2. Introduction
Anxiety is a diffuse apprehension that is
vague in nature and associated with feelings
of uncertainty and helplessness.
Anxiety derives from the Greek root meaning
“to press tight”. Anxious is related to the
Latin word angere, which means “to
strangle” and “to distress”.
3. Anxiety Disorders
a group of conditions where the
primary symptoms are anxiety or
defenses against anxiety.
the patient fears something
awful will happen to them.
Are anxiety disorders a neurosis or
psychosis.?
4. What is anxiety?
is a state of
intense
apprehension,
uneasiness,
uncertainty,
or fear.
5. Generalized Anxiety Disorder
An anxiety disorder in which a person
is continuously tense, apprehensive and
in a state of autonomic nervous system
arousal.
The patient is constantly tense and worried,
feels inadequate, is oversensitive, can’t
concentrate and suffers from insomnia.
6. Panic Disorder
An anxiety disorder marked by a
minutes-long episode of intense dread in
which a person experiences terror and
accompanying chest pain, choking and
other frightening sensations.
Can cause secondary disorders, such as
agoraphobia.
8. Obsessive Compulsive Disorder
An anxiety disorder
characterized by unwanted
repetitive thoughts (obsessions)
and/or actions (compulsions).
9. Common Examples of OCD
Common Obsessions:
Common
Compulsions:
Contamination fears of germs, dirt,
etc.
Washing
Imagining having harmed self or
others
Repeating
Imagining losing control of
aggressive urges
Checking
Intrusive sexual thoughts or urges Touching
Excessive religious or moral doubt Counting
Forbidden thoughts Ordering/arranging
A need to have things "just so" Hoarding or saving
A need to tell, ask, confess Praying
10. POST-TRAUMATIC STRESS
DISORDER
Strong reaction to persons who appear similar (e.g.
race, gender)
Extremes in mood (too manic or too withdrawn)
Self-harm
Compulsions (e.g. repetitive behaviour, hoarding)
Physical symptoms (e.g. headache, vomiting)
Changes in eating/sleeping habits
Self-talk
Change in appearance (e.g. gain weight, layer
clothes)
12. Causes of anxiety disorders
Biological/genetic
– General vulnerability
– Negative affect
– Intensity of fight/flight response
Psychological/environmental/learning
– Personal experiences (traumatic?)
– Vicarious learning
– Informational transmission
13. Persistence of anxiety disorders
Physiological
– Fight/flight response
Cognitive
– Dysfunctional beliefs and interpretations
– Overestimates of probability and severity
Behavioral
– Avoidance
– Safety behaviors, rituals, & safety signals
14. Five major types of anxiety
disorders are:
Panic Disorder
Generalized Anxiety Disorder
Phobias
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Anxiety Disorder Due to a General Medical
Condition
Substance-Induced Anxiety Disorder
17. HISTORICAL ASPECTS
Freud first introduced the term anxiety
neurosis in 1895. Freud wrote, “I called this
syndrome ‘anxiety neurosis’ because all its
components can be grouped round the chief
symptom of anxiety”(Freud 1959).
Liebowitz(1992) states; “anxiety disorders
provide an excellent of the complex
relationship between mind and body factors
in mental illness.
18. GENERALIZED ANXIETY
DISORDER (GAD) & PANIC
DISORDER
Generalized anxiety disorder (GAD) is
an anxiety disorder that is characterized by
excessive, uncontrollable and often
irrational worry about everyday things that
is disproportionate to the actual source of
worry.
19. GAD
This excessive worry often interferes with
daily functioning, as individuals suffering
GAD typically anticipate disaster
overly concerned about everyday matters such
as health issues, money,
death, family problems, friend problems,
relationship problems or work difficulties.
20. Generalized Anxiety Disorder
(GAD): Prevalence
~ 4% of the population (range from 1.9% to
5.6%)
2/3 or those with GAD are female in
developed countries
Prevalent in the elderly (about 7%)
Familial studies support a genetic model
(15% of the relatives of those with GAD
display it themselves-base rate is 4% in
general population)
21. Signs and symptoms (GAD)
Cognitive Responses
Impaired attention
Poor concentration
Forgetfulness
Confusion
Nightmares
Errors in judgment
Fear of losing control
24. Diagnostic Creteria
it is important to know that only a qualified professional who
also relies on clinical judgment can make an accurate
diagnosis.
A. At least 6 months of "excessive anxiety and worry" about
a variety of events and situations. Generally, "excessive" can
be interpreted as more than would be expected for a
particular situation or event. Most people become anxious
over certain things, but the intensity of the anxiety typically
corresponds to the situation.
B. There is significant difficulty in controlling the anxiety
and worry. If someone has a very difficult struggle to regain
control, relax, or cope with the anxiety and worry, then this
requirement is met.
25. C. The presence for most days over the
previous six months of 3 or more (only 1 for
children) of the following symptoms:
1. Feeling wound-up, tense, or restless
2. Easily becoming fatigued or worn-out
3. Concentration problems
4. Irritability
5. Significant tension in muscles
6. Difficulty with sleep
26. D. The symptoms are not part of another
mental disorder.
E. The symptoms cause "clinically
significant distress" or problems functioning
in daily life. "Clinically significant" is the
part that relies on the perspective of the
treatment provider. Some people can have
many of the aforementioned symptoms and
cope with them well enough to maintain a
high level of functioning.
F. The condition is not due to a substance or
medical issue
27. PANIC DISORDER
It is characterized by sudden attacks of
terror, usually accompanied by a pounding
heart, sweatiness, weakness, faintness, or
dizziness.
Panic attacks usually produce a sense of
unreality, a fear of impending doom, or a
fear of losing control
28. Signs & symptoms OF PANIC DISORDER
Chest pain or discomfort
Dizziness or faintness
Fear of dying
Fear of losing control or impending doom
Feeling of choking
Feelings of detachment
Feelings of unreality
Nausea or upset stomach
29. Epidemiology
The usual age of onset is variable - from
childhood to late adulthood, with the median
age of onset being approximately 31 (Kessler,
Berguland, et al., 2005).
Most studies find that GAD is associated with
an earlier and more gradual onset than the
other anxiety disorders.
Women are two to three times more likely to
suffer from generalized anxiety disorder than
men.
30. Causes of GAD & Panic disorder
Heredity :There is clear evidence that anxiety
disorders run in families. Studies show that if one
identical twin has an anxiety disorder, the second
twin is more likely to have an anxiety disorder
than non-identical (fraternal) twinS
Brain chemistry: Alterations in GABA,
increased level of norepinephrine & serotonin.
Psychological factors: strained interpersonal
relationship, stress, unresolved conflicts.
31. CONTD……
Medications and substances which can
induce anxiety: caffeine, cocaine, steroids.
Personality:
People who have low self-esteem and poor
coping skills may be more prone.
Life experiences:
Exposure to abuse, violence, or poverty is an
important area for further study, as life
experiences may affect an individual's
susceptibility to these disorders.
33. Therapy for generalized anxiety disorder
(GAD)
Relaxation skills can be taught either alone or
with the use of biofeedback.
Individual therapy therapist to take a
cognitive approach to treatment.
Hypnotherapy can be used as an effective
relaxation technique to battle anxiety.
34. Medication
Buspirone – This anti-anxiety drug, known by
the brand name Buspar, is generally considered
to be the safest drug for generalized anxiety
disorder.
Benzodiazepines – These anti-anxiety drugs
act very quickly (usually within 30 minutes to
an hour).
Antidepressants – A number of
antidepressants are used in the treatment of
generalized anxiety disorder (GAD).
35. Nursing Diagnosis
Panic anxiety related to real or perceived
threat to biological integrity or self concept
evidenced by any or all of the physical
symptoms identified by any or all of the
physical symptoms .
Powerlessness related to impaired cognition
evidenced by verbal expressions of no control
over life situation and nonparticipation in
decision making related to own care or life
situation.
36. Effective self-help techniques for generalized anxiety
disorder (GAD) include:
Dealing with your worry and anxiety in more
productive ways. This may involve challenging irrational
worrisome thoughts, learning how to postpone worrying,
and learning to accept uncertainty in your life.
Make any necessary anxiety-reducing lifestyle changes,
such as eliminating caffeine, starting an exercise program,
improving your diet, and drawing on the support of family
and friends.
Learn and practice relaxation techniques, such as
meditation and deep breathing. As you strengthen your
ability to relax, your nervous system will become less
reactive and you’ll be less vulnerable to anxiety and stress.
37. Try the following sensory-based, self-soothing
suggestions when your GAD symptoms are
acting up:
Vision – Look at treasured photos or an
interesting picture book.
Hearing – Listen to soothing music.
Smell – Smell the flowers in a garden.
Breathe in the clean, fresh air.
Taste – Cook a delicious meal.
Touch – Take a warm bubble bath. Wrap
yourself in a soft blanket. Sit outside in the
cool breeze. Get a massage.
38. To Cope with Anxiety, Remember
A-W-A-R-E
A: Accept the anxiety.
W: Watch your anxiety.
A: Act with the anxiety.
R: Repeat the steps.
E: Expect the best.
40. INTRODUCTION
PHOBIA
Phobia is described as fear. It is also used in a
non-medical sense ‘aversions of all sorts’. It
describes negative attitudes toward the
negative subjects.
DEFINITION:
Phobia is an irrational fear which is persistant
and is an consciousness.
41. HISTORY
`PHOBOS’ means fear or panic.
PHOBOS was a Greek God who frightened
once enemies.
Freud worked on hysteria but his daughter ANNA
worked more on phobia. Freud’s case of little
Hans is the model for the psychoanalytical
understanding of phobia. Freud conceptualized
little Hans fear of horses as resulting from
unconscious oedipal fears. little Hans denied
these fears and projected them on to horses.
42. DEFINITION:-
Phobias are characterized by intense,
persistent, irrational and recurrent fear of a
specific object, activity or situation that
results in a compelling desire to avoid the
dreaded object, place or situation.
43. Developmentally Normal Fears
Age Normal Fear
Birth- 6 Months Loud noises, loss of physical support,
rapid position changes, rapidly
approaching other objects
7-12 Months Strangers, looming objects, unexpected
objects or unfamiliar people
1-5 Year Strangers, storms, animals, dark,
separation from parents, objects,
machines loud noises, the toilet
6-12 Year Supernatural, bodily injury, disease,
burglars, failure, criticism, punishment
12-18 Performance in school, peer scrutiny,
appearance, performance
45. Phobias: Prevalence
Fears are very prevalent
Phobias occur in about 11% of the
population
More common among women
Tends to be chronic
31% of first degree relatives of phobics also
had a phobia (compared to 11% in the
general population)
46. CLINICAL SYNDROMES
1. Agoraphobia:- very
common
TYPES-
Three main themes –
*Fear of being alone
*Fear of leaving home
*Fear of being away
from home in a
situation
48. AGORAPHOBIA
EFFECTS ON PATIENT-
-Drug abuse
INCIDENCE-
-Starts in late teenage or early 20’s
-most common in women
-0.5% of population had agoraphobia at
sometime
49. SOCIAL PHOBIA
TYPES
-Speaking in public
-Eating in public
-Writing in public
-Using public lavatories
-stage phobia
-Attending parties
-Attending interviews
-Dancing in parties
50. SOCIAL PHOBIAS
EFFECTS ON PATIENT-
-Drug abuse
INCIDENCE-
-Among 5-10% of phobic patients seen by
psychiatrists
-Often begins in late childhood or early
adolescence
-More often in females
51. Social Phobia: Prevalence
13% of the general population
About equally distributed in males and
females, however, males more often seek
treatment
Usually begins around age 15
Equally distributed among ethnic groups
53. SIMPLE PHOBIA
TYPES:-
Fear of closed spaces-
Claustrophobia
Fear of height-Acrophobia
Fear of sight of blood-
Haematophobia
Fear of marriage- Gamophobia
Fear of insects-Insectophobia
Fear of AIDS-AIDS Phobia
Fear of cats-Ailurophobia
Fear of dogs-Cynophobia
Fear of dirt-Mysophobia
Fear of darkness-Nyctophobia
Fear of death-Thanatophobia
54. GENERAL
INFORMATION:-
Most common type.
Now reffered to as ‘Specific’ phobias.
Involves animals,particularly dogs,snakes,insects
& mice.
INCIDENCE:
-80% of phobic patients are suffered from simple
phobia.
-Common in children & may persist into adult life.
-Animal phobias are more common in women.
55. RELATED TO INTERNAL
STIMULI:-
ILLNESS
PHOBIAS(NOSOPHOBIA)
Persistent ,intense fear of
illness
TYPES:-
Cancer phobia
AIDS Phobia
Heart disease phobia
Venereal illnesses phobia
Death & dying phobia
56. GENERAL
INFORMATION:-
Previous illness in relatives or individual
may act as a precipitant
May have other mental illness like
depression but illness phobias fades as this
is treated.
INCIDENCE
Constitutes about 10 -20% of phobic
patients.
Equal in both sexes.
58. CONTD……
(B)
Blennophobia –fear of slime
(C)
Claustrophobia – fear of enclosed spaces
Cynophobia – fear of dogs
(D)
Decidophobia – fear of making decisions
(E)
Electrophobia – fear of electricity
(F)
Fremophobia – fear of being alone
59. Contd…..
(g)
Gamophobia –fear of marriage
Gatophobia –fear of cats
Gynophobia –fear of women
(H)
Hydrophobia –fear of water
(K)
Keraunophobia – fear of
thunder
(M)
Musophobia –fear of mice
(N)
Nyctophobia – fear of night
60. Contd……….
(O)
Ochlophobia – fear of crowd
Odynophobia – fear of pain
Ophidiophobia – fear of snakes
(P)
Pyrophobia – fear of fire
(S)
Scholionophobia – fear of school
Spheksophobia – fear of wasps
(T)
Technophobia – fear of technology
Thalessophobia – fear of ocean
Tropophobia – fear of moving or
making changes
61. GENERAL SYMPTOMS OF ALL
PHOBIAS
Blushing or shaking
Fear of vomiting
Urgency
Fear of micturition
Fear of defecation
Palpitation
Accelerated heart rate
Sweating
Trembling
Dry mouth
63. Contd…………
Fainting
Light headedness
Derealization (feeling
that objects are unreal)
Depersonalization
(self is distant or not
really here)
Fear of losing control
Going crazy or passing
out
Fear of dying
65. ETIOLOGY
PSYCHOANALYTICAL THEORY
EGO DEFENCE
MECHANISM
DISPLACEMENT
PROJECTION AVOIDANCE
GET THE SOURCE
OUTSIDE OF
THEMSELVES
INTO EXTERNAL
WORLD.
REDIRECTION OF
ANXIETY NOT COMING IN TO
CONTACT WITH THE
DISPLACED &
PROJECTED ITEM.
66. Contd………
CONDITIONED REFLEX THEORIES
Conditioning theory may account for some
cases of social and simple phobias- a traumatic
early public speaking, being bitten by dog, and
so forth.
BIOLOGICAL THEORIES
Dopaminergic, GABA, and Serotonin
dysfunction cause phobia.
In a study, about 32% of 1st degree relatives of
agoraphobia had an anxiety disorder + 9% of 1st
degree relatives had agoraphobia.
67. OTHER ETIOLOGICAL
FACTORS
Environmental factors are more significant.
Inadequate and obscessive personalities are
more prone.
Abnormal parent child relationship.
Traumatic experience during infancy.
69. DIFFERENTIAL
DIAGONSIS
The diagnosis of phobia disorder is not
made if a phobia is due any of these
disorders like-
Schizophrenia
Major depression
Obsessive compulsive disorder
Personality disorders
70. MANAGEMENT
Immediate management involves
reassurance.
Treatment should be started with
psychosocial assessment.
Hospitalization may be needed.
Psychotherapy :-it gives relief from troubled
symptoms.
Relaxation therapy.
Supportive therapy.
71. PROGNOSIS
Overall its prognosis is good.
Only 20% phobias which get away without
treatment.
Remaining 80% need treatment.
If phobia remains untreatable there may be
depression, low self esteem.
73. DEFENSE MECHANISM
Displacement:-A person does something as
a substitute for something else.
Projection:- The individual tries to ascribe
unethical behaviour or mistakes to other
people.
Avoidance
74. MANAGEMENT
PHARMOCOTHERAPY
DRUG DOSE INDICATIONS CONTRA
INDICATIONS
DIAZEPAM
(2-3 times daily)
Tab.2-10 mg
Inj 10 mg I.V
-Anxiety
-Tension
-Psychosomatic &
behavioral disorders
-Myaesthenia gravis
-Acute narrow angle
glaucoma
ALPRAZOLAM
(2-3 times daily)
Tab.0.25mg ,0.5
mg,1 mg
-Short term
treatment of anxiety
With depression
-Panic disorder
-Same as above
-Psychosis
-Under 18 years
IMIPRAMINE
(1-2 times daily)
Cap 25-75 mg
Tab 25-75 mg
-All types of
depression
-Nocturnal enuresis
-Sleep apnea
syndrome
-Acute MI
-Renal, hepatic
diseases
-Glaucoma
75. CONTD……….
DRUG DOSE INDICATIONS CONTRA
INDICATIONS
BUSPIRONE
(2-3 times daily)
Tab 5-10 mg -Short term
management of
anxiety with or
without
depression
-Renal hepatic
diseases
PHENOBARBIT
O -NE(2 times
daily)
Tab 15-60 mg
Inj 1 ml/200 mg
I.V
-Insomnia
-Convulsions
-Drug addiction
-Respiratory
insufficiency
76. BEHAVIOUR THERAPY
DEFINITION:-
It is the systematic application of principles of learning
to the analysis and treatment of disorders of behavior.
The aims of behavioral therapy is to improve the
symptoms by deconditioning and reconditioning
procedures.
77. CONTD…….
TECHNIQUES
A. SYSTEMATIC DESENSITIZATION
Given by Wolpe(1958) involving 3 stages:-
Training the patient to relax.
Constructing a hierarchy of anxiety-
arousing situation.
Presenting phobia items from the hierarchy
in graded way then, patient inhibited anxiety
by relaxation.
I. RELAXATION TEHNIQUES
Jacobson’s muscular relaxation
techniques (relaxing and tensing the
muscles)
II. HIERARCHY
Sequence of phobic stimuli from the least
to the most phobic stimuli.
78. Contd……
III. DESENSITIZATION
Is the imagination therapy.
Length of session is 40 minutes, depends upon
patient’s relaxation time.
In vivo is required when there is difficulty in
imagination, when patient feel anxious.
when patient fails to relax.
79. BEHAVIOURAL THERAPY TECHNIQUES
CONTD…..
B. FLOODING:
Exposing patients to a phobic object or
situation in a non-graded manner with no
attempt to reduce anxiety
No prior relation techniques are taught to
patient & it is usually given in a non-graded
manner or in reverse hierarchy.
Can be conducted in imagination or in viva.
80. IMPLOSION
Exposure to phobic ideas or scenes in
fantancy ,for quite long periods.
It is believed that if avoidance is not
allowed,the fear will diminish due to
emotional exhaustion or habituation.
Flooding can be used in groups.
81. SHAPING
Give positive reinforcement & praising.
Can used in the rehabilitation of physically
handicapped children.
MODELLING
Patient observes someone else carrying out an action
which the patient currently finds difficult to perform.
Used with other techniques such as flooding & role
playing in the treatment of OCD & phobia.
82. RESPONSE PREVENTION &
RESTRAINT
When combined with flooding, it is treatment of choice in
OCN.
Thought stopping used in OCN (e.g. Snapping an elastic band
on wrist)
AVERSION
o Giving pain in association with a stimulus.
o Pain stimulation e.g. induction of nausea & vomiting
with apomorphine,mild electric shock in alcoholics.
o Produces long lasting changes in behavior.
o Can used in hysteria, panic attacks and at last stage of
OCN.
83. SELF CONTROL
TECHNIQUES
Over eating & excessive smoking are examples.
Includes self monitoring & self evaluation.
In self monitoring patient should observe himself. e.g.,
should maintain diary about types and times of eating in
a day.
In self evaluation patient will see that up to what extent
he or she has stopped himself from overeating.
CONTINGENCY MANAGEMENT
Includes expressions of approval & disapproval by other people.
For example Beviourial ,marital or family therapy.
84. TOKEN ECONOMY
Consists of rewarding the patient in various
ways (e.g.tokens or points) may also be lost for
inappropriate behaviours.
ROLE PLAYING
A related practice is role reversal, thus experiences difficult
situation from another point of view.
COGNITIVE THERAPY
Learning by person’s own experiences.
Learning by imitation & modeling.
85. NURSING CARE PLAN
ASSESMENT:-
Anticipatory anxiety
Panic anxiety
Avoidance behaviors
Embarrassment
Sufficient discomfort
86. NURSING DIAGNOSIS:-FEAR RELATED TO PHOBIC STIMULI AS
EVIDENCEDBY SCREAMING,SHAKING,TREMBLING & SHOWING
ANXIETY
EXPECTED OUTCOMES:-The client will
verbalize feeling of fear and discomfort.
Responds to relaxation techniques.
INTERVENTIONS RATIONALE
-Encourage client to express feeling,
initially without discussing the phobic
situation specifically
-It will decrease the anxiety related to specific
situation.
-Reassure client that he/she can learn to
decrease anxiety.
-It will boost confidence of patient.
-Reassure client that he/she will not be
forced to confront the phobic situation
until she is ready.
-It will make situation relax able for patient.
-Instruct client about relaxation
techniques.
.
-It helps patient to relax.
87. CONTD………
INTERVENTIONS RATIONALE
-Encourage client to practice relaxation. -Patient can relax easily by practicing.
-Explain systemic desensitization to
client.
- To decrease phobia in graded manner
-Reassure client at every step. -It increases patient confidence
Encourage patient to face phobic stimuli
in a graded manner
-Preparation for next coming phobic object
-Encourage patient to relax completely at
every step & then move to other step, if
not return to previous step.
-Relaxation helps to face the next situation.
Convey message to patient at every step
that he/she is succeeding raded manner
-Feeling of boldness
88. NURSING DIAGNOSIS:-ALTERED COMMUNICATION R/T FIXED
FEAR OF PHOBIC STIMULI AS EVIDENCED BY SADNESS,SITTING
ALONE & DECREASED PARTICIPATION .
EXPECTED OUTCOMES:-Patient will share his
feelings r/t phobic stimuli in an effective
manner.
INTERVENTIONS RATIONALE
-Encourage patient to ventilate feelings
-Avoid group discussion in initial stages,
prefer individual talk.
-Patient can relax by ventilating his
feelings.
-To maintain confidentiality.
-Tell patient not to perceive phobic
stimuli too much dangerous than the
actual dangerness
-Help patient to perceive actual
dangerness.
-Win confidence of patient -Patient can easily ventilate feelings.
Don’t force patient to talk about specific
phobic situation.
-Reduces anxiety r/t particular situation.
89. NURSING DIAGNOSIS:-ALTERED ACTIVITY OF DAILY LIFE’S R/T
PHOBIC STIMULUS EVIDENCED BY LOW PERFORMANCE IN
ROUTINE WORK .
EXPECTED OUTCOME:- Patient will be able to perform all ADL’s very will
with normal pace.
INTERVENTIONS RATIONALE
Teach patient about activities of daily life. Teaching help patient to act accordingly.
Discourage patient’s excessive
screamming & shouting.
Patient’s scremming symptom will
decrease due to neglection.
Set an aim of the day to patient which has
to be completed by patient in a fixed time
to increase performance.
Can divert the mind of patient & keep busy
in fulfilling aim.
Teach patient how to avoid the phobic
stimuli & then continue the ADL ‘s.
It will teach avoidance defense mechanism
90. NURSING DIAGNOSIS:-LOW SELF ESTEEM R/T REPEATED
EMBARRASMENT AS EVIDENCED BY DECREASED
COMMUNICATION & AVOIDING SITUATION & PEOPLE.
EXPECTED OUTCOME:-Patient will have high self esteem & will feel superior
to himself.
INTERVENTIONS RATIONALE
Encourage patient to do participation by
the reinforcement.
Positive reinforcement increases
confidence.
Encourage patient not to feel inferior. Patient’s thinking can act as role model for
him.
Give appreciation at every small
achievement. Praise patient in big group.
Appreciation boost the patient’s spirit.
Encourage patient to perform small
activities(like peeling a potato).
It can make the patient feel that he is
getting respect in the group.
91. NURSING DIAGNOSIS:- DECREASED SOCIALISATION R/T
DISEASED CONDITION AS EVIDENCED BY ALTERED
RELATIONSHIP & DECREASED CONTACTS.
EXPECTED OUTCOME:-Patient’s contact will
increase and relationships will be good with all
family members & society.
INTERVENTIONS RATIONALE
Encourage patient to meet relatives. Helps in increased socialization.
Teach relatives to appreciate the patient for
smaller achievement.
Helps in developing confidence.
Involve patient in games with in a group. Group participation increases confidence
in a patient.
Encourage patient to make outlook better
and attending parties.
It will develop interest and divert mind.
92. CLIENT EDUCATION
Advice client to use relaxation techniques.
Advice client to do regular exercise.
Educate the client about various behaviour
techniques.
Educate them to learn and practice those
techniques.
Teach about various coping methods.
93. FAMILY EDUCATION
Educate about the diseased condition of the
client.
Educate about the behaviour of the client.
Educate the family about the various
techniques used during the behaviour
therapy.
Teach about the medication and its side
effects.
94. INTRODUCTION
OCN is an illness that traps
people in an endless cycle of
repetitive thoughts that
would not leave their minds
(obsessions) and in feelings
that they must repeat
certain actions over and
over again (compulsions)
20% of people would have
only obsessions or
compulsions but 80% have
both.
95. DEFINITION OF OCD
OCD is a psychiatric anxiety
disorder, characterized by a
subject’s obsessive distressing,
intrusive thoughts and related
compulsions/ task / rituals attempt
to neutralize the obsessions.
Obsessions and compulsions are
source of distress, time consuming
and causes impairment in individual's
ability socially, occupational and
school functioning.
96. OBSESSIONS (ACC. TO
DSM-4)
Recurrent and persistent
ideas thoughts impulses or
images that are
experienced at some time
during the disturbance , as
intrusive and inappropriate
that causes marked
distress or anxiety, e.g.
thoughts of committing
violence .
Thoughts impulses or
images are not simply
excessive worries about
real life problem.
97. Contd….
The personal attempt to ignore
or suppress such thoughts ,
impulses or images to neutralize
them with some other thought or
action.
The person recognise that the
obsessional thoughts , impulses or
images are a product of his or
her own mind and are not based
in reality.
98. COMPULSIONS (ACC. TO
DSM-4)
Repetitive behavior or
mental acts, that the person
feels driven to perform in
response to an obsession .
Mental acts are aimed at
preventing some dreaded
event or situation, however
these mental acts either or
not connected in a realistic
way with what they are
designed to neutralize.
99. Contd…
Compulsions are irresistible
urges (wishes) to carry out
meaningless and irrational
activities.
If the person does not
carry out these impulses he
experience discomfort and
tension.
This tension gets released
only when he acts out his
impulse.
100. EPIDEMIOLOGY
2 to 3 % in general
population.
10% of psychiatric
outpatients
SEX: ADULTS- equally
in men and women.
ADOLESCENTS- boys are
more affected than girls.
AGE: mean age of onset is
20 yrs. But can occur in
childhood also.
MARIETAL STATUS:
single people are more
affected.
102. BEHAVIOURAL THEORY
Interplay between classical and
operant conditioning.
The external aversive stimuli interact
with the organism with previous
learning, such stimuli have acquired
specific significance; this results in
stimuli gaining more strength resulting
in sensitization.
Ritual act produce relief and thus
through negative reinforcement
increase the possibility of repetition
of phenomenon.
103. MOWER’S TWO STAGE
THEORY
A neutral stimuli become
associated with fear, as it
occur with an event, which
provoke discomfort. Due to
this association, various
objects , thoughts , images are
also capable of causing
discomfort.
Responses that reduce anxiety
or discomfort are developed
and maintained.
104. PSYCHODYNAMIC THEORY
Acc. To freud , the anal
erotic phase of
psychosexual
development is
responsible for the
evolution of the
anankastic traits to
defend against the
unacceptable anal
impulses
105. EGO PSYCHOLOGICAL
THEORY
The conflict was thought to
arise due to inadequate
mastery of oedipal complex,
resulted in regression to the
anal sadistic stage to avoid
anxiety to which the subject
was already predisposed due to
difficulties in the period of
development
It stimulates anal and
aggressive impulses against
which defense mechanisms are
used e.g. isolation, undoing,
reaction formation, regression.
106. OTHER CAUSES
Autoimmune responses to group A
streptococcal infections.
Unconscious conflicts manifested
as OCD symptoms.
Abnormality in neurotransmitter
serotonin or blocked or damaged
receptor sites that prevents
serotonin from functioning to its
full potential.
Familial origin, in monozygotic twins
1st degree relative of OCD clients
the disease is common.
109. NEED TO OBTAIN APPROVAL FROM PARENTS BY BEING
EXCESSIVELY TIDY AND CONTROLLED
CHILD REACTS TO THE STANDARDS SET BY PARENTS
SOME OF THESE STANDARDS ARE EXCESSIVELY HIGH
CONFLICT BECOME NECESSARY FOR HEALTHY PERSONAL
GROWTH
FRUSTRATION EXIST BETWEEN CHILD’S TENDENCIES
AND PARENTS TABOOS
INCIDENCE OF OCD
111. Uncommon Obsessions
Contamination from people with disabilities
Thoughts of becoming pregnant (male)
Crumbs of the communion wafer fell in my
underwear
Put the baby in the oven by mistake
112. Some Common Compulsive Rituals
Washing/Cleaning – hand washing, showering,
toilet, inanimate objects, hand gel
Checking – locks, appliances, for assurance,
Mental rituals – praying, neutralizing, mental
reviewing
Repeating – steps, touching
Ordering/arranging – left-right balance
113. CLINICAL PICTURE
OCD sufferers performs
tasks or compulsions to seek
relief from obsession related
anxiety e.g.
Repeatedly checking that
one’s parked car is locked
before leaving
Turning lights on and off a
set number of times before
exiting the room
Repeatedly washing hands at
regular intervals throughout
the day.
114. Contd…
‘To others these tasks may
appear odd and unnecessary.
But for the sufferer , such
task can feel critically
important and must be
performed in a particular ways
to ward off dier consequences
and to stop stress from
building up.’
116. Contamination Obsessions
Concern with dirt or germs.
Excessive concern with
environmental contaminants.
Examples: asbestos, radiation,
pesticides or toxic waste.
Excessive concern with
household items. Examples:
cleansers, solvents.
Concern or disgust with bodily
waste or secretions. Examples:
urine, feces or saliva
Fear of blood. Fear could be a)
related to blood-borne illnesses
like AIDS or hepatitis or b)
caused by just the sight of
blood.
117. CONTD…
Bothered by sticky
substances or residues.
Examples: adhesives, chalk
dust or grease.
Excessive concern with
animals or insects.
(Distinguished from Specific
Phobia.)
Concerned will get ill because
of contaminants. Examples:
AIDS or cancer
118. CONTD…
Concerned will get others ill
by spreading contaminants.
No concern with
consequences of
contamination other than how
it might feel.
Fear of eating certain foods.
Examples: excessive concern
about risks of certain foods
or food preparations.
(Distinguished from anorexia
nervosa in which concern is
gaining weight.)
119. Symmetry, Order, Exactness and
“Just Right” Obsessions
Need for symmetry or exactness.
Examples: certain things can’t be
touched or moved, clothes
organized in closet alphabetically,
bothered if pictures are not
straight or canned goods not lined
up.
Exactness in dressing. Examples:
excessive concern about appearance
of clothing such as wrinkles, lint,
loose threads; may not wear
garments out of concern they will
become worn.
Symmetry in dressing. Examples:
bothered if stockings are not at the
same height or shoe laces not tied
at the same tension.
120. CONTD..
Exactness or symmetry in
grooming. Examples: bothered
if hair not parted exactly
straight or hair not precisely
same length on each side of
the head.
Fear of saying the wrong thing
or not saying it “just right”.
Example: patient may appear
to have thought-blocking
because she is reviewing every
interpretation of what she is
about to say.
121. CONTD…
Need for exactness related to
feared consequences. Example:
something terrible may happen if
things aren’t in their proper place
Finds certain sounds irritating.*
Examples: “sh” sound, lisps,
static/noise, sniffing/coughing,
ticking clocks, dripping water.
Need to know or remember.
Examples: needing to remember
insignificant things like license
plate numbers, bumper stickers,
advertising slogans, names of
actors.
122. Safety, Harm and Violent
Obsessions
Fear of harm due to
carelessness. Exclude
contamination obsessions.
Fear might harm self on
impulse. This involves
unwanted impulses or
inexplicable acts. Examples:
fear of stabbing self with a
knife, jumping in front of a
car, leaping out an open
window, or swallowing poison.
123. Contd…
Fear might harm others
because not careful enough.
Examples: parked car rolling
down hill, hit a pedestrian
because not paying attention,
customer gets injured because
you gave him wrong materials
or information.
Fear might harm others on
impulse. Examples: physically
harming loved ones, stabbing
or poisoning dinner guests,
pushing stranger in front of a
train. (Distinguished from
homicidal intent.)
124. Contd…
Fear of being responsible for
terrible events. Examples: fire,
burglary, flooding house, .
Fear of blurting out obscenities
or insults. Examples: shouting
blasphemies in church, yelling fire
in the movie theatre, writing
obscenities in a business letter.
Fear of doing something else
embarrassing. Examples: taking
off clothes in
public,(Distinguished from Social
Phobia.)
Violent or horrific images.
Examples: intrusive and
disturbing images of car crashes
or disfigured people.
125. Hoarding/Saving Obsessions
Need to hoard or save things.
Examples: afraid that
something valuable might be
discarded with recycled
newspapers even though all
valuables are locked up in the
safe.
Fear of losing objects or
information
126. Fear of losing people.
Example: otherwise rational
man feared “losing” his 5-
year old daughter when
mailing envelopes.
Fear of losing something
symbolic. Example: patient
concerned that her “essence”
would be left behind when
getting up from a chair.
127. Other Obsessions
Pathological doubting. Examples:
after completing a routine activity
patient wonders whether he
performed it correctly or did it at
all; may not trust his memory or
his own senses (i.e., “his mind
doesn’t trust what his eyes see.”).
Pathological indecisiveness.
Examples: continual weighing of
pros and cons about nonessentials
like which clothes to put on in the
morning or which brand of cereal
to buy. Differentiate from worries
about real-life decisions
characteristic of GAD.
128. Contd..
Excessive concern with
functioning of, or injury, to a
body part. Examples:
protecting face or eyes from
damage; obsessed with
mechanical functioning of feet.
In most cases of
preoccupations with physical
appearance.
Colors with special
significance. Examples: black
connected with death, red
associated with blood and
injury.
129. Superstitious fears.
Examples: black cats,
breaking mirror, stepping
on side walk cracks,
spilling salt, omens.
Lucky or unlucky
numbers. Example: the
number 13.
Intrusive meaningless
thoughts or images.
Intrusive nonsense
sounds, words or music.
Examples: songs or
music with no special
significance played over
like a broken record.
130. Common compulsions
Excessive double-
checking of things, such
as locks, appliances, and
switches.
Repeatedly checking in
on loved ones to make
sure they’re safe.
Counting, tapping,
repeating certain
words, or doing other
senseless things to
reduce anxiety.
Spending a lot of time
washing or cleaning.
131. Contd…
Ordering, evening out,
or arranging things
“just so.”
Praying excessively or
engaging in rituals
triggered by religious
fear.
Accumulating “junk”
such as old
newspapers,
magazines, and empty
food containers, or
other things you don’t
have a use for.
132. “Just because one
have obsessive
thoughts or perform
compulsive behaviors
does NOT mean that
he/she have
obsessive-compulsive
disorder.!!!!!!!!!!”
Many people have
mild obsessions or
compulsions that are
strange or irrational,
but they’re still able
to lead their lives
without much
disruption.
But with obsessive-
compulsive disorder,
these thoughts and
behaviors cause
tremendous distress,
take up a lot of time,
and interfere with
one’s daily routine,
job, or relationships.
134. TREATMENT
A combination of
therapies is helpful than
single option:
PHARMACOLOGICAL
THERAPY
BEHAVIOUR THERAPY
PSYCHOSURGERY
OTHER THERAPIES
135. PHARMACOLOGICAL
THERAPY
Antidepressants are the
main drug of choice for
treatment of OCD. Main
drugs used are:
Tricyclic antidepressants
Selective serotonin reuptake
inhibitors
Other drugs used are
• atypical antipsychotics
138. SELECTIVE SEROTONIN
REUPTAKE INHIBITORS
MOA: SSRI’S
PREVENT EXCESS SEROTONIN FROM BEING PUMPED BACK INTO
ORIGINAL NEURON THAT RELEASED IT
INSTEAD SEROTONIN CAN BIND TO RECEPTER SITES OF NEARBY
NEURONS
SEND CHEMICAL MESSAGES THAT CAN REGULATE THE OCN
THOUGHTS AND EXCESS ANXIETY
139. Contd…
EXAMPLES:
Paroxetine
DOSE: 40 mg/ day
Patients should be started on 20 mg/day
and the dose can be increased in 10-mg/day
increments..
It should be administered as a single daily
dose with or without food, usually in the
morning.
140. Contd…
Sertaline: (zoflot)
DOSE: 25-200 mg/day in adults
ZOLOFT treatment should be initiated
with a dose of 25 mg once daily in children
(ages 6-12) and at a dose of 50 mg once
daily in adolescents (ages 13-17).
ZOLOFT should be administered once
daily, either in the morning or evening.
141. Fluoxetine PROZAC®
(Fluoxetine hydrochloride) Pulvule®
for Oral Use
PROZAC
(Fluoxetine hydrochloride) Oral
Solution
PROZAC Weekly™
(Fluoxetine hydrochloride) Delayed-
Release Capsules for Oral Use
142. PROGNOSIS
A better prognosis is suggested by
good social adjustments.
Absence of compulsions in the
presence of obsessions.
Presence of precipitating events
20-30% have significnt improvement
40-50% have moderate improvement
20-40% either remain ill or worsening
their symptoms
143. DEFENCE MECHANISMS
DISPLACEMENT: A person does
something as a substitute of
something else.
UNDOING: asking excuses for wrong
deeds.
REACTION FORMATION: strongly
expressing the opposite of what one
really feels.
144. COMPLICATIONS
Drug abuse
Alcohol Abuse
Suicidal thoughts
psychological distress
Emotional distress
Physical health problems, such as
irritated skin from frequently
washing, bald spots from pulling your
hair, weight gain or loss, heart
problems , etc.
145. APPROACHES TO THE PATIENT
OF OCD
APPROACH SHOULD BE
FRIENDLY WITH THE
PATIENT OF OCD.
STRICT APPROACH SHOULD
BE AVOIDED BECAUSE
STRICT APPROACH LEADS
TO INCREASED ANXIETY
WHICH WILL LEAD TO
INCREASE PERFORMANCE
OF RITUALS.
146. ACTIVITIES TO BE ASSIGNED
TO THE PATIENTS
Diversional activities to be assigned to the
patients e.g.
Stretching the rubberband on the wrist
whenever obsessions are felt
Listening to the music
Physical exercises
Never assign the activities similar to the
rituals of the patient like dusting , cleaning
Never say the patients to confirm whether
room or car is locked or not.
148. NURSING DIAGNOSIS
Ineffective individual coping R/T underdeveloped
ego or punitive superego as evidenced by
ritualistic behaviour or obsessive thoughts.
Altered physical functioning R/T ritualistic
behaviour as evidenced by inadequate nutrition
sleep, hygiene.
Social isolation R/T anxiety and obsessional
thoughts as evidenced by poor IPR
Ineffective utilization of coping strategies due to
obsessional thoughts and compulsive behavior as
evidenced by poor coping.
