Obsessive-Compulsive Disorders

OBSSESSIVE-COMPULSIVE DISORDERS

Obsessive-Compulsive Disorder

Definition

  • Obsessions: Excessive, unwanted, intrusive, and persistent thoughts, impulses, or images that cause anxiety and distress.

    • Characteristics:

    • Not under the patient’s control.

    • Incongruent with the patient’s usual thought patterns.

  • Compulsions: Repeatedly performed behaviors in a ritualistic fashion aimed at preventing or relieving anxiety and distress caused by obsessions.

    • Common Compulsions:

    • Objects must be arranged in a certain order.

    • Motor activities performed in a rigid manner.

    • Requirement for perfect symmetry in arrangements.

Diagnostic Criteria

  • Presence of obsessions or compulsions.

  • Patient recognizes that thoughts and actions are unreasonable or excessive.

  • Thoughts and rituals cause severe disturbance in:

    • Daily routines.

    • Relationships.

    • Occupational function.

    • Time-consuming, taking longer than 1 hour a day to complete.

  • Thoughts or behaviors not attributable to another disorder.

  • Thoughts or behaviors not a result of substance use or medical conditions.

Clinical Course and Epidemiology

  • Onset: Early 20s to mid-30s; symptoms often begin in childhood.

  • Symptom Onset: Gradual.

  • Prevalence**: Females affected slightly more than males;

    • Lifetime prevalence: 1.2%.

    • Affects between 1% and 3% or more of children and adolescents.

  • Lifelong illness affecting all ages.

Etiology of Obsessive-Compulsive Disorder

Psychoanalytic Theory

  • Underdeveloped ego leading to anxiety.

  • Defense Mechanisms (examples include):

    • Isolation

    • Undoing

    • Displacement

    • Reaction formation

Learning Theory

  • Develops as a conditioned response to traumatic situations.

    • Passive Avoidance: Avoiding stress-triggering stimuli.

    • Active Avoidance: Engaging in compulsions to evade anxiety.

Psychosocial Influences

  • Stressful Life Situations: Inability to manage stress after significant life changes.

  • Adverse Childhood Experiences (ACEs) can play a role.

Biological Factors

  • Genetics: May have a heritable component.

  • Neuroanatomy: Impairment in motor inhibition.

  • Biochemical Factors:

    • Imbalances in neurotransmitters such as:

    • Dopamine

    • Serotonin

    • Glutamate

Recovery-Oriented Care for Persons with Obsessive-Compulsive Disorder

Teamwork and Collaboration

  • Various treatment approaches may include:

    • Electroconvulsive Therapy (ECT)

    • Transcranial Magnetic Stimulation (TMS)

    • Psychosurgery

    • Addressing Safety Issues.

Evidence-Based Nursing Care of Persons with OCD

Physical Assessment

  • Assessment areas include:

    • Physical Health

    • Nutrition

    • Medication Use

    • Substance Use

Functional Assessment

  • Utilize Rating Scales (examples can be found in Table 28.1).

  • Assess Quality of Life.

  • Conduct Strengths Assessment.

  • Employ Clinical Judgment.

Psychosocial Assessment

  • Evaluate:

    • Mental Status and Appearance

    • Self-Concept

    • Stress and Coping Patterns

    • Social Network/Support Systems

Nursing Management for the Biological Domain

Interventions

  • Maintain skin integrity.

  • Psychopharmacology:

    • Medications include:

    • Clomipramine

    • Sertraline

    • Fluvoxamine

    • Fluoxetine

    • Paroxetine

    • Citalopram

    • Escitalopram

    • Venlafaxine

  • Education about medications and treatments including ECT and Psychosurgery.

Nursing Management for the Psychological Domain

Assessment

  • Types and severity of obsessions and compulsions.

  • Ability to distract from obsessional thoughts.

  • Assess Dressing and Grooming habits; examine Speech – specifically for circumferential speech.

  • Measure the degree to which symptoms interfere with daily functioning using the Yale–Brown Obsessive Compulsive Scale and Maudsley Obsessive Compulsive Inventory.

Nursing Diagnoses

  • Common diagnoses include:

    • Hopelessness

    • Powerlessness

    • Loneliness

    • Chronic Low Self-Esteem

Nursing Management for the Psychosocial Domain

Interventions

  • Response Prevention: Delaying engagement in compulsions.

  • Thought Stopping: Techniques to interrupt obsessive thought patterns.

  • Relaxation Techniques: To reduce anxiety.

  • Cognitive Restructuring: Altering negative thought patterns.

  • Use of Cue Cards: Reminders for positive thinking.

  • Psychoeducation: Teaching about OCD.

  • Acceptance and Commitment Therapy (ACT): A therapeutic approach.

Behavioral Interventions and Interactions

  • Establish routines to diminish anxiety.

  • Ongoing assessment of anxiety levels, comorbidities, and potential suicide risk.

  • Initially allow compulsive rituals to reduce frustration.

  • Encourage discussions about feelings and behaviors.

  • Balance private time and social interactions.

  • Identify triggers for obsessive thoughts.

  • Employ Self-talk and cognitive restructuring techniques.

Nursing Management for the Social Domain

Assessment

  • Evaluating sociocultural factors and the patient’s social interactions.

Nursing Diagnoses

  • Reflecting areas of:

    • Role conflict

    • Sedentary lifestyle

    • Social interaction challenges

Interventions

  • Establishing routines to provide structure.

  • Recognition of the significance of rituals to the patient.

  • Scheduling of activities to promote engagement.

  • Involvement of Marital and Family Support.

Other Obsessive-Compulsive Disorders

Trichotillomania Disorder

  • Characterized by chronic self-destructive hair pulling leading to noticeable hair loss.

    • Diagnosis: Recurrent pulling-out of hair resulting in hair loss, with the individual being unable to stop, causing considerable distress.

    • Evidence-Based Nursing Care: Includes full assessment, Cognitive Behavioral Therapy (CBT) approach, and psychoeducation.

    • Medications: SSRIs.

Excoriation Disorder (Skin-Picking Disorder)

  • Prevalence: Varies from 1.4% to 5.4%.

    • Behavioral Interventions: CBT and ACT.

    • Medications: SSRIs, topiramate, N-acetylcysteine.

    • Nursing Care: Full assessment, CBT treatment, psychoeducation, cold compresses/creams for affected areas.

Body Dysmorphic Disorder

  • Characterized by a focus on real (but slight) or imagined defects in appearance, significantly impairing an individual's quality of life.

    • Primary Treatment Approach: Cognitive Behavioral Therapy (CBT).

    • Occurs in both men and women.

    • High risks for depression, suicidal ideation, and suicide.

Hoarding Disorder

  • Characterized by difficulty parting with or discarding possessions.

    • Prevalence: Ranges from 2% to 6%.

    • May begin in childhood.

    • Behavioral and Pharmacologic Interventions include CBT and medication for co-occurring mental disorders.