1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 26: Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders

2. Copyright © 2015 Wolters Kluwer All Rights Reserved 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)

3. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

4. Copyright © 2015 Wolters Kluwer All Rights Reserved Anxiety Disorders Panic disorder Obsessive-compulsive disorder (OCD) Generalized anxiety disorder (GAD) Acute stress disorder (ASD) Posttraumatic stress disorder (PTSD) Phobias

5. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

6. Copyright © 2015 Wolters Kluwer All Rights Reserved 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)

7. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

8. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

9. Copyright © 2015 Wolters Kluwer All Rights Reserved Question Is the following statement true or false? Panic is considered abnormal regardless of the situation and degree of threat.

10. Copyright © 2015 Wolters Kluwer All Rights Reserved 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.

11. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

12. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Biologic Domain Assessment –Rule out life- threatening medical causes; symptom evaluation –Substance use –Sleep patterns –Physical activity Nursing diagnoses –Anxiety –Risk for Self-Harm –Social Isolation –Powerlessness –Ineffective Family Coping

13. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Biologic Domain (cont’d) Interventions –Breathing control –Nutritional planning –Relaxation techniques (refer to Box 26.4) –Increased physical activity –Psychopharmacolo gy (refer to Table 26.4) SSRIs, SNRIs TCAs MAOIs) Benzodiazepin es (refer to Box 26.5)

14. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Psychological Domain Assessment –Self-report scales (refer to Box 26.6 and Table 26.3) –Mental status exam –Cognitive thought patterns: catastrophic misinterpretations (refer to Table 26.4) Nursing diagnoses –Anxiety –Risk for Self-Harm –Social Isolation –Powerlessness –Ineffective Family Coping

15. Copyright © 2015 Wolters Kluwer All Rights Reserved 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)

16. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Social Domain Assessment –Family factors –Cultural factors Nursing diagnoses –Social Isolation –Impaired Social Interaction –Risk for Loneliness –Interrupted Family Processes

17. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Social Domain (cont’d) Interventions –Lifestyle reevaluation –Time management –Prioritizing or lists

18. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

19. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

20. Copyright © 2015 Wolters Kluwer All Rights Reserved 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.

21. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

22. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

23. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

24. Copyright © 2015 Wolters Kluwer All Rights Reserved Etiology Biologic theories –Genetic –Neuropathology –Biochemical Psychological theories –Psychodynamic –Behavioral

25. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Biologic Domain Assessment –Multiple physical symptoms –Dermatologic lesions –Osteoarthritis joint damage Nursing diagnoses –Anxiety –Impaired Skin Integrity

26. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Biologic Domain (cont’d) Interventions –Skin integrity maintenance –Psychopharmacology Clomipramine Sertraline Fluvoxamine Paroxetine Fluoxetine Interventions (cont’d) –Education about medications –Electroconvulsive therapy –Psychosurgery

27. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

28. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Psychological Domain (cont’d) Nursing diagnoses –Hopelessness –Loneliness –Powerlessness –Self-Concept

29. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

30. Copyright © 2015 Wolters Kluwer All Rights Reserved 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.

31. Copyright © 2015 Wolters Kluwer All Rights Reserved 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)

32. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

33. Copyright © 2015 Wolters Kluwer All Rights Reserved Generalized Anxiety Disorder Feelings of frustration, disgust with life, demoralization, and hopelessness Sense of ill-being and uneasiness and fear of imminent disaster

34. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

35. Copyright © 2015 Wolters Kluwer All Rights Reserved Diagnostic Criteria Excessive worry and anxiety for at least 6 months; anxiety related to a number of real- life 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

36. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

37. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Biologic Domain Assessment –Symptoms –Diet and nutrition –Sleep patterns Nursing diagnoses –Insomnia –Spiritual distress –Role conflict

38. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Biologic Domain (cont’d) Interventions –Psychopharmacology Benzodiazepines (most common) Paroxetine, imipramine, venlafaxine Buspirone (BuSpar) Beta-blockers –Teaching about medications

39. Copyright © 2015 Wolters Kluwer All Rights Reserved 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.

40. Copyright © 2015 Wolters Kluwer All Rights Reserved Answer False. To be diagnosed with GAD, a person must experience excessive worry and anxiety for at least 6 months.

41. Copyright © 2015 Wolters Kluwer All Rights Reserved Nursing Management for the Psychosocial and Social Domains Assessment and intervention –Similar to those for panic disorder –Combination of Relaxation Supportive therapies Cognitive therapies

42. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

43. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

44. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

45. Copyright © 2015 Wolters Kluwer All Rights Reserved Etiology Biologic factors –Neurobiology (stress response) Hyperarousal Intrusion Avoidance and numbing (dissociative symptoms) –Genetic theories

46. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

47. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

48. Copyright © 2015 Wolters Kluwer All Rights Reserved 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

49. Copyright © 2015 Wolters Kluwer All Rights Reserved 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.

50. Copyright © 2015 Wolters Kluwer All Rights Reserved 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