Obsessive-Compulsive

Disorder

JYOTHIS PRAKASH

Introduction• Obsessive–compulsive disorder (OCD) is

a mental disorder where people feel the

need to check things repeatedly, have certain

thoughts repeatedly, or feel they need to

perform certain routines repeatedly.

• People are unable to control either the

thoughts or the activities.

History

• In the 1600s it was thought of as symptoms of

religious melancholy and naughty thoughts.

• Pierre Janet and Sigmund Freud isolated OCD from

the disorders it was grouped with.

• Continuing research is being done about the

causes of OCD and better treatments.

Cont…

• Recent research on mice points toward a

genetic cause. A missing gene making a

certain protein caused the mice to scratch

and groom themselves compulsively until an

OCD drug was introduced.

Epidemiology

• Obsessive–compulsive disorder affects about

2.3% of people at some point in their life.

• Rates during a given year are about 1.2% and

it occurs worldwide.

Cont…

• It is unusual for symptoms to begin after the

age of thirty five and half of people develop

problems before twenty.

• Males and females are affected about

equally.

Definition

• Obsessive-compulsive disorder (OCD) is an anxiety

disorder in which people have unwanted and

repeated thoughts, feelings, ideas, sensations

(obsessions), or behaviours that make them feel

driven to do something (compulsions).

Cont…

• A person's level of OCD can be anywhere

from mild to severe, but if severe and left

untreated, it can destroy a person's capacity

to function at work, at school or even to lead

a comfortable existence in the home.

Signs & SymptomsWhat is an obsession?

• Involuntary intrusive cognition.

• Types

Doubts (74%)

Thinking (34%)

Fears (26%)

Impulses (17%)

Images (7%)

Other (2%)

Obsessions-examples

• Doubt “Did I lock the door”

• Thought that he had cancer

• Thought / Image that he had knocked someone down

in his car

• Impulse + thought to shout obscenities in church

• Image of corpse rotting away

• Impulse to drink from inkpot and to strangle son

Themes in obsession…• Obsessions often have common themes

– Contamination, dirt, disease, illness (46%)

– Violence and aggression (29%)

– Moral and religious topics (11%)

– Symmetry and sequence (27%)

– Sex (10%)

– Other (22%)

• The themes often reflect contemporary concerns (the devil,

germs, AIDS)

Compulsions

• Some people with OCD perform compulsive

rituals because they inexplicably feel they

have to, others act compulsively so as to

mitigate the anxiety that stems from

particular obsessive thoughts.

Cont…

• Excessive skin picking (i.e., dermatillomania)

or hair plucking (i.e.,trichotillomania) and

nail biting (i.e., onychophagia) are all on

the obsessive-compulsive spectrum.

Examples of compulsions…

• Scanning text for “life” having read “death”.

• Touching the ground after swallowing saliva.

• Driving back to check he hadn’t knocked

someone down in his car.

• Counting 6,5,8,3,7,4 in your head.

• Hand washing.

Linking Obsessions and Compulsions

OCD Experiences OCD Not OCD

A man who washes his hands 100 times a day until they are red and

raw

A woman who unfailingly washer her hands before

every meal

A women who locks and relocks her door before going to work

every day – for half an hour

A woman who double-checks that her apartment

door and windows are locked each night before she

goes to bed.

A college student who must tap on the door frame of every classroom 14 times before

entering

A musician who practices a difficult passage over and over again until its perfect

A man who stores 19 years of newspapers “just in case” – with no system for filling or retrieving

A woman who dedicates all her spare time and money to

building her record collection

Cognitive Performance-Recent Research Findings

• A 2013 meta-analysis confirmed people with

OCD to have mild but wide-ranging cognitive

deficits; significantly regarding spatial memory,

to a lesser extent with verbal memory, fluency,

executive function and processing speed, while

auditory attention was not significantly affected.

Cont…

• Spatial memory had been evaluated by

results from Corsi block-tapping test, Rey-

Osterrieth Complex Figure Test-immediate

recall and Spatial Working Memory between

search errors.

Cont…

• Verbal memory had been evaluated by

Verbal Learning Test - delayed recall and

Logical Memory II.

• Verbal fluency was evaluated by Category

fluency and Letter fluency.

Cont…

• Auditory attention was evaluated by the

Digit Span Test.

• Processing speed was evaluated by

Trail Making Test part A.

Associated conditions…

• obsessive–compulsive personality disorder • major depressive disorder • bipolar disorder• generalized anxiety disorder • anorexia nervosa• social anxiety disorder • bulimia nervosa• Tourette syndrome

Cont…

• Asperger syndrome

• attention deficit hyperactivity disorder

• dermatillomania (compulsive skin picking)

• body dysmorphic disorder

• trichotillomania (hair pulling)

Cont…

• In 2009 it was reported that depression

among those with OCD is particularly

alarming because their risk of suicide is high;

more than 50 percent of people experience

suicidal tendencies, and 15 percent have

attempted suicide.

Cont…• Depression is also extremely prevalent among

sufferers of OCD. One explanation for the high

depression rate among OCD populations was

posited by Mineka, Watson, and Clark (1998), who

explained that people with OCD (or any other

anxiety disorder) may feel depressed because of an

"out of control" type of feeling.

Causes…

• GENETIC FACTORS:

genetic factors account for 45–65% of OCD

symptoms in children diagnosed with the

disorder.

identical twins more often affected than non-

identical twins

Genetic Factors cont…

Individuals with OCD are more likely to have

first-degree family members exhibiting the

same disorders than do matched controls.

A mutation has been found in the human

serotonin transporter gene, hSERT, in

unrelated families with OCD.

• CHEMICAL AND BRAIN DYSFUNCTION

The chemical messenger, Serotonin seems to be heavily

involved.

According to research, Serotonin is involved with

biological processes such as mood, aggression, sleep,

appetite and pain. It also seems that Serotonin is capable

of connecting to nerve cells in the brain in many different

ways and so can cause many different responses.

Causes…

Chemical and Brain Dysfunction cont…

• It is not even fully established if it is all or

part of the Serotonin chemical or another

chemical entirely acting on it; or a

malfunction in one or more of the receptors

in the brain that Serotonin attaches to that

causes the OCD problems.

• INFECTION

A streptococcal infection of the throat is

known to occasionally result in the body

confusing healthy cells with the infection

and causing cellular damage.

Causes…

Infection cont…

• If this has happened with the brain, the body’s infection

fighting system can attack the outside of nerve cells in the

Basal Ganglia part of the brain with the result that OCD

symptoms occur.

• Some research suggests that these symptoms don’t seem to

last very long and the occurrence of this ‘infection OCD’

seems to be very rare.

Causes…

• DEPRESSION

People with depression sometimes develop OCD

symptoms, and those with OCD very often develop

depression. Dealing with both together is very difficult

without clinical intervention and it is notoriously

difficult to undertake an exposure programme while the

depression is high.

Causes-Recent findings…

• OCD is no longer believed to be caused by life

experiences.

• Modern research suggests a biological and

neurological cause

• fMRI scans show the circuit connecting the amygdala,

frontal cortex, caudate nucleus (motor control), and

thalamus is abnormally active in people with OCD.

Causes-Recent Findings cont…

• Genetic research on families with OCD

members have found a genetic link.

• There’s a link between OCD and other tick

disorders such as Tourette’s disorder.

Causes-Recent Findings cont…

• Glutamate dysregulation has also been the subject

of recent research, although its role in the disorder's

etiology is not yet clear. Glutamate is known to act

as a cotransmitter with dopamine in

dopamine pathways that project out of the ventral

tegmental area.

Causes-Recent Findings cont…

• People with OCD evince increased

grey matter volumes in bilateral lenticular

nuclei, extending to the caudate nuclei,

while decreased grey matter volumes in

bilateral dorsal medial frontal/anterior

cingulate gyri.

Causes-Recent Findings cont…

• Orbitofrontal cortex overactivity is

attenuated in people who have successfully

responded to SSRI medication, a result

believed to be caused by increased

stimulation of serotonin receptors 5-HT2A

and 5-HT2C.

Freud’s View• A patient's mind responds

maladaptively to conflicts between

unacceptable, unconscious sexual or

aggressive id impulses and the

demands of conscience and reality.

• The ego defends against the id by

isolation and reaction formation.

• The imperfect success of the ego

gives rise to OCD symptoms.

Diagnosis• Formal diagnosis may be performed by a

psychologist, psychiatrist, clinical social worker, or

other licensed mental health professional.

• To be diagnosed with OCD, a person must have

obsessions, compulsions, or both, according to the

Diagnostic and Statistical Manual of Mental Disord

ers

(DSM).

Cont…

• According to ICD-10 criteria-

For a definite diagnosis, obsessional or compulsive

acts, or both, must be present on most days for at

least 2 successive weeks and be a source of distress

or interference with activities. The obsessional

symptoms should have the following charecteristics:

Cont…

1. They must be recognised as the individual’s

own thoughts or impulses;

2. There must be atleast one thought or act

that is still resisted unsuccessfully, even

though others may be present which the

sufferer no longer resists;

Cont…

• The thought of carrying out the act must not

in itself be pleasurable (simple relief of

tension or anxiety is not regarded as pleasure

in this sense);

• The thoughts, images, or impulses must be

unpleasantly repetitive.

Treatment

• Pharmacotherapy- treatment using drugs that affect

the neurotransmitter serotonin decrease the

symptoms of OCD.

• Selective serotonin reuptake inhibitors (SSRIs) such as

fluoxetine (Prozac) and sertraline (Zoloft) prevent

excess serotonin from being pumped back into

neurons causing it to bind to receptor sites that

regulate anxiety.

Cont…

• SSRIs are a second line treatment of adult

obsessive compulsive disorder (OCD) with

mild functional impairment and as first line

treatment for those with moderate or severe

impairment.

Cont…• Disadvantage: Once medication is stopped, symptoms

usually re-occur so the person needs to be put on

medication indefinitely.

• The atypical antipsychotics such as quetiapine have also

been found to be useful when used in addition to an SSRI in

treatment-resistant OCD. However, these drugs are often

poorly tolerated, and have metabolic side effects that limit

their use. None of the atypical antipsychotics appear to be

useful when used alone.

Treatment

• Behavior Therapy- "exposure and response

prevention“ where the patient deliberately

confronts their feared object or idea.

• Ex: OCD hand washer touched “contaminated”

object and is forced to not wash hands until

anxiety goes down.

Cont…• Behavior therapy is successful for most patients as

long as the therapist is fully trained and the person

is highly motivated and has a positive attitude. It

lasts longer after treatment than drug therapy.

• Cognitive-behavioral- therapy emphasizing changing

the OCD’s patient’s beliefs and thinking patterns.

• Cognitive behavioral therapy (CBT) has been shown to be

the most effective type of psychotherapy for this disorder.

• The patient is exposed many times to a situation that

triggers the obsessive thoughts, and learns gradually to

tolerate the anxiety and resist the urge to perform the

compulsion.

• Medication and CBT together are considered to be better

than either treatment alone at reducing symptoms.

Treatment cont…

Cont…

• Psychotherapy can also be used to:

– Provide effective ways of reducing stress

– Reduce anxiety

– Resolve inner conflicts

Nursing Management

• Diagnoses Nursing Care Plans For Obsessive

Compulsive Disorder

Anxiety

Chronic low self-esteem

Fear

Ineffective coping

Cont…

Ineffective role performance

Impaired social interaction

Risk for injury

Social isolation

Some interesting facts…• English footballer David Beckham has been outspoken

regarding his struggle with OCD. He said that he has to count

all of his clothes, and his magazines have to lie in a straight

line.

• British poet, essayist, and lexicographer Samuel Johnson is

an example of a historical figure with a

retrospective diagnosis of OCD. He had elaborate rituals for

crossing the thresholds of doorways, and repeatedly walked

up and down staircases counting the steps.

Research Findings…

• Nutrition deficiencies may also contribute to OCD and other

mental disorders. Vitamin and mineral supplements may aid

in such disorders and provide nutrients necessary for proper

mental functioning.

• μ-Opioids, such as hydrocodone and tramadol, may improve

OCD symptoms. Administration of opiate treatment may be

contraindicated in individuals concurrently takingCYP2D6

inhibitors such as fluoxetine and paroxetine.

Cont…

• Much current research is devoted to the therapeutic

potential of the agents that affect the release of the

neurotransmitter glutamate or the binding to its receptors.

These include riluzole, memantine, gabapentin, N-

acetylcysteine, topiramate and lamotrigine.

References– "What is Obsessive-Compulsive Disorder (OCD)?". Retrieved 27 May2015.

– Diagnostic and statistical manual of mental disorders : DSM-5 (5 ed.).

Washington: American Psychiatric Publishing. 2013. pp. 237–242. ISBN

9780890425558.

– Angelakis, I; Gooding, P; Tarrier, N; Panagioti, M (25 March 2015).

"Suicidality in obsessive compulsive disorder (OCD): A systematic review and

meta-analysis.". Clinical Psychology Review 39: 1–15. doi:

10.1016/j.cpr.2015.03.002. PMID 25875222.

– Fenske JN, Schwenk TL (August 2009).

"Obsessive compulsive disorder: diagnosis and management". Am Fam

Physician 80 (3): 239–45. PMID 19621834.