Guided Lecture Notes
Chapter 26: Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders
Learning Objective 1. Differentiate normal anxiety responses from those suggestive of an anxiety disorder.
· Define anxiety as an uncomfortable feeling of apprehension or dread that occurs in response to internal or external stimuli and can result in physical, emotional, cognitive, and behavioral symptoms (refer to PowerPoint slide 2 and Box 26.1).
· State that anxiety can be positive and motivate one to act or that it can produce paralyzing fear, causing inaction.
· Discuss anxiety in regard to intensity of anxiety relative to the situation, the trigger for the anxiety, and the particular symptom clusters that manifest the anxiety, comparing normal responses with potentially dysfunctional responses (refer to PowerPoint slide 2).
Learning Objective 2. Identify biopsychosocial indicators for four levels of anxiety and nursing interventions appropriate for each level.
· Describe the four degrees of anxiety and associated perceptual changes and patterns of behavior associated with each (refer to PowerPoint slide 2 and Table 26.1).
· Discuss nursing approaches appropriate for the care of individuals exhibiting the above perceptions and behavioral changes (refer to Table 26.5).
Learning Objective 3. Describe the prevalence and incidence of anxiety disorders.
· Identify anxiety disorders as the most common psychiatric illness treated by health care providers (refer to PowerPoint slide 3).
· Explain that approximately 40 million American adults older than 18 years of age within a given year have an anxiety disorder.
· State that women experience anxiety disorders more frequently than men.
· Describe the comorbidities associated with anxiety disorders, including depression, heart disease, and respiratory disease.
· Review that anxiety disorders tend to be chronic and persistent with full recovery likely among those who do not have other mental or physical illnesses.
· Explain that in the primary care setting, most patients with anxiety disorders present with coexisting physical disorders.
· Discuss anxiety disorders as the most common condition of adolescents and that the prevalence of anxiety disorders declines with age but that rates of anxiety disorders are as high as mood disorders in older adults.
Learning Objective 4. Delineate clinical symptoms and course of anxiety disorders.
· Identify anxiety disorders: panic disorder, obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and phobias (refer to PowerPoint slide 4).
· Describe panic disorder as a lifelong disorder peaking in the teenage years and then again in the 30s.
· Identify the two types of panic disorders as with and without agoraphobia (refer to PowerPoint slide 5).
· State that panic disorders are often characterized by panic attacks, which are sudden, discrete periods of intense fear or discomfort accompanied by significant physical and cognitive symptoms.
· Discuss the signs and symptoms associated with panic attacks, emphasizing that the physical symptoms are similar to those of cardiac emergencies.
· Explain that panic attacks can lead to the development of phobias (refer to Box 26.3)
· Describe the diagnostic criteria for panic disorder (refer to PowerPoint slide 6 and Key Diagnostic Characteristics 26.1).
· Explain that obsessive-compulsive disorder is characterized by obsessions and compulsions that are so consuming that they interfere with a person’s judgment and daily activities, such that the person believes that he or she does not have control over the obsessions and compulsions (refer to PowerPoint slide 21).
· Describe obsessions and compulsions and give examples of each.
· Describe the diagnostic criteria for OCD as including recurrent obsessions and compulsions that are excessive and unrealistic, causing distress and interference with normal daily routine (refer to PowerPoint slide 22).
· Discuss the typical age of onset of OCD (early 20s to mid-30s), the onset of symptoms (gradual), and gender differences (men are more often affected as children; women have a higher incidence of cleaning rituals and checking) (refer to PowerPoint slide 23).
· Explain that individuals with GAD generally feel frustrated, disgusted with life, demoralized, and hopeless.
· Describe the onset of GAD as insidious with many patients complaining of being constant worriers (refer to PowerPoint slide 33).
· Report that GAD affects about 4% of the population with about half the individuals reporting an onset in childhood or adolescence or possibly after the age of 20 years (refer to PowerPoint slide 34).
· Describe the diagnostic criteria for GAD as involving excessive worry and anxiety for at least 6 months with the anxiety related to a number of real-life activities or events (refer to PowerPoint slide 35).
· Discuss ASD and PTSD as resulting from major trauma, differentiating ASD as a short-term disorder and PTSD as a long-term disorder (refer to PowerPoint slide 42).
· Identify dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis as the possible basis for the link between trauma and these disorders.
· State that PTSD affects approximately 8% of the population but varies among groups (refer to PowerPoint slide 44).
· Identify the risk factors for PTSD, including prior diagnosis of ASD; extent, duration, and intensity of trauma involved; and environmental factors.
· Explain that women are approximately twice as likely to experience PTSD as men, with a median time from onset to remission of 4 years for women compared with 1 year in men.
· Discuss the diagnostic criteria for ASD and PTSD as a re-experiencing of the event through distressing images, thoughts, or perceptions, usually with recurrent nightmares, flashbacks, and extreme stress on exposure to an event or image resembling the traumatic event (refer to PowerPoint slide 43).
· Explain specific phobia as a persistent fear of clearly discernible, circumscribed objects or situations leading to avoidance behavior that generally affects women twice as often as men that peaks in childhood and again in the 20s (refer to PowerPoint slide 47 and Box 26.3).
· Describe social phobia as a persistent fear of social or performance situations in which embarrassment may occur (refer to PowerPoint slide 47).
· Discuss dissociative disorders as responses to extreme external or internal events or stressors, with a high prevalence among those who experienced childhood physical or sexual abuse, occurring suddenly or gradually, being transient or long term (refer to PowerPoint slide 50).
Learning Objective 5. Analyze biopsychosocial theories of anxiety disorders.
· For panic disorder, explain the following: biologic theories, including genetic factors (familial disposition and possible gene variants), neuroanatomic theories (“fear network”), and biochemical theories (neurotransmitter involvement such as serotonin, norepinephrine, gamma-aminobutyric acid [GABA] and the HPA), and psychological and social theories, including psychodynamic theories (related to separation and loss) and cognitive behavioral theories (learning theory and conditioning; refer to PowerPoint slide 8).
· For OCD, discuss the following: biologic theories, including genetic factors, neuropathologic theories (hyperactivity in certain brain areas and glucose metabolism), and biochemical theories (serotonin’s role), and psychological theories, including psychodynamic factors (three unconscious defense mechanisms) and behavioral factors (learning theory and conditioned stimuli; refer to PowerPoint slide 24).
· For GAD, describe the following: biologic theories, including neurochemical theories (activation of the sympathetic nervous system, serotonin–GABA interaction or dysfunction), and genetic theories, including possible inheritance link (refer to PowerPoint slide 36).
· For ASD and PTSD, describe the following: biologic theories, including neurobiologic theories (hyperarousal, intrusion, conditioning, avoidance and numbing), and genetic theories (relationship between genetic and familial factors; refer to PowerPoint slide 45).
Learning Objective 6. Apply nursing process with recovery-oriented interventions for persons with anxiety disorders.
· For panic disorder:
o Describe the important assessments for the biologic (life-threatening causes, characteristic symptoms, substance use, sleep patterns, physical activity level, and pregnancy [refer to Figure 26.1 and PowerPoint slide 12]), psychological (self-report scales [refer to Box 26.6 and Table 26.3], mental status exam, and cognitive thought patterns [refer to Table 26.4 and PowerPoint slide 14]) and social domains (family factors and cultural factors [refer to Figure 26.2 and PowerPoint slide 16]).
o Identify relevant nursing diagnoses for panic disorder for the biologic, psychological, and social domains (refer to PowerPoint slides 12, 14, and 16).
o Describe interventions for the biologic domain (teaching about breathing control, nutritional planning, relaxation techniques [refer to Box 26.4] and pharmacologic interventions, including selective serotonin reuptake inhibitors [SSRIs], serotonin–norepinephrine reuptake inhibitors, tricyclic antidepressants [TCAs], and monoamine oxidase inhibitors, and benzodiazepines [refer to Box 26.5, Table 26.2, and PowerPoint slide 13), psychological domain (distraction, positive self-talk, panic control treatment, exposure therapy, systematic desensitization, implosion therapy, cognitive behavioral therapy, and psychoeducation [refer to Box 26.8 and PowerPoint slide 15), and social domain (time management, lifestyle changes [refer to PowerPoint slide 17]).
o Discuss emergency care for a patient experiencing panic disorder (refer to PowerPoint slide 18).
· For OCD:
o Describe the important assessments for the biologic domain (multiple physical symptoms, dermatologic lesions [refer to PowerPoint slide 25]), psychological domain (severity and type of obsessions and compulsions, circumferential speech, interference with daily functioning [refer to Box 26.11 and PowerPoint slide 27]), and social domain (cultural or religious beliefs [refer to PowerPoint slide 32]).
o Identify relevant nursing diagnoses for OCD for the biologic, psychological, and social domains (refer to PowerPoint slides 25, 28, and 32).
o Describe interventions for the biologic domain (skin integrity maintenance, psychopharmacology such as SSRIs and TCAs [clomipramine, sertraline, fluvoxamine, paroxetine, fluoxetine], medication teaching [refer to Box 26.8], electroconvulsive therapy, and psychosurgery [refer to PowerPoint slide 26]), psychological domain (response prevention, thought stopping, relaxation techniques, cognitive restructuring, cue cards [refer to Box 26.13], and psychoeducation [refer to Box 26.14 and PowerPoint slide 31]), and social domain (routines, significance of rituals, activity scheduling [refer to PowerPoint slide 32]).
· For GAD:
o Describe the important assessments for the biologic domain (symptoms, diet and nutrition, and sleep patterns [refer to PowerPoint slide 37]), psychological domain, and social domain (refer to panic disorder and PowerPoint slide 41).
o Identify relevant nursing diagnoses for panic disorder for the biologic, psychological, and social domains.
o Describe interventions for the biologic domain (psychopharmacology such as benzodiazepines, antidepressants [paroxetine, imipramine, venlafaxine, buspirone] and beta-blockers and teaching [refer to Box 26.15 and PowerPoint slide 38]), psychological domain, and social domain (cognitive and behavioral therapies, relaxation, supportive therapies [refer to PowerPoint slide 41]).
· For ASD and PTSD:
o Describe the nursing management, including psychopharmacology (SSRIs, benzodiazepines, and beta-blockers), psychodynamic psychotherapy, cognitive behavioral therapy, eye movement, desensitization and reprocessing, stress management education, exposure techniques (little efficacy shown), group and family therapy, and social support (refer to PowerPoint slide 46).
· For other anxiety disorders:
o Review the assessment findings associated with specific phobia, including the heightening of anxiety to possible panic levels and the need to assess in light of ethnicity and culture (refer to PowerPoint slide 47).
o Identify exposure therapy as the treatment of choice for specific phobias and use of antianxiety agents for short-term relief.
o Discuss the assessment findings associated with social phobia, including increased sensitivity to disapproval or criticism, tendency for negative self-evaluation, poor self-esteem, distorted view of personal strengths and weaknesses, and fear that others will scrutinize behavior or judge negatively (refer to PowerPoint slide 47).
o Mention that SSRIs are used as treatment for social phobia because of the significant reduction in social anxiety and phobic avoidance and that benzodiazepines may be used to reduce anxiety related to phobias.
o Describe the essential feature of dissociative disorders as a failure to integrate identity, memory, and consciousness manifested by two distinct personality or identity states (refer to PowerPoint slide 50).
o Explain that treatment for dissociative disorders includes antidepressants, and psychotherapy such as hypnotherapy, cognitive behavioral therapy, and psychoanalytic psychotherapy.