Week 8: OCD

Obsessive Compulsive Disorder

characterized by the presence of obsessions and/or compulsions

OCD vs personality disorder

Obsessions or compulsions are ____-_____ and/or cause … in social, occupational, or other important areas of functioning

• time consuming (consumes >1 hr per day)

• cause clinically significant distress/impairment

Obsessions

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 causes marked anxiety or distress

How do people with OCD attempt to ignore/suppress thoughts, urges, or images, or to neutralized them?

with some other thought or action — performing the compulsion

Examples of Obsessions

• contamination obsession

• symmetry obsession

• forbidden or taboo thought obsession

• fear of harm obsession

• pathologic doubt

• recurrent intrusive thoughts of sounds, images, words, or numbers

• fear of losing or discarding something important

Contamination Obsession

fear of getting contaminated by people or the environment

Symmetry Obsession

Extreme concern with order, symmetry, precision, or completion

Forbidden or taboo thought obsession

disturbing sexual, violent, or religious thoughts or images

• e.g., continuously repeating a prayer or something really bad will happen

Fear of harm obsession 

fear of harming self or others

Pathologic doubt obsession 

fear or blurting out obscenities or insults

Compulsions

Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly

Compulsions are aimed at….

preventing or reducing anxiety or distress, or preventing some dreaded event or situation

Are compulsions connected in a realistic way with what they are designed to neutralize or prevent?

no

Examples of Compulsions

• Cleaning compulsions

• Ordering compulsions 

• Religious compulsions

• Repeatedly checking locks 

• Constantly seeking approval or reassurance

• Repeating and counting compulsion 

• Repeatedly cheating possession of an object

OCD primary symptoms (2 distinct elements)

• Intrusive and unwanted obsessions (thoughts, urges, images)

• Compulsions (repetitive behaviors or mental acts) performed to reduce the distress from the obsessions

Anxiety primary symptoms

persistent and excessive worry or fear that affects daily life and physical well being

OCD relationship to anxiety

• Anxiety is a consequence of the obsessions

• the compulsive behaviors are performed specifically to alleviate the anxiety — relief is temporary 

OCD behavioral response

Engaging in compulsions is the primary way individuals try to cope, as well as using avoidance behaviors

Anxiety behavioral response

Avoidance of anxiety-provoking situations is a common coping mechanism

• compulsive rituals are not a feature

OCD focus of thoughts

obsessions are specific and often illogical, centered on themes like contamination, harm, and perfectionism

Anxiety focus of thoughts

intrusive thoughts are typically relegated to general life worries, such as finances, health, or relationships

What is the average age of onset of OCD?

19.5 y/o

OCD is ____ and can be relieved by _____ _____. Anxiety is ______ to all parts of life and is not relieved by an action.

• specific and can be relieved by obsessive behavior

• Anxiety is generalized

If OCD is untreated, what is the course like?

the course is usually chronic and if often waxing and waning symptoms

OCD variability between cultures 

• rates of OCD are similar across all cultures

• OCD symptoms reflect characteristics of the culture — there are regional differences depending on the cultural aspects 

Functional consequences of OCD

• reduced quality of life

• high levels of social and occupational impairment across many domains of life

• specific symptoms can create specific obstacles

• when the disorder starts in childhood or adolescence, individuals may experience developmental difficulties 

What can cause social and occupational impairment related to OCD?

• caused by the time spent obsessing and doing compulsions 

• avoidance of situations that can trigger obsessions or compulsions 

What developmental difficulties may individuals experience when the disorder starts in childhood/adolescence?

• avoiding peer socialization 

• young adults may struggle when they leave home to live independently 

What is the result of developmental difficulties d/t early onset of OCD?

• few significant relationships outside the family

• a lack of autonomy and financial independence from their family origin

Biologic theories or OCD

• Genetic 

• Biochemical

Genetic biologic theory of OCD

Twins and family studies suggest a significant genetic component

Biochemical biologic theory of OCD

Dysregulation of serotonin

Behavioral etiological factors of OCD

• fear or anxiety becomes a learned response 

• compulsions and obsessions are conditioned mechanisms to neutralize anxiety

What is the #1 priority for nurses when performing an OCD assessment?

maintain skin integrity r/t cleaning compulsions 

Parts of the nursing assessment for OCD biological domain

• Maintain skin integrity 

• Eating

• Sleeping

• Monitor for repeated visits

How may skin integrity become compromised in those with cleaning compulsions OCD?

• excessive washing

• excessive teeth brushing

• excoriation disorder

• ritual hair pulling

Parts of the nursing assessment for OCD psychological domain

• Mood and affect 

• Thought process and content 

• Behavior 

• Insight

MSE mood and affect OCD

• anxious dread accompanies obsessions

• may present depressed

MSE thought process and content OCD

• Obsession intrudes persistently intro person’s conscious awareness

• Obsession is recognized as irrational 

Nursing interventions for OCD in the biological domain

• decrease rate of obsessions and compulsions with medications

• TCAs to maximum dose

• Antipsychotics in refractory cases

• Deep brain stimulation in refractory cases

Nursing interventions for OCD

• Safety!

• Manage medical complications (skin integrity, etc.)

• Monitor nutrition/sleep encourage meals/rest

• Do not arbitrarily forbid rituals

  • give positive reinforcement for non-ritualistic activity (e.g., don’t interrupt someone compulsively washing their hands 3x)

• Psychoeducation/information should focus on medication, interrupting obsessive thoughts, exposure therapies when available

Nursing interventions for OCD psychological domain

Behavior therapy to decrease rate of compulsive behaviors

What are the two types of behavior therapy for OCD?

• Exposure and Response Prevention

  • e.g., decreased washing your hands 3x down to 2x and have them realize nothing bad happened

• Graduated exposure therapy