Anxiety/OCD exam

• apprehension, uneasiness, tension, uncertainty, or dead from real or perceived threat
• - vague sense of dread related to an unspecified or unknown danger

reaction to a specific danger

• a healthy reaction necessary for survival
• - provides energy, motivation, prompts constructive behaviors

• - mild
• - moderate
• - severe anxiety 
• - panic

• - normal experience of everyday living
• - perceive reality in sharp focus
• - sees, hears, and grasps more information 
• physical s/s
• - slight discomfort
• - restlessness
• - irritability 
• - mild tension-relieving behaviors (nail biting, tapping foot, etc. )

• - sees, hearts, and grasps less information; selective inattention 
• - perceptual field decreases
• - ability to think clearly is decreased but learning and problem solving can still take place 
• S/S
• - tension, pounding heart, increase HR and RR, gastric discomfort, urinary urgency, headache, voice tremor

• - perceptual field is greatly reduced
• - may focus on one partcular detail or many scattered details
• - have difficulty noticing what is going on in the environment
• - learning and problem solving are not possible
• - dazed/confused
• S/S
• - headache, nausea, dizziness, insomnia, inc. trembling and a pounding heart, hyperventilation, sense of impending doom or dread

• - markedly disturbed behavior 
• - unable to process what is going on 
• - focus is lost
• - may lose touch with reality
• - manifest pacing, running, shouting, screaming, or withdrawal
• - hallucination or false sensory perceptions
• - physical behavior may become erratic, uncoordinated, and impulsive

autonomic coping styles that protect people from anxiety and maintain self-image by blocking feelings, conflicts, and memories

helps people lower anxiety to achieve goals in acceptable ways

occurs when one or several are used in excess: particularly in the overuse of immature defenses

• - compensation 
• - denial
• - displacement
• - dissociation 
• - identification 
• - intellectualization 
• - projection
• - rationalization
• - reaction formation
• - regression
• - repression 
• - splitting
• - sublimation 
• - suppression
• - undoing

• used to counterbalance perceived deficiencies by emphasized strengths
• adaptive use
• - shorter-than-average man becomes assertively verbal and excels in business
• Maladaptive use
• - ind. drinks alcohol when self-esteem is low to temp. diffuse discomfort

• escaping unpleasant, anxiety causing thoughts, feelings, wishes, or needs by ignoring their existence
• Adaptive use
• - saying "no i don't believe you" to the new of the death of a loved one to protect self from overwhelming news
• Maladaptive use
• - talking about a a loved one who passed in present tense and still having their belongings

• the transference of emotions associated with a particular person, object, or situation to another non threatening person, object, or situation
• Adaptive use
• - child yelling at his teddy bear after being picked on by a bully at school
• Maladaptive use
• -  a child who is unable to acknowledge fear of his father becomes fearful of animals

• a disruption in consciousness, memory, identify, or perception of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself
• Adaptive use
• - separating oneself from environment while becoming absorbed in some type of work
• Maladaptive use
• - perpetually disconnected from reality after experiencing abuse

• attributing to oneself the characteristics of another person or group (done consciously or unconsciously)
• Adaptive use
• - dressing up as a teacher and playing pretend classroom 
• Maladaptive use
• - looking up to street corner drug seller

• a process in which events are analyzed based on remote, clod facts and without passion, rather than incorporating feeling and emotion into processing
• Adaptive use
• - analyzing options after a disaster 
• Maladaptive use
• - responding to the death of a loved one by focusing on details of operating the household rather than processing the grief with his children

• unconscious rejection of emotionally unacceptable features and attributing them others
• Adaptive use
• - none, considered immature defense mechanisms
• Maladaptive use
• - repressed attraction towards same sex, refuses to socialize. fears that they will make homosexual advances towards them

• consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener 
• Adaptive use
• - saying "i didn't get a raise becuase the boss doesn't like me"
• Maladaptive use
• - a man who thinks his son was fathered by another man excuses his malicious treatment by saying "he is lazy and disobedient" when that is not the case

• when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion 
• Adaptive use
• - recovering alcoholic talking about the evils of alcohol 
• Maladaptive use
• - Overprotective and hovering over child, interfering with normal growth and development

• reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been previously exhibited
• Adaptive use
• - 4 yr old with new bby brother begins sucking thumb and requesting bottle
• Maladatptive use
• - man who loses promotion begins complaining, handing work in sloppy, miss appts. and comes into work late

• unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness
• Adaptive use
• - man forgets wife's Bday after marital fight
• Maladaptive use
• - women unable to enjoy sex after having pushed out of awareness a traumatic sexual incident from childhood

• inability to integrate the positive and negative qualities of oneself or others into a cohesive image 
• Adaptive use
• - none, pathological defense 
• Maladaptive use
• - looks up to idol and is disillusioned when they turn out to have flaws

• an unconscious process of submitting mature and socially acceptable activity for immature and unacceptable impulses 
• Adaptive use
• - a women who is angry with her boss writes a short story of a heroic women 
• maladaptive use
• - always constructive

• conscious denial of a disturbing situation or feeling 
• Adaptive use
• - i won't worry about paying my rent until after my exam tomorrow 
• Maladaptive use
• - women feels a lump in her breast and puts it in the back of her mind until after her 3 week vacation

• commenly seen in children. when a person makes up for an act or communication 
• Adaptive use
• - after cheating, the partner buys significant other a gift
• Maladaptive use
• - look at 283 chart

• - separation disorders
• - panic disorder
• - agoraphobia
• - specific phobias
• - social anxiety disorder
• - generalized anxiety disorder
• - other anxiety disorders

• - normal part of infant development; begins at 8 mnths and peaks at 18 mnths
• - developmentally inappropraite levels of concern over being away from a significant other
• - also fear of something horrible will happen to the other person
• - distracts suffers from normal activities
• - causes sleep disruptions and night mares without significant other close by
• - physical s/s GI disturbances and headaches

• - harm avoidance
• - worry
• - shyness
• - uncertainty
• - fatigability
• - lack of self-direction 
• - discomfort and disability that impairs social and occupational functioning 

does not respond well to the most popular type of psychotherapy, cognitive behavioral therapy

• normal functioning is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur
• - may believe they are losing their mind or having a heart attack
• - recurrent attacks
• physical symptoms
• - palpitations, chest pain, breathing difficulties, nausea, feeling of choking, chills, hot flashes

• the sudden onset of extreme apprehension or fear
• - come out of the blue
• - extremely intense
• - last a matter of minutes then subsides

• Excessive anxiety or fear about being in places or situations from which escape might be
• difficult or embarrassing 
• i.e. being alone outside, at home, etc. 
• - these situations more tolerable with friends

• - specific irrational fear of a specific object, activity of situation
• characterized by
• - experience of high levels of anxiety 
• - fear in response to a specific object or situations 
• - overwhelming, crippling anxiety when faced with phobia

• - also known as social phobia
• - severe anxiety or fear provoked by exposure to a social or a performance situation that could be evaluated negatively by others
• - fear of public speaking is most common form
• - experience crippling anxiety
• - avoidance of situations
• - may self-medicate to cope

• - excessive worry that lasts months; lasts for 6 months or longer
• - anticipate disaster and are restless, irritable, and experience muscle tension 
• - desicion making is difficult due to poor concentration and dread of making a mistake
• - sleep disturbance

• common worries include
• - inadequacy of interpersonal relationships, job responsibilities, finances, and health of family members
• Key Symptoms
• - avoidance 
• - putting things off

• S/S
• - anxiety 
• - panic attacks
• - obessions
• - compulsions that develop with use of a substance

- individuals S/S of anxiety are a direct physiological result of a medical condition

• thoughts, impulses, or images that persists and recur, so that they cannot be dismissed from the mind 
• - often seem senseless to the individual who experiences them and their presence causes severe anxiety

• ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety
• - temporarily reduces anxiety 
• - must be repeated again and again 
• - obsession and compulsion can be independent of one another

•Obsessive-compulsive disorder

•Body dysmorphic disorder

•Hoarding disorder

• •Hair
• pulling and skin picking disorders

•Other compulsive disorders

• - Pathological obsessions and compulsions
• cause marked distress to individuals
• - Rituals are time consuming and interfere
• with routine, social activities and relationships
• - performance of cognitive task for impaired in severe cases
• - Symptoms can be present as early as 3
• years old
• - young people may experience shame and helplessness

• - False assumptions about personal
• appearance and fear of rejection by others
• - See perfectionist behaviors
• - Disorder is chronic and resistant to
• treatment
• - obsessional thinking and compulsive behavior such as checking mirrors and camouflaging 
• - level of insight vary; may know or not know about obsession 
• - chronic disorder

• •The accumulation of belongings that may have little or no value is an obsession
• that intrudes into individuals lives and hinder relationships
• •Problem can progress to eviction from their home due to unsafe and unsanitary
• conditions
• •Individuals do not necessarily believe they have a problem

• - Typically pull hair from their head or eyebrows and limbs
• - Can be in small patches or to complete baldness
• - Pain results in reduced anxiety
• - may begin from as early as childhood

• - secretly swallowing the hair 
• - may lead to hair masses or trichbezoar
• - masses refereed to Rapunzel syndrome

• - Typically pick at their cuticles, nails,
• scabs
• - May use nail cutters or tweezers but usually nails to pick
• - Pain results in reduced anxiety
• - complications results in pain, sores, infection, scarring

Characterized by obsessions and compulsions that develop with use of a substance or within a month of stopping a drug

• individuals s/s of obsessions and compulsions are a direct physiological result of a medical condition 
• - TBI
• - Huntington’s disease
• - Seizures
• - Cerebral infarcts

anxiety

women more than men

• - amygdala plays a role in anxiety disprders
• - it alerts the brain to the presence of danger and brings about fear or anxiety to preserve the system 
• - memories with emotional significance are stored in the amygdala = affects phobias

• - epi
• - norepi
• - serotonin
• - dopamine
• - GABA

• - major inhibitory neurotransmitter that stops excitatory neurotransmistters
• - people with too little GABA may suffer from anxiety

• anxiety results when threatening repressed ideas or emotions are close to breaking through from the unconscious mind into the aware and conscious mind
• - suggested that ego-defense mechanisms are used to keep anxiety managable

believed that anixety is linked to the emotional distress cause when early needs go unmet (interpersonal theory)

also suggested that anxiety is contagious; being transmitted from infant to mother to caregiver

suggest that anxiety is a learned response to specific environmental stimuli (classical conditioning)

- believes that anxiety disorders are caused by distortions in the individuals thoughts and perceptions

- overly responding to situations

measures severity of compulsive behavior

• - still able to solve problems 
• - concentration decreases
• - can be helped to focus and problem solve when using specific communication techniques
• ØHelp client to focus and to problem solve
• ØEncourage client to talk about situation
• ØHelp client identify feelings or thoughts related to the situation
• ØExplore behaviors that have worked in the past

• - unable to problem solve and have poor grasp of what is happening 
• - removing the person to a quieter room 
• - providing gross motor activities to drain some of the tension 
• - use of medications may be considered 
• - firm, short, simple statements are useful
• ØStay calm and use low pitched voice
• ØUse clear, simple statements and repetition
• ØMove to quieter environment
• ØUse of fast acting medication should be considered

• - potentate or promote activity of GABA
• - Most commonly used antianxiety agent 
• - most commonly used because of quick onset of action
• - due to potential for dependence antianxiety drugs should be used for short periods
• - WATCH FOR ATAXIA, SEDATION, AND DECREASED COGNITIVE FUNCTION

• - are shown to be effective in treating anxiety disorders by blocking the reuptake of serotonin
• - first line treatment 
• - golden standard of tx
• - more rapid onset with fewer SE

• •Citalopram (Celexa) 
• •Fluoxetine (Prozac)
• •Escitalopram (Lexapro)
• •Paroxetine (Paxil) 
• •Sertraline ( Zoloft)
• •Fluvoxamine ( Luvox)

- PD, SAD

- OCD, PD

- GAD, SAD, PD, OCD, PTSD

• - PD, OCD, GAD, PTSD, SAD
• - most anticholenergic effect
• - more calming effect than other SSRIs

• - PD, OCD, PTSD, SAD
• - more calming effect than other SSRIs

- GAD

• - Duloxetine (Cymbalta) 
• - Venlafaxine (Effexor)

***Hypertension is a dose related side effect; at higher than 150 mg/day can increase diastolic pressure about 7 to 10 mmHg.

• - GAD, SAD, PD
• - most successful in treatment of several axiety disorders

• - PD, GAD
• - also used to treat depression and diabetic peripheral neuropathy

• - Diazepam (Valium) 
• - Clonazepam (Klonopin)
• - Alprazolam (Xanax) 
• - Lorazepam (Ativan)

- GAD, PD, SAD

PD

- PD, GAD

- PD, SAD, GAD

Used frequently for insomnia: client’s with GAD, PTSD, & acute stress disorders often problems with sleep

*imp. to teach how to learn ways to enhance sleep such as warm bath, hot milk, relaxing music, soft noise

• - Flurazepam (Dalmane)
• - Temazepam (Restoril)
• - Triazolam (Halcion) 
• - Estazolam (ProSom)
• - Quazepam (Doral)

• - Hydroxyzine HCL (Atarax)
• - Hydroxyzine Pamoate (Vistaril)

• BOTH USED TO TREAT GAD
• safe nonaddictive alternative to benzos

Propanolol (Inderal) – SAD

• side note
• - decreases HR

- Valproic Acid (Depakote) – Panic DO; SAD; GAD; PTSD

- Gabapentin (Neurontin) - Panic DO; SAD; GAD; PTSD

• - Exact mechanism not clearly understood
• - High affinity for serotonin and moderate affinity for dopamine receptors
• - Differs from benzodiazepines as it does not have muscle relaxant effects
• - Reduces anxiety without sedative-hypnotic properties

ØNot to drink ETOH beverages

Ø Use caution with mechanical equipment

Ø Avoid beverages with caffeine

Ø Teach patients taking MAOI’s about tyramine free diet

Ø Do NOT stop benzodiazepines abruptly – should be tapered if use is longer than 3 to 4 months

Ø Cimetadine interferes with metabolism of benzodiazepines, alcohol, barbiturates and CNS depressants all increase sedation

based on the belief that patients make errors in thinking that lead to mistaken negative beliefs about self and others

• therapist helps patient
• 1. identify automatic negative beliefs that cause anxiety
• 2. explore the basis for these thoughts
• 3. reevaluate the situation realistically 
• 4. replace negative self-talk with supportive ideas

• - relaxation therapy 
• - modeling
• - systematic desensitization 
• - flooding
• - response prevention
• - thought stopping

- relaxation exercises for breathing or muscle groups are target

- therapist or significant other acts as a role model to demonstrate appropriate behavior in a feared situation and then patient imitates it

- patient is gradually introduced to a feared object or experience through a series of steps from least frightening to most

• - exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response  
• - pt learns through prolonged exposure that survival is possible and that anxiety diminishes spontaneously

• - used for compulsive behavior
• - therapist does not allow the patient to perform the compulsive ritual 
• - patient learns that anxiety does subside even when ritual is not completed

• through this technique a negative thought or obsession is interrupted 
• - the patient may be instructed to say "STOP!" out loud when the idea comes to mind or snap a rubber band worn on the wrist

• combines cognitive therapy with specific behavioral therapies to reduce the anxiety response
• includes:
• - cognitive reconstructing 
• - psychoeducation
• - breath restraining and muscle relaxation