Anxiety, Obsessive-Compulsive, and Related Disorders

Anxiety, Obsessive-Compulsive, and Related Disorders 150 150 Tony Guo

Anxiety, Obsessive-Compulsive, and Related Disorders

  • Anxiety is an emotional response to anticipation of danger, the source of which is largely unknown or unrecognized.
  • Anxiety is a necessary force for survival. It is not the same as stress.
  • A stressor is an external pressure that is brought to bear on the individual.
  • Anxiety is the subjective emotional response to that stressor.
  • Anxiety may be distinguished from fear in that anxiety is an emotional process, whereas fear is a cognitive one.

Historical Aspects

  • Anxiety was once identified by its physiological symptoms, focusing largely on the cardiovascular system.
  • Freud was the first to associate anxiety with neurotic behaviors.
  • For many years, anxiety disorders were viewed as purely psychological or purely biological in nature.

Epidemiological Statistics

  • Anxiety disorders are the most common of all psychiatric illnesses.
  • More common in women than in men
  • A familial predisposition probably exists.
  • 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

 

Application of Nursing Process

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
  • Attacks may last minutes or rarely hours and individual often experience varying degrees of nervousness and apprehension between attacks.
  • May or may not be accompanied by agoraphobia

Symptoms of panic attack

  • Sweating, trembling, shaking
  • Shortness of breath, chest pain, or discomfort
  • Nausea or abdominal distress
  • Derealization or depersonalization
  • Fear of dying
  • Dizziness, chills, or hot flashes
  • Numbness or tingling sensations
  • Fear of losing control or “going crazy”

 

Generalized anxiety disorder (G A D)

  • Characterized by chronic, unrealistic, and excessive anxiety and worry
  • The disorder may begin in childhood or adolescence, but onset is not uncommon after they turn 20. 

 

Predisposing factors: Panic attacks and G A D

Psychodynamic theory

  • Ego unable to intervene between id and superego
  • Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety
  • Use of defense mechanisms rather than coping and management skills result in maladaptive responses to anxiety

Cognitive theory

  • Faulty, distorted, or counterproductive thinking patterns result in anxiety that is maintained by mistaken or dysfunctional appraisal of a situation.
  • Individuals have loss of ability to reason regarding the problem and feels vulnerable in a given situation, and distorted thinking results in an irritation appraisal thus a negative outcome

Biological aspects

  • Genetics
  • Neuroanatomical
  • Biochemical
  • Neurochemical

 

Phobias

Agoraphobia

  • Fear of being vulnerable in places or situations from which escape might be difficult or in which help might not be available in the event of panic-like symptoms or other incapacitating symptoms.
    • Traveling in public transportation
    • Being in open spaces
    • Being in shops, theaters, or cinemas
    • Standing in line or being in a crowd
    • Being outside of the home alone in other situations

Social anxiety disorder (social phobia)

  • Excessive fear of situations in which the affected person might do something embarrassing or be evaluated negatively by others
  • Exposure to the phobic situation usually results in feelings of panic anxiety with sweating, tachycardia, and dyspnea.
  • It appears to be more common in women than in men.

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, including palpitations, sweating, dizziness, and difficulty breathing
  • After a period of time, the person recognizes that their fear is excessive or unreasonable but is powerless to change, even though they occasionally endure the phobic stimulus when experiencing intense anxiety.

Type specifiers

  • Animal 
  • Natural environment type 
  • Blood-injection-injury type
  • Situational type 
  • Other type

 

Predisposing factors to phobias

Psychoanalytical theory 

  • Unconscious fears may be expressed in a symbolic manner as phobia. 

Learning theory 

  • Fears are conditioned responses and thus are learned by imposing reinforcements for certain behaviors.

Cognitive theory

  • Anxiety is the product of faulty cognitions or anxiety-inducing self-instructions.
    • Negative self-statements
    • Irrational beliefs
  • The individual begins to seek out avoidance behaviors to prevent the anxiety reaction, and phobias results.
  • Types of phobia
Classifications Fear Classifications Fear
Acrophobia Height Mysophobia Dirt, germs, contamination
Ailurophobia Cats Numerophobia Numbers
Algophobia Pain Nyctophobia Darkness
Anthophobia Flowers Ochophobia Riding in a car
Anthropophobia People Ophidiophobia Snakes
Aquaphobia Water Pyrophobia Fire
Arachnophobia Spiders Scoleciphobia Worms
Astraphobia Lightning Siderodromophobia Railroads or train travel
Belonephobia Needles Taphophobia Being buried alive
Brontophobia Thunder Thanatophobia Death
Claustrophobia Closed spaces Trichophobia Hair
Cynophobia Dogs Triskaidekaphobia The number 13
Dementophobia Insanity Xenophobia Strangers
Equinophobia Horses Zoophobia Animals
Gamophobia Marriage
Herpetophobia Lizards, reptiles
Homophobia Homosexuality
Murophobia Mice

 

Biological aspects

  • Neuroanatomical- Specific areas in the prefrontal cortex and the amygdala play a role in storing and recalling information about threatening or potentially deadly events.
  • Temperament- Children experience fears as a part of normal development
    • Characteristics with which one is born that influence how he or she responds throughout life to specific situations (for example, innate fears)

Life experiences

  • Early experiences may set the stage for phobic reactions later in life.
    • For instance, a child who fell a flight of stairs would have a fear of heights in the future.

 

Anxiety Disorder Due to another Medical Condition

  • Medical conditions that may produce anxiety symptoms include
    • Cardiac
    • Endocrine 
    • Respiratory 
    • Neurological

 

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 (O C D)

Assessment data

  • Recurrent obsessions 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 expunged by logic or reasoning

Compulsions

  • Repetitive ritualistic behavior or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded event or situation

 

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.
  • Symptoms of depression and obsessive-compulsive personality are common.

 

Hair-Pulling Disorder (Trichotillomania)

Assessment

  • 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
  • The disorder is not common, but it occurs more often in women than in men.

 

Hoarding Disorder

Assessment

  • The persistent difficulty discarding possessions regardless of their value.
  • Additionally, there can be a need for excessive acquiring of items (by purchasing or other means).
  • More men than women are diagnosed with this disorder.

 

Predisposing factors to O C D and Related disorder

Psychoanalytic theory

  • Clients with O C D have weak, underdeveloped egos.
  • Aggressive impulses are channeled into thoughts and behaviors that prevent the feelings of aggression from surfacing and producing intense anxiety fraught with guilt.

Learning theory

  • Conditioned response to a traumatic event
  • Passive avoidance
  • Active avoidance

Psychosocial influences related to trichotillomania

  • Stressful situations
  • Disturbances in mother–child relationship
  • Fear of abandonment
  • Recent object loss
  • Possible childhood abuse or emotional neglect

Biological aspects

  • Genetics: Possible with trichotillomania
  • Neuroanatomy: Possible abnormalities in basal ganglia and orbitofrontal cortex with O C D
  • Physiology: Some individuals with O C D exhibit electroencephalogram changes.
  • Biochemical factors: Possible decrease in serotonin with O C D and body dysmorphic disorder

 

Diagnosis/Outcome identification

  • Nursing diagnoses commonly associated with anxiety, O C D, and related disorders
    • Panic anxiety (panic disorder and G A D)
    • Powerlessness (panic disorder and G A D)
    • Fear (phobias)
    • Social isolation (agoraphobia)
    • Ineffective role performance (O C D)
    • Ineffective coping (O C D)
    • Disturbed body image (body dysmorphic disorder)
    • Ineffective impulse control (hair-pulling disorder)

Outcome: The Patient

  • Is able to recognize signs of escalating anxiety and intervene before reaching panic level (panic and G A D)
  • Is able to maintain anxiety at manageable level and make independent decisions about life situation (panic and G A D)
  • Functions adaptively in the presence of the phobic object or situation without experiencing panic anxiety (phobic disorder)
  • Verbalizes a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety (phobic disorder)
  • Is able to maintain anxiety at a manageable level without resorting to the use of ritualistic behavior (O C D)
  • Demonstrates more adaptive coping strategies for dealing with anxiety than ritualistic behaviors (O C D)
  • Verbalizes a realistic perception of his or her appearance and expresses feelings that reflect a positive body image (body dysmorphic disorder)
  • Verbalizes and demonstrates more adaptive strategies for coping with stressful situations (hair-pulling disorder)

 

Planning/Implementation

  1. Panic Anxiety: Real or perceived threat to biological integrity or self-concept and evident any or all of the physical symptoms identified by the DSM-5
  • Maintain calm, nonthreatening approach.
  • Keep the immediate surroundings low in stimuli.
  • Teach the client signs of escalating anxiety.
  1. Fear: Causing embarrassment to self in front of others, being in a place from which one is unable to escape, or a specific stimulus and evident by behavior directed towards avoidance of the feared object or situation
  • Include the client in making decisions.
  • Encourage the client to explore underlying feelings.
  1. Ineffective Coping: Undeveloped ego, punitive superego; avoidance learning; possible biochemical changes and evident by ritualistic behavior or obsessive thoughts
  • Initially meet the client’s dependency needs.
  • Provide a structured schedule of activities.
  1. Disturbed Body Image: Repressed severe anxiety and evident by preoccupation with imagined defect; verbalizations that are out of proportion to any actual physical abnormalities that may exist; and numerous visits to plastic surgeons or dermatologists seeking relief
  • Help client see his or her body image is distorted.
  • Involve client in activities that reinforce positive sense of self.
  • Make referrals to support groups.
  1. Ineffective Impulse Control: Possible genetic or biochemical factors; poor parent-child relationship; history of child abuse or neglect and evident by recurrent pulling out of the hair in response to stressful situations
  • 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 O C D?
  • What is body dysmorphic disorder? 
  • What is trichotillomania?
  • Symptoms of anxiety, O C D, and related disorders
  • Management of the Illness
    • Medication management
      • Possible adverse effect
      • Length of time to take effect
      • What to expect from the medication
  • Stress management
    • Teach ways to interrupt escalating anxiety.
    • Teach relaxation techniques.
  • Support Services
    • Crisis hotline
    • Support groups
    • Individual psychotherapy

 

Evaluation

  • Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria.
  • Can the client recognize signs and symptoms of escalating anxiety, and interrupt before it reaches panic level?
  • Can the client demonstrate activities that can be used to maintain anxiety at a manageable level?
  • Can the client discuss the phobic object or situation without becoming anxious?
  • Can the client function in the presence of the phobic object or situation without experiencing panic anxiety?
  • Can the O C D client refrain from performing rituals when anxiety level rises and demonstrate substitute behaviors to maintain anxiety at a manageable level?
  • Can the client with trichotillomania refrain from hair-pulling and substitute a more adaptive behavior when urges to pull hair occur?
  • Does the client with body dysmorphic disorder verbalize a realistic perception and satisfactory acceptance of personal appearance?

 

Treatment Modalities

  • Individual psychotherapy
  • Cognitive therapy
  • Behavior therapy
    • Systematic desensitization
    • Implosion therapy
    • Other non-pharmacologic treatments for anxiety

Treatment Modalities: Psychopharmacology

Classifications of Meds used

  • Selective serotonin reuptake inhibitors (SSRIs)—first line
  • Selective serotonin-norepinephrine reuptake inhibitors (SNRIs)—first line
  • Tricyclic antidepressants
    (TCAs)—second or third line
  • Benzodiazepines
  • β-Blockers

Medication for specific disorders

  • Panic and G A D
    • Anxiolytics
    • Antidepressants
    • Antihypertensive agents
  • O C D and body dysmorphic disorder
    • Antidepressants
  • Phobic disorders
    • Anxiolytics
    • Antidepressants
    • Antihypertensive agents
  • Hair-pulling disorder
    • Chlorpromazine
    • Amitriptyline
    • Lithium carbonate
    • Selective serotonin reuptake inhibitors and pimozide
    • Olanzapine

Examples of anti-anxiety agents

  • Hydroxyzine (Vistaril)
  • Alprazolam (Xanax)
  • Chlordiazepoxide (Librium)
  • Clonazepam (Klonopin)
  • Clorazepate (Tranxene)
  • Diazepam (Valium)
  • Lorazepam (Ativan)

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