Chapter 15: Anxiety & Obsessive-Compulsive Disorders

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Welcome to the Deep Dive.

We're here to break down essential knowledge from key sources, making it easy to grasp.

Today we're tackling a really big topic, anxiety and obsessive -compulsive disorders, drawing insight straight from foundational psychiatric nursing texts.

Right.

And to kick things off, we really need to nail down a core difference, anxiety versus fear.

They sound similar, but they're not.

Absolutely fundamental.

Fear is that immediate hit, right?

Specific danger, you see a car coming at you.

Yeah, you react.

Exactly.

Anxiety, it's more of a background hum.

A sense of dread, maybe, but the threat is vague, unspecified, you just feel uneasy.

And it's important to say, some anxiety is totally normal, even necessary.

Oh, for sure.

It's adaptive.

It's the juice that gets you to study for that exam, you know, or prep for a big presentation that helps us function.

But when it gets stuck or becomes overwhelming,

that's where we get into the disorders.

Precisely.

And that's our mission today, to map out that whole spectrum.

We'll look at the theory, how we cope using defense mechanisms, walk through the main clinical disorders, and then tie it all together with nursing approaches and treatments.

Okay, so let's start with the theory.

How do we actually measure or assess anxiety?

The source material really leans on Hildegard Pepeau's four -level model.

Why is that still so central?

Because everything hinges on it for intervention.

Seriously, you can't treat someone in a full -blown panic the same way you help someone with mild anxiety.

Makes sense.

Pepeau's levels focus on two key things.

How much you can perceive your perceptual field and your ability to solve problems.

Okay.

So level one, mild anxiety, perception, sharp, problem solving, effective.

You might just be a bit restless.

Maybe tapping your foot, biting your nails, normal energy.

Right, like getting ready for something.

Then moderate anxiety.

Here, the perceptual field starts to narrow.

It's like selective hearing or selective seeing, really.

You might miss things unless someone points them out.

Okay, so focus gets tighter.

Yeah, and problem solving is still possible, but definitely not optimal.

And you start feeling it physically,

the sympathetic nervous system wakes up.

Pounding heart, maybe some muscle tension,

headache, that kind of thing.

And then it ramps up to severe anxiety.

It really does.

Now the perceptual field is way down.

You might fixate on one tiny detail or just be overwhelmed by scattered bits of information.

Learning,

problem solving.

Forget it, it's impossible.

Behavior becomes automatic, just trying to get relief.

And there's often this awful feeling like something terrible is about to happen, impending doom.

That sounds terrifying.

And the final level, panic.

The most extreme.

The environment just isn't processing.

The person might not be making sense.

They could even lose touch with reality.

Maybe hallucinations, delusions.

So completely overwhelmed.

Totally.

Behavior can be all over the place.

Running, shouting, withdrawing completely.

And there's a real physical danger here too, like sheer exhaustion.

Okay, so understanding those levels is step one for assessment.

What about how people cope internally?

Defense mechanisms.

Right.

These are those automatic things we do, mostly without thinking.

Freud, and later Anna Freud, talked about them a lot.

They basically protect our self -image by blocking upsetting thoughts or feelings.

And they're not always bad, right?

Like suppressing worry to focus.

Exactly.

Suppression can be adaptive.

The problem comes when the use is too frequent, too intense, or lasts too long.

That's when it becomes pathological, maladaptive.

It stops you from dealing with reality.

Gotcha.

Any examples of maladaptive ones from the source?

Yeah, a few key ones.

Denial is classic, short -term after a loss, maybe.

But the example given is a woman, three years after her husband died, still keeping his clothes ready, talking about him like he's still there.

That's avoiding reality.

Okay, that's pretty extreme.

Then there's conversion.

That's when anxiety unconsciously gets turned into a physical symptom, like suddenly going blind after seeing something traumatic.

But there's no medical reason for the blindness.

We also see projection, putting your own unacceptable feelings onto someone else.

And splitting, which the source says is always pathological, that's seeing everything in black and white.

People are either all good or all bad, no middle ground.

Right, that inability to see complexity.

Okay, let's shift to the clinical disorders themselves.

The source says these are incredibly common.

Hugely common, affecting something like 19 % of adults.

And the defining feature is that people get locked into these rigid, repetitive behaviors,

trying to control the anxiety, but it doesn't really work.

So what are the main types we need to know?

Well, there's separation anxiety disorder.

You usually think of kids, but it's this developmentally inappropriate fear about being away from someone important.

Often shows up as physical stuff like stomach aches or headaches.

And there's adult form too.

Yeah, newly recognized.

It looks like intense clinginess, lots of worry about harm coming to loved ones or relationships ending.

Interesting.

What about phobias?

Specific phobias.

Intense irrational fear of one particular thing.

Spiders, heights, flying, leading to major avoidance.

People really shrink their lives to avoid the trigger.

And there's that specific one, BII.

Ah, yes.

Blood injury injection phobia.

It's unique.

Most phobias rev up the heart rate.

BII does that initially, then your heart rate and blood pressure plummet.

Bradycardia.

So people actually faint.

Often, yeah.

It's a vasovagal response, very distinct physiology.

Okay, then social anxiety disorder.

Or social phobia.

This is all about fear of negative judgment in social situations or performing.

Public speaking is the classic example.

I think a lot of people can relate to that on some level.

Sure, but this is debilitating.

In kids, it might even look like them refusing to speak at all in certain situations or acting out.

Got it.

And panic disorder.

Key here is the unexpected panic attack.

Comes out of the blue, peaks really fast.

Within minutes, you need four or more symptoms.

Heart pounding, sweating, chest pain, choking feeling, fear of dying, fear of going crazy.

It's intense.

And the big problem is worrying about the next attack.

Exactly.

They start to fear the fear.

That fear drives avoidance, which leads us straight into agoraphobia.

Which isn't just fear of open spaces, right?

Right.

It's fear of any situation where escape might be tough or help unavailable if panic strikes.

So crowds, buses, elevators, bridges.

Being outside the home alone, it can make people completely housebound.

Such a loss of freedom.

Okay, one more major one.

Generalized anxiety disorder, GAD.

The absolute core of GAD is excessive worry.

Worrying constantly about everything, job, health, money, family.

Way out of proportion to the actual risk.

So it's not focused like a phobia.

No, it's pervasive and it leads to real problems.

Procrastination because they dread decisions, avoiding things, second -guessing everything.

And huge issues with sleep and just feeling exhausted all the time.

Before we move to treatment, the source mentions a cultural aspect.

Attack the nervios.

Yes.

Important for assessment.

It's a culture -bound syndrome seen mainly in Hispanic communities.

A reaction to stress that looks dramatic, trembling, shouting, maybe seizure -like movements,

feeling heat rise up the body.

Need to recognize it's not panic disorder per se, but a cultural expression of distress.

Crucial distinction.

Okay, assessment.

Where does the nursing process start when someone presents with these symptoms?

First stop, rule out the medical mimics.

Always.

You need a thorough physical and neurological workup.

Why?

Because so many medical conditions can cause anxiety symptoms.

Hyperthyroidism, COPD, heart problems like arrhythmias, pulmonary embolism, even caffeine intoxication or substance withdrawal.

You have to know if the anxiety is primary or if it's a symptom of something else.

Right, get the physical causes off the table.

Yeah.

And then using assessment tools.

Yeah, tools help quantify things.

Like you could visualize the severity measure for generalized anxiety disorder in adults.

It's basically a self -report checklist.

The patient rates, how often they felt symptoms like being keyed up or on edge, having worrisome thoughts, needing reassurance gives you a baseline.

Okay, so once you've assessed the level and ruled out medical causes, how do interventions differ based on that PIP loss scale?

Massively.

If the patient is in mild to moderate anxiety, they can still think, they can still problem solve.

So you can talk with them?

Exactly.

Use therapeutic communication, open -ended questions, ask for clarification, offer broad openings, be calm, encourage them to talk about what's worked for them before, build on their strengths.

But if they're in severe to panic levels?

Safety first, period.

They cannot process complex information.

Keep communication short,

firm, simple statements, reduce stimuli, get them to a quiet place as possible.

Reinforce reality if they're misinterpreting things, take care of basic needs, fluids, rest.

And look, if other things aren't working, medication or even temporary seclusion might be necessary to ensure their safety and everyone else's.

Got it.

Let's talk treatment then, pharmacotherapy.

What's the go -to?

First line is generally the SSRIs, drugs like paroxetine, phylloxetine, sertraline, acetalapram, and the SNRIs like venlafaxine and deloxetine.

What about benzodiazepines like Valium or Xanax?

They work fast, right?

They do work fast, which is why they're tempting for acute situations.

But, and this is a big but, the risk of dependence is high.

They should really only be used short term.

And side effects.

Sedation, potential for ataxia that's like unsteadiness, which increases fall risk, especially in older adults.

Generally not great for anyone with a history of substance use issues either.

So alternatives.

Busbarone or Busbar is a good non -addictive option, particularly for JD,

the catch.

It takes time, two to four weeks for the full effect.

So you need to manage patient expectations.

Okay, any others?

Yeah, sometimes beta blockers are used, mostly for the physical symptoms like a racing heart, especially in performance anxiety.

And antihistamines can be an option.

They cause sedation but aren't addictive.

So sometimes useful if substance use is a concern.

What about psychological therapies?

The source mentions CBT, cognitive behavioral therapy.

CBT is huge, very evidence -based.

And interestingly, the source notes some research suggesting CBT might even have biological effects, like improving cellular stress protection markers.

That's fascinating.

Talk therapy changing biology.

It is.

And there are specific behavioral techniques too.

Modeling, where the therapist shows how to handle a feared situation.

Systematic desensitization.

That's the gradual exposure one.

Exactly.

Slow step -by -step exposure to the feared thing paired with relaxation techniques at each stage.

Very effective for phobias.

And the opposite end is?

Flooding.

More intense.

Prolonged exposure to the feared stimulus without the gradual buildup.

The idea is to stay in the situation until the anxiety peaks and then naturally decreases, kind of extinguishing the fear response.

Can be faster but tougher on the patient.

Right.

And thought stopping.

That's about interrupting those automatic negative thoughts.

Literally, you teach the patient to internally yell stop or maybe snap a rubber band on their wrist when the thought occurs and then immediately replace it with a prepared positive thought.

OK, that makes sense.

So that covers anxiety generally.

Now let's pivot to obsessive compulsive and related disorders.

Still anxiety driven but distinct.

Yes, now a separate chapter in the DSM -5, but anxiety is definitely the engine.

The core is obsessions.

These are intrusive persistent thoughts, images, or urges that feel unwanted.

Even alien to the person that's the ego dystonic part.

They cause major distress.

Like contamination fears or worries about harm.

Exactly.

Or unwanted sexual thoughts, religious fears, needing things to be just right.

And then comes the compulsion.

The ritual.

The ritual.

It's a behavior the person feels driven to perform to reduce the anxiety caused by the obsession or to prevent some dreaded event.

Checking, washing, counting, ordering things.

But the relief doesn't last.

Nope.

It's temporary.

So the compulsion has to be repeated again and again.

It becomes this exhausting time consuming cycle.

There are related disorders in this category too.

Right.

Body dysmorphic disorder, BDD.

Here the obsession is about a perceived flaw in appearance.

Could be skin, hair, nose, anything that seems minor or invisible to others.

Leads to compulsive behaviors like mirror checking, excessive grooming, camouflaging.

And the source mentions high suicide risk here.

Tragically, yes.

Very high risk associated with BDD.

Then you have hoarding disorder.

Not just collecting, but accumulating possessions to the point that living spaces become unusable.

Often linked to real difficulty with decision making.

And the body furbs repetitive behaviors.

Trichotillomania, which is compulsive hair pulling.

And excoriation disorder, which is skin picking.

Often done to relieve stress or boredom, but can cause significant physical damage.

And there's a specific danger with hair pulling.

Yeah.

Trichophagia, swallowing the pulled out hair.

It can lead to something called Rapunzel syndrome.

A potentially fatal blockage in the gut from a hairball.

Or trichobizor.

Rare, but serious.

Goodness.

Okay.

So nursing care for OCD and related disorders.

Assessment tools.

Assessment often uses scales like the obsessive -compulsive inventory revised, the OCIR, to measure symptom type and severity.

In terms of care, initially, patients might resist talking about the behaviors themselves.

So a key focus is often safety and managing consequences.

Like skin integrity issues from all the washing or picking.

Or just the sheer exhaustion from rituals.

And treatment.

Similar meds.

Similar SSRIs are first -line fluoxetine, fluvoxamine, sertraline.

Also, the older tricyclic chlomopremine is specifically FDA approved for OCD.

Anything more advanced for tough cases?

Yes.

For treatment -resistant OCD, there's deep brain stimulation, DBS.

It's a surgical option.

Involves implanting electrodes in specific brain areas.

It's reversible.

But the main psychological therapy is different from general anxiety.

Yes.

The gold standard for OCD is exposure and response prevention, ERP.

It directly targets that obsession -compulsion link.

How does it work?

You expose the person to their trigger, maybe touching something they see as contaminated.

And then you prevent them from doing the compulsion, the ritual washing.

They have to sit with the anxiety until it naturally decreases on its own.

Breaking the cycle.

Exactly.

It teaches the brain that the feared consequence doesn't happen.

And that the anxiety will subside without the ritual.

It takes courage, but it's very effective.

Okay.

So wrapping this deep dive up, what are the absolute must -know nuggets for our listeners?

I'd say number one, anxiety is universal, but the disorders involve anxiety that's excessive and impairs function.

Two, PIPLAS levels are your assessment framework.

Mild and moderate means they can still process.

Severe panic means safety first.

Three, treatment is often dual.

SSRIs are usually first -line meds combined with powerful therapies like CBT and especially ERP for OCD.

Great summary.

And maybe a final thought for people that chew on.

Given that anxiety disorders are the most common psychiatric issue and often show up in primary care disguised as physical symptoms, headaches, stomach problems, chest pain.

Right, the somatic complaints.

Exactly.

Think about how vital it is for all healthcare providers, not just mental health specialists, to understand these non -drug therapies.

Knowing about CBT, about exposure, these give patients tools to break that awful cycle of fear and avoidance.

It's about helping them reclaim control.

A really empowering perspective.

Thanks for walking us through all that.

And thank you for joining us on this deep dive into psychiatric nursing foundations.