Chapter15: Obsessive-Compulsive and Related Disorders Study Notes

Obsessive-Compulsive and Related Disorders

Key Terms

• Body dysmorphic disorder (BDD): Preoccupation with an imagined or slight defect in physical appearance.
• Body identity integrity disorder (BIID): Feeling alienated from a part of one's body and desiring amputation.
• Compulsions: Repetitive behaviors or mental acts performed to neutralize anxiety.
• Dermatillomania: Skin-picking disorder; also known as excoriation disorder.
• Excoriation: Skin-picking disorder; also known as dermatillomania.
• Exposure: Deliberately confronting situations and stimuli that are usually avoided.
• Hoarding: Excessive acquisition of animals or apparently useless things, cluttered living spaces that become uninhabitable, and significant distress or impairment for the individual.
• Kleptomania: Compulsive stealing; a reward-seeking behavior driven by the thrill of stealing rather than the value of the item.
• Obsessions: Recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that cause marked anxiety.
• Oniomania: Compulsive buying; an acquisition type of reward-seeking behavior where the pleasure is in acquiring the purchased object rather than any subsequent enjoyment of its use.
• Onychophagia: Chronic nail-biting; a self-soothing behavior.
• Response prevention: Delaying or avoiding performance of rituals to tolerate anxiety.
• Trichotillomania: Chronic repetitive hair-pulling; a self-soothing behavior.

Learning Objectives

1. Discuss etiologic theories of obsessive-compulsive disorder (OCD).
2. Describe related compulsive disorders, including self-soothing and reward-seeking behaviors and disorders of body appearance and function.
3. Develop a plan of care for clients and families with OCD.
4. Provide education to clients, families, caregivers, and community members to increase knowledge and understanding of OCD and related disorders.
5. Evaluate your feelings, beliefs, and attitudes regarding OCD and related disorders.

Nursing Concepts

• Anxiety
• Stress & Coping

Introduction

• OCD was previously classified as an anxiety disorder but varies from other anxiety disorders in significant ways.
• The obsessive-compulsive spectrum includes:
  • Self-soothing behaviors (e.g., trichotillomania, dermatillomania, onychophagia).
  • Reward-seeking behaviors (e.g., hoarding, kleptomania, pyromania, oniomania).
  • Disorders of body appearance or function (e.g., body dysmorphic disorder).
• Some disorders in the obsessive-compulsive spectrum are not official diagnoses by the American Psychiatric Association.
• The DSM-5 diagnoses include OCD, BDD, hoarding disorder, trichotillomania, excoriation disorder, and disorders attributable to substances, medication, or other origins.

Obsessive-Compulsive Disorder (OCD)

• Obsessions: Recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that cause marked anxiety and interfere with interpersonal, social, or occupational function.
  • The person knows these thoughts are excessive or unreasonable but believes they have no control over them.
• Compulsions: Ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety.
  • Usually, the theme of the ritual is associated with that of the obsession.
  • Examples:
    • Repetitive handwashing when someone is obsessed with contamination.
    • Repeated prayers or confession for someone obsessed with blasphemous thoughts.
• Common compulsions include:
  • Checking rituals (e.g., repeatedly making sure the door is locked or the coffee pot is turned off).
  • Counting rituals (e.g., each step taken, ceiling tiles, concrete blocks, or desks in a classroom).
  • Washing and scrubbing until the skin is raw.
  • Praying or chanting.
  • Touching, rubbing, or tapping (e.g., feeling the texture of each material in a clothing store; touching people, doors, walls, or oneself).
  • Ordering (e.g., arranging and rearranging furniture or items on a desk or shelf in perfect order; vacuuming the rug pile in one direction).
  • Exhibiting rigid performance (e.g., getting dressed in an unvarying pattern).
  • Having aggressive urges (e.g., to throw one’s child against a wall).
• OCD is diagnosed only when these thoughts consume the person or when they are compelled to act out the behaviors to a point at which they interfere with personal, social, and occupational functions.
  • Examples: person who can no longer work because they spend most of their day aligning and realigning all items in their apartment or someone who feels compelled to wash their hands after touching any object or person.
• The person understands that these rituals are unusual and unreasonable but feels forced to perform them to alleviate anxiety or to prevent terrible thoughts.
• Obsessions and compulsions are a source of distress and shame to the person, who may go to great lengths to keep them secret.
• Onset and Clinical Course
  • OCD can start in childhood, especially in males.
  • In females, it more commonly begins in the 20s.
  • Overall, distribution between the sexes is equal.
  • Onset is typically in late adolescence, with periods of waxing and waning symptoms over the course of a lifetime.
  • Individuals can have periods of relatively good functioning and limited symptoms.
  • Other times, they experience exacerbation of symptoms that may be related to stress.
  • Small numbers of people exhibit either complete remission of their symptoms or a progressive, deteriorating course of the disorder (Black & Andreasen, 2021).

Related Disorders

• The following are DSM-5 diagnoses and are included in the diagnostic classification by the American Psychiatric Association.

Excoriation Disorder (Skin-Picking) - Dermatillomania

• A self-soothing behavior; an attempt to comfort themselves, not that picking itself is necessarily a positive sensation.
• The most common area is the face, followed by fingers, hands, arms, and legs (Boland & Verduin, 2022).
• The behavior can cause significant distress to the individual, who is often embarrassed and ashamed.
• It may also lead to medical complications and loss of occupational functioning.
• It may be necessary to involve medicine, surgery, and/or plastic surgery, as well as psychiatry on the treatment team.
• Alternative therapies, such as yoga, acupuncture, and biofeedback, are helpful when included in the treatment plan.

Trichotillomania (Hair-Pulling)

• A self-soothing behavior that can cause distress and functional impairment.
• Onset in childhood is most common, but it can also persist into adulthood with the development of anxiety and depression.
• It occurs more often in females than in males.
• Trichotillomania can be successfully treated with behavioral therapy; although results are mixed and long-term outcomes are not well documented.
• Selective serotonin reuptake inhibitor (SSRI) antidepressants or clomipramine (Anafranil), which are the most frequently prescribed medications, may help reduce urges to pull hair (Black & Andreasen, 2021).

Body Dysmorphic Disorder (BDD)

• A preoccupation with an imagined or slight defect in physical appearance that causes significant distress for the individual and interferes with functioning in daily life.
• The person ruminates and worries about the defect, often blaming all of life’s problems on their “flawed” appearance.
• Elective cosmetic surgery is sought repeatedly to “fix the flaw,” yet after surgery the person is still dissatisfied or finds another flaw in their appearance.
• There is considerable overlap between BDD and other diagnoses, such as anxiety, depression, social anxiety disorder, and excoriation disorder.
• Treatment with SSRIs has been effective in relapse prevention.
• Cosmetic surgery is discouraged (Black & Andreasen, 2021).

Hoarding Disorder

• A progressive, debilitating, compulsive disorder only recently diagnosed on its own.
• Had been a symptom of OCD previously but differs from OCD in significant ways.
• Diagnosis most commonly occurs between the ages of 20 and 30 years.
• The prevalence and severity of the disorder is $2\%$ to $5\%$ of the population and increases with age.
• It is more common in females, with a parent or first-degree relative who hoards as well.
• People with hoarding disorder may also exhibit maladaptive personality traits (Dozier et al., 2020).
• Involves excessive acquisition of animals or apparently useless things, cluttered living spaces that become uninhabitable, and significant distress or impairment for the individual.
• Can seriously compromise the person’s quality of life and even become a health, safety, or public health hazard.
• Treatment and interventions can be medication, cognitive–behavioral therapy (CBT), self-help groups, or the involvement of outside community agencies.

Onychophagia (Chronic Nail-Biting)

• A self-soothing behavior.
• Typical onset is childhood, with a decrease in behavior by age 18.
• However, some nail-biting persists into adulthood.
• It may lead to psychosocial problems or cause complications involving the nails and oral cavity.
• SSRIs and CBT have proven effective in the treatment of onychophagia (Erdogan et al., 2021).

Kleptomania (Compulsive Stealing)

• A reward-seeking behavior; the reward is not the stolen item but rather the thrill of stealing and not getting caught.
• Different than stealing items needed for survival.
• More common in females with frequent comorbid diagnoses of depression and substance use.
• Associated with significant legal repercussions.
• There is a lack of standardized treatment for kleptomania, but it seems that longer term therapy may be needed (Torales et al., 2020).

DSM-5-TR Diagnostic Criteria: Obsessive-Compulsive Disorder (F42)

• Presence of obsessions or compulsions or both:
  • Obsessions are defined by:
    1. 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 cause marked anxiety or distress.
    2. The individual attempts to ignore or suppress such thoughts, urges, or images or to neutralize them with some other thought or action (i.e., by performing a compulsion).
  • Compulsions are defined by:
    1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
    2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
       • Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
• The obsessions or compulsions are time-consuming (e.g., take >1 hour/day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
• The disturbance is not better explained by the symptoms of another mental disorder.

Oniomania (Compulsive Buying)

• An acquisition type of reward-seeking behavior.
• The pleasure is in acquiring the purchased object rather than any subsequent enjoyment of its use.
• Spending behavior is often out of control, well beyond the person’s financial means.
• Once acquired, the object may be infrequently or never used.
• Approximately $80\%$ of compulsive buyers are females, who develop onset of the behavior in the early 20s; it is often seen in college students.
• Compulsive shopping runs in families who also have a high comorbidity for depression and substance use.
• Both CBT and person-centered experiential therapy can be effective (Kellett et al., 2021).

Body Identity Integrity Disorder (BIID)

• The term given to people who feel “overcomplete,” or alienated from a part of their body and desire amputation.
• Also known as amputee identity disorder and apotemnophilia, or “amputation love” (Stone et al., 2021).
• Not an officially APA-accepted diagnosis, and there is disagreement about the existence of the condition.
• People describe feelings of anguish and distress with their intact bodies and report feeling “natural, like they were intended to be” after an amputation.
• From an ethical standpoint, few surgeons will amputate a limb merely on a person’s request.
• People with BIID resort to actions such as packing the limb in dry ice until the damage is so advanced that amputation becomes a medical necessity, or in some cases, amputation is done with a power tool by nonmedical persons, leaving a physician to save the person’s life and mitigate the damage.

Etiology

• The etiology of OCD is being studied from a variety of perspectives.

Cognitive Models of OCD

• Arise from Aaron Beck’s cognitive approach to emotional disorders.
• The cognitive model describes the person’s thinking as:
  1. Believing one’s thoughts are overly important, that is, “If I think it, it will happen,” and therefore having a need to control those thoughts.
  2. Perfectionism and the intolerance of uncertainty.
  3. Inflated personal responsibility (from a strict moral or religious upbringing) and overestimation of the threat posed by one’s thoughts.
• The cognitive model focuses on childhood and environmental experiences of growing up.
• However, environmental influences are not solely responsible for the development of OCD (Boland & Verduin, 2022).
• It is important to remember that the client is trying to deal with overwhelming urges and emotions, including anxiety.
• The compulsive behavior may seem purposeless and senseless, even to the client.
• It is the client’s attempt to ward off feared consequences or manage/decrease overwhelming feelings that are escalating out of control.
• It isn’t possible to reason with or tell the patient to simply stop.
• Population-based studies have confirmed substantial heritability in OCD.
• Genome-wide and candidate gene association studies have found variations that may be involved in OCD pathology and support the idea that a complex network of several genes may contribute to the genetic risk for OCD (Mahjani et al., 2021).

Cultural Considerations

• OCD is generally thought to be fairly similar or universal among different countries.
• Studies found that OCD was consistent across cultures in terms of diagnosis, but variances exist in symptom expression or beliefs about symptoms.
• Highly religious individuals may have a heightened sense of personal guilt and believe that they should be responsible for controlling unwanted, threatening thoughts.
• Shame and guilt are prominent feelings among people with OCD and OCD-related disorders (Candea & Szentagotai-Tata, 2018).
• In some cultures, patients with OCD believe a supernatural cause exists and are therefore much more likely to contact a faith healer for help.
• Studies found that $64\%$ of individuals experienced unwanted mental intrusions associated with OCD, BDD, hypochondriasis, and eating disorders.

Treatment

• Optimal treatment for OCD combines medication and behavioral therapy.
• SSRI antidepressants, such as fluvoxamine (Luvox) and sertraline (Zoloft), are first-line choices, followed by venlafaxine (Effexor).
• Treatment-resistant OCD may respond to second-generation antipsychotics, such as risperidone (Risperdal) and aripiprazole (Abilify) (Boland & Verduin, 2022).
• Children and adolescents with OCD also respond well to behavioral therapy and SSRI antidepressants.
• Behavioral therapy specifically includes exposure and response prevention.
• Exposure involves assisting the client in deliberately confronting the situations and stimuli that they usually avoid.
• Response prevention focuses on delaying or avoiding performance of rituals.
• The person learns to tolerate the thoughts and the anxiety and to recognize that it will recede without the disastrous imagined consequences.
• A combination of exposure and response prevention and CBT has been found to be superior to either one alone (Reid et al., 2021).
• Other techniques, such as deep breathing and relaxation, can also assist the person with tolerating and eventually managing the anxiety.
• Other somatic therapies have been used primarily for people with treatment-resistant OCD.
• Targeting neurosurgical lesions in cortico-striatal-thalamic-cortical tracts of the brain has shown success (Boland & Verduin, 2022).
• Deep brain stimulation with implanted electrodes and transcranial magnetic stimulation have been studied but are not in wide use at this time.

Clinical Vignette: OCD

• Example of a person with OCD and their ritualistic behavior in the shower.

Plan of Care for a Client with OCD

• Problem: Disruption of life routines
• Assessment Data
  • Ambivalence regarding decisions or choices
  • Disturbances in normal functioning caused by obsessive thoughts or compulsive behaviors (loss of job, loss of/or alienation of family members, etc.)
  • Inability to tolerate deviations from standards
  • Rumination
  • Low self-esteem
  • Feelings of worthlessness
  • Lack of insight
  • Difficulty or slowness completing daily living activities because of ritualistic behavior
• Expected Outcomes
  • Immediate
    • The client will talk with staff and identify stresses, anxieties, and conflicts within 2 to 3 days.
    • Verbalize realistic self-evaluation; for example, make a list of strengths and abilities and review list with staff within 3 to 4 days.
    • Establish adequate nutrition, hydration, and elimination within 4 to 5 days.
    • Establish a balance of rest, sleep, and activity; for example, sleep at least 4 hours per night.
  • Stabilization
    • The client will identify alternative methods of dealing with stress and anxiety.
    • Complete daily routine without staff assistance or prompting by a specified date.
    • Verbalize knowledge of illness, treatment plan, and safe use of medications, if any.
  • Community
    • The client will demonstrate a decrease in obsessive thoughts or ritualistic behaviors to a level at which the client can function independently.
    • Demonstrate alternative ways of dealing with stress, anxiety, and life situations.
    • Maintain adequate physiological functioning, including activity, sleep, and rest.
• Implementation
  • Nursing Actions
    • Observe the client’s eating, drinking, and elimination patterns, and assist the client as necessary.
    • Assess and monitor the client’s sleep patterns, and prepare them for bedtime by decreasing stimuli and providing comfort measures or medication.
    • You may 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).
    • Encourage 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.
    • 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.
    • Convey honest interest in and concern for the client. Do not flatter or be otherwise dishonest.
    • Provide opportunities for the client to participate in activities that are easily accomplished or enjoyed by the client; support the client for participation.
    • Teach the client social skills, such as appropriate conversation topics and active listening. Encourage them to practice these skills with staff members and other clients, and give the client feedback regarding interactions.

Care of Clients with OCD

• Box 15.1 presents a screening tool for obsessive–compulsive disorder (OCD).

Assessment Data

• The client usually seeks treatment only when obsessions become too overwhelming or when compulsions interfere with daily life.
• Clients are hospitalized only when they have become completely unable to carry out their daily routines.
• Most treatment is outpatient.
• The client often reports that rituals began many years before; some begin as early as childhood.

General Appearance and Motor Behavior

• Clients with OCD often seem tense, anxious, worried, and fretful.
• They may have difficulty relating symptoms because of embarrassment.
• Their overall appearance is unremarkable; nothing observable seems to be “out of the ordinary.”
• The exception is the client who is almost immobilized by their thoughts and the resulting anxiety.

Mood and Affect

• Clients report ongoing overwhelming feelings of anxiety in response to the obsessive thoughts, images, or urges.
• They may look sad and anxious.

Thought Processes and Content

• Many clients describe the obsessions as arising from nowhere during the middle of normal activities.
• The harder the client tries to stop the thought or image, the more intense it becomes.
• The client describes how these obsessions are not what they want to think about and that they would never willingly have such ideas or images.
• Assessment reveals intact intellectual functioning.
• The client may describe difficulty concentrating or paying attention when obsessions are strong.
• There is no impairment of memory or sensory functioning.

Judgment and Insight

• The client recognizes that the obsessions are irrational but cannot stop them.
• They can make sound judgments (e.g., “I know the house is safe”) but cannot act on them.
• The client still engages in ritualistic behavior when the anxiety becomes overwhelming.

Self-Concept

• The client voices concern that they are “going crazy.”
• Feelings of powerlessness to control the obsessions or compulsions contribute to low self-esteem.
• The client may believe that if they were “stronger” or had more willpower, they could possibly control these thoughts and behaviors.

Roles and Relationships

• As time spent performing rituals increases, the client’s ability to fulfill life roles successfully decreases.
• Relationships also suffer as family and friends tire of the repetitive behavior, and the client is less available to them as they are more consumed with anxiety and ritualistic behavior.

Physiological and Self-Care Considerations

• As with other anxiety disorders, clients with OCD may have trouble sleeping.
• Performing rituals may take time away from sleep, or anxiety may interfere with the ability to go to sleep and wake refreshed.
• Clients may also report a loss of appetite or unwanted weight loss.
• In severe cases, personal hygiene may suffer because the client cannot complete the needed tasks.

Data Analysis and Priorities

• The client’s physical health and safety are priorities—that is, are they suicidal? Eating and sleeping? Have damaged skin?
• Common problems can include:
  • Anxiety
  • Ineffective coping
  • Fatigue
  • Low self-esteem
  • Skin breakdown (if scrubbing or washing rituals)

Outcome Identification

• Outcomes for clients with OCD include:
  • The client will complete daily routine activities within a realistic time frame.
  • The client will demonstrate effective use of relaxation techniques.
  • The client will discuss feelings with another person.
  • The client will demonstrate effective use of behavioral therapy techniques.
  • The client will spend less time performing rituals.

Actions Using Therapeutic Communication

• Offering support and encouragement to the client is important to help them manage anxiety responses.
• The nurse can validate the overwhelming feelings the client experiences while indicating the belief that the client can make needed changes and regain a sense of control.
• The nurse encourages the client to talk about the feelings and describe them in as much detail as the client can tolerate.
• Discussing these thoughts, behaviors, and resulting feelings with the nurse is an important step.

Teaching Relaxation and Behavioral Techniques

• The nurse can teach the client about relaxation techniques such as deep breathing, progressive muscle relaxation, and guided imagery.
• This intervention should take place when the client’s anxiety is low so they can learn more effectively.
• The nurse encourages the client to practice these techniques until they are comfortable doing them alone.
• When the client has mastered relaxation techniques, they can begin to use them when anxiety increases.
• In addition to decreasing anxiety, the client gains an increased sense of control that can lead to improved self-esteem.
• To manage anxiety and ritualistic behaviors, a baseline of frequency and duration is necessary.
• The client can keep a diary to chronicle situations that trigger obsessions, the intensity of the anxiety, the time spent performing rituals, and the avoidance behaviors.
• This record provides a clear picture for both client and nurse.
• The client can then begin to use exposure and response prevention behavioral techniques.
• Initially, the client can decrease the time they spend performing the ritual or delay performing the ritual while experiencing anxiety.
• Eventually, the client can eliminate the ritualistic response or decrease it significantly to the point that interference with daily life is minimal.
• Clients can use relaxation techniques to assist them in managing and tolerating the anxiety they are experiencing.

Completing a Daily Routine

• To accomplish tasks efficiently, the client may initially need additional time to allow for rituals.
• It is important for the nurse not to interrupt or to attempt to stop the ritual, because doing so will escalate the client’s anxiety dramatically.
• The nurse and client can agree on a plan to limit the time spent performing rituals.
• When the client has completed the ritual or the time allotted has passed, the client must then engage in the expected activity.
• This may cause anxiety and is a time when the client can use relaxation and stress reduction techniques.
• At home, the client can continue to follow a daily routine or written schedule to help them stay on task and accomplish activities and responsibilities.

Nursing Actions for OCD

• Offer encouragement, support, and compassion.
• Be clear with the client that you believe they can change.
• Encourage the client to talk about feelings, obsessions, and rituals in detail.
• Gradually decrease time for the client to carry out ritualistic behaviors.
• Assist the client in using exposure and response prevention behavioral techniques.
• Encourage the client to use techniques to manage and tolerate anxiety responses.
• Assist the client in completing daily routine and activities within agreed-upon time limits.
• Encourage the client to develop and follow a written schedule with specified times and activities.

Client and Family Education for OCD

• For Clients
  • Teach about OCD.
  • Review the importance of talking openly about obsessions, compulsions, and anxiety.
  • Emphasize medication compliance as an important part of treatment.
  • Discuss necessary behavioral techniques for managing anxiety and decreasing prominence of obsessions.
  • Tolerating anxiety is uncomfortable but not harmful to health or well-being.
• For Families
  • Avoid giving advice such as “Just think of something else.”
  • Avoid trying to fix the problem; that never works.
  • Be patient with your family member’s discomfort.
  • Monitor your own anxiety level, and take a break from the situation if you need to.
• Helping the client and family talk openly about the obsessions, anxiety, and rituals eliminates the client’s need to keep these things secret and to carry the guilty burden alone.
• Family members can also give the client needed emotional support when they are fully informed.
• Teaching about the importance of medication compliance to combat OCD is essential.
• The client may need to try different medications until their response is satisfactory.
• The chances for improved OCD symptoms are enhanced when the client takes medication and uses behavioral techniques.

Evaluation

• Treatment has been effective when OCD symptoms no longer interfere with the client’s ability to carry out responsibilities.
• When obsessions occur, the client manages resulting anxiety without engaging in complicated or time-consuming rituals.
• They report regained control over their life and the ability to tolerate and manage anxiety with minimal disruption.

Age-Related Considerations

• Individuals with early-onset OCD (average age of 11 years) and those with late-onset OCD (average age of 23 years) differ in several ways.
• Early onset is more likely to affect males, has more severe symptoms, more comorbid diagnoses, and a greater likelihood of a family history of OCD (Black & Andreasen, 2021).
• Onset of OCD after age 50 years is extremely rare.
• Recently acquired obsessive or compulsive behavior by an older adult should alert the physician to a possible organic cause for the behavior, such as infections, degenerative disorders, brain injury, and cerebrovascular lesions, particularly in the frontal lobes and basal ganglia.
• Treatment is then directed at the underlying cause, and the obsessive–compulsive behaviors can improve if the underlying cause can be successfully resolved.
• Related disorders often have roots in childhood or adolescence but may not be diagnosed until later.
• Trichotillomania, dermatillomania, and onychophagia all begin in preteen or early adolescence following the onset of puberty.
• Hoarding disorder traits may be evident by 11 to 15 years of age, with the disorder becoming full blown by the person’s mid-20s.
• Treatment options include CBT, behavioral techniques, and SSRI antidepressants.
• Most of these disorders persist into adulthood.
• Hoarding disorder often has a late-age onset.
• Multiple community agencies may be needed to deal with hoarding in the older adult.
• Treatment for hoarding in older adults may need to continue over a long period of time to reach successful outcomes.

Community-Based Care

• Treatment for OCD involves both medication and CBT, as discussed in the “Treatment” section.
• The therapist or treatment team can teach the client exposure and response prevention techniques, but the client will need to continue to practice those techniques at home in the community over an extended time.
• Successful outcomes of treatment require consistent use of the techniques on a daily basis.

Self-Awareness Issues

• It may be difficult for nurses and others to understand why the person cannot simply stop performing the bizarre behaviors interfering with their life.
• People with OCD are usually aware that their ritualistic behavior appears senseless or even bizarre to others.
• Family and friends may believe that the person “should just stop” the ritualistic behavior.
• “Just find something else to do” or other unsolicited advice only adds to the guilt and shame that people with OCD experience.
• It is important for the nurse (and other health professionals) to avoid taking that same point of view.
• People with OCD appear “perfectly normal” and therefore capable of controlling their own behaviors.
• The nurse must remember that overwhelming fear and anxiety interfere with the person’s ability to monitor or control their own actions.
• OCD is often chronic in nature, with symptoms that wax and wane over time.

Points to Consider When Working With Clients With Obsessive–Compulsive and Related Disorders

• When clients experience severe symptoms of OCD, they are usually not able to change their patterns of thinking and behavior without treatment and assistance from professionals.
• Clients with OCD will have stressful periods that may increase symptoms and necessitate professional support and assistance.
• It is not beneficial to tell the client that their thoughts and rituals interfere with life or that the ritual actions really have no lasting effect on anxiety; they already know that.

Key Points

• OCD involves recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses (obsessions) and ritualistic or repetitive behaviors or mental acts (compulsions) carried out to eliminate the obsessions or to neutralize anxiety.
• Rituals or compulsions may include checking, counting, washing, scrubbing, praying, chanting, touching, rubbing, ordering, or other repetitive behaviors.
• OCD can start in childhood and often lasts into adulthood.
• OCD is a chronic progressive disease. Symptoms wax and wane over time, increasing during periods of stress.
• Disorders related to OCD include dermatillomania, trichotillomania, onychophagia, kleptomania, oniomania, BDD, body integrity identity disorder, and hoarding.
• Etiology of OCD is not specifically known but includes genetic influences and environmental experiences.
• OCD is universal across countries, with some variation in symptoms.
• Treatment includes medications, SSRIs, and behavioral therapy, specifically exposure and response prevention.
• Effective nursing interventions include therapeutic communication, teaching relaxation and behavioral techniques, following a daily routine, and client and family education about OCD and its treatment.
• Onset of OCD after age 50 years is rare. The incidence of hoarding increases with age.