CHAPTER 15

Anxiety and
Obsessive-
Compulsive Related
Disorders

1
Anxiety

nxiety – Apprehension, uneasiness, uncertainty, or dread from real

or perceived threat

ear – Reaction to specific danger

ormal anxiety – Necessary for survival

2
Levels of Anxiety

ild anxiety

oderate anxiety

evere anxiety

anic

3
 Mild Anxiety

erceptual field heightened

rasps what is happening

dentifies disturbing things

an work toward a goal

an examine alternatives

xperiences slight discomfort

estlessness, irritability

ild tension relieving behaviors

4
 Moderate Anxiety
• Perceptual field narrows

• Selective inattention

• Needs to have things pointed out/ benefits from guidance

• Problem solving ability moderately impaired

• Shaky voice, concentration difficulty

• Sympathetic nervous system symptoms

5
Interventions: Mild to Moderate Anxiety
Nurse remains calm
Help identify anxiety and antecedents to anxiety
Anticipate anxiety-provoking situations
Demonstrate interest
Encourage talking about feelings/concerns
Keep communication open
Broad open-ended questions, exploring, clarification
Encourage problem solving
Use role playing, modeling
Explore past coping mechanisms
Provide outlets for excess energy

6
 Severe Anxiety
Perceptual field greatly reduced
Attention scattered or may only be able to focus on one detail
Self-absorbed
Can’t attend to events or see connections
Perceptions distorted
Feelings of dread or doom
Sympathetic nervous system symptoms
Confusion, purposeless activity
Cannot problem-solve or learn
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 Panic Level of Anxiety
Unable to focus on environment

Terror, emotional paralysis

Hallucinations/delusions (may lose touch with reality)

Muteness, severe withdrawal

Immobility or extreme agitation, severe shakiness

Disorganized, irrational thinking

Unintelligible speech, shouting, screaming

Sleeplessness

8
Interventions: Severe to Panic Anxiety
Nurse maintains calm manner
Remain with patient
Minimize environmental stimuli
Use clear, simple, statements and repetition
Low pitched voice; speak slowly
Reinforce reality if distortions occur
Listen for themes
Meet physical and safety needs
Set verbal limits/physical limits
Assess need for medication or seclusion

9
Interventions: Panic Anxiety
Instruct to take slow, deep breaths
Keep expectations minimal and simple
Help connect feelings with attack onset (triggers)
Help patient recognize symptoms as anxiety, not a physical problem
Teach abdominal breathing and positive self talk (CBT)
Psychoeducation
Medications

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Audience Response Question
Anita, 34, is shopping with a 5-year-old child in a large, busy urban
mall. The parent suddenly realizes the child is missing. Which level
of anxiety would likely result?

A.Mild
B.Moderate
C.Severe
D.Panic

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Audience Response Question

What behaviors might Anita be exhibiting that would

indicate panic-level anxiety?

A.Seeing and grasping information efficiently and

quickly to make problem solving more effective
B.Voice tremors, perspiration, and headache
C.Dazed, confused, with automatic behaviors aimed at
reducing anxiety
D.Running, shouting, and screaming

Copyright © 2018, Elsevier Inc. All rights reserved. 12

Audience Response Question

hat would be some appropriate interventions for the parent

whose child is missing at the mall and is experiencing panic level
anxiety?

13
Defenses Against Anxiety

efense mechanisms
• Automatic coping styles
• Protect people from
anxiety
• Maintain self-image by
blocking
• Feelings
• Conflicts
• Memories
• Can be healthy or
unhealthy
14
15
Healthy Defense Mechanisms

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Health Defense Mechanisms
Altruism

17
Sublimation

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Compensation

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Denial

20
Denial

21
Displacement

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Introjection

23
Identification

24
Reaction Formation

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Repression

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Suppression

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Somatization

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Humor

29
Undoing

30
Rationalization

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Regression

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Projection

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34
 Anxiety Disorders
Behaviors used to control anxiety
◦ Rigid
◦ Repetitive
◦ Ineffective
Functioning that the degree of anxiety interferes with
include
◦ The person
◦ The person's occupation
◦ The person's social interactions

35
Anxiety Disorders (continued)
anic disorder

eneralized anxiety disorder

eparation anxiety disorder

hobias
• Specific
• Social anxiety disorder
• Agoraphobia

bsessive-compulsive disorder
• Body dysmorphic disorder
• Hoarding disorder
• Hair pulling and skin picking disorders
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 Clinical Picture

eparation anxiety disorder

• Developmentally inappropriate levels of concern over being away from
a significant other

anic disorder
• Recurrent attacks of severe anxiety
• Key feature = panic attack
• No stimulus –sudden/spontaneous
• Can last moments to hours
• Normal function between attacks

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Panic Disorder (continued)
• Physical Symptoms
• Palpitations, tachycardia, nausea, diarrhea
• Dyspnea or feelings of choking/suffocation
• Dilated pupils, face flushed
• Dizziness, feeling faint
• Sense of impending doom
• Fear of going crazy or dying

Advanced states mimic MI, mitral valve prolapse

38
 Clinical Picture (continued)

goraphobia
• Excessive anxiety or fear about being in places or situations from which
escape might be difficult or embarrassing

pecific phobias

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 Clinical Picture (continued)

• Social anxiety disorder

• Severe anxiety or fear provoked by exposure to a social or a
performance situation that will be evaluated negatively by others
• Fears humiliation, embarrassment, sounding foolish
• Can fears public speaking, interacting with superiors, aggressive
individuals

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 Clinical Picture (continued)
eneralized anxiety disorder
• Excessive worry that lasts for months

ess debilitating than PD

• ANS symptoms less frequent/severe

ervasive and persistent anxiety

hronic feelings of nervousness

onstant worry

nsomnia, fatigue

wice as common in females than males

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Obsessive-Compulsive Disorders
bsessions
• Thoughts, impulses, or images that persist and recur, so that they cannot
be dismissed from the mind

ompulsions
• Ritualistic behaviors an individual feels driven to perform in an attempt to
reduce anxiety

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 Obsessive-Compulsive Disorder
go-dystonic: recognizes unreasonable nature of thoughts and
behavior

ears consequences if act not carried out

ear inability to control impulses

eels shame

hronic course

qual occurrence: males=females

43
 Obsessive-Compulsive Disorders
(continued)

ody dysmorphic disorder

• Preoccupation with an imagined defective body part
• Obsessional thinking and compulsive behavior
• Fear of rejection by others, perfectionism, and conviction of being disfigured lead to
emotions of disgust, shame and depression

oarding disorder

air pulling (trichotillomania)

• Trichophagia
• Trichobezoar

kin picking (excoriation disorder)

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 Anxiety Disorders

pidemiology
• Most common form of psychiatric disorder in United States
• Affects approximately 18%
of adult population

omorbidity
• Major depression
• Substance abuse

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Theory

enetic correlates
• Tend to cluster in families

iological findings
• Neurochemicals that regulate anxiety: epinephrine,
norepinephrine, dopamine, serotonin, GABA
• -Aminobutyric acid (GABA) /benzodiazepine theory

• Excess norepinephrine / decreased serotonin

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Psychological Theories

sychodynamic theories
• Sigmund Freud

• Harry Stack Sullivan

• Behavior theories

• Cognitive theories

ultural considerations
47
 Nursing Diagnosis - NANDA
• Anxiety
• Fear
• Hopelessness
• Ineffective coping
• Social Isolation
• Disturbed sleep pattern
• Self-care deficit

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 Planning: Behavioral Theory

earned response

an be unlearned

ehavior modification
• Conditioning techniques: positive & negative reinforcements

• Systemic desensitization

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 Behavioral Interventions

elaxation

odeling

ystemic desensitization

looding

esponse prevention

hought stopping

50
 Planning: Cognitive theory

nxiety disorders are caused by distortions in an individuals thinking

and perception
• Ex: Catastrophic results will occur if any mistake is made

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 Cognitive Interventions

ournal writing

ognitive restructuring

umor

ssertiveness training

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 Basic Level
Nursing Interventions

ounseling

ilieu therapy

romotion of self-care activities

harmacological interventions

ealth teaching

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 Phobia: Interventions

etermine type of phobia and onset

ave patient list consequences of contacting feared object/activity

dentify therapies for phobias (i.e., systemic desensitization)

each relaxation techniques

odel unafraid behavior

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OCD: Interventions
Anticipate needs, especially for information (medication, therapy)
Focus on the patient rather than the ritual
Monitor nutrition/sleep
Encourage meals/rest
Avoid hurrying patient
Do not arbitrarily forbid rituals
Give positive reinforcement for non-ritualistic activity

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Generalized Anxiety Disorder: Interventions
ncourage patient to discuss preceding events

ink patient’s behavior to feelings

each cognitive therapy principles

• Anxiety is the result of a dysfunctional appraisal of a situation
• Anxiety is the result of automatic thinking

sk questions that clarify and dispute illogical thinking

ave patient give alternate interpretation

dentify relief behaviors

ssist to reframe situation

onitor own feelings (anxiety is transmittable)

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Implementation

harmacological interventions
• Antidepressants
• Anti-anxiety drugs
• Other classes

sychobiological interventions

ntegrative therapy

ealth teaching

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Audience Response Questions
1. What is your usual level of anxiety on the day of a nursing exam?

A. Mild
B. Moderate
C. Severe
D. Panic

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Audience Response Question
A patient complains of frustration with his impulse to use tissues
“to touch or grab anything and everything around me. I just feel
clean and safe doing it that way, but sometimes if I don’t have a
tissue, I can barely stand to open a door.” This patient appears to
have which anxiety problem?

A. Panic disorder
B. Generalized anxiety disorder
C. Posttraumatic stress disorder
D. Obsessive-compulsive disorder

Copyright © 2018, Elsevier Inc. All rights reserved. 59

Anxiety Disorders: Medications

ntidepressants
• Selective serotonin reuptake inhibitors- SSRI
• Lexapro (escitalopram), Prozac (fluoxetine), Luvox
fluvoxamine), Paxil (paroxetine), Zoloft (sertraline)

• Serotonin-norepinephrine reuptake inhibitors-SNRI

• Cymbalta (duloxetine), Effexor(venlafaxine)

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Anxiolytics

enzodiazepines (BZD)
• Alprazolam (Xanax)

• Chlordiazepoxide (Librium)

• Diazepam (Valium)

• Clonazepam (Klonopin)

• Lorazepam (Ativan)

• Oxazepam (Serax)

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BZD-MOA

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 Anxiolytics (continued)

on-Benzodiazepines
• Buspirone (BuSpar)

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Other Classes

ntihistamines
• Atarax/Vistaril (hydroxyzine)

-Blockers
• Tenormin (atenolol), Inderal (propranolol)

nticonvulsants
• Tegretol (carbamazepine) , Neurontin (gabapentin), Depakote
(divalproex), Lyrica (pregabalin)

ntegrative therapy – Kava Kava, Valerian root

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Antianxiety and Hypnotic Drugs
(continued)

hort-Acting Sedative-Hypnotic Sleep Agents (“Z-hypnotics”)

• Zolpidem (Ambien)
• Zaleplon (Sonata)
• Eszopiclone (Lunesta)

65
Antianxiety and Hypnotic Drugs
(continued)

elatonin Receptor Agonist

• Ramelteon (Rozerem)

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