Stress & Coping: OCD and Body Dysmorphic Disorder

What percentage of people with BDD report suicidal thoughts

80 and 1/4 of them will attempt suicide

True or False

Patients with BDD have an increased risk of both attempted and completed suicide

True

What medications may be prescribed to a patient with BDD

Antidepressants and Antianxiety

The goal of CBT for patients with BDD

Identification and recognition of unhealthy thoughts and then changing those thoughts

What is the lowing criteria for diagnosing BDD

* Appearance preoccupations
* Repetitive behaviors
* Clinical significance
* Differentiation from an eating disorder

How long does a patient need to spend, in a day focusing, on their perceived flaw to be diagnosed with BDD

1 hour

Patients with BDD may be misdiagnosed as having

* OCD
* Social anxiety disorder
* Trichotillomania (hair-pulling)
* Excoriation disorder (skin-picking)
* Agoraphobia
* Generalized anxiety disorder
* Schizophrenia and schizoaffective disorder
* Olfactory reference syndrome (preoccupation with smelling bad)
* Eating disorder

How many years does it typically take for someone with BDD to seek help

10

Patients with BDD report feelings of

* Shame
* Self-disgust
* Hopelessness
* Depression
* Anger
* Anxiety

Behaviors commonly seen in patients with BDD

* Camouflaging
* Comparing themselves to others
* Seeking surgery
* Checking their appearance in a mirror
* Skin picking
* Excessive grooming
* Excessive exercise
* Frequently changing clothes
* Excessive tanning
* Excessive shopping

What age does BDD typically develop

Adolescent years, typically between ages 12 and 13

Obsessions

Recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses

Compulsions

Ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety

Common compulsions

* Checking
* Counting
* Washing/scrubbing
* Praying/chanting
* Touching/rubbing/tapping
* Ordering (arranging and rearranging)
* Exhibiting rigid performance
* having aggressive urges

OCD checking

Repeatedly making sure the door is locked or the coffee pot is turned on

OCD counting

Counting each step taken, ceiling tiles, concrete blocks, or desk in a classroom

OCD touching

Feeling the texture of each material in a clothing store; touching people, doors, walls, or oneself

OCD ordering

Arranging and rearranging furniture or items on a desk or shelf into perfect order; vacuuming the rug pile in one direction

When is OCD diagnosed?

Once thoughts or behaviors consume the person to the point where the thoughts or actions interfere with personal, social, and/or occupational functioning

Does a person with OCD realizes that thoughts/behaviors are unreasonable?

Yes, but they cannot stop/control them

In females OCD more commonly begins when?

20s

Is OCD that starts during childhood more common in males or females?

Males

Onset of OCD is typically when?

Late adolescence, with periods of waxing and waning symptoms over their lifetime.

Average age for early-onset OCD

11

Average age for late-onset OCD

23

What is the different between early and late onset OCD?

Early onset is more likely to effect males, has more severe symptoms, more comorbid diagnoses, and a greater likelihood of a family history of OCD

Excoriation or Dermatillomania

Skin-picking

Trichotillomania

Chronic repetitive hair-pulling

Does trichotillomania happen more often in males or females?

Females

BDD

Preoccupation with an imagined or slight defect in physical appearance that causes significant distress for the individual and interferes with function in daily life

Onychophagia

Chronic nail biting

Typical onset of onychophagia

Childhood

Kleptomania

Compulsive stealing

Is kleptomania more common in males or females?

Females

Oniomania

Compulsive buying

Body Identity Integrity Disorder (BIID)

People who feel “overcomplete” or alienated from a part of their body and desire amputation. Also know as amputee identify disorder and apotemnophilia or “amputation love”

What religious individuals may have a heightened sense of personal guilt about their symptoms and believes that they should be responsible for controlling unwanted, threatening thoughts?

Christians and Muslims

What medicine is the first line choice for OCD treatment?

SSRIs

* Fluvoxamine
* Sertraline

What medicine is the second line choice for OCD treatment?

SNRI

* Venlafaxine

What is the medicine for treatment resistant OCD?

Second generation antipsychotics

* Risperidone
* Quetiapine
* Olanzapine

What does behavioral therapy include?

Exposure and response prevention

Exposure behavioral therapy

Assisting the client in deliberately confronting the situations and stimuli that they usually avoid

Response prevention behavioral therapy

Delaying or avoiding performance of rituals

Why would you observe the patient eating, drinking, and elimination patterns, and assist the patient as necessary?

Patient may be unaware of physical needs or may ignore feelings of hunger, thirst, or the urge to defecate, and so forth.

Why is it important to assess and monitor the patient’s sleep patterns, and prepare them 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.

Why might you 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.

Encouraging 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. What is the rationale for this?

Gradually reducing the frequency of compulsive behaviors will diminish the client’s anxiety and encourage success.

As the client’s anxiety decreases and as a trust relationship builds, talk with the client about their thoughts and behavior and the client’s feelings about them. Help the client identify alternative methods for dealing with anxiety. Why would you do this?

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.

Why would you Convey honest interest in and concern for the client and 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.

What is the point of teaching the client social skills like suitable conversation topics and active listening? Encourage them to practice these abilities with staff and other clients, and provide feedback on encounters.

Because of their OCD behaviors, the client may be ashamed and may have had little social contact. They may lack social skills and confidence, which may add to the client's anxiety.

Why is it important to 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.

Why would you advise the client to attend follow-up therapy, if needed, and assist the client in locating supporting resources in the community or on the internet?

Clients often experience long-term difficulties in dealing with obsessive thoughts.

What are potential nursing diagnosis for OCD

* Anxiety
* Ineffective coping
* Fatigue
* Situational low self-esteem
* Impaired skin integrity (if scrubbing or washing rituals)

Outcomes for a patient with OCD?

* Complete daily routine activities within a realistic time frame
* Demonstrate effective use of relaxation techniques.
* Discuss Feelings with another person.
* Demonstrate effective use of behavioral therapy techniques.
* Spend less time performing rituals.

What is the motor behavior of a patient with OCD?

* Tense
* Anxious
* Worried
* Fretful

What is the general appearance of someone with OCD?

Unremarkable; nothin out of the ordinary

What is the mood and affect of a patient with OCD?

Patient reports ongoing overwhelming feelings of anxiety

What is the judgement and insight like for a patient with OCD?

Recognizes obsessions as irrational but unable to stop them

How might a patient with OCD feel about themselves?

Powerless; low self-esteem

What are some physiological and self-care concerns for a patient with OCD?

* Sleeping problems
* Appetite
* Weight changes

After what age is the onset of OCD rare?

50

Recently acquired obsessive or compulsive behavior by an elderly person should alert the physician to what?

An organic cause for the behavior such as:

* Infections
* Degenerative disorders
* Brain injury
* Cerebrovascular lesion (frontal lobes and basal ganglia)

True or False

OCD is a chronic progressive disease. Symptoms wax and wane over time, increasing during periods of stress.

True

True or False

Onset of OCD after 40 is rare?

False

Onset of OCD after 50 is rare

True or False

The incidence of hoarding increases with age.

True

True or False

OCD can start in childhood and often does not lasts into adulthood.

False

OCD can start in childhood and often lasts into adulthood.

A client with OCD is admitted to the hospital due to ritualistic hand washing that occupies several hours each day. The skin on the client’s hands is red and cracked, with evidence of minor bleeding. The goal for this client is

\
a. decreasing the time spent washing hands.

b. eliminating the hand washing rituals.

c. providing milder soap for hand washing.

d. providing good skin care.

a

Which would be an appropriate intervention for a client with OCD who has a ritual of excessive constant cleaning?

\
a. A structured schedule of activities throughout the day

b. Intense psychotherapy sessions daily

c. Interruption of rituals with distracting activities

d. Negative consequences for ritual performance

a

Clients with OCD often have exposure/response prevention therapy. Which statement by the client would indicate positive outcomes for this therapy?

\
a. “I am able to avoid obsessive thinking.”

b. “I can tolerate the anxiety caused by obsessive thinking.”

c. “I no longer have any anxiety when I have obsessive thoughts.”

d. “I no longer feel a compulsion to perform rituals.”

b

The client with OCD has counting and checking rituals that prolong attempts to perform activities of daily living. The nurse knows that interrupting the client’s ritual to assist in faster task completion will likely result in

\
a. a burst of increased anxiety.

b. gratitude for the nurse’s assistance.

c. relief from stopping the ritual.

d. symptoms of depression or suicidality.

a

Interventions for a client with OCD would include (Select all that apply)

\
a. encouraging the client to verbalize feelings.

b. helping the client avoid obsessive thinking.

c. interrupting rituals with appropriate distractions.

d. planning with the client to limit rituals.

e. teaching relaxation exercises to the client.

f. telling the client to tolerate any anxious feelings.

d, e, f

Which of the following characteristics describe the obsessional thoughts experienced by clients with OCD? (Select all that apply)

\
a. Intrusive

b. Realistic

c. Recurrent

d. Uncontrollable

e. Unwanted

f. Voluntary

a, c, d, e

True or False

Excoriation is a self-soothing behavior

True

True or False

Trichotillomania is a not a self-soothing behavior

False

Trichotillomania is a self soothing behavior

What age is hoarding most commonly diagnosed?

20 to 30

Hoarding is more common with who?

Females with a parent or first degree relative who hoards as well

What self-soothing behavior normally begins in childhood and declines by the age of 18?

Onychophagia

With oniomania does the enjoyment come form using the item or acquiring the item?

Acquiring

80% of compulsive buyers are what?

Female, onset of behavior starts in their early 20s

Compulsive shopping run in families who have a high comorbidity for what?

Depression and substance use