Anxiety related to medical disorders
Cardiac - MI, CHF, Mitral Valve Prolapse Endocrine -
hypoglycemia, hypo/hyperthyroidism, pheochromocytoma
Respiratory - copd, hyperventilation Neurological -
seizures, neoplasms and encephalitis
Anxiety related to substance abuse
Alcohol, sedatives, hypnotics, anxiolytics
Amphetamines, cocaine Hallucinogens
Caffeine Cannabis
OCD
Obsessions - Recurrent and persistent thoughts, impulses or
images experienced as intrusive and stressful unable to be rid of by
logic or reasoning. Compulsions - Repetitive ritualistic
behavior (hand washing, ordering, checking/ mental acts - praying
counting, repeating words silently) or thoughts to prevent dreaded
events or situations. OCD - Repetitive ritualistic behavior
or thoughts to prevent distress
Body Dysmorphic Disorder
Exaggerated belief body is distorted/deformed - if deformity is
present then person's concern is exaggerated to a higher level.
Symptoms of depression of Obsessive-Compulsive/Depression
Disorder Associated with delusional thinking and may cause
social/occupational impairment
Trichotillomania/Hair Pulling Disorder
Recurrent pulling out of one's hair that results in hair
loss Preceded by tension and release results in
gratification More in women than in men
OCD/Related Disorders
Psychoanalytical Theory
Learning Theory
OCD - have weak underdeveloped egos. Aggressive impulses are
channeled into intrusive thoughts. Learning Theory -
conditioned response to a traumatic event. Use of passive/active
avoidance Biological Theory -
Trichotillomania/Hair Pulling Disorder
Psychosocial - Stressful situations, disturbances in
mother-child relationship, fear of abandonment, recent object loss,
possible childhood or emotional abuse.
OCD/Related Disorders
Biological Theory
Genetics Neuroanatomy - OCD: Basal
ganglia/Orbitalfrontal cortex Biochemical - decrease in
serotonin in OCD/Dysmporphia
GAD Outcomes
Client is able to recognize signs of increasing anxiety and
intervene before reaching panic level Able to maintain
anxiety at manageable levels.
Phobia Outcomes
Functions adaptively in presence of object or situation w/out
experience panic anxiety Verbalize plan to respond to
phobic object or situation
OCD Outcomes
Manage anxiety without use of ritualistic behaviors
Demonstrates adaptive coping measures
Trichotillomania/Body Dysmorphic Disorders
Trichotillomania - client demonstrates more adaptive coping
measures instead of pulling hair. Body Dysmorphia - client
will verbalize a realistic perception of self/Positive Image
Panic Interventions
With client experiencing a panic attack - use simple words or
brief messages for communication. Stay with client and
offer reassurance of safety and security - don't leave client alone
in panic anxiety. Maintain a calm, nonthreatening
approach. Keep immediate surroundings low in stimuli - dim
lighting, few people, simple decor. Administer
tranquilizing medication - assess for effectiveness. When
anxiety levels decrease - explore possible reasons for attack.
Teach ways to interrupt escalating anxiety -walking,
jogging,
Fear Interventions
Explore client's perception of threat to physical integrity or
threat to self-concept. Discuss reality situation with the
client to change aspects and those that can't Include the
client in making decisions related alternative coping strategies -
encourage choices that promote feelings of empowerment.
Systemic Desensitization - exposes individuals to gradually to
situation/object until fear is no longer felt.
Implosion/Flooded therapy - individual is flooded with stimuli
until anxiety associated with the object is no longer
experienced. Teach relaxation technique
Hamilton Anxiety Rating Scale
14-17 - Mild Anxiety 18-24 - Moderate Anxiety
25-30 - Severe Anxiety 1- mild, 2 -moderate, 3 -
severe, 4 - very severe
OCD/Ineffective Coping Interventions
Work with client to determine types of situations that increase
anxiety. Initially - accept and allow client's
dependency/ritualistic behaviors. Allow plenty of time for rituals -
i.e. wake client early to perform rituals. Don't be
judgmental and deny client behavior as this may increase
anxiety. Explore meaning and purpose of behavior. He/She is
unware of the relationship between emotional problems and compulsive
behaviors Provide a structure schedule of activities
including completion of rituals. Gradually begin to limit
time for ritualistic behavior and replace these with more adaptive
behaviors.
Body Dysmorphic/Disturbed Body Image
Assess client's perception of his or her body image. Help
client see body image is distorted. Encourage verbalization
of fears and anxieties associated w/stressful life situations.
Discuss alternative adaptive coping strategies - verbalization
of feelings may help one come to terms with unresolved issues.
Involve client in activities that reinforce a positive sense of
self not based on appearance.
Treatment Modalities
Individual Psychotherapy - Insight oriented help patients
unconscious meaning of anxiety Cognitive - Alters cognitive
distortion thoughts to reduce anxiety Behavior Therapy -
Systemic densitization & implosion therapy
Psychopharmacology - Antianxiety agents
Antianxiety Agents
Action - Depress subcortical levels in CNS, increase inhibitory
action of GABA, (Buspirone - doesn't depress CNS acts on
serotonin levels, dopamine levels )
Antianxiety Agents
Hydroxyzine (Antihistamine); S/E: Drowsiness, confusion,
lethargy Alprazolam/Xanax (Benzo); S/E: Tolerance, physical
and psychological dependence - taper off long term
Chlordiazepoxide (Librium) (Benzo); S/E: Same as above
Clonazepam/Klonopin (Benzo); S/E: Same as above
Clorazeparte (Tranxene) (Benzo); S/E: Potentiates effects of
other CNS depressants, don't take with alcohol or other
depressants. Diazepam/Valium (Benzo); S/E: Same as above
Lorazepam/Ativan (Benzo); S/E: Same as above
Oxazepam Meprobamate (Carbamate); S/E: May aggravate
symptoms of depression
GAD Medications
Anxiolytics - Benzos are used on prn basis . Warn client
against ABRUPT discontinuation of drugs. Been replaced by SSRIs and
SNRIs as antianxiety. Antidepressants -
Imipramine/clomimpramine Antihypertensive Agents -
Propranolol - helps with palpitations and tremors from panic anxiety
"performance anxiety & test anxiety" and clonidine -
blocks acute anxiety.
Phobic Disorders
Anxiolytics - treat social anxiety disordrs
Antidepressants - imipramine and MAOI's decreased symptoms
agorophobia and social anxiety Antihypertensives -
Propranolol and atenolol useful in stage fright.
OCD/Body Dysmorphic/Trichotillomania
OCD - Antidepressants: SSRI's (Fluxetine, paroxetine,
sertraline, and fluvoxamine). s/e: sleep disturbances, headache,
restlessness. Body Dysmorphic Disorder - Antidepressants:
Clomipramine (Anfranil) and fluoxetine(Prozac) reduce symptoms in
about 50% off clients. Trichotillomania - Chlorpromazine,
amitriptyline, and lithium .Olanzapine has been reported as
safe.