Purpose:Analyze and apply critical thinking skills in the psychopathology of mental health patients and provide treatment and health promotion while applying evidence-based research.Scenario:
J.T. is a 20 year-old who reports to you that he feels depressed and is experiencing a significant amount of stress about school, noting that he’ll “probably flunk out.” He spends much of his day in his dorm room playing video games and has a hard time identifying what, if anything, is enjoyable in a typical day. He rarely attends class and has avoided reaching out to his professors to try to salvage his grades this semester. J.T. has always been a self-described shy person and has had a very small and cohesive group of friends from elementary through high school. Notably, his level of stress significantly amplified when he began college.
You learn that when meeting new people, he has a hard time concentrating on the interaction because he is busy worrying about what they will think of him – he assumes they will find him “dumb,” “boring,” or a “loser.” When he loses his concentration, he stutters, is at a loss for words, and starts to sweat, which only serves to make him feel more uneasy. After the interaction, he replays the conversation over and over again, focusing on the “stupid” things he said. Similarly, he has a long-standing history of being uncomfortable with authority figures and has had a hard time raising his hand in class and approaching teachers. Since starting college, he has been isolating more, turning down invitations from his roommate to go eat or hang out, ignoring his cell phone when it rings, and habitually skipping class. His concerns about how others view him are what drive him to engage in these avoidance behaviors.
Questions:
Remember to answer these questions from your textbooks and NP guidelines. At all times, explain your answers.
Generate a primary and differential diagnosis using the DSM-5 criteria.
Develop a biopsychosocial plan of care for this client.
Compare and contrast fear, worry, anxiety, and panic.
Anxiety and Related
Disorders
Week 3
NUR 530 Psychopathology
Etiologies of Anxiety (models)
• Diathesis Model: Individual heritable vulnerability that when acted
on by a stressor produces disease/dysfunction
• Hans Selye’s General Adaptation Syndrome (GAS): An emotional or
physiological change due to a perceived event or “stressor“
Etiologies of Anxiety (models)
Epidemiology
• One of the most common mental health issues in the U.S.
• Among U.S. population, 12%-25% experience pathological anxiety
in lifetime
• Most patients seek care first in primary care setting
• Lifetime rate: Women 30.5%; men 19.2%
• Increased prevalence in lower socioeconomic demographic
Anxiety, Fear and Panic
FIGURE 4.1
© 2019 Cengage. All rights reserved.
Biological Contributions to Anxiety and Panic,
Part 1
• Genetic vulnerability
• More likely to be anxious if there is a family history of anxiety
• Anxiety and brain circuits
• Depleted levels of GABA are associated with more anxiety
• Deficits in norepinephrine and serotonin also associated with
greater anxiety
Specific Phobias: Associated Features and
Treatment
• Causes of phobias
• Direct experience
• Biological and evolutionary vulnerability
• Traumatic conditioning
• Preparedness
• Psychological treatments of specific phobias
• Cognitive-behavior therapies are highly effective – exposure is critical
• Cultural factors – certain objects feared more in different cultures
Biological Contributions to Anxiety and Panic,
Part 2
• Limbic system and the septal-hippocampal systems
• Behavioral inhibition system (BIS)
• Fight/flight system (FFS)
Generalized Anxiety Disorder, Part 1
• Statistics
• Affects about 3.1% of the general population
• Females outnumber males approximately 2:1
• Onset is often insidious, beginning in early adulthood
• Very prevalent among the elderly
• Tends to run in families
Diagnostic Criteria:
Generalized Anxiety Disorder
A. Excessive anxiety and worry that is present for at least 6 months
B. Difficulty to control worrying
C. Anxiety and worry related to 3 or more of the following 6 symptoms:
feeling restlessness/on edge, easily fatigued, trouble concentrating,
irritability, muscle tension, sleep disturbances.
D. Causes significant distress/impairment in social, occupational, or
important areas of functioning
E. Not attributed to the effects of a substance
F. Not better explained by another mental disorder
Specific Phobias: An Overview, Part 2
• Facts and statistics
• Females are again over-represented
• Affects about 12.5% of the general population
• Phobias tend to run a chronic course
• Specific phobias are one of the most common psychological
disorders in the United States and around the world, as well as
consistently female at 4:1, also consistent around the world
Diagnostic Criteria: Specific Phobia
1.
2.
3.
4.
5.
Marked fear/anxiety about specific object/situation
Object/situation almost always provokes immediate response
Object/situation actively avoided or endured with intense fear/anxiety
Fear/anxiety/avoidance is persistent, lasting at least 6 months
Fear/anxiety/avoidance out of proportion to actual danger posed by
object/situation and to sociocultural context
6. Fear/anxiety/avoidance causes clinically significant distress in social,
occupational, or other areas of functioning
7. Is not better explained by symptoms of another mental disorder
Specific Phobias: An Overview, Part 3
• Common specific phobias
• Animals (e.g., bees, dogs, snakes)
• Natural environment (e.g., heights, storms)
• Situational (e.g., flying, driving)
• Blood-injection-injury: Blood draws, getting injections, seeing
blood from a minor cut; watching others get blood drawn or
injections
• Sometimes associated with unusual vasovagal response > fainting
Social Anxiety Disorder: An Overview, Part 1
• Overview and defining features
• Extreme fear or discomfort in social or performance situations
• Markedly interferes with one’s ability to function
• Often avoid social situations or endure them with great distress
• Performance-only subtype: Anxiety only occurs in performance
situations (e.g., public speaking) without anxiety in everyday
interactions
Social Anxiety Disorder: An Overview, Part 2
• Facts and statistics
• Affects about 12.1% of the general population, 6.8% in 1-year
period
• Prevalence is slightly greater in females than males
• Second only to specific phobia in the anxiety disorders
• Onset is usually during adolescence
• Peak age of onset at about 13 years
Diagnostic Criteria:
Social Anxiety Disorder
A. Fear or anxiety related to social situation where the individual is
exposed to scrutiny by others
B. Person fears they will act in a way or show anxiety symptoms that will
be appraised negatively
C. Social situation incite fear and anxiety
D. Social situation are avoided or tolerated with intense fear/anxiety
E. Fear/anxiety is out of proportion to actual threat posed by the social
situation
F. Fear/anxiety/avoidance persists, lasting 6 months or more
G. Causes significant distress/impairment
Diagnostic Criteria:
Panic Disorder
A. Recurrent unexpected panic attacks
B. A panic attack is a sudden surge of intense fear or discomfort that
peaks within minutes during which 4 or more of the following
symptoms occur: palpitations, sweating, trembling, shortness of
breath, chest pain, feelings of choking, abdominal distress or nausea,
dizziness, paresthesia, derealization, fear of losing control, fear of
dying.
C. At least one attack is followed by 1 month or more of either persistent
concern/worry about additional panic attacks or significant
maladaptive changes in behavior designed to avoid having panic
attacks
Panic Disorder, Part 2
• Facts and statistics
• Affects about 2.7% of the general population
• Onset is often acute, mean onset between 20 and 24 years of
age
• 66% of individuals with agoraphobia are female
• Cultural influences
• Panic attacks interpreted differently across cultures
Diagnostic Criteria:
Agoraphobia
A. Anxiety related to 2 or more situations: using public transport, being in
open spaces, being in enclosed spaces, being in a crowd, being outside
of the home alone.
B. Person fears/avoids these situations because of thoughts that escape
may be difficult
C. Situations provoke fear/anxiety
D. Agoraphobic situations are actively avoided
E. Anxiety/fear is out of proportion to the actual danger posed
F. Fear, anxiety, avoidance persists, lasting 6 months or more
G. Fear, anxiety, avoidance cause significant distress/impairment
DSM-5 Criteria for Agoraphobia (1 of 2)
C. The agoraphobic situations almost always provoke fear or anxiety.
D.The agoraphobic situations are actively avoided, require the
presence of a companion, or are endured with intense fear or
anxiety.
E.The fear or anxiety is out of proportion to the actual danger posed
by the agoraphobic situations, and to the sociocultural context.
F.The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more.
Diagnostic Criteria:
Obsessive Compulsive Disorder
• Obsessions-recurrent and persistent thoughts or urges that are intrusive
and unwanted, resulting in significant destress or anxiety
➢Person may try to neutralize or suppress the unwanted thoughts or urges
by performing a compulsion
• Compulsion-repetitive behavior or mental acts that are preformed in
response to an obsession.
➢Acts are intended prevent or reduce anxiety or distress or to avert a
dreaded event or situation. Mental acts or behaviors are not realistically
connected to what they are designed to prevent, neutralize or avert
A. Presence of obsessions, compulsions, or both
B. Obsessions or compulsions are time consuming; more then 1hr/day
Diagnostic Criteria:
Hoarding
A. Persistent difficulty discarding or parting with possessions, regardless
of their actual value.
B. Difficulty related to the perceived need to save the items and to the
distress associated with discarding them.
C. The difficulty discarding possessions results in the accumulation of
possessions that congest and clutter active living areas and
substantially compromises their intended use.
D. The hoarding causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Obsessive-Compulsive and Related Disorders
• New Classification in DSM-5
• Grouped together because of shared features including
obsessive thoughts and/or compulsive behaviors
• Include OCD, hoarding disorder, body dysmorphic disorder,
trichotillomania, excoriation
Obsessive-Compulsive Disorder (OCD): An
Overview
• Overview and defining features
• Obsessions – intrusive and nonsensical thoughts, images, or
urges
• Compulsions – thoughts or actions to neutralize anxious
thoughts
• Vicious cycle of obsessions and compulsions
• Cleaning and washing or checking rituals are common
DSM-5 Obsessive-Compulsive Disorder
Summary (1 of 3)
Features of OCD include the following:
A.Presence of obsessions, compulsions or both:
• Obsessions: Recurrent and persistent thoughts, urges, or
images that are experienced, at some time during the
disturbance, as intrusive and inappropriate and cause anxiety or
distress; the individual attempts to ignore or suppress such
thoughts, impulses, or images, or to neutralize them with some
other thoughts or action.
DSM-5 Obsessive-Compulsive Disorder
Summary (2 of 3)
• Compulsions: Repetitive behaviors (e.g., counting, repeating
words silently) that the individual feels driven to perform in
response to an obsession, or according to rules that must be
applied rigidly; the behaviors or mental acts are aimed at
preventing or reducing distress or preventing some dreaded
event or situation; however, these behaviors or mental acts
either are not connected in a realistic way with what they are
designed to neutralize or prevent or are clearly excessive.
DSM-5 Obsessive-Compulsive Disorder
Summary (3 of 3)
B.The obsessions or compulsions are time-consuming (e.g.,
take more than 1 hour per day) or cause clinically significant
distress or impairment in important areas of functioning.
C.The disturbance is not due to the direct physiological effects
of a substance or another medical condition and is not better
explained by the symptoms of another mental disorder.
From American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington, DC.
OCD: Causes and Associated Features, Part
1
• Statistics
• Affects about 2% of the general population
• Approximately equal gender distribution
• Similar incidence and presentation across cultures
• Onset is typically in early adolescence or young adulthood
• OCD tends to be chronic
OCD: Causes and Associated Features, Part
2
• Causes of OCD
• Parallels the other anxiety disorders
• Early life experiences
• Learning that some thoughts are dangerous/unacceptable
• Thought-action fusion – the thought is similar to the action;
thinking something will make it more likely to happen
Assessment
A. History & Physical
B. Rule out medical causes
C. Rule out substance abuse/withdrawal
D. Labs: Thyroid Function Test, Blood Chemistry, Complete Blood Count,
Toxicology screens
E. Beck Anxiety Inventory
➢ Developed by Aaron Beck
➢ 21 questions, multiple choice, used to measure anxiety
Treatment
• Pharmacological intervention
• SSRIs SNRIs, Tricyclics, BB, Benzodiazepines
• Non pharmacologic interventions
• CBT
• Behavioral therapy
• Psychodynamic therapy
• Relaxation therapy
• Diet
• Removal or reduction in caffeine intake
References
• American Psychiatric Association. (2013). Diagnostic and Statistical
Manual of Mental Disorders DSM5 (5 ed.). Arlington, Virginia:
American Psychiatric Association.
• Johnson, K., & Vanderhoef, D. (2017). Psychiatric Mental Health
Nurse Practitioner Review and Resource Manual (4 ed.). Silver
Spring: American Nurses Association.
• Pedersen, D. D. (2018). Pocket Psych Drugs Point-of-Care Clinical
Guide (2 ed.). Philadelphia: F.A. Davis Company.