Obsessive-Compulsive and Related Disorders

What are obsessions?

• Excessive, unwanted, intrusive, and persistent thoughts, impulses, or images causing anxiety and distress

• Not under the patient’s control; incongruent with the patient’s usual thought patterns

What are compulsions?

• Repeatedly performed behaviors in a ritualistic fashion

• Goal of preventing or relieving anxiety and distress caused by obsessions

What to know about obsessive-compulsive disorders?

• Obsessive –compulsive behaviors are characteristics of Obsessive-compulsive and related disorders (OCD).

• Other disorders include body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation disorder, substance-medication induced OCD

What are the types of obsession?

• Fear of contamination

• Pathologic doubt

• Need for symmetry and completion

• Thoughts of hurting someone

• Thoughts of sexual images

What are the types of compulsion?

• Excessive hand washing

• Excessive cleaning

• Checking stove, checking for locked doors

• Arranging things

• Counting

• Ordering

• Hoarding

What is the clinical course of OCD?

• Chronic waxing and waning course

• Often begin in childhood; misdiagnosed as separation anxiety

• Early onset has better outcomes than late onset

• Rituals such as handwashing related to fear of contamination

• Dissociative absorption: a tendency to become excessively absorbed in gaming, movies, fantasy like activities leading to decreased self-awareness

What is the diagnostic criteria for OCD?

• Presence of obsessions or compulsions

• Patient recognition that thoughts and actions are unreasonable or excessive

• Thoughts and rituals causing severe disturbance in daily routines, relationships, or occupational function; time consuming, taking longer than 1 hour a day to complete

• Thoughts or behaviors not a result of another disorder

• Thoughts or behaviors not a result of the presence of a substance or a medical condition

What to know about OCD across the life span?

• Children and Adolescents

  • May go unnoticed

  • Often one additional mental disorder

    Pediatric acute onset neuropsychiatric syndrome (PANS)

  • Link between beta-hemolytic strep and other infections with antibiotic treatment

• Older Adults

  • Linked to higher rates of depression

  • Poorer mental and social functioning

  • Those engaged in checking compulsions and hoarding may have more thought disturbances and communication difficulties

What to know about the epidemiology and risk factors for OCD?

• Lifetime prevalence of 2.3%

• Age of onset in early adolescence and early adulthood

• Gender differences (female adults more likely to experience symptoms of contamination

• Males more likely to experience blasphemous obsessions

• Family, ethnicity, and culture differences

• Catholics

  Comorbidity

What to know about the etiology of OCD?

• Biologic Theories: research suggest that OCD has a biologic basis.

  • Genetic: occurs more often in those whose first-degree relatives may be affected (hoarding, contamination)

  • Neuropathology: dysfunction in stopping the dynamics of normal brain networks

  • Biochemical: chemical imbalances, serotonin

• Psychological and Psychosocial theories

  • Psychodynamic (isolation, undoing,  reaction formation)

  • Behavioral

What is the family response to OCD?

• Considerable caregiving burden on families

  • Linked to family distress

    • Family accommodation

  • Family assessment

  • Family involvement

What is included in recovery-oriented care for persons with OCD?

• Teamwork and collaboration: Working toward recovery

  • Electroconvulsive Therapy (ECT)

  • Transcranial Magnetic Stimulation (TMS)

  • Psychosurgery

  • Safety Issues***

What is included in evidenced-based nursing care of persons with OCD?

• Physical Assessment

  • Physical Health

  • Nutrition

  • Medication

  • Substance Use

• Functional  Assessment

  • Rating Scales

    • Yale-Brown Obsessive Compulsive Scale

    • The Sheehan Disability Scale (SDS)

    • Family Accommodation Scale for OCD (FAS-SR)

    • The Brown Assessment of Beliefs Scale (BABS)

  • Quality of Life

  • Strengths Assessment

  • Clinical Judgement.

• Psychosocial Assessment

  • Mental Status and Appearance

  • Self-Concept

  • Stress and Coping Patterns

  • Social Network/Support Systems

What is included in mental health nursing interventions?

• Therapeutic Relationship

• Establishing Recovery and Wellness Goals

• Wellness Challenges

• Psychosocial Assessment

  • Mental Status and Appearance

  • Self-Concept

  • Stress and Coping Patterns

  • Social Network/Support Systems

• Physical Care Nursing Interventions

  • Maintaining Skin Integrity

  • Relaxation Techniques

  • Medication Interventions

    • Administering and Monitoring Medications

    • Monitoring for Drug Interactions

    • Management of Complications

• Psychosocial Nursing Interventions

  • Therapeutic Interactions

  • Enhancing Cognitive Functioning/:Cognitive Restructuring

    • Personalized Cue Cards/Cognitive Coping Cards

    • Exposure and Response Prevention

  • Acceptance and Commitment Therapy

• Behavioral Interventions and Interactions 

  • Routines

  • Assess anxiety

  • Monitor comorbidities and suicide risk

  • Initially allow rituals

  • Avoid increase of frustration

  • Encourage discussions

  • Balance private and social time

  • Identify triggers

  • Self-talk and cognitive restructuring

• Mindfulness

• Psychoeducation

  • Teaching strategies

  • Wellness strategies

  • Providing family education

What are the medication interventions for OCD?

• SSRI’s

  • Fluoxetine(Prozac)

  • Fluxoxamine (Luvox),

  • Paroxetine (paxil),

  • Sertraline (Zoloft),

  • Citalopram (Celexa),

  • Escitalopram (Lexapro) (Table 12.8) Brand names

• Tricyclics

  • clomipramine (Anafranil)

• SSNRI

  • Venlafaxin (Effexor)

What is included in the evaluation and treatment outcomes?

• Continuum of care

• Emergency care

• Inpatient-focused care

• Community care

• Virtual mental health care

  • Virtual assessment and treatment for OCD

  • Online and tele-support groups for OCD

  • Emerging technologies

• Integration with primary care

What are the other obsessive-compulsive disorders?

• Trichotillomania disorder

• Chronic self-destructive hair pulling that results in noticeable hair loss

  • Clinical course

  • Diagnostic criteria

  • Etiology and treatment

  • Evidenced-based nursing care

• Excoriation disorder

  • Skin-picking disorder

  • Prevalence varies from 1.4% to 5.4%

  • Behavioral and pharmacologic interventions

• Body dysmorphic disorder

  • Focus on real (but slight) or imagined defects in appearance

  • Extremely debilitating disorder and can significantly impair an individual's quality of life

  • Cognitive–behavioral therapy is the primary treatment approach

  • Occurs in men and women

  • The risk of depression, suicide ideation, and suicide is high

• Hoarding disorder

  • Difficulty parting with or discarding possessions

  • 2% to 6% prevalence

  • May start in childhood

  • Behavioral and pharmacologic interventions

  • Cognitive behavior therapy (CBT) and medication for co-occurring mental disorders