Ch. 18 Anxiety/OCD Related Disorders

Question 1

Anxiety is…

Answer 1

A feeling of discomfort, apprehension, or dread related to anticipation of danger, the source of which is often nonspecific or unknown. Anxiety is considered a disorder (or pathology) when fears and anxieties are excessive (in a cultural context) and there are associated behavioral disturbances such as interference with social and occupational functioning

Question 2

Anxiety can be considered abnormal or pathological if:

Answer 2

1. It is out of proportion to the situation that is creating it.
2. The anxiety interferes with social, occupational, or other important areas of functioning.

Question 3

Panic Disorder is…

Answer 3

Panic disorder is characterized by recurrent panic attacks, the onset a of which are unpredictable. Panic attacks are manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom (clients often fear they are dying) and accompanied by intense physical discomfort. The physical sensations can be so intense that the individual believes he or she is having a heart attack or other critical illness.

Question 4

The DSM-5 states that what must be present to identify the presence of a panic attack:

Answer 4

Four of the following symptoms must be present
■ Palpitations, pounding heart, or accelerated heart rate
■ Sweating
■ Trembling or shaking
■ Sensations of shortness of breath or smothering
■ Feelings of choking
■ Chest pain or discomfort
■ Nausea or abdominal distress
■ Feeling dizzy, unsteady, lightheaded, or faint
■ Chills or heat sensations
■ Paresthesias (numbness or tingling sensations)
■ Derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself)
■ Fear of losing control or going crazy
■ Fear of dying

Question 5

The average age of onset of panic disorder is…

Answer 5

the late 20s
The disorder may last for a few weeks or months or for a number of years. Sometimes the individual experiences periods of remission and exacerbation.
Genetic vulnerability, tendency toward negative emotions, history of childhood physical and sexual abuse, and smoking have also been identified as risk factors

Question 6

Generalized anxiety disorder (GAD) is…

Answer 6

Characterized by persistent, unrealistic, and excessive anxiety and worry, which have occurred more days than not for at least 6 months and cannot be attributed to specific organic factors, such as caffeine intoxication or hyperthyroidism. The anxiety and worry are associated with muscle tension, restlessness, or feeling keyed up or on edge.

Question 7

Generalized Anxiety Disorder characteristics

Answer 7

• These symptoms are like those often associated with anxiety in the general population but, unlike the typical experience of anxiety, the symptoms in GAD are intense enough to cause clinically significant impairment in social, occupational, or other important areas of functioning.
• The individual often avoids activities or events that may result in negative outcomes or spends considerable time and effort preparing for such activities.
• Anxiety and worry often result in procrastination in behavior or decision making, and the individual repeatedly seeks reassurance from others.
• Depressive symptoms are common, and numerous somatic complaints may also be a part of the clinical picture.

Question 8

Average age of onset for Generalized Anxiety Disorder

Answer 8

The disorder may begin in childhood or adolescence, but onset is not uncommon after age 20
GAD tends to be chronic, with frequent stress-related exacerbations and fluctuations in the course of the illness.

Question 9

Psychodynamic Theory behind Panic and Generalized Anxiety Disorders

Answer 9

• Focuses on the inability of the ego (reality) to intervene when conflict occurs between the id (instincts) and the superego (morality), producing anxiety
• For various reasons (unsatisfactory parent-child relationship, conditional love, or provisional gratification), ego development is delayed.
• When defects in ego functions compromise the capacity to modulate anxiety, the individual resorts to unconscious mechanisms to resolve the conflict.
• Use of defense mechanisms rather than coping and management skills results in maladaptive responses to anxiety.

Question 10

Cognitive Theory behind Panic and Generalized Anxiety Disorders

Answer 10

• Faulty, distorted, or counterproductive thinking patterns accompany or precede maladaptive behaviors and emotional disorders
• A disturbance in this central mechanism of cognition causes a consequent disturbance in feeling and behavior.
• Because of distorted thinking, anxiety is maintained by erroneous or dysfunctional appraisal of a situation. There is a loss of ability to reason regarding the problem, whether it is physical or interpersonal.
• The individual feels vulnerable in a given situation, and the distorted thinking results in an irrational appraisal, fostering a negative outcome.

Question 11

Biological Aspects behind Panic and Generalized Anxiety Disorders
Genetics

Answer 11

• Genetic studies have identified variations in specific genes that may be associated with anxiety disorders (including panic disorder and obsessive-compulsive disorder)
• Some studies suggest that genetic variations may affect the sensitivity of emotional processing centers in the brain
• Twin studies identify a 30 to 40 percent risk of heritability.
• Current genetic studies reveal that environmental factors in interaction with genes have more of an impact on risk than genetic influences alone.

Question 12

Biological Aspects behind Panic and Generalized Anxiety Disorders
Neuroanatomical

Answer 12

• Structural brain imaging studies in patients with panic disorder have implicated pathological involvement in the temporal lobes, particularly the hippocampus and the amygdala
• Dysfunctions in the limbic system and the frontal cerebral cortex have also been noted in clients with anxiety disorders.

Question 13

Biological Aspects behind Panic and Generalized Anxiety Disorders
Biochemical
Neuroanatomical

Answer 13

• Abnormal elevations of blood lactate have been noted in clients with panic disorder. Likewise, infusion of sodium lactate in clients with anxiety neuroses produces symptoms of panic disorder.
• Strong evidence exists for the involvement of the neurotransmitter norepinephrine in the etiology of panic disorder.
• The neurotransmitters serotonin and GABA are thought to be decreased in anxiety disorders. (benzos enhance GABA and SSRIs enhance serotonin).

Question 14

Agoraphobia is…

Answer 14

Agoraphobia is the fear of being in open shops and markets, but more specifically, it is the fear of being vulnerable and unable to get help or escape the setting, should panic symptoms occur. It is possible that the individual may have experienced symptoms in the past and is preoccupied with fears of their recurrence. In extreme cases, the individual is unable to leave his or her home without being accompanied by a friend or relative. If this is not possible, the person may become totally confined to his or her home.

Question 15

Age of onset of agoraphobia is…

Answer 15

Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years. It is diagnosed more commonly in women than in men.

Question 16

Diagnostic Criteria for Agoraphobia

Answer 16

1. Marked fear or anxiety about two (or more) of the following five situations:
   - Using public transportation (e.g., automobiles, buses, trains, ships, planes)
   - Being in open spaces (e.g., parking lots, marketplaces, bridges)
   - Being in enclosed places (e.g., shops, theaters, cinemas)
   - Standing in line or being in a crowd
   - Being outside of the home alone
2. The individual fears these situations because of thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly, fear of incontinence).
3. The agoraphobic situations almost always provoke fear or anxiety.
4. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
5. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
6. The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more.
7. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
8. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive.
9. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder - the symptoms are not confined to specific phobia, situational type; do not involve only social situations (social anxiety disorder); are not related exclusively to obsessions (OCD), perceived defects or flaws in physical appearance (body dysmorphic disorder), reminders of traumatic events (PTSD), or fear of separation (as in separation anxiety disorder).

Question 17

Social Anxiety Disorder is…

Answer 17

An excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others. The individual has extreme concerns about being exposed to possible scrutiny by others and fears social or performance situations in which embarrassment may occur. Exposure to the phobic situation usually results in feelings of panic anxiety with sweating, tachycardia, and dyspnea.

Question 18

Age of onset for Social Anxiety Disorder

Answer 18

Onset of symptoms of this disorder often begins in late childhood or early adolescence and runs a chronic, sometimes lifelong, course.
It appears to be more common in women than in men.

Question 19

Diagnostic Criteria for Social Anxiety Disorder

Answer 19

1. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (having a conversation, meeting unfamiliar people), being observed (eating or drinking), and performing in front of others (giving a speech). In children, the anxiety must occur in peer settings and not just during interactions with adults.
2. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
3. The social situations almost always provoke fear or anxiety. In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
4. The social situations are avoided or are endured with intense fear or anxiety.
5. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
6. The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more.
7. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.
8. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
9. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
10. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
    Specify if:
    - Performance only: If the fear is restricted to speaking or performing in public

Question 20

Specific phobia is….

Answer 20

Identified by fear of specific objects or situations that could conceivably cause harm (e.g., snakes, heights), but the person’s reaction to them is excessive, unreasonable, and inappropriate. Exposure to the phobic stimulus produces overwhelming symptoms of panic, including palpitations, sweating, dizziness, and difficulty breathing. The person recognizes that his or her fear is excessive or unreasonable but is powerless to change, even though the individual may occasionally endure the phobic stimulus when experiencing intense anxiety.

Question 21

Age of onset for specific phobia is…

Answer 21

Phobias may begin at almost any age. Those that begin in childhood often disappear without treatment, but those that begin or persist into adulthood usually require assistance with therapy. The disorder is diagnosed more often in women than in men.

Question 22

Psychoanalytic Theory behind Phobias

Answer 22

• Unconscious fears may be expressed in a symbolic manner as phobias
• Ex: a female child who was sexually abused by an adult male family friend when he was taking her for a ride in his boat grew up with an irrational fear of all water vessels.
• Psychoanalytic theory postulates that fear of the man was repressed and displaced onto boats.
• Boats became an unconscious symbol for the feared person but one that the young girl viewed as safer because her fear of boats prevented her from having to confront the real fear.

Question 23

Learning Theory behind Phobias

Answer 23

• Classic conditioning in the case of phobias may be explained as follows: a stressful stimulus produces an “unconditioned” response of fear.
• When the stressful stimulus is repeatedly paired with a harmless object, eventually the harmless object alone produces a “conditioned” response: fear.
• This conditioning becomes a phobia when the individual consciously avoids the harmless object to escape fear.
• Fears are conditioned responses and thus are learned by imposing rewards for certain behaviors. In the instance of phobias, when the individual avoids the phobic object, he or she escapes fear, which is indeed a powerful reward.
• Phobias also may be acquired by direct learning or imitation (modeling; e.g., a mother who exhibits fear toward an object will provide a model for the child)

Question 24

Cognitive Theory behind Phobias

Answer 24

• Anxiety is the product of faulty cognitions or anxiety-inducing self-instructions.
• Two types of faulty thinking have been investigated: negative self-statements and irrational beliefs.
• Some individuals engage in negative and irrational thinking that produces anxiety reactions. The individual begins to seek out avoidance behaviors to prevent the anxiety reactions, and phobias result.
• Locus of control: individuals with internal locus of control and those with external locus of control might respond differently to life change.
• Individuals with an external control orientation experiencing anxiety attacks in a stressful period are likely to mislabel the anxiety and attribute it to external sources (crowded areas) or to a disease (heart attack). They may perceive the experienced anxiety as being outside of their control.

Question 25

Biological Aspects behind Phobias
Neuroanatomical
Temperament

Answer 25

• (Neuro) Specific areas in the prefrontal cortex and the amygdala play a role in storing and recalling information about threatening or potentially deadly events. Similar future events can trigger those memories, after which the amygdala triggers release of fight-or-flight hormones and the individual experiences heightened stress and fear.
• (Neuro) Parental traumatic exposure creates genetic “memories” that are passed down to subsequent generations via parental gametes, which are then expressed as phobias in their offspring.
• (Temp) Innate fears represent a part of the overall characteristics or tendencies with which one is born that influence how he or she responds throughout life to specific situations.
• Innate fears usually do not reach phobic intensity but may have the capacity for such development if reinforced by events in later life. For example, a 4 yo is afraid of dogs. By age 5, she’s overcome her fear and plays with her own dog. At 19, she is bitten by a stray dog and develops a phobia of dogs.

Question 26

Life Experiences behind Phobias

Answer 26

• Certain early experiences may set the stage for phobic reactions later in life.
• Some researchers believe that phobias, particularly specific phobias, are symbolic of original anxiety-producing objects or situations that have been repressed.
  Ex
  A child who is punished by being locked in a closet develops a phobia of elevators or other closed places.
  A child who falls down a flight of stairs develops a phobia of high places.
  A young woman who, as a child, survived a plane crash in which both her parents were killed has a phobia of airplanes

Question 27

Anxiety Disorder Due to Another Medical Condition is…

Answer 27

• The symptoms associated with these disorders are judged to be the direct physiological consequence of another medical condition.
• Medical conditions: Myocardial infarction, Congestive heart failure, and Mitral valve prolapse; Hypoglycemia, Hypo- or Hyperthyroidism, and Pheochromocytoma; COPD and Hyperventilation; Complex partial seizures, Neoplasms, and Encephalitis.
• Nursing care of patients with this disorder must take into consideration the underlying cause of the anxiety.
• Holistic nursing care is essential to ensure that the patient’s physiological and psychosocial needs are met.

Question 28

Substance/Medication-Induced Anxiety Disorder

Answer 28

• The symptoms associated with these disorders are judged to be due to the direct physiological effects of substance intoxication or withdrawal or exposure to a medication
• Diagnosis made only if the anxiety symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and warrant independent clinical attention.
• Withdrawal must be seen in history, physical examination, or lab findings to substantiate the diagnosis.
• May be associated with use of the following substances: alcohol, amphetamines, cocaine, hallucinogen, sedatives, hypnotics, anxiolytics, caffeine, cannabis, or other substances
• Nursing care of the patient with substance-induced anxiety disorder must take into consideration the nature of the substance and the context in which the symptoms occur—that is, intoxication or withdrawal.

Question 29

Obsessive-Compulsive Disorder is…

Answer 29

The presence of obsessions or compulsions, or both, the severity of which is significant enough to cause distress or impairment in social, occupational, or other important areas of functioning.
The individual recognizes that the behavior is excessive or unreasonable but, because of the feeling of relief from discomfort that it promotes, is compelled to continue the act.
Common compulsions include hand washing, ordering, checking, praying, counting, and repeating words silently.

Question 30

Age of onset for OCD

Answer 30

The disorder is equally common among men and women. It may begin in childhood but more often begins in adolescence or early adulthood.
The course is usually chronic and may be complicated by depression or substance abuse. OCD is identified more frequently in single people than in married people, but this finding probably reflects the difficulty that individuals with this disorder have with maintaining interpersonal relationships

Question 31

OCD: Obsessions and Compulsions defined

Answer 31

Obsessions are…
- Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
- The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are…
- Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
- The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

Question 32

OCD Diagnostic Criteria

Answer 32

1. Presence of obsessions, compulsions, or both
2. The obsessions or compulsions are time consuming (e.g., take more than 1 hour a day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. The obsessive-compulsive symptoms are not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
4. The disturbance is not better explained by the symptoms of another mental disorder
   Specify if:
   - With good or fair insight
   - With poor insight
   - With absent insight/delusional beliefs
   Specify if:
   - Tic-related

Question 33

Body dysmorphic disorder is…

Answer 33

• Characterized by the exaggerated belief that the body is deformed or defective in some specific way.
• The most common complaints involve flaws of the face or head, such as wrinkles or scars, the shape of the nose, excessive facial hair, and facial asymmetry that are slight or not observable by others.
• Other complaints involve the ears, eyes, mouth, lips, or teeth.
• Some clients may present with complaints involving other parts of the body, and in some instances a true defect is present. The significance of the defect is unrealistically exaggerated, however, and the person’s concern is grossly excessive.
• These beliefs are differentiated from delusions in that the individual with body dysmorphic disorder is aware that his or her beliefs are exaggerated.
• The person’s medical history may reflect numerous visits to plastic surgeons and dermatologists in an unrelenting drive to correct the imagined defect.

Question 34

Comorbidities of body dysmorphic disorder

Answer 34

People with body dysmorphic disorder often have other comorbid mental disorders:
- Major depressive disorder
- Anxiety disorder (often OCD)
- Psychotic disorder

Question 35

Diagnostic Criteria for Body Dysmorphic Disorder

Answer 35

1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
2. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
3. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
   Specify if…
   - With muscle dysmorphia
   Specify if…
   - With good or fair insight
   - With poor insight
   - With absent insight/delusional beliefs

Question 36

Trichotillomania (Hair-Pulling Disorder) is…
May be accompanied with…

Answer 36

• The recurrent pulling out of one’s hair that results in hair loss.
• The impulse is preceded by an increasing sense of tension and results in a sense of release or gratification from pulling out the hair.
• The most common sites for hair pulling are the scalp, eyebrows, and eyelashes but may occur in any area of the body on which hair grows.
• Pain is seldom reported to accompany the hair pulling, although tingling and pruritus in the area are not uncommon.
• It may be accompanied by nail biting, head banging, scratching, biting, or other acts of self-mutilation.

Question 37

Comorbidities and age of onset for Trichotillomania (Hair-Pulling Disorder) is…

Answer 37

• Comorbid psychiatric disorders are common with hair-pulling disorder. The most common are mood and other anxiety disorders.
• The disorder usually begins in childhood and is seven times more prevalent in children than adults
• This phenomenon occurs more often in women than in men.

Question 38

Hoarding Disorder is…

Answer 38

• “Persistent difficulties discarding or parting with possessions, regardless of their actual value”
• Additionally, the diagnosis may be specified as “with excessive acquisition,” which identifies the excessive need for continual acquiring of items (either by buying them or by other means).
• Associated symptoms include perfectionism, indecisiveness, anxiety, depression, distractibility, and difficulty planning and organizing tasks

Question 39

Age of onset and comorbidities of Hoarding Disorder

Answer 39

• More men than women are diagnosed with the disorder, and it is almost three times more prevalent in older adults (ages 55–94) than in younger adults
• The symptoms, regardless of when they begin, appear to become more severe with each decade of life.
• In addition to OCD, hoarding is associated with high comorbidity for dependent, avoidant, schizotypal, and paranoid personality disorders

Question 40

Psychoanalytic Theory behind OCD and Related Disorders

Answer 40

• Individuals with OCD have weak, underdeveloped egos (for any of a variety of reasons: unsatisfactory parent-child relationship, conditional love, or provisional gratification)
• Views clients with OCD as having regressed to earlier developmental stages of the infantile superego—the harsh, exacting, punitive characteristics that now reappear as part of the psychopathology.
• Regression and use of defense mechanisms (isolation, undoing, displacement, reaction formation) produce the clinical symptoms of obsessions and compulsions

Question 41

Learning Theory behind OCD and related disorders

Answer 41

• Explain obsessive-compulsive behavior as a conditioned response to a traumatic event.
• The traumatic event produces anxiety and discomfort, and the individual learns to prevent the anxiety and discomfort by avoiding the situation with which they are associated. (passive avoidance)
• When passive avoidance is not possible, the individual learns to engage in behaviors that provide relief from the anxiety and discomfort associated with the traumatic situation. (active avoidance)
• According to this classic conditioning interpretation, a traumatic event should mark the beginning of the obsessive-compulsive behaviors. However, in a significant number of cases, the onset of the behavior is gradual.

Question 42

Psychosocial influences behind OCD and Related Disorders

Answer 42

• The onset of trichotillomania can be related to stressful situations in more than one quarter of cases.
• Additional factors that have been implicated include disturbances in mother-child relationship, fear of abandonment, and recent object loss.
• Trichotillomania has at times been connected to childhood trauma
• Hoarding disorder has been associated with unmanaged stress following the sudden loss of a loved one, divorce, or other significant life stressors

Question 43

Biological Aspects behind OCD and Related Disorders
Genetics

Answer 43

• Twin studies and family studies support a genetic susceptibility for OCD, especially in childhood onset OCD
• Trichotillomania has commonly been associated with OCDs among first-degree relatives, leading researchers to conclude that the disorder has a possible hereditary or familial predisposition.
• Structural abnormalities in various areas of the brain, as well as alterations in the serotonin and endogenous opioid systems, have also been noted.
• Genetics also may play a role in the development of hoarding disorder. Family and twin studies indicate that approximately 50% of individuals who hoard report having a relative who also hoards

Question 44

Biological Aspects behind OCD and Related Disorders
Neuroanatomy

Answer 44

• Abnormalities in various regions of the brain have been implicated in the neurobiology of OCD.
• Neuroimaging and neurocognitive assessment have identified impairment in motor inhibition responses (the ability to stop an action once initiated) in patients with OCD and trichotillomania
• In individuals with hoarding disorder, neuroimaging studies have indicated less activity in the cingulate cortex, the area of the brain that connects the emotional part of the brain with the parts that control higher-level thinking
• Animal models and brain imaging studies of patients with trichotillomania suggest abnormalities in neural regions involved in cognition (frontal cortex), affect regulation (amygdala-hippocampal formation), and habit learning (putamen). One study suggests that [trichotillomania] may be associated with altered reward processing within the CNS

Question 45

Biological Aspects behind OCD and Related Disorders
Physiological

Answer 45

• Electrophysiological studies, sleep electroencephalogram studies, and neuroendocrine studies have suggested that there are commonalities between depressive disorders and OCD.
• Neuroendocrine commonalities were suggested in studies in which about one-third of OCD clients show nonsuppression on the dexamethasone-suppression test and decreased growth hormone secretion with clonidine infusions.

Question 46

Biological Aspects behind OCD and Related Disorders
Biochemical Factors

Answer 46

• A number of studies have implicated the neurotransmitter serotonin as influential in the etiology of obsessive-compulsive behaviors
• The serotonergic system may also be a factor in the etiology of body dysmorphic disorder. This can be reflected in a high incidence of comorbidity with major mood disorder and anxiety disorder and the positive responsiveness of the condition to the serotonin-specific drugs.

Question 47

Behaviors associated with nursing diagnosis: Anxiety (severe/panic)

Answer 47

Palpitations, trembling, sweating, chest pain, shortness of breath, fear of going crazy, fear of dying (panic disorder); excessive worry, difficulty concentrating, sleep disturbance (generalized anxiety disorder)

Question 48

Behaviors associated with nursing diagnosis: Powerlessness

Answer 48

Verbal expressions of having no control over life situation; nonparticipation in decision making related to own care or life situation; expressions of doubt regarding role performance (panic and generalized anxiety disorders)

Question 49

Behaviors associated with nursing diagnosis: Fear

Answer 49

Behavior directed toward avoidance of a feared object or situation (phobic disorder)

Question 50

Behaviors associated with nursing diagnosis: Social Isolation

Answer 50

Stays at home alone, afraid to venture out alone (agoraphobia)

Question 51

Behaviors associated with nursing diagnosis: Ineffective Coping

Answer 51

Ritualistic behavior; obsessive thoughts, inability to meet basic needs; severe level of anxiety (OCD)

Question 52

Behaviors associated with nursing diagnosis: Ineffective role performance

Answer 52

Inability to fulfill usual patterns of responsibility because of need to perform rituals (OCD)

Question 53

Behaviors associated with nursing diagnosis: Disturbed body image

Answer 53

Preoccupation with imagined defect; verbalizations that are out of proportion to any actual physical abnormality that may exist; numerous visits to plastic surgeons or dermatologists seeking relief (body dysmorphic disorder)

Question 54

Behaviors associated with nursing diagnosis: Ineffective impulse control

Answer 54

Repetitive and impulsive pulling out of one’s hair (trichotillomania)

Question 55

The following criteria may be used for measurement of outcomes in the care of the patient with anxiety disorders. The patient:

Answer 55

■ Is able to recognize signs of escalating anxiety and intervene before reaching panic level (panic and generalized anxiety disorders).
■ Is able to maintain anxiety at manageable level and make independent decisions about life situation (panic and generalized anxiety disorders).
■ 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 (OCD).
■ Demonstrates adaptive coping strategies for dealing with anxiety instead of ritualistic behaviors (OCD).
■ 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 (trichotillomania).

Question 56

Nursing Diagnosis: Panic Anxiety
Patient Goals

Answer 56

The patient will verbalize ways to intervene in escalating anxiety within 1 week.
By time of discharge from treatment, the patient will be able to recognize symptoms of onset of anxiety and intervene before reaching panic level.

Question 57

Nursing Diagnosis: Panic Anxiety
Interventions and Rationales for them

Answer 57

1. Stay with the patient and offer reassurance of safety and security. Do not leave the patient in panic anxiety alone.
   - Presence of a trusted individual provides a feeling of security and assurance of personal safety.
2. Maintain a calm, nonthreatening, matter-of-fact approach.
   - Anxiety is contagious and may be transferred from staff to patient or vice versa. Patient develops a feeling of security in the presence of a calm staff person.
3. Use simple words and brief messages, spoken calmly and clearly, to explain hospital experiences.
   - In an intensely anxious situation, the patient is unable to comprehend anything but the most elemental communication.
4. If hyperventilation occurs, assist the patient to breathe into a small paper bag held over the mouth and nose. Six to 12 natural breaths should be taken, alternating with short periods of diaphragmatic breathing.
   - Hyperventilation may result in injury to the patient, and patient safety is a nursing priority.
5. Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor).
   - stimulating environment may increase level of anxiety.
6. Administer tranquilizing medication, as ordered by physician. Assess for effectiveness and for side effects.
   - Antianxiety medication provides relief from the immobilizing effects of anxiety.
7. When level of anxiety has been reduced, explore possible reasons for occurrence.
   - Recognition of precipitating factor(s) is the first step in teaching client to interrupt escalation of anxiety.
8. Teach signs and symptoms of escalating anxiety, and ways to interrupt its progression
   - Relaxation techniques result in a physiological response opposite that of the anxiety response. Physical activities discharge excess energy in a healthful manner.

Question 58

Nursing Diagnosis: Fear
Goals for Patient

Answer 58

Patient will discuss the phobic object or situation with the healthcare provider within (time specified).
By time of discharge from treatment, patient will be able to function in presence of phobic object or situation without experiencing panic anxiety.

Question 59

Nursing Diagnosis: Fear
Interventions and Rationales for them

Answer 59

1. Reassure patient that he or she is safe.
   - At the panic level of anxiety, patient may fear for his or her own life.
2. Explore patient’s perception of the threat to physical integrity or threat to self-concept.
   - It is important to understand patient’s perception of the phobic object or situation to assist with the desensitization process.
3. Discuss reality of the situation with patient to recognize aspects that can be changed and those that cannot.
   - Patient must accept the reality of the situation before the work of reducing the fear can progress.
4. Include patient in making decisions related to selection of alternative coping strategies.
   - Allowing the patient choices provides a measure of control and serves to increase feelings of self-worth.
5. If patient elects to work on elimination of the fear, techniques of desensitization or implosion therapy may be employed.
   - Fear is decreased as the physical and psychological sensations diminish in response to repeated exposure to the phobic stimulus under nonthreatening conditions.
6. Encourage patient to explore underlying feelings that may be contributing to irrational fears and to face them rather than suppress them.
   - Exploring underlying feelings may help the patient to confront unresolved conflicts and develop more adaptive coping abilities.

Question 60

Nursing Diagnosis: Ineffective Coping
Goals for Patient

Answer 60

Within 1 week, the patient will decrease participation in ritualistic behavior by half.
By time of discharge from treatment, patient will demonstrate ability to cope effectively without resorting to obsessive-compulsive behaviors.

Question 61

Nursing Diagnosis: Ineffective Coping
Interventions and Rationales for them

Answer 61

1. Work with patient to determine types of situations that increase anxiety and result in ritualistic behaviors.
   - Recognition of precipitating factors is the first step in teaching the patient to interrupt the escalating anxiety.
2. In the beginning of treatment, allow plenty of time for rituals. Do not be judgmental or verbalize disapproval of the behavior.
   - To deny patient this activity may precipitate panic anxiety. Conversely, indulging the patient’s need for ritualistic behavior initially decreases anxiety and promotes the ability to learn alternative coping strategies.
3. Support patient’s efforts to explore the meaning and purpose of the behavior
   - Patient may be unaware of the relationship between emotional problems and compulsive behaviors. Recognition is important before change can occur.
4. Provide structured schedule of activities for patient, including adequate time for completion of rituals.
   - Structure provides a feeling of security for the anxious patient.
5. Gradually begin to limit amount of time allotted for ritualistic behavior as patient becomes more involved in other activities.
   - Anxiety is minimized when patient is able to replace ritualistic behaviors with more adaptive ones.
6. Give positive reinforcement for nonritualistic behaviors.
   - Enhances self-esteem and encourages repetition of desired behaviors.
7. Help patient learn ways of interrupting obsessive thoughts and ritualistic behavior with techniques such as thought stopping, relaxation, and physical exercise.
   - Knowledge and practice of coping techniques that are more adaptive will help patient change and let go of maladaptive responses to anxiety.

Question 62

Nursing Diagnosis: Disturbed Body Image
Goals for Patient

Answer 62

Patient will verbalize understanding that changes in bodily structure or function are exaggerated out of proportion to the change that actually exists. (Time frame for this goal must be determined according to individual patient’s situation.)
Patient will verbalize perception of own body that is realistic to actual structure or function by time of discharge from treatment.

Question 63

.Nursing Diagnosis: Disturbed Body Image
Interventions and Rationales for them

Answer 63

1. Assess patient’s perception of his or her body image. Keep in mind that this image is real to the patient.
   - Assessment info is necessary in developing an accurate plan of care. Denial of the pt’s feelings impedes the development of a trusting, therapeutic relationship.
2. Help pt to see that his/her body image is distorted or that it is out of proportion in relation to the significance of an actual physical anomaly.
   - Recognition that a misperception exists is necessary before the patient can accept reality and reduce the significance of the imagined defect.
3. Encourage verbalization of fears and anxieties associated with identified stressful life situations. Discuss alternative adaptive coping strategies
   - Helps the patient come to terms with unresolved issues. May help the patient respond to stress more adaptively in the future.
4. Involve patient in activities that reinforce a positive sense of self not based on appearance.
   - When the patient is able to develop self-satisfaction based on accomplishments and unconditional acceptance, significance of the imagined defect or minor physical anomaly will diminish
5. Make referrals to support groups of individuals with similar histories.
   - Having a support group of understanding, empathic peers can help the patient accept the reality of the situation, correct distorted perceptions, and make adaptive life changes.

Question 64

Nursing Diagnosis: Ineffective Impulse Control
Goals for Patient

Answer 64

Patient will verbalize adaptive ways to cope with stress by means other than pulling out own hair (time dimension to be individually determined).
Patient will be able to demonstrate adaptive coping strategies in response to stress and a discontinuation of pulling out own hair (time dimension to be individually determined).

Question 65

Nursing Diagnosis: Ineffective Impulse Control
Interventions and Rationales for them

Answer 65

1. Support pt in his or her effort to stop hair pulling. Help pt understand that it is possible to discontinue the behavior.
   - Pt realizes that the behavior is maladaptive but feels helpless to stop. Support from the nurse builds trust.
2. Ensure that a nonjudgmental attitude is conveyed, and criticism of the behavior is avoided.
   - An attitude of acceptance promotes feelings of dignity and self-worth.
3. Assist patient with habit reversal training (HRT).
   - Shown to be an effective tool in treatment of hair-pulling disorder.
4. Once patient has become aware of hair-pulling times, suggest that patient hold something (a ball, paperweight, or other item) in his or her hand at times when hair pulling is anticipated.
   - This would help to prevent behaviors occurring without patient being aware that they are happening.
5. Practice stress management techniques: deep breathing, meditation, stretching, physical exercise, listening to soft music.
   - Hair pulling is thought to occur at times of increased anxiety.
6. Offer support and encouragement when setbacks occur. Help patient to understand the importance of not quitting when it seems that change is not happening as quickly as he or she would like.
   - Although some people see a decrease in the behavior within a few days, most will take several months to notice the greatest change.

Question 66

HRT (habit reversal training) has been shown to be an effective tool in treatment of hair-pulling disorder.
Three components of HRT include the following: (rationales)
Intervention in Ineffective Impulse Control

Answer 66

1. Awareness training. Help the patient become aware of times when the hair pulling most often occurs (e.g., client learns to recognize urges, thoughts, or sensations that precede the behavior; the therapist points out to the patient each time the behavior occurs).
   - This helps the patient identify situations in which the behavior occurs or is most likely to occur. Awareness gives the patient a feeling of increased self-control.
2. Substituting an incompatible behavior may help to extinguish the undesirable behavior.
   - Competing Response Training, For example, when a patient experiences a hair-pulling urge, suggest that the individual ball up his/her hands into fists, tightening arm muscles, and “locking” his/her arms so as to make hair pulling impossible at that moment.
3. Social support. Encourage family members to participate in the therapy process and to offer positive feedback for attempts at habit reversal.
   - Enhances self-esteem and increases patient’s desire to continue with the therapy. It also provides cues for family members to use in their attempts to help the patient in treatment.

Question 67

Hamilton Anxiety Rating Scale (HAM-A) What do the scores mean?

Answer 67

Symptoms:
0= Not present
1 = Mild
2 = Moderate
3 = Severe
4 = Very severe
Scoring:
14 – 17 = Mild Anxiety
18 – 24 = Moderate Anxiety
25 – 30 = Severe Anxiety

Question 68

Evaluation of the nursing actions for the patient with an anxiety, OCD, or related disorder may be facilitated by asking whether the patient can:

Answer 68

• Recognize signs and symptoms of escalating anxiety?
• Use skills learned to interrupt the escalating anxiety before it reaches the panic level?
• Demonstrate the activities most appropriate for him or her that can be used to maintain anxiety at a manageable level (e.g., relaxation techniques, physical exercise)?
• Maintain anxiety at a manageable level without medication?
• Verbalize a long-term plan for preventing panic anxiety in the face of a stressful situation?
• Discuss the phobic object or situation without becoming anxious?
• Function in the presence of the phobic object or situation without experiencing panic anxiety?
• Refrain from performing rituals when anxiety level rises?
• Demonstrate substitute behaviors to maintain anxiety at a manageable level?
• Recognize the relationship between escalating anxiety and the dependence on ritualistic behaviors for relief?
• Refrain from hair pulling (for patients with trichotillomania)?
• Successfully substitute a more adaptive behavior when urges to pull hair occur (for patients with trichotillomania)?
• Verbalize a realistic perception and satisfactory acceptance of personal appearance (for patients with body dysmorphic disorder)?

Question 69

How is Individual Psychotherapy used for Anxiety/OCD related disorders?

Answer 69

• Most clients experience a decrease in anxiety when given the opportunity to discuss their difficulties with a therapist
• Supportive psychotherapy: helps clients identify personal strengths and explore adaptive coping mechanisms.
• Insight-oriented psychotherapy, (Freudian): designed to help clients identify, explore, and resolve internal psychological conflicts that are contributing to anxiety.
• Can use logical and rational explanations to increase the client’s understanding about various situations that create anxiety in his or her life.
• Psychoeducational info may also be presented in individual psychotherapy.

Question 70

How is Cognitive Therapy used for Anxiety/OCD Related disorders?

Answer 70

• Cognitive therapy strives to assist the individual to reduce anxiety responses by altering cognitive distortions.
• Cognitive therapy for anxiety is brief and time limited. This discourages the client’s dependency on the therapist and encourages the client’s self-sufficiency.
• A sound therapeutic relationship is a necessary condition for effective cognitive therapy.
• A major component of treatment is encouraging the client to face frightening situations in order to view them realistically, and talking about them is one way of achieving this goal.
• The therapist uses questions to encourage the client to correct his or her anxiety-producing thoughts.
• Client is encouraged to become aware of the thoughts, examine them for cognitive distortions, substitute more balanced thoughts, and develop new patterns of thinking.
• Cognitive therapy is structured and orderly, which is important for the client who is often confused and lacks self-assurance
• Cognitive therapy is based on education. With practice, individuals can learn more effective ways of responding to life experiences through cognitive reframing

Question 71

How is Behavior Therapy used for Anxiety/OCD related disorders?
Systemic Desensitization

Answer 71

• The client is gradually exposed to the phobic stimulus, real or imagined
• Emphasis is placed on reciprocal inhibition (counterconditioning):the restriction of anxiety prior to the effort of reducing avoidance behavior.
• Rationale: Because relaxation is antagonistic to anxiety, individuals cannot be anxious and relaxed at the same time. 2 main elements:
  1. Training in relaxation techniques
  2. Progressive exposure to a hierarchy of fear stimuli while in the relaxed state
• The individual is taught several relaxation techniques and is encouraged to use the one that is most effective for them
• When the individual has mastered the relaxation technique, exposure to the phobic stimulus is initiated.
• The client is asked to present a hierarchal list of situations involving the phobic stimulus in order from most disturbing to least disturbing.
• While in a state of maximum relaxation, the client may be asked to imagine the phobic stimulus. Initial exposure is focused on a concept of the phobic stimulus that produces the least amount of fear or anxiety.
• In subsequent sessions, the individual is gradually exposed to stimuli that are more fearful.

Question 72

How is Behavior Therapy used for Anxiety/OCD related disorders?
Implosion Therapy (Flooding)

Answer 72

• Therapeutic process in which the client, for a prolonged period, must imagine situations or participate in real-life situations that he or she finds extremely frightening.
• The therapist “floods” the client with information concerning situations that trigger the client’s anxiety by describing anxiety-provoking situations in vivid detail.
• The more anxiety is provoked, the more expedient the therapeutic endeavor. This tactic is continued for as long as it arouses anxiety in the client.
• The therapy concludes when a topic no longer elicits inappropriate anxiety on the part of the client.
• Relaxation training is not a part of this technique. Plenty of time must be allowed for these sessions because brief periods may be ineffective or even harmful.
• Session ends when the client responds with considerably less anxiety than at the beginning of the session.

Question 73

Meds for Panic and Generalized Anxiety Disorders

Answer 73

ANXIOLYTICS:
- Benzos: used for GAD. Alprazolam, lorazepam, and clonazepam are used for Panic disorder
- Buspirone: used for GAD
ANTIDEPRESSANTS:
- Tricyclics: clomipramine and imipramine are used for Panic disorders
- SSRIs: Paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft) are used for Panic disorder. Paroxetine (Paxil) and escitalopram (Lexapro) are used for GAD.
- SNRI: Venlafaxine is used for Panic Disorder. Duloxetine (Cymbalta), and extended-release venlafaxine (Effexor XR) are used for GAD
- nefazodone (Serzone) and mirtazapine (Remeron)
ANTIHYPERSTENSIVES
- Beta blockers (e.g., propranolol) and alpha2-receptor agonists (e.g., clonidine) in the amelioration of anxiety symptoms
- Clonidine is effective in blocking the acute anxiety effects in conditions such as opioid and nicotine withdrawal

Question 74

Antianxiety agents include…

Answer 74

Antihistamines:
- Hydroxyzine (Vistaril)
Benzodiazepines:
- Alprazolam (Xanax, Niravam)
- Chlordiazepoxide (Librium)
- Clonazepam (Klonopin)
- Clorazepate (Tranxene)
- Diazepam (Valium, Diastat)
- Lorazepam (Ativan)
- Oxazepam (Serax)
- Midazolam (Versed)*
Carbamate derivative
- Meprobamate (Miltown, Equanil)
Azaspirodecanedione
- Buspirone (BuSpar)

Question 75

Common side effects of antianxiety agents

Answer 75

■ Drowsiness, confusion, lethargy.
■ Tolerance; physical and psychological dependence (does not apply to buspirone or hydroxyzine). Client should be tapered off long-term use.
■ Potentiates the effects of other CNS depressants. Client should not take alcohol or other CNS depressants with the medication.
■ May aggravate symptoms of depression.
■ Orthostatic hypotension. Client should rise slowly from lying or sitting position.
■ Paradoxical excitement. If symptoms opposite of desired effect occur, notify physician immediately.
■ Dry mouth.
■ Nausea and vomiting. May be taken with food or milk.
■ Blood dyscrasias. Symptoms of sore throat, fever, malaise, easy bruising, or unusual bleeding should be reported to the physician immediately.
■ Delayed onset (with buspirone). Lag time of 10 to 14 days for anxiety symptoms to diminish with buspirone. Buspirone is not recommended for prn administration.

Question 76

Meds for Phobic Disorders

Answer 76

ANXIOLYTICS
- Benzos: Social Anxiety Disorder (alprazolam and clonazepam)
ANTIDEPRESSANTS
- Tricyclic: imipramine used in Agoraphobia
Social Anxiety Disorder
- MAOIs: phenelzine, selegiline, isocarboxazid, and tranylcypromine used in Agoraphobia and Social Anxiety Disorder
- Additional clinical trials have also indicated efficacy with other antidepressants, including nefazodone, venlafaxine, and bupropion.
- SSRIs
ANTIHYPERTENSIVES
- Beta Blockers: propranolol and atenolol used for anticipatory performance anxiety or “stage fright.” - Reduces sweaty palms, racing pulse, trembling hands, dry mouth, labored breathing, nausea, and memory loss

Question 77

Meds for Obsessive-Compulsive Disorder

Answer 77

ANTIDEPRESSANTS
- SSRIs fluoxetine, paroxetine, sertraline, and fluvoxamine
Doses in excess of what is effective for treating depression may be required for OCD. Common side effects are sleep disturbances, headache, and restlessness.
- Tricyclics: Clomipramine

Question 78

Meds for Body Dysmorphic Disorder

Answer 78

ANTIDEPESSANTS
- Tricyclic: clomipramine
- SSRI: fluoxetine

Question 79

Meds for Trichotillomania

Answer 79

No medications have demonstrated consistent benefits for clients with trichotillomania but SSRIs have yielded moderate results for some clients with this condition
1) Chlorpromazine
2) Amitriptyline
3) Lithium carbonate
4) SSRIs/pimoz
5) Olanzapine

Question 80

Acrophobia:
Ailurophobia:
Algophobia:
Anthophobia:
Anthropophobia:
Aquaphobia:
Arachnophobia:
Astraphobia:
Belonephobia:
Brontophobia:
Claustrophobia:
Cynophobia:
Dementophobia:
Equinophobia:
Gamophobia:
Herpetophobia:
Homophobia:
Murophobia:
Mysophobia:
Numerophobia:
Nyctophobia:
Ochophobia:
Ophidiophobia:
Pyrophobia
Scoleciphobia:
Siderodromophobia:
Taphophobia:
Thanatophobia:
Trichophobia:
Triskaidekaphobia:
Xenophobia:
Zoophobia:

Answer 80

Acrophobia: Height
Ailurophobia: Cats
Algophobia: Pain
Anthophobia: Flowers
Anthropophobia: People
Aquaphobia: Water
Arachnophobia: Spiders
Astraphobia: Lightning
Belonephobia: Needles
Brontophobia: Thunder
Claustrophobia: Closed spaces
Cynophobia: Dogs
Dementophobia: Insanity
Equinophobia: Horses
Gamophobia: Marriage
Herpetophobia: Lizards, reptiles
Homophobia: Homosexuality
Murophobia: Mice
Mysophobia: Dirt, germs, contamination
Numerophobia: Numbers
Nyctophobia: Darkness
Ochophobia: Riding in a car
Ophidiophobia: Snakes
Pyrophobia: Fire
Scoleciphobia: Worms
Siderodromophobia: Railroads or train travel
Taphophobia: Being buried alive
Thanatophobia: Death
Trichophobia: Hair
Triskaidekaphobia: The number 13
Xenophobia: Strangers
Zoophobia: Animals

Question 81

Benzodiazepines Side Effects

Answer 81

Sedation, dizziness, weakness, ataxia, decreased motor performance, dependence, withdrawal

Question 82

SSRIs Side Effects

Answer 82

Nausea, diarrhea, headache, insomnia, somnolence, sexual dysfunction

Question 83

SNRIs Side Effects

Answer 83

Headache, dry mouth, nausea, somnolence, dizziness, insomnia, asthenia (physical weakness), constipation, diarrhea

Question 84

Beta Blocker: Propanolol Side Effects

Answer 84

Bradycardia, hypotension, weakness, fatigue, impotence, gastrointestinal upset, bronchospasm

Question 85

Alpha-2 Agonist Clonidine Side Effects

Answer 85

Dry mouth, sedation, fatigue, hypotension

Question 86

Barbiturates Side Effects

Answer 86

Somnolence, agitation, confusion, ataxia, dizziness, bradycardia, hypotension, constipation

Question 87

Buspirone Side Effects

Answer 87

Dizziness, drowsiness, dry mouth, headache, nervousness, nausea, insomnia

Question 88

Areas of the brain affected by anxiety disorders and the symptoms that they mediate include the following:
* ________: Fear, which is particularly important in panic and phobic disorders
* ________: Associated with memory related to fear responses
* ________: Arousal
* ________: Respiratory activation, heart rate
* ________: Activation of stress response
* ________: Cognitive interpretations
* ________: Integration of sensory stimuli
* ________: Tremor

Answer 88

Amygdala
Hippocampus
Locus ceruleus
Brainstem
Hypothalamus
Frontal cortex
Thalamus
Basal ganglia

Question 89

Hyperventiltion symptoms

Answer 89

lightheadedness, rapid heart rate, shortness of breath, numbness or tingling in the hands or feet, and syncope

Question 90

Antianxiety meds are used to treat…

Answer 90

Anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation

Question 91

Comorbidities of anxiety include…

Answer 91

Common comorbidities include another anxiety disorder, depression, and substance abuse. Vulnerability to comorbidities includes parental psychiatric history, childhood trauma, and negative life events