Ch. 11 Anxiety, Anxiety Disorders, and Obsessive-Compulsive and Related Disorders
Moderate Selective inattention is noted in moderate anxiety. The individual's perceptual field is reduced and the he or she is not able to see the entire picture of events. Selective inattention is not a feature of mild, severe, or panic level anxiety. p. 132
Selective inattention is first noted when an individual experiences which level of anxiety? Mild Moderate Severe Panic
"It's not a mistake. Some antidepressant medications also work well for managing anxiety." A variety of medications are used widely for the treatment of anxiety, including selective serotonin reuptake inhibitors (SSRIs) like paroxetine. A client with generalized anxiety disorder has concerns about many aspects of daily life, and any disturbance can trigger increased anxious feelings. The nurse should reassure the client that no medication mistake was made. Telling the client that the internet is not always a reliable source of information does not provide adequate reassurance. Paroxetine is not a benzodiazepine. Because the prescription was not an error, the nurse does not need to call the health care provider. p. 145
A client diagnosed with generalized anxiety disorder receives a new prescription for paroxetine 10 mg at hour of sleep (qhs). The client finds information on the internet that states the drug is an antidepressant. The client calls the nurse, saying, "The health care provider gave me the wrong drug. I have anxiety, not depression." What is the nurse's best response? "The internet is not always a reliable source for medication information." "It's not a mistake. Some antidepressant medications also work well for managing anxiety." "You misinterpreted the information. Paroxetine is a benzodiazepine, not an antidepressant." "Thank you for phoning about this error. I'll confer with the health care provider and call you back."
Encourage the client to take slow, deep breaths. Slow diaphragmatic breathing can induce relaxation and reduce symptoms of anxiety. Often the nurse has to tell the client to "breathe with me" and keep the client focused on the task. The slower breathing also reduces the threat of hypercapnia with its attendant symptoms. Verbalizing disapproval, offering an explanation about the symptoms, and asking the client what he or she means will not be helpful to the client during a panic attack and may exacerbate it. p. 149
A client is experiencing a panic attack. Which nursing intervention will be most therapeutic? Encourage the client to take slow, deep breaths. Verbalize mild disapproval of the anxious behavior. Offer an explanation about why the symptoms are occurring. Ask the client what he or she means when he or she says "I am dying."
Use contraceptive methods. Chlordiazepoxide belongs to the benzodiazepine class of antianxiety drugs. It causes congenital anomalies in the fetus; therefore, the client should avoid becoming pregnant. Abruptly stopping the medication can cause withdrawal symptoms like dry mouth, tremors, and convulsions. The nurse should suggest discontinuing the medication after 3 to 4 months. Because caffeine decreases the efficacy of the benzodiazepines, the nurse should suggest the client avoid drinking coffee and tea. p. 148
A female client diagnosed with panic disorder is prescribed chlordiazepoxide. What is the most appropriate suggestion by the nurse? Use contraceptive methods. Stop the medication if there is insomnia. Stop the medication after 3 months. Coffee and tea are safe to drink and won't interact with the medication.
Talk slowly and calmly with the client. Ask the client to write a list of his or her strengths. Encourage the client to discuss feelings associated with the fear. The symptoms of generalized anxiety disorder include inability to perform a given task and avoiding interacting with others. The nurse should help the client feel safe by talking slowly and calmly. The nurse can increase the self-esteem of the client by administering the task of writing and assessing his or her strengths. The nurse should encourage the client to discuss the feelings associated with the fear. It helps the nurse to identify possible stressors and to eliminate them from the patient's surroundings. The nurse should not leave the client alone but stay with the client to convey acceptance. The nurse should avoid giving strict instructions to the client, because doing so may hinder nurse-client communication. p. 133
As a part of group therapy, a client diagnosed with an anxiety disorder was asked to present a speech to the group. The client was unable to perform the given task and started avoiding the nurse. How should the nurse relieve the anxiety of the client? Leave the client alone in a room. Talk slowly and calmly with the client. Ask the client to write a list of his or her strengths. Give strict instructions to the client to complete the given task. Encourage the client to discuss feelings associated with the fear.
Teach the client to limit caffeine intake. Caffeine is an antagonist of antianxiety medication. The nurse should instruct the client to limit caffeine intake. The dose is not excessive. Benzodiazepines are typically taken short-term. Mild insomnia is not a typical side effect of lorazepam. p. 149
When a client is prescribed lorazepam 1 mg orally four times a day for 1 week for generalized anxiety disorder, what should the nurse do? Question the health care provider's prescription regarding the high dose. Explain the long-term nature of benzodiazepine therapy to the client. Teach the client to limit caffeine intake. Tell the client to expect mild insomnia.
This medication would increase the client's risk for falls. An important nursing intervention is to monitor for side effects of the benzodiazepines, including sedation, ataxia, and decreased cognitive function. In older adults who may have a higher risk of falls, a benzodiazepine may be contraindicated. There is no evidence to suggest that older adults become addicted faster than younger clients. Medication and other therapies are used congruently with all age levels. This classification of medications generally is not associated with nonadherence. p. 148
A 72-year-old client is diagnosed with Parkinson's disease and anxiety. The health care provider prescribes a benzodiazepine. The nurse knows to double-check this prescription based on what fact related to this classification of medications? This medication would increase the client's risk for falls. Older adults become addicted faster than younger clients. Cognitive therapies are more effective than medications for the older adult. Benzodiazepines have serious side effects, so clients are often noncompliant.
Amygdala The amygdala plays a role in anxiety disorders. 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 and are implicated in phobic responses. The thalamus relays sensory information to other brain centers. The hypothalamus is involved in regulation of the autonomic nervous system. The pituitary gland secretes regulatory hormones. p. 137
A client is fearful of riding in elevators and always takes the stairs. Which brain structure is involved in this fear and behavior? Thalamus Amygdala Hypothalamus Pituitary gland
"Certain antidepressant medications work well for managing anxiety. It may take several weeks for you to feel the full benefit." The nurse should explain to the client that selective serotonin reuptake inhibitors (SSRIs) are considered the first line of defense in most anxiety disorders, including social anxiety. Sertraline and paroxetine are SSRIs with calming effects. The website was not incorrect, and the prescription was not made in error. The nurse should provide a more complete response than telling the client to simply have confidence in the health care provider's judgment. p. 145
A client receives a new prescription for sertraline 50 mg daily. The client phones the nurse and says, "I read on the internet that this drug is for depression. I have social anxiety, not depression." Which response should the nurse provide? "The website was incorrect. Sertraline is an antianxiety medication rather than an antidepressant." "Thank you for informing us of this error. I will discuss the situation with your health care provider and call you back shortly." "Certain antidepressant medications work well for managing anxiety. It may take several weeks for you to feel the full benefit." "It is important for you to take the medication. Try to have confidence in your health care provider's judgment about how to help you.
The parents were talking in trembling voices. The parents were having increased rates of respiration. People having moderate anxiety have voice tremors and tend to talk in a trembling voice. They show increased pulse rate and respiratory rate. In severe anxiety, people are usually confused and are unable to make decisions. They cannot make decisions to solve problems at an optimum level. People with mild anxiety exhibit mild tension-relieving behavior such as foot or finger tapping and lip chewing. p. 131
A nurse observes a client's parents at an intensive care unit. The nurse determines that the client's parents have moderate anxiety. Which symptoms of anxiety did the nurse assess in the client's parents? The parents were talking in trembling voices. The parents were having increased rates of respiration. The parents were confused and unable to make any decisions. The parents were effectively making decisions to solve problems. The mother was tapping her foot, and the father was chewing his lip.
The client has body dysmorphic disorder. Body dysmorphic disorder is characterized by a preoccupation with an imagined defective body part. Client with body dysmorphic disorder often pay excessive attention to body parts that they imagine to be defective. As a result, they may compulsively look at themselves in mirrors. Clients with panic disorder may have an unusual fear of future events. In hoarding disorder, the client accumulates and collects materials for future use. Obsessive-compulsive disorder is marked by performing repeated activities or rituals. p. 141
A student nurse observes that a client compulsively looks at his or her reflection in the mirror. Based on the client's behavior, what is the most likely diagnosis the student nurse will expect the health care provider to make? The client has panic disorder. The client has hoarding disorder. The client has body dysmorphic disorder. The client has obsessive-compulsive disorder.
Fear related to misinterpretation and misinformation about breast self-exams Fear is a response to a perceived threat or danger that may inhibit problem-solving and lead to apprehension about the future. The person is ill-informed about the findings and misinterprets the potential prognosis. Although the body image may be disturbed, it is not related to malignant cancer. There is no evidence of self-esteem disturbance. p. 140
A woman feels a lump in her breast. She anxiously says to her spouse, "I have cancer. It probably has spread all over my body." Which nursing diagnosis and etiology best apply to this situation? Ineffective coping related to panic level anxiety Disturbed body image related to malignant breast cancer Self-esteem disturbance related to outcome of breast self-exam Fear related to misinterpretation and misinformation about breast self-exams
Cease any further attempt at preoperative teaching at this time and instead encourage deep breathing. Clients experiencing severe anxiety, as the symptoms suggest, are unable to learn or solve problems, so the nurse should cease preoperative teaching and encourage deep breathing exercises to help the client calm down. Restating the preoperative teaching slowly, having the client read the teaching materials instead of listening to them, and having a familiar family member read the preoperative materials to the client would not be effective because a person is unable to learn effectively while experiencing severe anxiety. p. 131
As the nurse teaches a preoperative client, the client becomes more and more anxious as the information is presented. Soon the client begins to report dizziness and heart pounding. The nurse observes obvious trembling and confusion. Which is the nurse's priority intervention? Reinforce the preoperative teaching by restating it slowly. Have the client read the teaching materials instead of listening to them. Have a familiar family member read the preoperative materials to the client. Cease any further attempt at preoperative teaching at this time and instead encourage deep breathing.
Help the individual identify several stress situations that he or she successfully managed. Positive self-concepts result from positive experiences, leading to perceived competence and acceptance. Assisting the client in identifying such situations that he or she successfully managed will aid in building confidence. Being praised for successes is appropriate, but praise should be reserved for situations that the individual recognizes as meaningful. Although stress management techniques are important, they are not linked directly to a sense of competence. Describing how one demonstrates control and competence is applicable but has limited favor in actually assisting the client to feel competent. p. 132
Which nursing intervention is most helpful to support improvement in an anxious individual's sense of control and competence? Provide large amounts of praise when the individual accomplishes assigned tasks. Educate the individual regarding the usefulness of stress management techniques. Help the individual identify several stress situations that he or she successfully managed. Have the individual describe how to demonstrate control and competence over stress.
Can the client meet self-care needs effectively? Is the client able to maintain satisfying interpersonal relationships? Has the client learned to use newly acquired methods to manage anxiety? Does the client understand that anxiety is the cause of the ritualistic behavior? In general, evaluation of outcomes for clients with anxiety and obsessive-compulsive disorders deals with questions such as: Does the client adequately perform self-care activities? Can the client maintain satisfying interpersonal relations? Is the client able to use newly learned behaviors to manage anxiety? Does the client recognize symptoms as anxiety-related? Cognitive abilities are not related directly to obsessive-compulsive disorders. p. 149
Which questions would assist a nurse in determining whether a client diagnosed with obsessive-compulsive disorder has achieved treatment outcomes? Can the client meet self-care needs effectively? Is the client able to maintain satisfying interpersonal relationships? Have the client's cognitive abilities improved since beginning treatment? Has the client learned to use newly acquired methods to manage anxiety? Does the client understand that anxiety is the cause of the ritualistic behavior?
An individual who received a liver transplant volunteers at a local organ procurement agency Altruism is a healthy defense mechanism in which emotional conflicts and stressors are addressed by meeting the needs of others. With altruism, the person receives gratification either vicariously or from the response of others. Volunteering at a local organ procurement agency after receiving an organ transplant meets the needs of others. Attending a support group, playing tennis, and volunteering at an animal shelter to address one's own fears are all examples of meeting the individual's needs, but they are not necessarily altruistic. p. 133
Which scenario presents the most accurate example of altruism? After recovering from a gunshot wound, a police officer attends a local support group. After recovering from open-heart surgery, an individual plays tennis three times a week. An individual with a longstanding fear of animals volunteers at a community animal shelter. An individual who received a liver transplant volunteers at a local organ procurement agency.
Clients diagnosed with OCD should be assessed regularly for risk for suicide. People suffering from OCD may become desperate and attempt suicide. Risk for suicide should be assessed regularly in these clients. Obsessive-compulsive disorder can begin in childhood, with symptoms present as early as age 3, but symptoms would not be expected in infancy. People with obsessive-compulsive disorders rarely need hospitalization unless they are suicidal or have compulsions that cause injury. Compulsions are ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety. Obsessions are thoughts, impulses, or images that persist, recur, and cannot be dismissed from the mind. p. 141
Which statement is true regarding obsessive-compulsive disorder (OCD)? Behaviors suggestive of OCD usually begin in infancy. Hospitalization is often necessary for persons diagnosed with OCD. Clients diagnosed with OCD should be assessed regularly for risk for suicide. Compulsions are repetitive thoughts, whereas obsessions are ritualistic behaviors.
They are characterized by a sudden onset of extreme apprehension. The fear is so intense that it interferes with a person's ability to function normally. People with a history of panic attacks develop a deep-seated fear of having an attack. A panic attack is the sudden onset of extreme apprehension or fear. The feelings are so severe that normal functioning is suspended. People who experience these attacks begin to "fear the fear" and become so preoccupied about future episodes of panic that they avoid what could be pleasurable and adaptive activities, experiences, and obligations. Typically, panic attacks appear randomly and are not necessarily in response to stress. Uncomfortable physical symptoms such as palpitations, chest pain, breathing difficulties, nausea, and feelings of choking, chills, and hot flashes may occur. p. 138
Which statements about panic attacks are true? A stressful situation is generally the trigger for a panic attack. They are characterized by a sudden onset of extreme apprehension. The symptomology of panic attacks is primarily psychological in nature. The fear is so intense that it interferes with a person's ability to function normally. People with a history of panic attacks develop a deep-seated fear of having an attack.
Rationalization The correct answer, rationalization, refers to justifying an action to satisfy the teller and the listener, which the client does by using hiking shoes as an excuse to mask the real reason for not going. Displacement is the transfer of emotions about a particular person, object, or situation to one that is nonthreatening. Passive aggression is the indirect and unassertive expression of aggression toward others. Reaction formation involves keeping unacceptable feelings or behaviors out of one's awareness by developing the opposite behavior or emotion. p. 135
Friends invite an adult diagnosed with type 2 diabetes to go on a mountain hike the following week. The client replies, "I can't go because I don't have any hiking shoes." In actuality, this adult fears difficulty with blood glucose management during strenuous activity. Which defense mechanism is evident in the adult's response? Displacement Rationalization Passive aggression Reaction formation
Behavioral theory According to behavioral theory, the client shows a learned response to specific environmental stimuli. The client has observed his or her mother's fear of darkness and also developed a fear of darkness. According to cognitive theory, the client has poor perception of situations and tends to develop a panic attack by thinking about the situation. According to interpersonal theory, the client develops emotional distress transmitted from mother or caregivers. According to psychodynamic theory, anxiety disorder is developed in a person during childhood due to unconscious conflicts in his or her surroundings. p. 138
In a clinical interview, a client says, "My mother and I are afraid of darkness, so we always carry a flashlight with us." Which theory is evident in this case? Cognitive theory Behavioral theory Interpersonal theory Psychodynamic theory
Panic attacks with agoraphobia Panic disorder with agoraphobia is characterized by recurrent panic attacks combined with agoraphobia. Agoraphobia involves intense, excessive anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurred. Symptoms of obsessive-compulsive disorder include intrusive thoughts and/or ritualistic behaviors. Posttraumatic stress response occurs after an individual experiences or witnesses severe trauma. Generalized anxiety disorder is a chronic disorder marked by excessive and constant worrying. p. 138-139
Inability to leave one's home in order to avoid severe anxiety suggests which anxiety disorder? Panic attacks with agoraphobia Obsessive-compulsive disorder Posttraumatic stress response Generalized anxiety disorder
Fear of dying Fear of dying is often involved in panic attacks in Latin Americans. Blushing may be related to social phobias in Japanese and Korean cultures. Offensive verbalizations are typically not seen in panic attacks. Repetitive involuntary actions are typically not seen in panic attacks. p. 138
Panic attacks in Latin American individuals often involve which symptom? Blushing Fear of dying Offensive verbalizations Repetitive involuntary actions
Preventing the client from washing hands after touching a dirty object Response prevention is a technique by which the client is prevented from engaging in the compulsive ritual. A form of behavior therapy, response prevention is never undertaken without health care provider approval. Not allowing the client to wash hands after touching a perceived "dirty" object is an example of response prevention. Not allowing reassurance, repeatedly touching "dirty" objects, , and telling the client to relax are not examples of response prevention. p. 145
The plan of care for a client who uses elaborate washing rituals specifies that response prevention is to be applied. Which scenario is an example of response prevention? Withholding reassurance from staff Having the client repeatedly touch dirty objects Telling the client to relax whenever tension mounts Preventing the client from washing hands after touching a dirty object
Sleep disturbance Clients who must engage in compulsive rituals for anxiety relief rarely are afforded relief for any prolonged period. The high anxiety level and need to perform the ritual may interfere with sleep. Excessive socialization, command hallucinations, and altered states of consciousness are not typically associated with obsessive-compulsive disorder. p. 140
What is the most likely potential problem for a client diagnosed with severe obsessive-compulsive disorder? Sleep disturbance Excessive socialization Command hallucinations Altered state of consciousness
Mowing the lawn Lorazepam is a benzodiazepine commonly prescribed for short-term management of anxiety. These medications may make it unsafe to handle mechanical equipment, such as a lawn mower. It would be safe for the client to sew, play video games, and prepare meals. p. 149
A client diagnosed with panic disorder begins a new prescription for lorazepam. The nurse should provide instructions to discontinue which of this client's usual routine activities? Sewing Mowing the lawn Playing video games Preparing dinner for the family
Normal anxiety Normal anxiety is a healthy life force needed to carry out the tasks of living and striving toward goals. It prompts constructive actions. Denial involves ignoring unpleasant realities. Compensation involves adopting opposite behaviors or emotions to deal with unpleasant ones. Selective inattention involves a narrowing of one's perceptual field. p. 131
A young adult applying for a job is mildly tense but eager to begin the interview. What is does this experience represent? Denial Compensation Normal anxiety Selective inattention
Saying to the guests, "We are having a vegetarian Thanksgiving dinner this year." In this scenario, announcing a vegetarian dinner indicates the adult has adapted to the anxiety-producing situation. Leaving guests unattended and canceling the dinner are dysfunctional responses. Saying the oven malfunctioned demonstrates maladaptive use of displacement. p. 133
An adult invites 14 guests for Thanksgiving dinner. Just before the guests arrive, the adult notices the turkey is burned and inedible. Which behavior by this adult indicates adaptive coping? Going to bed and leaving the guests unattended. Calling all the guests and canceling the invitation for dinner. Saying to the guests, "We are having a vegetarian Thanksgiving dinner this year." Telling the guests, "My oven malfunctioned. You will have to eat burned turkey."
Caffeinated beverages should be avoided. Benzodiazepines have a quick onset of action. Antacid use can affect medication absorption. Beverages containing caffeine should be avoided because they decrease the desired effects of the drug. Benzodiazepines are commonly used for treatment of anxiety disorders because they have a quick onset of action. Antacids may delay absorption. Medications should be taken with or shortly after meals to reduce gastrointestinal discomfort. Because of the potential for dependence, these medications ideally should be used for short periods only until other medications or treatments reduce symptoms. p. 149
What information will the nurse include in medication education for a client prescribed an antianxiety medication for obsessive-compulsive behavior? Caffeinated beverages should be avoided. Benzodiazepines have a quick onset of action. Antacid use can affect medication absorption. Medication should be taken on an empty stomach. The medication is recommended for long-term use.
To determine whether the anxiety is primary or secondary in origin The symptoms of anxiety can be caused by an underlying physical disorder. The treatment for secondary anxiety is treatment of the underlying cause. The physical examination does not serve to protect the nurse legally. The physical examination may inform the nursing diagnoses but this is not its primary purpose. Information about the client's psychosocial background can be obtained by interviewing the client, not through a physical examination. p. 142
What is the primary purpose of performing a physical examination before beginning treatment for any anxiety disorder? To protect the nurse legally To establish the nursing diagnoses of priority To obtain information about the client's psychosocial background To determine whether the anxiety is primary or secondary in origin
Panic level anxiety Panic level anxiety is the most extreme level and results in markedly disturbed thinking, which may include delusions. Acute anxiety, severe anxiety, and chronic anxiety typically do not involve delusional thinking. p. 132
What type of anxiety may be associated with delusional thinking? Acute anxiety Severe anxiety Chronic anxiety Panic level anxiety
Severe Severe anxiety is characterized by feelings of falling apart and impending doom, impaired cognition, and severe somatic symptoms such as headache and pounding heart. Mild to moderate anxiety would not involve a pounding heart and throbbing head. Panic-level anxiety would render a client unable to ask the nurse for help. p. 131
A client frantically reports to the nurse, "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." At what level should the nurse assess the client's anxiety? Mild Moderate Severe Panic
Schedule a home visit to assess the safety of the client's living conditions. Safety is the nurse's first priority in the case of a client with hoarding disorder. Individuals diagnosed with hoarding disorder often live in unsafe conditions. A home visit will help identify whether safety is the primary concern. Reviewing the client's medications and diet, and referring the client for CBT are proper steps to take, but only after the client's safety has been established. p. 142
An outpatient psychiatric nurse assesses a client diagnosed with hoarding disorder. The client has lost 12 lb in the past two months and is wearing dirty, disheveled clothing. What is the nurse's priority action? Review the client's medication regime. Ask the client, "What types of foods have you been eating?" Refer the client to a psychologist for cognitive behavioral therapy (CBT). Schedule a home visit to assess the safety of the client's living conditions.
Suppression Defenses against anxiety can be adaptive or maladaptive. Suppression is a conscious, deliberate effort to avoid painful and anxiety-producing memories. Repression is an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. In this scenario, the client is aware of the memory. Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations. Intellectualization is a process in which events are analyzed based on facts and without passion, rather than including feeling and emotion. p. 134
A client attempted suicide 3 days ago. When the nurse asks about the related events, the client says, "I don't want to think about that now, but maybe we could talk about it later." Which defense mechanism has the client used? Repression Suppression Rationalization Intellectualization
"It will take 3 or more weeks for you to feel the full benefit." Buspirone is an alternative antianxiety medication that does not cause dependence, but 3 or more weeks are required for it to reach full effects. It should be taken with food. The drug may be used for long-term treatment and should be taken regularly. Aged cheese products should be avoided when taking MAOIs (monoamine oxidase inhibitors). p. 147
Buspirone is prescribed for a client diagnosed with anxiety. Which instruction should the nurse provide to this client? "Take this medication on an empty stomach." "Take this medication only when you feel anxious." "It will take 3 or more weeks for you to feel the full benefit." "Avoid consuming aged cheese products while you are taking this medication."
Modeling Modeling calm behavior in the face of anxiety or unafraid behavior in the presence of a feared stimulus are interventions that can be used independently by the nurse. Thought stopping, response prevention, and systematic desensitization require agreement of the treatment team. p. 133
Which therapeutic intervention can the nurse implement independently to help a client experiencing mild anxiety regain control? Modeling Thought stopping Response prevention Systematic desensitization
Cognitive restructuring The purpose of cognitive restructuring is to change the individual's negative view of an event or a situation to a view that remains consistent with the facts but that is more positive. Exposure and response prevention are useful in obsessive-compulsive disorder. Desensitization is useful in panic disorder. p. 148
Which therapeutic modality helps a client view a disturbing occurrence in a more positive light? Exposure Desensitization Response prevention Cognitive restructuring
A second anxiety disorder may co-occur with the first. In many instances, when one anxiety disorder is present, a second one co-occurs. Health care providers and researchers have clearly shown that anxiety disorders frequently co-occur with other psychiatric problems. Major depression often co-occurs and produces a greater impairment with poorer response to treatment. Substance abuse also frequently co-occurs and has a negative impact on treatment. p. 137
Which statement is true regarding the comorbidity of anxiety disorders? Anxiety disorders generally exist alone. A second anxiety disorder may co-occur with the first. Anxiety disorders virtually never coexist with mood disorders. Substance abuse disorders rarely coexist with anxiety disorders.
