin resistance and lipid metabolism
Client Education: May produce sedation avoid activity requiring alertness and concentration,
anticholinergic side effects, and decreased seizure threshold, encourage well-balanced diet and exercise.
Antianxiety (anxiolytics) Medications
Class
Benzodiazepine
Generic
Chlordiazepoxide
Diazepam
Oxazepam
Lorazepam
Alprazolam
Clonazepam
Trade Name
Librium
Valium
Serax
Ativan
Xanax
Klonopin
Antihistamine
Hydroxyzine
Diphenhydramine
Atarax, Vistaril
Benadryl
Nonbarbituate anxiolytic
Beta-adrenergic blocker
Buspirone
Propranolol
Buspar
Inderal
Barbiturates
Secobarbital
Pentobarbital
Seconal
Nembutal
Page 9
Anxiety and Obsessive-Compulsive Disorders
Complementary and Integrative Therapies
Complementary and alternative medicine (CAM): healing philosophies, approaches, and therapies,
that focus on the entire client; include biopsychosocial & spiritual aspects
 Used alone called alternative medicine
 Combined with other therapies referred to as complementary or integrated medicine
 Anxiety and depression among top six conditions for which adults accessed CAM
 Most clients did not tell their PCPs they are using CAM
 Safety Implications -research findings have alerted the public to potential dangers of certain CAM
therapies, particularly some herbal medicines
 Serious medical events from the use of ephedra, an over-the-counter stimulant, prompted Food and
Drug Administration (FDA) to implement restrictions on ephedra products
 Serious interactions possible when combining herbal products and conventional medications
 No FDA control, lack of quality control for herbal products
 Some CAM have unfounded/exaggerated claims about safety and effectiveness
 Many people use these therapies without first consulting health care professional
Examples: Herbs
o St John’s Wort-believed to modulate serotonin, norepinephrine and dopamine, risk of developing
serotonin syndrome, interacts with other meds so do not take with antidepressants, birth control
bills, digoxin
o Kava Kava-interfere with dopaminergic transmission, MAO-B enzyme, modulates GABA
receptors, can cause liver injury, thrombocytopenia, leukopenia, and hearing impairments.
o Valerian- product for insomnia. Side effects: potentiates other CNS depressants, blurred vision,
research indicates relatively safe, but some studies indicate it can cause hepatoxicity
Dietary supplements-neurotransmitters are made from foods we take in, nutritional deficits can cause
psychiatric disorders. Fatigue, apathy, and depression are caused by deficits in iron, folic acid,
magnesium, vitamin C, and biotin.
o Melatonin-sleep
o Tryptophan-precursor for serotonin low levels cause depression and aggression
Nursing Implications
 CAM therapies can impact psychiatric nursing practice
 Many are beneficial, safe, cost effective, easily implemented in psychiatric settings
 Advance practice nurses can prescribe and implement CAM
 Nurses should follow research literature regarding their effectiveness and safety
Role of Nurse- Provide up-to-date knowledge, evidence-based CAM
o When offering or referrals for CAM mental health care, must consider clinical judgments, client
expectations, liability
o Clients must be informed about risks and benefits of CAM, and implications regarding delay
of conventional therapies
cdillen 1/2021
Page 10