Chapter 15: Obsessive Compulsive Disorders

what are obesessions in OCD?

Recurrent, persistent thoughts, impulses, or images that are intrusive and cause anxiety; the person tries to ignore or suppress them

What are compulsions in OCD?

Repetitive behaviors or mental acts performed to reduce anxiety or prevent a dreaded event; provide only temporary relief.

Why are obsessions considered ego dystonic?

Because they are inconsistent with the person’s self-image and values, causing distress.

What is the continuum of obsessive-compulsive behavior?

It ranges from mild, common behaviors (e.g., checking locks) to pathological OCD, which involves daily, distressing obsessions and compulsions that impair functioning

How does OCD affect functioning?

Rituals are time-consuming, interfere with routines and relationships, and can impair cognitive tasks due to mental preoccupation.

What factors increase the risk of developing OCD?

• Childhood trauma or abuse

• Genetic predisposition (2x risk in first-degree relatives)

• Postinfectious autoimmune syndromes in children

What defines an obsession?

• Recurrent, intrusive, unwanted thoughts, urges, or images causing anxiety or distress.

• The person attempts to ignore, suppress, or neutralize them with a compulsion.

What defines a compulsion?

• Repetitive behaviors (e.g., handwashing) or mental acts (e.g., praying, counting) in response to an obsession.

• Aimed at reducing anxiety or preventing a feared event, but not realistically connected or are clearly excessive

What is Hoarding Disorder?

A disorder where individuals have persistent difficulty discarding or parting with possessions, regardless of their value, leading to cluttered living spaces and significant distress or impairment.

When do hoarding symptoms typically begin and worsen?

Symptoms emerge in adolescence, interfere in the 20s, and significantly impair functioning in the 30s; worsens with each decade.

What are common comorbidities of Hoarding Disorder?

Major depressive disorder, anxiety disorders (75%), and OCD (20%)

What psychological trait and life events are associated with hoarding?

Indecisiveness and stressful life events often precede symptom onset.

What is Trichotillomania?

A disorder characterized by recurrent, irresistible pulling of hair from any part of the body, leading to noticeable hair loss and distress.

What is trichophagia and its dangerous complication?

The swallowing of pulled hair, which can lead to trichobezoars (hair masses) in the GI tract and possibly Rapunzel syndrome (potentially fatal obstruction).

What is Excoriation Disorder?

Repetitive, compulsive skin picking that results in tissue damage, often done to relieve anxiety or without conscious awareness.

Which tools are used in excoriation and what areas are targeted?

Fingernails, teeth, tweezers, nail clippers; common areas: face, arms, legs, back, hands/feet, cuticles.

What are common risk factors?

Family history of OCD is a risk factor.

What is Body Dysmorphic Disorder?

A mental disorder characterized by obsessive focus on a perceived flaw in appearance, which is imagined or minor, leading to significant distress and compulsive behaviors (e.g., mirror checking, camouflaging).

What kinds of settings do patients with Body Dysmorphic Disorder commonly present in?

Community clinics, psychiatric, cosmetic surgery, and dermatology settings.

what are common behaviors associated with Body Dysmorphic Disorder?

Mirror checking, camouflaging, comparing body parts, seeking reassurance, and sometimes seeking cosmetic procedures.

what are the emotional consequences of Body dysmorphic disorder?

Feelings of disgust, shame, depression, anxiety, and fear of rejection due to perceived disfigurement.

How does insight vary in body dysmorphic disorder?

Ranges from good insight (recognizing the thoughts are distorted) to poor or absent insight (believing the defect is real and severe).

Which body parts are commonly the focus of concern in body dysmorphic disorder?

• Women: Skin, weight, stomach, breasts, buttocks, thighs, legs, hips, toes

• Men: Body build, genitals, hair, skin, nose

What beliefs and traits are often seen in individuals with BDD?

• False assumptions about the importance of appearance

• Perfectionism

• Fear of rejection

• Distorted self-image

When is hospitalization necessary for individuals with OCD or related disorders?

When the person is suicidal or when compulsions result in injury, such as cutting or infected skin sores from picking.

What objective tools are available for assessing OCD severity?

•Obsessive Compulsive Inventory-Revised (OCI-R)

What is the most universal nursing diagnosis for all OCD-related disorders?

Anxiety – All obsessive-compulsive disorders are rooted in dysfunctional anxiety.

What two diagnoses are directly linked to the core symptoms of OCD?

• Obsession

• Compulsive behavior

What nursing diagnoses apply to OCD patients who engage in frequent handwashing or skin picking?

• Impaired skin integrity

• Risk for self-destructive behavior

Which nursing diagnosis is ideal for someone with body dysmorphic disorder?

Disturbed body image

What additional nursing diagnoses are useful across many OCD-related disorders?

• Impaired socialization

• Fear

• Impaired coping

• Chronic low self-esteem

What is the desired outcome for the nursing diagnosis of Anxiety?

Reduced anxiety

What is the desired outcome for the diagnosis of Impaired skin integrity (e.g., handwashing, skin picking)?

Improved skin integrity

What outcome corresponds with Risk for self-destructive behavior (e.g., hair pulling, excoriation)?

Reduced self-destructive behavior

What outcome is associated with Disturbed body image in body dysmorphic disorder?

Improved body image

What is the goal for patients with Impaired socialization due to compulsive rituals or hoarding?

Improved socialization

What is the desired outcome for the nursing diagnosis of Fear?

reduced fear

What is the expected outcome for Impaired coping?

Improved coping

What is the target outcome for patients with Chronic low self-esteem?

Improved self-esteem

What is the primary focus when evaluating a patient’s progress with OCD?

Assess the patient’s level of functioning and reduction in distress.

What indicates positive progress in treatment for OCD or related disorders, even if minor?

small improvements in functioning and symptom management should be recognized and affirmed

Why is family evaluation important in the care of patients with OCD?

Because OCD symptoms often disrupt family dynamics, evaluating and supporting the family is essential.

What is the “acid test” of improvement for a patient with obsessive-compulsive behaviors?

Whether the patient’s compulsions and obsessions interfere less with daily life and cause less distress.

Which class of medications is most commonly approved for treating OCD?

SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine)

What older antidepressant is FDA-approved for OCD and belongs to the tricyclic class?

Clomipramine (Anafranil)

Which SNRI is commonly used for OCD, even though not FDA-approved?

Venlafaxine (Effexor)

Are antipsychotic medications used for OCD?

Yes, they are used adjunctively with antidepressants to reduce severe symptoms.

Are SSRIs used off-label in pediatric OCD?

yes, several SSRIs are used off-label to treat OCD in children

What is gamma knife surgery used for in OCD?

To cause irreversible lesions that disconnect overactive brain circuits in severe OCD.

What is deep brain stimulation (DBS), and when is it used for OCD?

A surgical procedure where electrodes are implanted in the brain and connected to a pulse generator; used in treatment-resistant OCD after failure of at least 3 SSRIs

What are potential adverse effects of Deep Brain Stimulation for OCD?

Generally mild, but may include intracerebral hemorrhage and infection.

What is the first-line cognitive-behavioral therapy (CBT) for obsessive-compulsive behaviors?

Exposure and Response Prevention (ERP)

What is the goal of Exposure and Response Prevention (ERP)?

To help the patient learn that anxiety will subside even without completing the compulsive ritual.

How does ERP typically work for contamination-related OCD?

A technique that exposes the patient to a large amount of a feared stimulus to help them learn that anxiety will diminish without the compulsive response.

What is the expected patient outcome after flooding therapy?

The patient learns that they can tolerate the anxiety, which lessens over time without the compulsion.

Who typically performs ERP or flooding therapies for OCD?

Advanced practice providers such as nurse practitioners, psychologists, and social workers trained in CBT.