Hahahahahhahhahajajajjahahajaajajajajjajajajajajjajajajajjajajajaajajjakakakaakkakakakakakakakakakakakakaiiaiakakakakkakakakaiaiak

1. Anxiety Disorders:
OCD and PTSD
NUR444
Spring2015

2. Learning Objectives
1. Recognize the clinical features of OCD and
PTSD
2. Identify predisposing factors for OCD and
PTSD
3. Formulate nursing diagnoses, outcomes, and
interventions specific to the symptoms of OCD
and PTSD
4. Discuss various treatment options that are
available for managing OCD and PTSD

3. Required Activities
 Read Chapter 27: OCD
 Read Chapter 28: PTSD
Townsend, M. (2015). Psychiatric mental health
nursing : Concepts of care in evidence-based
practice (8th ed.).

4. Obsessive-Compulsive Disorder (OCD)
 Recurrent obsessions or compulsions that
are severe enough to be time-consuming or
to cause marked distress or significant
impairment
 DSM-IV-TR

5. Compulsions
 Unwanted repetitive behavior patterns or
mental acts that are intended to reduce
anxiety, not to provide pleasure or gratification
 A “driven” response to an obsession according
to the person’s own “rules” that must be
applied rigidly
 The individual feels compelled to perform
certain repeated ritualistic behaviors in
response to a mental obsession

6. Obsessions
 Unwanted, intrusive, persistent ideas,
thoughts, impulses, or images that occur
repeatedly and result in significant anxiety or
distress

7. Common Obsessions
 Contamination (fears of germs, dirtiness,
chemicals, AIDS, cancer)

• Symmetry or exactness (of belongings,
spoken or written words, the way one moves
or completes actions)

• Doubting (whether appliances are turned
off, doors are locked, written work is accurate,
etc.)

• Aggressive Impulses (thoughts of stabbing
one’s children, pushing loved ones into traffic,
etc.)

8. Common Obsessions
 The need to have things in a certain order, certain
place

• Accidental Harm to Others (fears of contaminating
or poisoning a loved one, or of being responsible for
an accident or a fire)

• Religion

• Other miscellaneous obsessions having to do with
themes such as lucky or unlucky colors or numbers,
or with the need to know “trivial” details (house #’s,
license plates)

9. Common Compulsions
Washing and Cleaning (ex: excessive showering,
hand washing, house cleaning)
• Checking (ex: locks, appliances, paperwork, driving
routes)
• Counting (ex: preferences for even or odd
numbers, tabulating figures, )
• Repeating Actions or Thoughts (ex: turning lights
on and off, getting up and down in chairs, re-reading,
re-writing)

10. Common Compulsions
• Need to Ask or Confess (ex: requesting or
demanding assurance from others)
• Hoarding (ex: magazines, flyers, clothing,
information)
• Ordering and Arranging (ex: need for things to be
straight, sequenced, or in a certain order)
• Repeating Words, Phrases, or Prayers to
Oneself (ex: repeating "safe" words or prayers)

11. OCD
 The individual must have obsessions and
compulsions that cause distress and last at least
one hour per day.
 Adults usually have some insight into the fact
that their symptoms are excessive or unrealistic.
Children often do not have this insight.
 The obsessions and compulsions seem worse
in situations of emotional stress

12. Epidemiology
 OCD affects about 1-3 percent of the population
 Equally common in men and women
 Single people are affected more than married
 Symptoms often begin during childhood but is
diagnosed more often in adulthood
 Depression and substance abuse are common
comorbidities

13. What Causes OCD?
 Biological aspects
Neurobiological disturbances may
play a role.
Brain
Serotonin
Autoimmune mechanism
Strep throat
PANDAS (Pediatric Autoimmune
Neuropsychiatric Disorder
Associated with Group A strep)

14. OCD Spectrum Disorders
 Tourette Disorder
 Trichotillomania
 Body Dysmorphic Disorder
 Habit disorders (nail biting or picking)

15. OCD: Nursing Diagnosis

16. Assessment
 Always assess for potential for self-harm
 Thorough physical and neurological exam
 Concealing
 Anxiety rating scale (Hamilton, etc)
 Yale-Brown Obsessive Compulsive Scale
 Community/family support and resources
 Recent emotional stressor

17. Nursing Interventions
 Educate
 In beginning of tx- do not interrupt the
behavior…….allow plenty of time for rituals
 Do not get involved with the client's
obsessions and rituals.
 Do not be judgmental or verbalize disapproval of
the behavior
 Provide structure
 Always make sure their needs are met

18. Treatment for OCD
 Cognitive & behavioral therapy
 Medication
 Family support
 School support (if child)

20. Cognitive/Behavioral Therapy
 Exposure and response prevention (ERP)
therapy
 Systematic desensitization
 Flooding
 Skills training: Relaxation and other tools
 Cognitive restructuring

21. Medication
 SSRIs – 1st line of treatment
 high dosages
 Luvox (up to 300 mg/day)
 Prozac (40-80 mg/day)
 Zoloft (up to 200 mg/day)
 Paxil (40-60 mg/day)
 Celexa (up to 80 mg/day)
 Tricyclics
 Clomipramine (Anafranil)(up to 250 mg/day)
 Other medications
 Beta blockers, buspirone, benzodiazepines

22. Health Promotion and
Maintenance
 Health & Wellness
 Management of Illness
 High Risk Behaviors
 Lifestyle Choices
 Coping
 Stress Management

23. Post-traumatic Stress Disorder (PTSD)
 Development of characteristic symptoms
following exposure to an extreme traumatic
stressor involving a personal threat to
physical integrity of self or others

24. PTSD
 Person’s response involves:
Intense fear
Helplessness
Or
Horror

25. Diagnosing
 Must last at least one month and cause
significant impairment or distress
 Characteristic symptoms

26. Characteristic symptoms
 1. reexperiencing of the event
 2. avoidance of reminders of the
event
 3. increased arousal (not present
before the trauma)

28. Characteristics (cont.)
 1. Reexperiencing the traumatic event (1 or
more)
 Intrusive recollections of the event
 Acting as if the trauma were recurring
 Recurrent, distressing dreams of the events
 Intense psychological distress with exposure to
cues
 Physiological reactivity with exposure to cues

29. Characteristics (cont.)
 2. Avoidance (3 or more)
 Attempts to avoid thoughts, feelings, or
conversations r/t the trauma
 Attempts to avoid activities, places, or
people r/t the trauma
 Inability to recall important aspects of the
trauma
 Markedly diminished interest or
participation in activities

30. Characteristics (cont.)
 Avoidance (cont.)
Feeling of detachment or estrangement
from others
Restricted range of affect
Sense of foreshortened future

31. Characteristics (cont.)
 Increased arousal (2 or more)
 Difficulty falling or staying asleep
 Irritability or outbursts of anger
 Difficulty concentrating
 Hypervigilance
 Exaggerated startle response*

33. Causes PTSD?
 Predisposing factors
Prior psychiatric history
Poor social support
Individual’s vulnerability
Many biological theories

34. Comorbidity and PTSD
 Mood disorders
 Anxiety disorders
 Substance use disorders
 Mood (depressive) and substance use
disorders are likely secondary

35. Nursing Diagnosis

36. Nursing Care for PTSD
 Assign same staff
 Be consistent
 Use non-threatening, matter-of-fact approach
 Stay with client during flashbacks*
 Encourage client to talk about the trauma (at
their own pace)

37. Medications
 Antidepressants
 Zoloft (SSRI)
 Paxil (SSRI)
 Amitryptaline (tricyclic)
 Imipramine (tricyclic)
 Phenelzine (MAOI)
 Anxiolytics
 Alprolzolam (Xanax)
 Antihypertensives
 Propanolol
 Clonidine
 Others
 Tegretol, Depakote, Lithium

38. Treatment
 Cognitive Therapy
 Cognitive restructuring
 Behavior Therapy
 Exposure (imagined or in vivo)
 EMDR (Eye Movement Desensitization Reprocessing)
 Anxiety management
 Relaxation, breathing, positive thinking training
 Thought Field Therapy
 Tapping with fingers on meridian points

39. Health Promotion and
Maintenance
 Health & Wellness
 Management of Illness
 High Risk Behaviors
 Lifestyle Choices
 Coping
 Stress Management

40. Practice Question
 The nurse is using an intrapersonal approach to
assist a patient in dealing with survivor’s guilt.
Which nursing intervention would be appropriate?
 A. Encourage the patent to attend a survivors
group for peer support
 B. Facilitate expression of feelings during one to
one interactions with the nurse
 C. Ask the patient to challenge the irrational
beliefs associated with the event
 D. Administer scheduled paroxetine (paxil) to
deal with depressive symptoms.

41. Practice Questions
 A patient in an out patient clinic states, “I am
so tired of all these medications.” Which
nursing response would encourage the patient
to elaborate further?
 A. “I see you have been taking your
medications.”
 B. “Tired of taking you medications?”
 C. “Let’s discuss different ways to deal with
your problems.”
 D. “ How would your family fell about your
stopping your medications.”