Chapter 26: Anxiety,
Obsessive-Compulsive,
Trauma, and Stressor-Related
Disorders
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Anxiety
• Uncomfortable feeling of apprehension or dread
in response to internal or external stimuli
• Physical, emotional, cognitive, and behavioral
symptoms (refer to Box 26.1)
• Normal vs. abnormal
• Factors that determine if a symptom of mental
disorder:
– Intensity of anxiety related to situation
– Trigger for anxiety
– Symptom clusters manifested (refer to Table
26.1)
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Overview of Anxiety Disorders
• Most common of the psychiatric illnesses; chronic
and persistent
• Women experience anxiety disorders more often
than men
• Association with other mental or physical
comorbidities such as depression, heart disease, and
respiratory disease.
• Most common condition of adolescents
• Prevalence decreasing with age
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Anxiety Disorders
• Panic disorder
• Obsessive-compulsive disorder (OCD)
• Generalized anxiety disorder (GAD)
• Acute stress disorder (ASD)
• Posttraumatic stress disorder (PTSD)
• Phobias
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Panic Disorder
• Extreme, overwhelming form of anxiety often
experienced when an individual is placed in a
real or perceived life-threatening situation
• Panic normal during periods of threat; abnormal
when continuously experienced in situations of
no real physical or psychological threat
• Panic attacks: sudden, discrete periods of
intense fear or discomfort accompanied by
significant physical and cognitive symptoms
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Diagnostic Criteria
• Recurrent and unexpected panic attacks and 1
month or more after an attack of one of the
following:
– Persistent concern about having another attack
– Worry about implications of attack or
consequences
– Significant changes in behavior because of fear
of the attacks
• With agoraphobia (fear of open spaces)
• Without agoraphobia (refer to Key Diagnostic
Characteristics 26.1)
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Epidemiology
• Risks: female; middle aged; low socioeconomic
status, and widowed, separated or divorced
• Higher rates in whites than other races
• Other risk factors: family history, substance and
stimulant use or abuse, smoking tobacco,
severe stressors
• Several anxiety symptoms + experience of
separation anxiety during childhood  panic
disorder later in life
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Etiology
• Biologic theories
– Genetic factors
– Neuroanatomic theories
– Biochemical theories
• Serotonin and norepinephrine; GABA
• Hypothalamus–pituitary–adrenal (HPA) axis
• Psychological and social theories
– Psychoanalytic and psychodynamic theories
– Cognitive behavioral theories
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Question
Is the following statement true or false?
• Panic is considered abnormal regardless of
the situation and degree of threat.
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Answer
False.
• Panic is considered normal during periods of
threat; it is considered abnormal when it is
continuously experienced in situations of no
real physical or psychological threat is
present.
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Interdisciplinary Treatment of Panic
Disorder
• Safe and therapeutic environment
• Medication and monitoring of effects
• Individual psychotherapy
• Psychological testing
• Priority care issues: safety because of a high
risk for suicide
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Nursing Management for the Biologic
Domain
• Assessment
• Nursing diagnoses
– Rule out lifethreatening
medical causes;
symptom
evaluation
– Substance use
– Sleep patterns
– Anxiety
– Risk for Self-Harm
– Social Isolation
– Powerlessness
– Ineffective Family
Coping
– Physical activity
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Nursing Management for the Biologic
Domain (cont’d)
• Interventions
– Breathing control
– Nutritional
planning
– Psychopharmacolo
gy (refer to Table
26.4)
– Relaxation
techniques (refer
to Box 26.4)
– Increased physical
activity
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• SSRIs, SNRIs
• TCAs
• MAOIs)
• Benzodiazepin
es (refer to
Box 26.5)
Nursing Management for the
Psychological Domain
• Nursing diagnoses
• Assessment
– Self-report scales
(refer to Box 26.6
and Table 26.3)
– Anxiety
– Mental status exam
– Social Isolation
– Cognitive thought
patterns:
catastrophic
misinterpretations
(refer to Table
26.4)
– Powerlessness
– Risk for Self-Harm
– Ineffective Family
Coping
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Nursing Management for the
Psychological Domain (cont’d)
• Interventions
– Trigger identification
– Distraction techniques
– Positive self-talk
– Panic control treatment
– Exposure therapy; systematic desensitization;
implosion therapy
– CBT
– Psychoeducation (refer to Box 26.8)
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Nursing Management for the Social
Domain
• Assessment
• Nursing diagnoses
– Family factors
– Social Isolation
– Cultural factors
– Impaired Social
Interaction
– Risk for Loneliness
– Interrupted Family
Processes
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Nursing Management for the Social
Domain (cont’d)
• Interventions
– Lifestyle reevaluation
– Time management
– Prioritizing or lists
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Panic Disorder: Emergency Care
• Stay with the patient
• Reassure him or her that you will not leave
• Give clear, concise directions
• Assist the patient to an environment with
minimal stimulation
• Walk or pace with the patient
• Administer PRN anxiolytic medications
• Afterward allow the patient to vent his or her
feelings
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Question
Which agent would a nurse least likely expect
to administer to a patient experiencing panic
disorder?
A. Fluoxetine
B. Sertraline
C. Imipramine
D. Buspirone
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Answer
D. Buspirone
• Buspirone is more likely to be prescribed for
a patient experiencing generalized anxiety
disorder. Fluoxetine, sertraline, and
imipramine are used to treat panic disorder.
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Obsessive-Compulsive Disorder
• Obsessions
– Excessive, unwanted, intrusive, and persistent
thoughts, impulses, or images causing anxiety
and distress
– Not under the patient’s control; incongruent with
the patient’s usual thought patterns
• Compulsions
– Repeatedly performed behaviors in a ritualistic
fashion
– Goal of preventing or relieving anxiety and
distress caused by obsessions
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Diagnostic Criteria
• Presence of obsessions or compulsions
• Patient recognition that thoughts and actions
are unreasonable or excessive
• Thoughts and rituals causing severe disturbance
in daily routines, relationships, or occupational
function; time consuming, taking longer than 1
hour a day to complete
• Thoughts or behaviors not a result of another
Axis 1 disorder
• Thoughts or behaviors not a result of the
presence of a substance or a medical condition
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Clinical Course and Epidemiology
• Onset in the early 20s to mid-30s with
symptoms often beginning in childhood
• Gradual symptom onset
• Men affected more often as children and most
commonly affected by obsessions
• Women with a higher incidence of checking and
cleaning rituals, with onset typically in the early
20s
• Lifetime prevalence of 2.0%
• All ages affected; lifelong illness
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Etiology
• Biologic theories
– Genetic
– Neuropathology
– Biochemical
• Psychological theories
– Psychodynamic
– Behavioral
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Nursing Management for the Biologic
Domain
• Assessment
• Nursing diagnoses
– Multiple physical
symptoms
– Dermatologic
lesions
– Anxiety
– Impaired Skin
Integrity
– Osteoarthritis
joint damage
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Nursing Management for the Biologic
Domain (cont’d)
• Interventions (cont’d)
• Interventions
– Skin integrity
maintenance
– Education about
medications
– Psychopharmacology
– Electroconvulsive
therapy
• Clomipramine
• Sertraline
– Psychosurgery
• Fluvoxamine
• Paroxetine
• Fluoxetine
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Nursing Management for the
Psychological Domain
• Assessment
– Type and severity of obsessions and
compulsions
– Distraction by obsessional thoughts
– Dressing and grooming
– Speech-circumferential speech
– Degree to which symptoms interfere with daily
functioning (refer to Box 26.11)
• Yale-Brown Obsessive Compulsive Scale
• Maudsley Obsessive-Compulsive Inventory
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Nursing Management for the
Psychological Domain (cont’d)
• Nursing diagnoses
– Hopelessness
– Loneliness
– Powerlessness
– Self-Concept
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Question
A patient with OCD has a fear of
contamination. Which nursing diagnosis
would be a priority?
A. Impaired Skin Integrity
B. Hopelessness
C. Ineffective Role Performance
D. Social Isolation
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Answer
A. Risk for impaired skin integrity
• Although hopelessness, ineffective role
performance, and social isolation may be
appropriate, fear of contamination, the
most common obsession, results in
compulsive hand washing, placing the
patient at risk for impaired skin integrity.
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Nursing Management for the
Psychological Domain (cont’d)
• Interventions
– Response prevention
– Thought stopping
– Relaxation techniques
– Cognitive restructuring
– Cue cards (refer to Box 26.13)
– Psychoeducation (refer to Box 26.14)
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Nursing Management for the Social
Domain
• Assessment
– Sociocultural factors and the patient’s ability to
relate to others
• Nursing diagnoses: reflect areas involving role
conflict, sedentary lifestyle, social interaction
• Interventions
– Routines
– Recognition of significance of rituals
– Scheduling
– Marital and family support
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Generalized Anxiety Disorder
• Feelings of frustration, disgust with life,
demoralization, and hopelessness
• Sense of ill-being and uneasiness and fear of
imminent disaster
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Epidemiology
• Affecting nearly 4% of the population; lifetime
prevalence rate of 5%
• 25% have GAD and a primary or comorbid
diagnosis
• Twice as common in women than in men
• Insidious onset
• Individuals of all ages affected
• Typical onset (more than half) in childhood and
adolescence; onset after age 20 years also
common
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Diagnostic Criteria
• Excessive worry and anxiety for at least 6
months; anxiety related to a number of reallife activities or events
• Patient with little or no control over the
worry
• At least three of the following along with
excessive worry: sleep disturbance, easy
fatigueability, restlessness, poor
concentration, irritability, and muscle tension
• Significant impairment in daily personal or
social life
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Etiology
• Biologic theories
– Neurochemical theories
– Genetic theories
• Psychological theories
– Cognitive behavioral theory: inaccurate
environmental danger assessment
– Psychoanalytic theory: unresolved unconscious
conflicts
• Sociologic theories
– Possible contribution of high-stress lifestyle and
multiple stressful events
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Nursing Management for the Biologic
Domain
• Assessment
– Symptoms
– Diet and nutrition
– Sleep patterns
• Nursing diagnoses
– Insomnia
– Spiritual distress
– Role conflict
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Nursing Management for the Biologic
Domain (cont’d)
• Interventions
– Psychopharmacology
• Benzodiazepines (most common)
• Paroxetine, imipramine, venlafaxine
• Buspirone (BuSpar)
• Beta-blockers
– Teaching about medications
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Question
Is the following statement true or false?
• To meet the diagnostic criteria, a person
with GAD must experience excessive worry
and anxiety for a minimum of 3 months.
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Answer
False.
• To be diagnosed with GAD, a person must
experience excessive worry and anxiety for
at least 6 months.
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Nursing Management for the Psychosocial
and Social Domains
• Assessment and intervention
– Similar to those for panic disorder
– Combination of
•Relaxation
•Supportive therapies
•Cognitive therapies
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Acute Stress Disorder and Posttraumatic
Stress Disorder
• ASD: short-term disorder related to
experience of major trauma
• PTSD: long-term disorder related to
experience of major trauma
• Possible dysregulation of the hypothalamic–
pituitary–adrenal (HPA) axis as the basis for
the link
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Diagnostic Criteria
• ASD: stress-related symptoms occurring within 1
month of a traumatic event, persisting for at least
2 days and causing significant distress
• PTSD: symptoms of ASD persisting beyond 1
month
• Reexperiencing of event through distressing
images, thoughts or perceptions
• Recurrent nightmares
• Flashbacks
• Extreme stress on exposure to event or image
that resembles traumatic event
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Epidemiology
• PTSD: about 8% of population; rates highly variable
• Risk factors
– Prior diagnosis of ASD
– Extent, duration, and intensity of trauma
– Environmental factors
• Women twice as likely to experience PTSD than men
• Symptoms fluctuating in intensity, increasing during
periods of stress
• 27% of female and 35% of male veterans are
diagnosed with PTSD
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Etiology
• Biologic factors
– Neurobiology (stress response)
•Hyperarousal
•Intrusion
•Avoidance and numbing (dissociative
symptoms)
– Genetic theories
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Nursing Management
• Education about stress management:
relaxation techniques and meditation
• Cognitive behavioral therapy
• Exposure techniques (little empirical
evidence about efficacy)
• Group therapy
• Family therapy
• Social support
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Other Anxiety Disorders
• Specific phobia
– Persistent fear of clearly discernible,
circumscribed objects or situations leading to
avoidance behavior(refer to Box 26.3)
– Anxiolytics for short-term relief of anxiety
– Exposure therapy (treatment of choice)
• Social phobia
– Persistent fear of social or performance situation
in which embarrassment may occur
– SSRIs to reduce social anxiety and phobic
avoidance
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Question
A patient with PTSD startles easily and reacts
irritably to small annoyances. The nurse
interprets this as which of the following?
A. Hyperarousal
B. Intrusion
C. Avoidance
D. Numbing
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Answer
A. Hyperarousal
• Hyperarousal is manifested by being
hypervigilant for signs of danger, becoming
easily startled, reacting irritably to small
annoyances and sleeping poorly. Intrusion
refers to the individual continually
experiencing the event through flashbacks
and nightmares. Avoidance and numbing
reflect complete powerlessness by the
individual.
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Dissociative Disorders
• Responses to extreme external or internal events or
stressors; failure to integrate identity, memory, and
consciousness
• Types:
– Dissociative amnesia: inability to recall
– Dissociative fugue: unexpected travel away from
home
– Depersonalization disorder: being detached from
one’s body
– Dissociative identity disorder (multiple
personality disorder)
– Dissociative disorder not otherwise specified
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