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Chapter 11

Anxiety, Anxiety Disorders, Obsessive-Compulsive, and Related Disorders

Anxiety: Universal Human Experience

Is the most basic emotion.

Dysfunctional behavior is often a defense against anxiety.

When behavior is recognized as dysfunctional, interventions can be initiated by the nurse to reduce anxiety.

As anxiety decreases, dysfunctional behavior will frequently decrease.

Anxiety Versus Fear

Anxiety and fear are indistinguishable except for the cause.

FEAR = a reaction to a specific danger.

ANXIETY = a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized.

Objective 1: Differentiate among normal anxiety, acute anxiety, and chronic anxiety.

Normal anxiety: Healthy life force necessary for survival.

Acute anxiety: Precipitated by imminent loss or threat.

“Pathological anxiety differs from normal anxiety in terms of duration, intensity, and disturbance in a person’s ability to function (e.g., dysfunctional behaviors or extreme withdrawal).”

Chronic anxiety: Long-term; thought to be associated with increased risk for cardiovascular morbidity; usually begins at young age.

Objective 2: Contrast and compare the four levels of anxiety in relation to perceptual field, ability to learn, and physical and other defining behavioral characteristics.

Levels of Anxiety

Mild

Moderate

Severe

Panic

Behaviors and Characteristics

Perceptual field

Ability to learn

Physical or other characteristics

Case Studies—Anxiety

Choose Normal, Acute, or Chronic for the following:

Charlie is 19 years old with an ileostomy caused by rectal surgery for cancer, which has rendered him sexually impotent. He is admitted to the psychiatric unit and is unable to state his name.

Alex has a chemistry test this morning. She “crammed” for the test the previous night but did not study before that. She has an upset stomach and headache.

Mr. Jones has not left his house for 3 months. He tells his family, “I know this is not normal, but I just can’t go outside.” His wife died 3 years earlier.

Case Studies—Anxiety (Answers)

Choose Normal, Acute, or Chronic for the following:

Acute—Charlie is 19 years old with an ileostomy caused by rectal surgery for cancer, which has rendered him sexually impotent. He is admitted to the psychiatric unit and is unable to state his name.

Normal—Alex has a chemistry test this morning. She “crammed” for the test the previous night but did not study before. She has an upset stomach and headache.

Chronic—Mr. Jones has not left his house for 3 months. He tells his family, “I know this is not normal, but I just can’t go outside.” His wife died 3 years earlier.

Objective 3: Summarize five properties of the defense mechanisms.

Defense mechanisms are:

Major means of managing conflict

Relatively unconscious

Discrete from one another

Hallmarks of major psychiatric syndromes, which are reversible

Adaptive as well as pathologic

Group Challenge: Suggest the best classification (on the left) for each defense mechanism listed here.

Classification

Healthy

Intermediate

Immature

Defense Mechanisms

Altruism

Sublimation

Humor

Suppression

Repression

Displacement

Reaction formation

Somatization

Undoing

Rationalization

Passive aggression

Acting out

Dissociation

Devaluation

Idealization

Splitting

Projection

Denial

Objective 4: Give a definition for at least six defense mechanisms.

Immature

Passive aggression

Acting out

Dissociation

Devaluation

Idealization

Splitting

Projection

Denial

Healthy

Altruism

Sublimation

Suppression

Humor

Intermediate

Repression

Displacement

Reaction formation

Somatization

Undoing

Rationalization

Objective 5: Rank the defense mechanisms from healthy to highly detrimental.

Immature

Passive aggression

Acting out

Dissociation

Devaluation

Idealization

Splitting

Projection

Denial

Healthy

Altruism

Sublimation

Suppression

Humor

Intermediate

Displacement

Reaction formation

Somatization

Rationalization

Undoing

Anxiety Disorders: Prevalence and Co-Morbidity

Highly co-occurring

Substance abuse

Major depressive disorder (MDD)

Frequently co-occurring

Eating disorder, bipolar disorder, dysthymia

Co-occurring medical conditions

Cancer, heart disease, hypertension, irritable bowel syndrome, renal or liver dysfunction, reduced immunity

Chronic anxiety

Associated with increased risk for cardiovascular morbidity and mortality

Theory

Neurobiology

Limbic system

Main mediators of anxiety

Serotonin, norepinephrine, gamma-aminobutyric acid (GABA)

Genetics (twin studies)

Cognitive-behavioral

Cultural considerations

Clinical Picture

Panic Disorders (PD)

Panic attack

Sudden onset of extreme apprehension or fear, usually with a feeling of doom

Terror is so severe that normal function is suspended

Signs similar to a heart attack

Phobias

Persistent, intense irrational fear of something

Social anxiety disorders (SADs) or social phobias (e.g., agoraphobia)

General Anxiety Disorders

Severe distress with pervasive cognitive dysfunction and impaired functioning; no specific triggers or targets

Clinical Picture (Cont.)

Anxiety Due to Medical Conditions

Respiratory: asthma, hypoxia, pulmonary edema, chronic obstructive pulmonary disease (COPD), pulmonary embolism

Cardiovascular: cardiac dysrhythmias such as torsades de pointes, angina, congestive heart failure, mitral valve prolapse, hypertension

Endocrine: hyperthyroidism, hypoglycemia, hypercortisolism, pheochromocytoma

Neurologic: Parkinson disease, akathisia, postconcussion syndrome, complex partial seizures

Metabolic: hypercalcemia, hyperkalemia, hyponatremia, porphyria

Objective 6: Describe the clinical manifestations of each anxiety disorder. (Let’s take a closer look now at each disorder in the following slides.)

Panic disorder (PD)

PD with agoraphobia

Phobia

Social anxiety disorder (SAD) or social phobia

Generalized anxiety disorder (GAD)

Anxiety caused by a medical condition

Obsessive-compulsive disorder (OCD) and related disorders

Body dysmorphic disorder and hoarding

Panic Disorders

Panic attack:

Feelings of terror

Suspension of normal function

Severely limited perceptual field

Misinterpretation of reality

Sudden occurrence of panic attacks (not necessarily in response to stress)

Increased rates of suicide and suicide attempts

Symptoms include:

Palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nausea, feelings of choking, chills, hot flashes, and gastrointestinal symptoms

Panic Disorders (Cont.)

Someone is rushed to the emergency department with signs and symptoms of a heart attack.

An extensive workup is negative for cardiac problems.

The patient needs a referral for the potential diagnosis and treatment of an anxiety disorder (e.g., PD).

Panic Disorders with Agoraphobia

Agoraphobia

Is an intense and excessive level of anxiety and a fear of being in places and situations from which escape is impossible.

Feared places are avoided to control anxiety.

Avoidance behaviors can be debilitating and life constricting. (Discuss.)

Phobias

Specific phobias

Specific objects or situations include dogs, spiders, heights, storms, water, blood, and closed spaces, among others.

Are common, but do not usually cause much difficulty.

Social Anxiety Disorders Social Phobias

SAD

Is severe anxiety provoked by exposure to a social or performance situation.

Fear of saying something foolish, not being able to answer questions in a classroom, eating in the presence of others, and performing on a stage, among others

Fear of public speaking is the most common.

Anxiety Caused by Medical Conditions

Symptoms of anxiety are a direct physiologic result of a medical condition.

Respiratory

Cardiovascular

Endocrine

Neurologic

Metabolic

Evidence must be present in the history, physical examination, and/or laboratory findings to diagnose the medical condition.

Obsessive-Compulsive Disorder

Obsessions:

Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause significant anxiety or distress

Compulsions:

Unwanted, ritualistic behavior the individual feels driven to perform to reduce anxiety

I have to wash my hands!

I don’t want to!

Obsessive-Compulsive Disorder (Cont.)

OCD behavior exists along a continuum.

“Normal” individuals may experience mild obsessive-compulsive behaviors.

Mild compulsions are valued traits in U.S. society.

More severe symptoms:

Center on dirtiness, contamination, and germs and occur with corresponding compulsions such as cleaning and hand washing

Most severe symptoms:

Include persistent thoughts of sexuality, violence, illness, and death

Other Diagnoses Related to OCD

Body Dysmorphic Disorder

Preoccupation with an imagined “defective body part”

Obsessional thinking about the body

Impairment of normal social activities related to academic or occupational functioning

Compulsive Hoarding

Excessive collection of items considered worthless

Individual is ashamed of failure to discard items

Extreme life disruption and distress

Social isolation

Unsafe living conditions

Objective 7: Compare and contrast the difference between hoarding behaviors with OCD and hoarding behaviors without OCD.

Hoarding Behaviors with OCD

Excessively collects items, and exhibits a failure to discard items.

Approximately 50% of patients who exhibit hoarding have co-occurring OCD.

OCD and excessive hoarding are associated with:

Increase in co-morbidity

Impairment in performing activities of daily living (ADLs)

Reduced insight

Poor response to treatment

Genetic and neurobiologic profile

Hoarding Behaviors Without OCD

Exhibits compulsive and disabling hoarding.

Results in social isolation.

No extreme disruption occurs in the performance of ADLs.

Has difficulty discarding possessions.

Has strong urges to save items.

Exhibits distress when discarding items.

Accumulation results in clutter.

Interventions of third parties (family members, cleaners, authorities) are staged.

Nursing Process Guidelines

Assessment Guidelines

Physical/neurologic exam to determine whether anxiety is primary or secondary

Assess for potential self-harm

Psychosocial assessment

Cultural and background assessment

Nursing Diagnoses

Anxiety (rated)

Fear

Ineffective coping

Deficient diversional actions

Social isolation

Ineffective role performance

Impaired social interaction

Posttrauma syndrome

Fatigue; sleep deprivation

Low self-esteem, spiritual distress

Self-care deficit

Remind students that nursing diagnoses for patients with anxiety are too numerous to list here. Refer the class to Table 11-7 for more details.

Objective 8: Formulate four NANDA International nursing diagnoses that might be appropriate in the care of an individual with an anxiety disorder.

Patient X: Symptoms

History of severe domestic abuse, including social isolation in a locked basement

Patient is now hypervigilant, has intrusive memories of being held hostage by spouse

Impulse to keep child safe by isolating her as well

Inability to go to sleep related to her intrusive thoughts, worrying, replaying of a traumatic event, hypervigilance

Nursing Diagnoses

Anxiety (rated)

Ineffective coping

Social isolation

Ineffective role performance

Impaired social interaction

Posttrauma syndrome

Fatigue; sleep deprivation

Remind students that nursing diagnoses for patients with anxiety are too numerous to list here. Refer the class to Table 11-7 for more details.

Objective 9: Propose realistic outcome criteria for patients with the following anxiety disorders.

Anxiety disorders:

GAD

OCD

Outcomes should:

Reflect patient values and ethical and environmental situations.

Be culturally appropriate.

Be documented as measurable goals.

Include a time estimate.

PLANNING: Whenever possible, include the patient in planning to increase likelihood of possible outcomes.

Self-Care for Nurses

Burnout: Exhaustion caused by long-term involvement in emotionally demanding situations

Compassion Fatigue: Cumulative physical, emotional, and psychologic effect of working closely with those suffering from the consequences of heart-wrenching/traumatic events (see Chapter 10)

“Common responses when working with anxiety-disordered clients include increased anxiety, frustration, anger and other negative emotions.”

Point out that supervision, stress management courses, mindfulness, yoga, exercise, creative activities, and humor are all examples of stress reduction techniques (refer to Box 11-1 for selected stress reduction techniques).

Implementation

Identify community resources offering specialized treatment.

Identify community support groups for people with specific anxiety disorders and their families.

Use therapeutic communication, milieu therapy, promotion of self-care activities, psychotherapy, and health teaching and health promotion as appropriate.

(See Table 11-7 with this case study.)

Behavior Modification Therapy

Modeling—mimicking appropriate behaviors in situations

Systematic desensitization—gradually exposing a person to the feared object or situation until the person is free of incapacitating anxiety

Response prevention—starts with the therapist preventing the compulsion, such as hand washing, and gradually helping the patient limit the time between rituals until the urge dissipates

Thought stopping—examples include snapping a rubber band on one’s wrist to stop an obsession or negative thought

(See Table 11-7 with this case study.)

Case Study

Remember Charlie?

He is the 19-year-old with an ileostomy and rectal surgery for cancer that has rendered him sexually impotent. He is admitted to the psychiatric unit and is unable to state his name.

Five days have now passed. His anxiety has subsided as a result of medication management and milieu therapy. You are emptying his ileostomy bag. He is tearful.

(Continued)

(See Table 11-7 with this case study.)

Audience Response Question

Charlie asks you, “How will I ever be able to go to the beach or be with a girl with this gross bag hanging on my stomach?

What is your best therapeutic response?

A. “This has to be extremely difficult for you to face.”

B. “Don’t worry about that now. Just get well!”

C. “I will ask your doctor to increase your medicine.”

D. “If a girl really likes you, the bag won’t matter.”

Answer

*A. Stating that Charlie’s condition is extremely difficult to face lets him know that you are actually listening to and thinking about what he is saying. This helps establish trust so that the conversation can possibly continue.

Telling a patient not to worry implies that you do not really want to engage in meaningful and therapeutic communication. It also devalues the patient’s concerns.

Attributing the patient’s concern strictly to medication management sidesteps the problem.

Offering a cliché does not communicate to the patient that you are interested in helping solve the problem.

Objective 10: Discuss three classes of medications that have demonstrated evidence-based effectiveness in treating anxiety disorders.

Medications

Benzodiazepines (anxiolytics): Prescribed for short-term treatment only; not for patients with substance use problems

Buspirone: Management of anxiety disorders. Non-addictive; excellent for long-term relief of anxiety symptoms, e.g. GAD

SSRIs: First-line treatment for anxiety disorders, OCD, and BDD

SNRIs: Panic disorder (PD), generalized anxiety disorder (GAD), and social affective disorder (SAD)

Tricyclic antidepressants: Second- or third-line use for PD, GAD, and SAD; clomipramine is effective in obsessive-compulsive disorder (OCD)

MAOIs: Reserved for treatment-resistant conditions due to risk of life-threatening hypertensive crisis. Recently being used in people with social anxiety disorder (SAD) and rejection sensitivity

Audience Response Question

Rene, a restaurant manager, is hospitalized after working 15-hour days for several weeks. Her anxiety level is severe upon admission. She has not slept well during the past 2 weeks. Her psychiatrist has ordered amitriptyline (Elavil) 25 mg, to be administered orally, three times daily. Rene asks you, her nurse, why she is so drowsy. What is your best response?

A. “Drowsiness is a side effect of this medication.”

B. “Don’t worry about being drowsy at this time.”

C. “Aren’t you glad you will finally get to sleep?”

D. “I will tell the doctor. I don’t want you to fall.”

Answer

*A. Giving an anxious patient a simple and accurate answer helps the patient understand that she is experiencing something that is expected.

Telling the patient not to worry diminishes her concern and does not convey interest on your part. Cliché responses are not therapeutic.

Although it may be true that the patient will sleep better with this medication, this answer does not give the patient requested information.

The patient is at risk for falling as a result of the sedative effects of the medication and the level of anxiety she is experiencing. Placing the patient on the unit’s Falls Precautions Protocol is a critical nursing intervention. You would not notify the physician.

Objective 11: Identify the patient’s experience and needs when planning patient-centered care for a person with OCD.

Case Study

A patient is admitted to your psychiatric unit after being found by a friend in his apartment. The patient has not left his apartment for 2 weeks.

You are completing the admission assessment and search his small brown suitcase. You observe that the patient, using black ink and precise lettering, has etched his first name, Klim, on the side.

(Continued)

Case Study (Cont.)

The suitcase contains three T-shirts, three pajama bottoms, and a toothbrush wrapped in several layers of plastic wrap. You return the suitcase to him.

Klim begins to unfold and refold his clothing slowly and repetitively.

(Continued)

Klim

Audience Response Question

What is your best nursing action in response to Klim?

Immediately stop Klim, and tell him his behavior is inappropriate.

Continue the interview and allow Klim to continue as long as he is not harming himself or others.

Explain that his behavior is a part of his illness and that you can help him work toward change.

Leave the room and come back later when Klim has stopped the behavior.

Answer

Klim’s compulsive behavior is likely triggered or worsened by anxiety as a result of his admission to the psychiatric unit. Telling him that his behavior is inappropriate (he already knows that) will only serve to increase his anxiety.

During the initial hours of Klim’s hospitalization, he needs to be allowed to continue his ritual as long as it does not pose harm to himself or others. You will need to begin to set appropriate behavior limits later.

An explanation during the admission process will probably result in increased anxiety. When Klim is feeling more comfortable and trusting, he may be able to invest in behavior changes.

It would not be safe at this time to leave Klim alone. Although his current behavior is benign, his compulsive behavior indicates that his anxiety is increasing.

Closing Discussion: Nursing Interventions

As time on the unit passes for Klim, how would you, his nurse, intervene? Use the following topics to conduct the discussion:

Counseling

Milieu therapy

Promotion of self-care activities

Pharmacologic interventions

Health teaching

Klim