Obsessive–Compulsive and Related Disorders
INTRODUCTION
Obsessive–compulsive disorder (OCD) was previously classified as an
anxiety disorder due to the sometimes extreme anxiety that people experience.
However, it varies from other anxiety disorders in significant ways. Certain
disorders characterized by repetitive thoughts and/or behaviors, such as OCD,
can be grouped together and described in terms of an obsessive–compulsive
spectrum. The spectrum approach includes repetitive behaviors of various
types: self-soothing behaviors, such as trichotillomania, dermatillomania, or
onychophagia; reward-seeking behaviors, such as hoarding, kleptomania,
pyromania, or oniomania; and disorders of body appearance or function, such
as body dysmorphic disorder (BDD). These related disorders are described
later in this chapter.
Some of the disorders described in the obsessive–compulsive spectrum
have not been accepted by the American Psychiatric Association as official
diagnoses. Scholarly debate continues among psychiatrists as different
clusters of behaviors are identified and studied to determine whether or not
they are a stand-alone disorder or a symptom/behavior that should be included
in another diagnosis. Sometimes the discussions and debates go on for many
years with no consensus as is the case with dissociative identity disorder,
formerly known as multiple personality disorder (see Chapter 13). The
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-
5) diagnoses include OCD, BDD, hoarding disorder, trichotillomania (hair-
pulling), excoriation (skin-picking), and disorders due to substances,
medication, or other origins.
OBSESSIVE–COMPULSIVE DISORDER
Obsessions are 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 he or she has no control
over them. Compulsions are 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, such
as repetitive hand washing when someone is obsessed with contamination or
repeated prayers or confession for someone obsessed with blasphemous
thoughts. Common compulsions include the following:
• Checking rituals (repeatedly making sure the door is locked or the coffee pot is turned off)
• Counting rituals (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 (feeling the texture of each material in a
clothing store; touching people, doors, walls, or oneself)
• Ordering (arranging and rearranging furniture or items on a desk or shelf
into perfect order; vacuuming the rug pile in one direction)
• Exhibiting rigid performance (getting dressed in an unvarying pattern)
• Having aggressive urges (for instance, to throw one’s child against a wall)
OCD is diagnosed only when these thoughts, images, and impulses
consume the person or he or she is compelled to act out the behaviors to a
point at which they interfere with personal, social, and occupational functions.
Examples include a man who can no longer work because he spends most of
his day aligning and realigning all items in his apartment or a woman who
feels compelled to wash her hands after touching any object or person.
OCD can be manifested through many behaviors, all of which are
repetitive, meaningless, and difficult to conquer. 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 (Stein & Lochner, 2017).
Individuals with early-onset OCD (average age of 11) and those with late-
onset OCD (average age of 23) 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 (Stein & Lochner, 2017).
Related Disorders
The following are DSM-5 diagnoses. They are included in the diagnostic
classification by the American Psychiatric Association.
Excoriation disorder, skin-picking, also known as dermatillomania, is
categorized as a self-soothing behavior; that is, the behavior is an attempt of
people to soothe or comfort themselves, not that picking itself is necessarily a
positive sensation. Eventually, the behavior can cause significant distress to
the individual and 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 (Torales, Barrios, & Villalba, 2017).
Trichotillomania, or chronic repetitive hair-pulling, is 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
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 (Cison, Kus, Popowicz, Szyca, & Reich, 2018).
BDD is 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 his or her “flawed” appearance,
that is, the appearance is the reason the person is unsuccessful at work or
finding a significant other, for feelings of unhappiness, and so forth. Elective
cosmetic surgery is sought repeatedly to “fix the flaw,” yet after surgery, the
person is still dissatisfied or finds another flaw in his or her appearance. It
becomes a vicious cycle. There is considerable overlap between BDD and
other diagnoses, such as anxiety, depression, social anxiety disorder, and
excoriation disorder. Treatment with selective serotonin reuptake inhibitors
(SSRIs) has been effective in relapse prevention (Hong, Nezgovorova, &
Hollander, 2018).
Hoarding disorder is a progressive, debilitating, compulsive disorder only
recently diagnosed on its own. Hoarding had been a symptom of OCD
previously but differs from OCD in significant ways. Diagnosis most
commonly occurs between the ages of 20 to 30. 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 (Dozier, Porter, & Ayers, 2016). Hoarding involves excessive acquisition
of animals or apparently useless things, cluttered living spaces that become
uninhabitable, and significant distress or impairment for the individual.
Hoarding 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. Not a great deal is known
about the success of these approaches at this time.
The following disorders are sometimes viewed as related to OCD, that is,
repetitive, compulsive behavior that is potentially harmful to the individual.
Others view them as behavioral addictions, characterized by an inability to
resist the urge to engage in potentially harmful actions.
Onychophagia, or chronic nail-biting, is 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 have proven
effective in the treatment of onychophagia (Halteh, Scher, & Lipner, 2017).
Kleptomania, or compulsive stealing, is a reward-seeking behavior. The
reward is not the stolen item, but rather the thrill of stealing and not getting
caught. Kleptomania is different than stealing items needed for survival, such
as a parent stealing food for a hungry child. Kleptomania is more common in
females with frequent comorbid diagnoses of depression and substance use. It
is associated with significant legal repercussions. There is a lack of
standardized treatment for kleptomania, but it seems that longer term therapy,
as opposed to limited 10 or 12 sessions, may be needed (Grant &
Chamberlain, 2018).
Oniomania, or compulsive buying, is 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. And, once acquired, the
object may be infrequently or never used. Approximately 80% of compulsive
buyers are females with 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 (Leite & Silva, 2016).
Body identity integrity disorder (BIID) is the term given to people who
feel “overcomplete,” or alienated from a part of their body and desire
amputation. This condition is also known as amputee identity disorder and
apotemnophilia or “amputation love.” This is 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
with the damage.
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
with the damage. medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another
mental disorder (e.g., excessive worries, as in generalized anxiety
disorder; preoccupation with appearance, as in BDD; difficulty
discarding or parting with possessions, as in hoarding disorder; hair-
pulling, as in trichotillomania [hair-pulling disorder]; skin-picking, as
in excoriation [skin-picking] disorder; stereotypies, as in stereotypic
movement disorder; ritualized eating behavior, as in eating disorders;
preoccupation with substances or gambling, as in substance-related and
addictive disorders; preoccupation with having an illness, as in illness–
anxiety disorder; sexual urges of fantasies, as in paraphilic disorders;
impulses, as in disruptive, impulse control, and conduct disorders;
guilty ruminations, as in major depressive disorder; thought insertion or
delusional preoccupations, as in schizophrenia spectrum and other
psychotic disorders; or repetitive patterns of behavior, as in autism
spectrum disorder).
Etiology
The etiology of OCD is being studied from a variety of perspectives. Different
studies show promise but have yet to definitively explain how or why people
develop OCD. Cognitive models of OCD arise from Aaron Beck’s cognitive
approach to emotional disorders. This has long been accepted as a partial
explanation for OCD, particularly since CBT is a successful treatment. 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; and (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 (Stein & Lochner, 2017).
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. But 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 (Yue et
al., 2016).
CULTURAL CONSIDERATIONS
OCD is generally thought to be fairly similar or universal among different
countries. Several 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, both Christian and Muslim, may
have a heightened sense of personal guilt (about their symptoms) and beliefs
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 therefore
are much more likely to contact a faith healer for help.
Ethnic differences may also be found in the types of OCD symptoms or
beliefs that people experience. Some report more contamination-related OCD
symptoms, while others have higher levels of obsessional beliefs. This may
indicate a need to tailor treatment approaches to accommodate such
differences where they exist.
Despite the universality of the existence of OCD, pharmacologic treatment
varies a great deal. In seven different countries, the use of SSRIs was most
prevalent but varied from 59% to 96% overall. These authors suggested the
need to study such variances and compare them with treatment outcomes
(Brakoulias et al., 2016).
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), quetiapine (Seroquel), or olanzapine (Zyprexa). Children and adolescents with OCD also respond well to behavioral therapy and SSRI
antidepressants, even when symptoms are treatment refractory (Casale et al.,
2018).
Behavioral therapy specifically includes exposure and response prevention.
Exposure involves assisting the client in deliberately confronting the
situations and stimuli that he or she usually avoids. 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 (Albano & Pimentel, 2017).
Other techniques, such as deep breathing and relaxation, can also assist the
person with tolerating and eventually managing the anxiety. History
The client usually seeks treatment only when obsessions become too
overwhelming or when compulsions interfere with daily life (e.g., going to
work, cooking meals, or participating in leisure activities with family or
friends) or both. 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. The more responsibility the client has as
he or she gets older, the more the rituals interfere with the ability to fulfill
those responsibilities.
General Appearance and Motor Behavior
The nurse assesses the client’s appearance and 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 his or her thoughts and the resulting anxiety.
Mood and Affect
During assessment of 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
The nurse explores the client’s 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 he or she wants to think about and that he or she
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 nurse examines the client’s judgment and insight. The client
recognizes that the obsessions are irrational, but he or she cannot stop
them. He or she 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
During exploration of self-concept, the client voices concern that he or she
is “going crazy.” Feelings of powerlessness to control the obsessions or
compulsions contribute to low self-esteem. The client may believe that if
he or she were “stronger” or had more will power, he or she could
possibly control these thoughts and behaviors.
Roles and Relationships
It is important for the nurse to assess the effects of OCD on the client’s
roles and relationships. As the 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 he or she is more consumed with anxiety and ritualistic behavior.
Physiological and Self-Care Considerations
The nurse examines the effects of OCD on physiology and self-care. 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.
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.
Using Therapeutic Communication
Offering support and encouragement to the client is important to help him or her 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. Because many clients try to hide their rituals and keep obsessions secret, discussing these thoughts, behaviors, and resulting feelings with the nurse is an important step. Doing so can begin to relieve some of the “burden” the client has been keeping to him or herself.
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 he or she can learn more effectively. Initially, the nurse can demonstrate and practice the techniques with the client. Then, the nurse encourages the client to practice these techniques until he or she is comfortable doing them alone. When the client has mastered relaxation techniques, he or she 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 then can begin to use exposure and response prevention behavioral techniques. Initially, the client can decrease the time he or she spends 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. It is important to note that the client must be willing to engage in exposure and response prevention. These are not techniques that can be forced on the client.
Completing a Daily Routine
To accomplish tasks efficiently, the client initially may need additional time to allow for rituals. For example, if breakfast is at 8 AM and the client
has a 45-minute ritual before eating, the nurse must plan that time into the
client’s schedule. 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. Again, the client must be willing to make changes in his or
her behavior. The nurse and client can agree on a plan to limit the time
spent performing rituals. They may decide to limit the morning ritual to 40
minutes, then to 35 minutes, and so forth, taking care to decrease this time
gradually at a rate the client can tolerate. When the client has completed
the ritual or the time allotted has passed, the client then must 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 that helps him or her
to stay on tasks and accomplish activities and responsibilities.
NURSING INTERVENTIONS
For OCD
• Offer encouragement, support, and compassion.
• Be clear with the client that you believe he or she 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.
Providing Client and Family Education
It is important for both the client and family to learn about OCD. They are
often relieved to find the client is not “going crazy” and that the
obsessions are unwanted, rather than a reflection of any “dark side” to the
client’s personality. 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
his or her 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. He or she reports regained control
over his or her life and the ability to tolerate and manage anxiety with
minimal disruption.
ELDER CONSIDERATIONS
Onset of OCD after age 50 is extremely rare. Recently acquired obsessive or
compulsive behavior by an elder person 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 then is directed at the underlying cause,
and the obsessive–compulsive behaviors can improve if the underlying cause
can be successfully resolved.
Community-Based Care
Treatment for OCD involves both medication and CBT, as discussed in
“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.
One of the promising newer developments for clients is technology-
enhanced delivery. Though in its infancy, a few small studies have tried
various technology-delivered techniques: bibliotherapy, telephone-delivered
CBT, and computerized CBT. These technologies have promise and should be
implemented in large studies to evaluate their effectiveness over time. In
addition, self-help and online therapy can be an effective add-on to standard
therapy. While online self-help methods alone may not produce optimal
results, they might be the only type of treatment that people who are shamed
and stigmatized by their OCD symptoms will be willing to seek.
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 his or her life.
Why does the hand washer who has scrubbed himself raw keep washing his
sore hands every hour on the hour? People with OCD are usually aware that
their ritualistic behavior appears senseless or even bizarre to others. Given
that, 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. Most times, 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.
In addition, OCD is often chronic in nature, with symptoms that wax and
wane over time. Just because the client has some success in managing
thoughts and rituals doesn’t mean they will never again need professional help
in the future.
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.
• As with any chronic illness, 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 his or her thoughts and rituals
interfere with life or that the ritual actions really have no lasting effect on
anxiety—he or she already knows that.