Chapter 15- Anxiety and OCD

Question 1

Anxiety is…?

Answer 1

Defined as a feeling of apprehension, uneasiness, uncertainty, or dread r_esulting from a real or perceived threat._

• Will feel anxious no matter what.
• Fear is defined as a reaction to a specific danger.
• The body reacts the same to both fear and anxiety.

Question 2

What Neurotransmitters are low in anxiety?

Answer 2

Serotonin low

GABA is low

Question 3

GABA’s general function? Deficit and excess symptoms too?

Answer 3

• General function:
  
  • reduces arousal, aggression, anxiety, excitation ( lowers)
• Deficit- to low:
  
  • Irritability, hostility, tension and worry, anxiety, seizure activity
• Excess- to much:
  
  • Sedation, impaired memory
    
    • sedation- increases the risk for falls!

Question 4

How does Amygdala play a role in anxiety?

Answer 4

• it’s a set of neurons located deep in the brain’s medial temporal lobe. Shown to play a key role in the processing of emotions.
• The fear response starts in the amygdala, This reaction is more pronounced with anger and fear.
  • A threat stimulus, such as the sight of a predator, triggers a fear response in the amygdala, which activates areas involved in preparation for motor functions involved in fight or flight. ( SNS)
• Test Anxiety can initiate this reaction-> SNS activated

Question 5

Risk Factors for OCD, Phobias, or anxiety?

Answer 5

• Genetics:
  
  • First-degree biological relatives of those with OCD and phobias have a higher frequency
• Neurobiological:
  
  • Amygdala and low GABA, dopamine, NE, and low serotonin
• GABA is an inhibitory neurotransmitter, the focus of treatment for panic disorders- slows you down!
  
  • Too little GABA theorized to cause anxiety

Question 6

Levels of Anxiety (Peplau)? 4

Answer 6

1. Mild
   
   • Occurs in everyday life, good to have.
   • See, hears, and grasps more information and problem-solving becomes more effective- focus!
2. Moderate
   
   • Sees, hears, and grasps less information, details become excluded from observations
   • Learning can still take place, but not at optimal levels
   • SNS kicks in, may experience tension, pounding heart, increase HR, RR, sweating, and GI distress (bubble guts) - Diff., from mild.
3. Severe
   
   • perceptual field reduces, even more, tunnel vision.
   • Focus on one particular detail or scattered details and has difficulty noticing things in the environment even when it’s pointed out to them.
   • Learning and problem solving are not possible.
4. Panic
   
   • Unable to process what is going on in the environment and may lose touch with reality.
   • Pacing, running, shouting, screaming, or withdrawal.
     
     • May experience hallucinations and become impulsive= dangerous!

Question 7

ALL Anxiety disorder talked about? 11

Answer 7

1. Separation Anxiety Disorder
2. Specific phobia
3. Social Anxiety Disorder (Social Phobia)
4. Panic Disorder
5. Agoraphobia
6. Generalized Anxiety Disorder
7. Obsessive-Compulsive Disorder
8. Body Dysmorphic Disorder
9. Hoarding Disorder
10. Trichotillomania (hair-pulling) Disorder
11. Excoriation (skin-picking) disorder

Question 8

What is Separation Anxiety?

Answer 8

• Normal part of infant development.
  
  • Usually begins at 8 months, peeks at 18 months, and should decline after.
• People with this disorder present with great concern and distress over being away from a significant other.
  
  • May also feel like horrible things will happen to their significant other that will result in permanent separation.
• Anxiety is so intense that it interferes with daily functioning, disrupts sleep, causes nightmares, headaches and GI issues.
  
  • Usually dx before age 18 after 1 month of symptoms

Question 9

Specific Phobias are?

Answer 9

• Persistent irrational fear of a specific object, activity, or situation.
  
  • Examples: water, dogs, spiders, snakes, closed spaces, bridges, water, blood etc.
  • Cannot think about or be around the object without overwhelming and crippling anxiety
• Go to great lengths to avoid objects!

Question 10

Social Anxiety Disorder is?

Answer 10

• AKA Social Phobia
  
  • Severe anxiety or fear provoked by social or performance situations.
    
    • Ex: speaking in class; fear of negative feedback or judgment ( told to shut up at a young age, not seen or herd)
  • Fear of public speaking is the most common form
  • Risk factors: childhood trauma, or having shy or timid caregivers
  • Substance use is common b/c they will use alcohol to soothe their anxiety.

Question 11

Panic Disorder is?

Answer 11

• Key feature: panic attacks
  
  • Panic attack= the sudden onset of extreme apprehension or fear, sometimes with feelings of impending doom
• May feel like they are losing their minds or having a heart attack
  
  • Last for around 10 minutes and then subside
• Children; won’t verbalize like adults and may become avoidant, feel hopeless, or become depressed.
  
  • Self medicate with substances

Question 12

Agoraphobia is?

Answer 12

• Agora= open space
• Anxiety due to fear of being in a open place where escape might feel difficult or embarrassing
  
  • Avoid being in car, bus, bridge, elevator, school etc.
  • May lead to MDD or substance use

Question 13

Generalized Anxiety Disorder is?

Answer 13

• Key feature: excessive worrying
  
  • Common worries: job performance, interpersonal relationships, finances, health of family members
• Symptoms: putting things off or avoiding, lateness, absence, sleep disturbances
  
  • Females to Males, 2:1
• Feeling easily fatigued, restless, irritable, muscle tension, headaches
• Tx: SSRI, CBT, 1:1 therapy

Question 14

Additional Anxiety Disorders are?

Answer 14

1. Selective Mutism:
   
   • child does not speak due to fear of negative response or evaluation, commonly seen in sexually/physically abused children.
2. Substance-induced anxiety:
   
   • Can be caused by ETOH, Cocaine, Hallucinogens
3. Anxiety due to medical conditions:
   
   • hyperthyroidism, PE( caused by not being able to breathe) or cardiac dysrhythmias

Question 15

Obsessive Compulsive Disorders is?

Answer 15

• Obsessions:
  
  • Thoughts, impulses or images that persist and reoccur that cannot be dismissed from the mind even if the person tries to do so.
• Compulsion:
  
  • ritualistic behaviors a person feels driven to perform to reduce anxiety
• Both can persist independently, but the majority have both!
• For Dx of OCD: both have to occur on a daily basis and involve issues with sexuality, violence, contamination ( afraid of pooping- bleach), illness, or death.
• Rituals are time-consuming and interfere with daily activities.

Question 16

Body Dysmorphic Disorder is?

Answer 16

• Pt usually has normal body with imagined defects
  
  • May or may not be aware of the imagined defects
• High risk of suicide
  
  • Slightly higher in females to male

Question 17

Hoarding Disorder is?

Answer 17

• Accumulation of items that have little to no value, interferes with patient life
  
  • Symptoms usually emerge in adolescence and condition worsens with each decade of life ( people start to die in their life)
• More women are treated for disorder, but men can have it just as much
• 75% have MDD or Anxiety

Question 18

Trichotillomania and Excoriation Disorder are?

Answer 18

• Trichotillomania=Hair pulling
• Excoriation= skin picking
  
  • May begin as early as the age of 1
• Trichophagia= swallowing the hair; can lead to digestion issues and malnutrition
• Excoriation= usually on the face, but can happen on different parts of the body
• Both help to deal with stress and eases anxiety
  
  • Usually done without thinking about it
  • Can have one or the other or both

Question 19

Psychological Factors that can cause anxiety?

Answer 19

1. Behavioral theories:
   
   • Anxiety is a learned response from a caregiver.
2. Cognitive theories:
   
   • Anxiety is caused by distortions in a person’s thoughts or perceptions
3. Interpersonal theories:
   
   • Early needs went unmet or constant disapproval is experienced in early years, trust vs mistrust.

Question 20

Cultural cues for anxiety?

Answer 20

• Hispanics: ataque de nervois, “Attack of the Nerves”, in response, to death of family member, acute family dischord, witnessing an accident
• North American: Choking, smothering, tingling sensations

Question 21

Assessment for anxiety?

Answer 21

• Usually go without hospitalization unless they are suicidal or have compulsions that cause injury, or taken to ED to rule out heart attact
  
  • Assessment needs to be patient-centered and empathetic
• Mostly subjective
• Objective scales can be used such as:
  
  • Severity Measure for Generalized Anxiety Disorder pg. 283 in book

Question 22

Diagnosing anxiety?

Answer 22

• Practitioners use GAD-7
  
  • 7 questions about the past 2 weeks.

Question 23

Treatment plan?

Answer 23

• Patient needs to be considered with planning, if safe and not in severe panic mode
• When you include the patient in decision making, the patient is more likely to be compliant
• Fluids and rest to prevent exhaustion (Anxiety is EXHAUSTING)

Question 24

Implementation of anxiety treatments?

Answer 24

• Keep in mind the levels of anxiety, s/s and which ones you can teach in
• During severe and panic anxiety use firm, short and simple statements, may need to repeat. Be patient as the nurse
• Anxiety management and reduction is the goal

Question 25

Treatment of anxiety?

Answer 25

* Counseling: Nurse can provide deep breathing strategies, early identification of trigger and additional calming interventions * **Inpatient: SAFETY FIRST,** use calm consistent care, low stimulation if possible * Self Care activities: proper nutrition and food intake (decrease caffeine and high sugar intake), elimination (can be hindered by OCD), sleep hygiene

Question 26

CBT?

Answer 26

* Helps to reframe negative thinking or thought patterns that can lead to anxiety * Give an example of a thought that causes anxiety? * How can you use CBT to reframe that thought and decrease anxiety?

Question 27

Behavioral Therapies are 3?

Answer 27

1. Modeling- * Therapist use themselves as significant models to appropriate a negative behavior in a feared situation and the patient models it. * Show you its okay to do that behavior * Therapist goes in elevator first, models comfort * Pt models what the therapist does 2. Systematic Desensitization * Takes baby steps to learn how to deal with feared situation. * Ex: Agoraphobia- opens door, goes on to lawn, gets in car, turns on car. Takes several days to months * Imagine it in office before doing it in real life 3. Flooding * Introduced to stimuli all at once, can be overwhelming. * Very intense. Pt learns to recognize s/s and intervene with coping skills. * Ex: A person afraid of germs asked to hold a dirty cup with no gloves. 4. Response Prevention- * For Compulsive behavior * Therapist restricts pt from rituals to show patient anxiety still exist without the ritual * After trying this in the office, the pt goes home and begins to set limits on themselves * Thought Stopping- * When a negative thought or obsession begins the pt says “STOP!” or pluck themselves with a rubber band. * Distracts pt and stops the negative thought process so they can insert a positive option

Question 28

Antidepressants for anxiety? ## Footnote **Paroxetine, fluoxetine, Escitalopram, Sertraline**

Answer 28

* SSRI are first line of therapy. * Less side effects and non addictive. * **Paroxetine, fluoxetine, Escitalopram, Sertraline** * SNRI can be used if SSRI is not effective. * **_Helps to treat anxiety and decreases panic attacks when taken as prescribed over time_**

Question 29

Noradrenergic Drugs is? **_Propranolol,Clonidine_**:

Answer 29

* Used for **short-term relief of social or performance anxiety.** * May reduce some peripheral symptoms of anxiety, such as tachycardia and sweating, and general tension, can help control symptoms of stage fright and public-speaking fears, has few side effects. * Take 30 minutes before event * Need to check HR and BP before administer * Lowers both HR and BP, do not give with HR 60 or BP 90/60 * Examples: * **_Propranolol:_** * **_used for short term relief of social and performance anxiety._** * **_Clonidine_**: * used for anxiety disorders and panic attack

Question 30

Benzodiazepines is?

Answer 30

Noradrenergic Drug: * **Lorazepam, diazepam, alprazolam** * MOA: * increase GABA ( because GABA is low in anxiety) * GABA is an inhibitory neurotransmitter * s/e: * drowsiness, confusion, dizziness, trembling, impaired coordination. * **Highly addictive** * **Sedatives:** * risk for fall, Given to treat and prevent panic attacks

Question 31

Buspirone is? drug...

Answer 31

* Trade name: Buspar * **Anti anxiety, non-addictive** * Helps to **increase level of Serotonin** in the body * Treats worrying associated with GAD * S/E: dizziness, drowsiness, headache, n/v, trouble sleeping * Can cause Serotonin Syndrome

Question 32

Evaluation question for nurse to patient, anxiety?

Answer 32

1. Has anxiety decreased? 2. Does patient recognize symptoms of THEIR anxiety? 3. In the presence of obsession and compulsion, are the s/s increasing or decreasing? 4. Is the patient able to use new behaviors to manage anxiety? 5. Does the pt adequately perform self care activities? 6. Can the pt maintain satisfying interpersonal relationships? 7. Is the pt able to assume usual roles? * **Use these questions to help guide charting, shift change report, debrief with pt and advocate for patient during treatment team meetings.**