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Obsessive-Compulsive Disorder

9 min read

References:

  1. Psychiatric-Mental Health Nursing, 8th Edition, 978-1-975116-37-8, by Sheila L. Videbeck

Obsessions are recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that cause marked anxiety and interfere with interpersonal, social, or occupational function. The person knows these thoughts are excessive or unreasonable but believes he or she has no control over them.

Compulsions are ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety. Usually, the theme of the ritual is associated with that of the obsession, such as repetitive hang washing when someone is obsessed with contamination or repeated prayers or confession for someone obsessed with blasphemous thoughts. Common compulsions include the following:

  • Checking rituals: repeatedly making sure the door is locked or the coffee pot is turned off
  • Counting rituals: each step taken, ceiling tiles, concrete blocks, or desks in a classroom
  • Washing and scrubbing until the skin is raw
  • Praying or chanting
  • Touching, rubbing or taping: feeling the texture of each material in a clothing store; touching people, doors, walls, or oneself
  • Ordering: arranging and rearranging furniture or items on a desk or shelf into perfect order; vacuuming the rug pile in one direction
  • Exhibiting rigid performance: getting dressed in an unvarying pattern
  • Having aggressive urges: for instance, to throw one’s child against a wall

A diagnosis is only made when these thoughts, images, and impulses consume the person or he or she is compelled to act out the behaviors to a point at which they interfere with personal, social, and occupational functions.

Onset and Clinical Course

OCD can start in childhood, especially in males. In females, it more commonly begins in the 20s. Overall, distribution between the sexes is equal. Onset is typically in late adolescence, with periods of waxing and waning symptoms over the course of a lifetime. Early onset OCD is more common in males, often more severe, has comorbid diagnoses, and a greater likelihood of a family history of OCD.

Related Disorders

  1. Excoriation disorder (skin-picking) also known as dermatillomania is a self-soothing behavior to comfort oneself, despite the act of skin-picking not actually being felt as a positive sensation. Medicine, surgery, and/or plastic surgery may become necessary.
  2. Trichotillomania (chronic repetitive hair-pulling) is a self-soothing behavior that can cause distress and functional impairment. More common in females than in males. Therapy may become successful with behavioral therapy.
  3. Body Dysmorphic Disorder (BDD) is a preoccupation with an imagined or slight defect in physical appearance that causes significant distress for the individual and interferes with functioning in daily life. It can become the perceived root cause of all the individual’s problems.
  4. Hoarding Disorder is a progressive, debilitating, compulsive disorder commonly diagnosed between the ages of 20 and 30. It is more common in females, with a parent or first-degree relative who hoards as well. Hoarding can seriously compromise the person’s quality of life and even become a health, safety, or public health hazard. Treatment may require medications, cognitive-behavioral therapy, self-help groups, or the involvement of outside community agencies. However, success of treatment is not currently well-studied.
  5. Onychophagia (chronic nail-biting) is a self-soothing behavior. It often begins by childhood and ends by age 18, but may persist into adulthood. This may lead to psychosocial problems or cause complications involve the nail and oral cavity. SSRIs have proven effective in treatment.
  6. Kleptomania (compulsive stealing) is a reward-seeking behavior. The reward is not the stolen item, but rather the thrill of stealing and not getting caught. This is more common in females and is often comorbid with depression or substance use.
  7. Oniomania (compulsive buying) is an acquisition type of reward-seeking behavior. The pleasure is in acquiring the purchased object rather than any subsequent enjoyment of its use. Spending is often out of control and out of the person’s financial means. This is more common in females (80%) with the onset in the early 20s; college students. It is also often comorbid with depression or substance use.
  8. Body Identity Integrity Disorder (BIID), also known as “amputee identity disorder” or “apotemnophilia” (love for amputation), is the term given to people who feel “overcomplete,” or alienated from a part of their body and desire amputation.

Diagnostic Criteria (DSM-5)

  1. Presence of obsessions or compulsions or both:
    • Obsessions are defined by (1) and (2):
      1. Recurrent and persistent thoughts, urges, or images that are experienced at some time during the disturbance as intrusive and unwanted and that in most individuals cause marked anxiety or distress
      2. The individual attempts to ignore or suppress such thoughts, urges, or images or to neutralize them with some other thought or action (i.e., by performing a compulsion).
    • Compulsions Are Defined by (1) and (2):
      1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, 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.
      2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
  2. The obsessions or compulsions are time-consuming (e.g., take > 1 hour/day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  3. The obsessive–compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
  4. The disturbance is not better explained by the symptoms of another mental disorder (e.g., generalized anxiety disorder; body dysmorphic disorder; hoarding disorder; trichotillomania; excoriation disorder; stereotypic movement disorder; eating disorders; substance-related and addictive disorders; illness–anxiety paraphilic disorders; disruptive, impulse control, and conduct disorders; major depressive disorder; schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Etiology

There is no definitive explanation on how and why people develop OCD. Aaron Beck’s cognitive approach to emotional disorders has been accepted as a partial explanation for OCD, particular because CBT is a successful treatment for OCD. His explanations show the thought processes of:

  1. Believing one’s thoughts are overly important, i.e., “If I think it, it will happen,” and therefore having a need to control those thoughts
  2. Perfectionism and the intolerance of uncertainty
  3. Inflated personal responsibility such as those from strict moral or religious upbringing and overestimation of the threat posed by one’s thoughts.

Treatment

Optimal treatment for OCD combines medication and behavioral therapy.

  1. SSRI antidepressants: fluvoxamine (Luvox) and sertraline (Zoloft) are first-line choices, followed by venlafaxine (Effexor).
  2. Second-generation antipsychotics such as risperidone (Risperdal), quetiapine (Seroquel), or olanzapine (Zyprexa) may be used for treatment-resistant OCD.
  3. Behavioral therapy specifically includes exposure (confronting stimuli that the individual often avoids) and response prevention (avoiding or delaying the performance of rituals).
    • Other techniques such as deep breathing and relaxation can also assist the person with tolerating and eventually managing the anxiety.

Nursing Interventions

  1. Observe the client’s eating, drinking, and elimination patterns, and assist the client as necessary. The client may be unaware of physical needs or may ignore feelings of hunger, thirst, or the urge to defecate, and so forth.
  2. Assess and monitor the client’s sleep patterns, and prepare him or her for bedtime by decreasing stimuli and providing comfort measures or medication. Limiting noise and other stimuli will encourage rest and sleep. Comfort measures and sleep medications will enhance the client’s ability to relax and sleep.
  3. You may need to allow extra time, or the client may need to be verbally directed to accomplish activities of daily living (personal hygiene, preparation for sleep, and so forth). The client’s thoughts or ritualistic behaviors may interfere with or lengthen the time necessary to perform tasks.
  4. Encourage the client to try to gradually decrease the frequency of compulsive behaviors. Work with the client to identify a baseline frequency and keep a record of the decrease. Gradually reducing the frequency of compulsive behaviors will diminish the client’s anxiety and encourage success.
  5. As the client’s anxiety decreases and as a trust relationship builds, talk with the client about his or her thoughts and behavior and the client’s feelings about them. Help the client identify alternative methods for dealing with anxiety. The client may need to learn ways to manage anxiety so that he or she can deal with it directly. This will increase the client’s confidence in managing anxiety and other feelings.
  6. Convey honest interest in and concern for the client. Do not flatter or be otherwise dishonest. Your presence and interest in the client convey your acceptance of the client. Clients do not benefit from flattery or undue praise, but genuine praise that the client has earned can foster self-esteem.
  7. Provide opportunities for the client to participate in activities that are easily accomplished or enjoyed by the client; support the client for participation. The client may be limited in his or her ability to deal with complex activities or in relating to others. Activities that the client can accomplish and enjoy can enhance self-esteem.
  8. Teach the client social skills, such as appropriate conversation topics and active listening. Encourage him or her to practice these skills with staff members and other clients, and give the client feedback regarding interactions. The client may feel embarrassed by his or her OCD behaviors and may have had limited social contact. He or she may have limited social skills and confidence, which may contribute to the client’s anxiety.
  9. Teach the client and family or significant others about the client’s illness, treatment, or medications, if any. The client and family or significant others may have little or no knowledge about these.
  10. Encourage the client to participate in follow-up therapy, if indicated. Help the client identify supportive resources in the community or on the internet. Clients often experience long-term difficulties in dealing with obsessive thoughts.

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