Psych / Mental Health · Anxiety & Related Disorders
Anxiety Disorders & OCD
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.
If you or someone you know is in crisis: call or text 988 (Suicide & Crisis Lifeline, U.S.) or call 911 for immediate danger. This guide is for exam study, not for diagnosing or treating anyone.
1. Overview
Anxiety is a normal alarm response. It becomes a disorder when it is excessive, persistent, out of proportion to the threat, and interferes with daily life. Neurobiology involves an overactive fear circuit (amygdala) and imbalances in GABA, serotonin, and norepinephrine. Always rule out medical causes: hyperthyroidism, hypoglycemia, cardiac arrhythmias, hypoxia, caffeine/stimulants, and alcohol or benzodiazepine withdrawal.
2. Levels of Anxiety (high-yield)
| Level | Perception & learning | Nursing approach |
|---|---|---|
| Mild | Alert, wider perception; learning is enhanced | Good time for teaching |
| Moderate | Narrowed focus; can learn with direction | Help focus, problem-solve |
| Severe | Very narrow focus on details; can’t problem-solve; physical symptoms | Calm presence, simple directions, reduce stimuli; no teaching |
| Panic | Disorganized, may lose touch with reality; risk of harm | Safety, stay with patient, short commands, quiet room, PRN meds |
3. Key Disorders (conceptual)
- Generalized anxiety disorder (GAD): chronic, hard-to-control worry about many things most days for months, with restlessness, fatigue, poor concentration, irritability, muscle tension, sleep problems
- Panic disorder: recurrent unexpected plus persistent worry about future attacks or avoidance; may lead to agoraphobia
- Specific phobia / social anxiety disorder: intense fear of a specific object/situation or of being judged; avoidance
- Obsessive-compulsive disorder (OCD): (intrusive thoughts) and/or (rituals) that are time-consuming (often > 1 hr/day). Most patients recognize the thoughts are excessive (ego-dystonic)
- Related: hoarding, body dysmorphic disorder, trichotillomania
4. Signs & Symptoms
- Physical (sympathetic): tachycardia, palpitations, rapid breathing, dizziness, sweating, tremor, GI upset, urinary frequency, dry mouth
- Cognitive: worry, poor concentration, catastrophizing (), fear of losing control
- Behavioral: avoidance, restlessness, rituals, reassurance seeking
- Hyperventilation during panic → respiratory alkalosis (tingling, lightheadedness)
5. Priority Nursing Actions
- Rule out physical causes (chest pain → treat as cardiac until proven otherwise)
- Panic attack: stay with the patient, remain calm, use short simple sentences, move to a quiet low-stimulus area, guide slow breathing, give PRN anxiolytic as ordered
- OCD: do not interrupt or forbid rituals at first — that raises anxiety. Allow time for rituals, then gradually set limits on time, collaboratively. Build structure into the day
- Teach coping when anxiety is mild to moderate: deep breathing, progressive muscle relaxation, grounding (5-4-3-2-1), journaling
- Encourage evidence-based therapy: CBT, exposure and response prevention (ERP) for OCD, systematic desensitization for phobias
6. Medications
| Drug/class | Use | Nursing considerations |
|---|---|---|
| SSRIs/SNRIs (sertraline, escitalopram, venlafaxine, duloxetine) | First-line long-term for GAD, panic, OCD (often higher doses for OCD) | Take 2–6+ weeks to work; early jitteriness; sexual effects; boxed warning for suicidality < 25 yr; don’t stop abruptly |
| Benzodiazepines (lorazepam, alprazolam, clonazepam) | Short-term / acute relief | Sedation, fall risk, respiratory depression with alcohol/opioids; dependence; taper — never stop abruptly (seizures); antidote flumazenil (caution: seizures) |
| Buspirone | GAD | Not sedating, no dependence; takes weeks; not for PRN/panic |
| Hydroxyzine | PRN anxiety | Anticholinergic, sedating |
| Propranolol | Performance anxiety (physical symptoms) | Bradycardia, hypotension; caution in asthma |
7. Emergencies
- Panic vs. MI: chest pain + risk factors → ECG, troponin per protocol first
- Benzodiazepine overdose with opioids/alcohol: airway, breathing, naloxone for opioid component; flumazenil only per provider (can trigger seizures in dependent patients)
- Benzodiazepine withdrawal: can cause seizures — see the Substance Use guide
8. Patient Education
- Medications are part of a plan that includes therapy; SSRIs are not habit-forming but take weeks
- Avoid caffeine, nicotine, alcohol; regular sleep and exercise
- Benzodiazepines: no alcohol, no driving until response known, don’t stop suddenly
9. Memory Aids
- “Mild = Mind open; Panic = Protect”
- Buspirone = “Bus is slow” — weeks to work, no PRN use
- OCD rituals: “Allow, then limit”
10. NCLEX-Style Practice Questions
1. A patient is pacing, hyperventilating, and says, “I’m going to die!” What is the nurse’s priority action?
A. Teach the patient diaphragmatic breathing in detail
B. Stay with the patient and speak in short, calm sentences
C. Ask the patient what triggered the episode
D. Leave the patient alone to calm down
Answer: B. In panic-level anxiety, the patient can’t learn or problem-solve. Staying with the patient provides safety. Teaching (A) and exploring triggers (C) come later.
2. A patient with OCD washes their hands for 45 minutes before breakfast and is missing meals. Which initial intervention is best?
A. Lock the bathroom to prevent handwashing
B. Allow time for the ritual and wake the patient earlier
C. Tell the patient the ritual is unnecessary
D. Give a PRN benzodiazepine before every meal
Answer: B. Preventing rituals abruptly increases anxiety. Build in time first, then gradually limit it with the patient.
3. A patient starting buspirone asks if it will help during a panic attack. The best response is:
A. “Yes, take it whenever you feel anxious.”
B. “It works best when combined with alcohol.”
C. “It takes several weeks to work and isn’t used for sudden attacks.”
D. “It works within 30 minutes.”
Answer: C. Buspirone has a delayed onset and is not a PRN medication.
4. Which client is at greatest risk from taking alprazolam?
A. A client who drinks 3–4 beers nightly
B. A client with seasonal allergies
C. A client with mild hypertension
D. A client taking a daily multivitamin
Answer: A. Alcohol + benzodiazepine causes additive CNS and respiratory depression.
5. A nurse can best teach relaxation techniques when the client’s anxiety is:
A. Mild
B. Severe
C. Panic level
D. Escalating rapidly
Answer: A. Perception and learning are enhanced at mild anxiety levels.
References
Chand, S. P., & Marwaha, R. (2023). Anxiety. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470361/
National Institute of Mental Health. (n.d.). Anxiety disorders. Retrieved October 15, 2026, from https://www.nimh.nih.gov/health/topics/anxiety-disorders
National Institute of Mental Health. (n.d.). Obsessive-compulsive disorder. Retrieved October 15, 2026, from https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). (Concepts summarized in original words; no DSM text reproduced.)
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page