Anxiety, Obsessive-Compulsive, & Related Disorders Flashcards
Anxiety
- Emotional process
- Provides motivation
- Response to a stressor
- Normal vs abnormal
Levels
- Mild
- Moderate
- Severe
- Panic
Neurobiology of Anxiety Disorders: Neurotransmitters
?
↑ or ↓ serotonin
↑ or ↓ norepinephrine
↑ or ↓ gamma-aminobutyric acid (GABA)
↓
↑
↓
Areas of the brain affected
?
Fear; particularly important in panic & phobia disorders
amygdala
?
Arousal
Locus ceruleus
?
Associated with memory r/t fear responses
Hippocampus
?
Respiratory activation; HR
Brainstem
?
Cognitive interpretations
Frontal cortex
?
Activation of stress response
Hypothalamus
?
Integration of sensory stimuli
Thalamus
?
Tremor
Basal ganglia
Epidemiological statistics
> most common of all psychiatric illnesses
> more common in women than in men by at least 2:1
> familial predisposition
> common comorbidities include another anxiety disorder, depression, & substance abuse
?
- persistent, unrealistic, & excessive anxiety
- worry that have occurred more days than not for @ least 6 mos
- cannot be attributed to specific organic factors
- muscle tension, restlessness
- procrastination, activity avoidance, seek reassurance
- feeling keyed up or on edge
Clinically significant impairment in social, occupational, or other important areas of functioning
Generalized Anxiety Disorder (GAD)
- avoiding activities or events d/t a negative outcome or excessive preparation prior
- affects decision-making; repeatedly seeking assurance from others
- onset not common >20
- tends to be chronic w/freq stress-related exacerbations & fluctuations in course of illness
?
- recurrent panic attacks, onset unpredictable
- intense apprehension, fear, terror, feelings of impending doom
- intense physical discomfort
- not triggered by situations in which the person is the focus of others’ attention
Panic Disorder
Panic Disorder
- lasts min or rarely hrs; sx’s of depression common
> avg age of onset of PD is late 20’s; remission & exacerbation periods
> risk factors: genetic vulnerability; tendency toward negative emotions; h/o childhood/sexual abuse; smoking
DSM V Criteria for Panic Disorders
At least 4 of the following sx’s must be present to identify the presence of a panic attack
Theories of Etiology Related to Panic & Generalized Anxiety Disorders
- Psychodynamic Theory
- Cognitive Theory
- Biological aspects include
1. Genetics
2. Neuroanatomical
3. Biochemical
4. Neurochemical
Psychodynamic Theory
- Conflict between id & superego that produces anxiety
Cognitive Theory
- There’s distorted or counterproductive thinking patterns that accompany or precede maladaptive behaviors in emotional disorders
Neuroanatomical
- Pathological involvement in temporal lobes
- Dysfunction in limbic system (“emotional brain”) & frontocerebellar cortex have been noted in clients w/anxiety disorders
Biochemical
- Abn elevations of blood lactate in those w/panic disorder
?
A persistent, intensely felt, & irrational fear of a specific object, activity, or situation that results in a compelling desire to avoid the feared stimulus
- Responses: intense anxiety or panic attacks
- More often dx’d in women than men
Phobias
Theories of Etiology Related to Phobias
- Psychoanalytic Theory
- Learning Theory
- Cognitive Theory
- Life experiences
- Biological aspects include
1. Neuroanatomical
2. Temperament
Psychoanalytic Theory
> Freud’s theory of displacement
Learning Theory
> classical conditioning (Pavlov)
Cognitive Theory
> A result of faulty thinking that may include negative self-statements & irrational beliefs
Neuroanatomical
- Neurotransmitters
> amygdala - “fight or flight” hormones
Temperament
- May explain the idea of innate fears becoming phobias if reinforced from the past, e.g., childhood-dog-adulthood getting bit
Specific phobias
?
an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others
- more common in women than men
- impairment interferes w/social or occupational functioning; causes marked distress
e.g., fear of speaking, eating in a public place, using a public restroom → sweating, tachycardia, dyspnea
Social Anxiety Disorder (Social Phobia)
?
fear of being in places or situations from which escape might be difficult or in which help might not be available should panic sx’s occur
- more common in women than men
- can lead to isolation
Agoraphobia
In both phobias, the fear, anxiety, or avoidance is persistent, typically lasting 6 mos or more for dx
Anxiety Disorder due to Another Medical Condition & Substance/Medication-Induced Anxiety Disorder
direct physiological consequence of another medical condition, substance intoxication, or withdrawal, or exposure to a medication
Cardiac → MI, CHF, MVP
Endocrine → hypoglycemia, hypo or hyperthyroidism, pheochromocytoma
Respiratory → COPD, hyperventilation
Neurological → complex partial seizures, neoplasms, encephalitis
?
- obsessions, compulsions, or both
- the severity of which is significant enough to cause distress or impairment in social, occupational, or other important areas of functioning
- individual recognizes that the behavior is excessive or unreasonable
- equally common among men & women
Obsessive-Compulsive Disorder
?
Are defined by repetitive behaviors
Include hand washing, ordering, checking, or mental acts like praying, counting, and repeating words silently
Behaviors or mental acts are aimed at preventing or reducing anxiety & distress or preventing some dreaded event or situation
Not better explained by sx’s of another medical condition
Can impair social, occupational, & other areas of function
compulsions
?
Recurrent & persistent thoughts, urges, or images that are experienced some time during the disturbance as intrusive & unwanted in that most individuals causes marked anxiety or distress
Can also be the individuals’ attempt to ignore or suppress such thoughts, urges, & images or to neutralize them w/some thought or action (e.g., by performing a compulsion)
obsessions
Obsessions & compulsions are time consuming, usually >1 hr/day
Other related disorders
- Body Dysmorphic Disorder (client is not delusional)
- Trichotillomania
> not assoc w/alopecia
> “hair-pulling” disorder (scalp, eyebrows, eyelashes) - Hoarding disorder
Assessment Scales
- Hamilton Anxiety Rating Scale
> clinician-administered
> psychic & somatic sx’s - Beck Anxiety Inventory [self-administered]
- Zung Self-Rated Anxiety Scale [self-administered]
Nursing Diagnoses
Interventions & Outcomes
Anxiety/Panic
- Remain w/client
- Calm approach
- Simple, brief messages
- Teach strategies for addressing hyperventilation
- Provide low stimuli
- Administer tranquilizing medication
- Patient education (coping skills)
Fear
- Explore the client’s perception of the threat
- Discuss the reality of the situation
- Encourage the client to explore underlying feelings
- Specific techniques
Ineffective Coping
- Help client recognize factors that precipitate onset
- Provide support & praise independent behaviors
- Help client identify relationship between emotional problems & compulsive behaviors
- Provide a structured schedule of activities
- Gradually limit the amount of time allotted for ritualistic behavior
- Educate on thought-stopping & relaxation
Disturbed Body Image
- Assess the client’s perception of body image
- Help w/recognition of misperception
- Encourage verbalization of fears & anxieties
- Involve the client in activities that reinforce a positive sense of self
Ineffective Impulse Control
Defined as a pattern of performing rapid, unplanned reactions to internal or external stimuli w/o regard for the negative consequences of these reactions to the impulsive individual or to others
- Support the client in his or her effort to stop behavior (e.g., hair pulling)
- Provide a nonjudgmental attitude
- Assist the client w/habit reversal training
- Educate on stress management techniques
Treatment Modalities
- Individual Psychotherapy
- Cognitive Therapy
- Behavior Therapy
- Psychopharmacology
Anti-anxiety Agents (anxiolytics)
- Limbic system & reticular formation, GABA
- Benzodiazepines: short-term use
- Buspirone: doesn’t depress CNS; for those w/anxiety disorder & addiction problem
! Interactions, contraindications
- Caution w/ h/o drug abuse or addiction
- Tolerance/dependence
- Avoid abrupt withdrawal (e.g., sweating, agitation, tremors, N/V, delirium, seizures)
Sedatives - Hypnotics
- Anticonvulsants
- Preoperative sedatives
- Generalized CNS depression
- Barbiturates
- Eszopiclone (Lunesta), Zaleplon (Sonata), Zolpidem (Ambien) [nonbenzodiazepines]
Medications for Panic and Generalized Anxiety Disorders (GAD)
- Anxiolytics
- Tricyclics - for Panic disorder; cause severe s/e @ high doses compared to SSRIs
> clomipramine (Anafranil), imipramine (Tofranil) - SSRIs & SNRIs for GAD
- SSRIs for Panic disorder
> paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft) - SNRI - Venlafaxine (Effexor) for Panic disorder
Anti-hypertensive agents
- beta blockers, alpha-2 receptor agonists to decrease anxiety; less effective on psychic sx’s, more somatic
Anticonvulsants
- pregabalin (Lyrica) [schedule V substance!]
Clomipramine
1st rx approved by the FDA to treat OCD
! most selective for serotonin reuptake than any of the other tricyclics
! Benzodiazepines are not considered 1st line of treatment d/t abuse potential; have helped in social anxiety disorder
Medications for Obsessive-Compulsive Disorder
Antidepressants/SSRI’s
- fluoxetine, paroxetine, sertraline, fluvoxamine (Luvox) (in increased doses to treat OCD)
Medications for Phobic Disorders
- Anxiolytics
- Antidepressants
- Anti-hypertensive agents
For anticipatory performance anxiety or stage fright:
> atenolol, propranolol [beta blockers]
For agoraphobia & social anxiety disorder:
imipramine [tricyclic]
phenelzine (Nardil) [MAOI]
Medications for Body Dysmorphic Disorder
- Antidepressants
- clomipramine (tricyclic)
- fluoxetine (SSRI)
Medications for Trichotillomania
- SSRI (have shown moderate results)
SSRI’s in OCD
- SSRIs are more efficacious in OCD when used at high doses, in excess of the typical dose range
- Also take longer to respond to SSRI monotherapy than do those of MDD; an adequate trial is 8-12 wks
Doses of up to:
40 mg of escitalopram (Lexapro)
80 mg of fluoxetine (Prozac)
100 mg of paroxetine (Paxil)
300 mg of fluvoxamine (Luvox)
