OBSESSIVE COMPULSIVE

DISORDER

Premnath R.

Definition

Obsessive compulsive disorder is a disorder

characterized by two main clinical features, recurrent

obsessions or compulsions (or a combination of both)

that are severe enough to cause marked distress or

significant deterioration in general functioning.

Obsessions:

It is defined as unwanted, intrusive, persistent ideas, thoughts, impulses or images that cause marked anxiety or distress. The most common include repeated thoughts about contamination, imagining doing harm, repeated doubts, a need to have things in a particular order aggressive or horrific impulses of sexuality and violence.

(APA, 2000)

Compulsions:

It is defined as unwanted repetitive

behaviour patterns or mental acts that are

intended to reduce anxiety, not to provide

pleasure or gratification. The common

compulsions involve ordering and

arranging, checking, touching, praying,

focusing on a number etc.

(APA, 2000)

Epidemiology

•It is equally common in men and women.

•Age of onset; 6-15 in males & 20-29 in females

•Onset is usually in childhood or early adult life.

•The course is variable and more likely to be chronic.

•Lifetime prevalence 2-3%.

•It is the fourth most common psychiatric disorder

(Rasmussen & Eisen, 1992)

•Tenth leading cause of disability in the world(WHO)

•Remains a significant social and health service

concern with high degrees of personal disability, co-

morbidity and relatively poor long-term prognosis

(Eisen et al., 1999;)

Common Obsessions & Compulsions

Obsessions

• Contamination

• Pathological doubt

• Somatic

• Need for Symmetry

• Aggressive

• Sexual

• Blasphemous

Compulsions

• Checking

• Washing

• Counting

• Need to ask or confess

• Ordering & Arranging

• Hoarding

• Miscellaneous rituals

Classification

F42 Obsessive-compulsive disorder

F42.0 Predominantly obsessive thoughts or

ruminations

F42.1 Predominantly compulsive acts

F42.2 Mixed obsessional thoughts and acts

F42.8 Other obsessive-compulsive disorders

F42.9 Obsessive-compulsive disorder, unspecified

Etiology

• Genetic factors

• Biological factors

• Psychoanalytic theory

• Behaviour theory

Genetic factors

• Twin studies have consistently found a significantly

higher concordance rate for monozygotic twins

than for dizygotic twins.

• Family studies of these patients shown that 35% of

the first degree relatives of OCD patients are also

affected by the disorder.

Biological factors

• Abnormal levels of the neurotransmitter, serotonin

in individuals with OCD.

• PET & SPECT have shown increased metabolism

and blood flow in the frontal lobes, basal ganglia,

cingulum of patients with OCD.

• CT and MRI studies revealed, bilaterally decreased

size of caudate in patients with OCD. In some

patients, enlarged basal ganglia can be noted.

12

PET & SPECT studies

Psychoanalytic theory

• Individuals with OCD have weak, under developed

egos.

• Clients with OCD are regressed to developmentally

earlier stages of the infantile super ego, whose harsh,

punitive characteristics, which now reappear as part of

the psychopathology.

• Regression to the pre-oedipal, anal sadistic phase

combined with the use of specific ego defense

mechanisms (isolation, undoing, displacement,

reaction formation) produces the clinical symptoms

of obsessions and compulsions.

Behaviour theory

• This theory explains obsessions as a conditioned

stimulus to anxiety.

• Compulsions have been described as learned

behaviour that decreases the anxiety associated

with obsessions.

• This decrease in anxiety positively reinforces the

compulsive acts and they become stable learned

behaviour.

Clinical Features• Obsessional thoughts

Words, ideas and beliefs that intrude forcibly into patient’s mind. They are usually unpleasant and shocking to the patient and may be obscene or blasphemous.

• Obsessional image

These are vividly imagined scenes, often of a violent or disgusting kind involving abnormal sexual practices.

• Obsessional ruminations

These involve internal debates in which arguments for and against even the simplest everyday actions are reviewed endlessly.

• Obsessional impulses

These are urges to perform acts, usually of a violent

or embarrassing kind, such as injuring a child,

shouting in church.

• Obsessional rituals

These may include both mental activities counting

repeatedly in a special way or repeating a certain

form of words, and repeated but senseless

behaviors. Sometimes such compulsive acts may be

preceded by obsessional thoughts.

• Obsessive slowness

Severe obsessive ideas or extensive compulsive rituals characterize obsessionalslowness in the relative absence of manifested anxiety. This leads to marked slowness in daily activities.

Other features are

• Recognition that the thoughts are produced in his or her own mind.

• Lack of concentration and task completion.

• Impaired social or work functioning.

Course and prognosis

•Long and fluctuating course

•Prognosis appears to be worse when the onset is in

childhood, the personality is obsessional, symptoms

are severe, compulsions are bizarre, or there is a

coexisting major depressive disorder.

Diagnosis

• History collection, Mental Status Examination, Physical

examination

• Imaging studies like MRI, CT, PET

• Based on ICD criteria

• Rating scales to assess severity of OCD.

E.g. Y-BOCS (Yale-Brown Obsessive Compulsive Scale),

Maudsley Obsessive Compulsive Inventory.

TREATMENT

Pharmacotherapy

• Benzodiazepines; limited role

E.g. alprazolam, clonazepam

• Antidepressants;

SSRIs- e.g. Fluoxetine 20-80mg/day, Fluvoxamine

50-200mg/day, Paroxetine 20-40mg/day, and

Sertraline 50-200mg/day.

• Non-specific SRI- Clomipramine 75-300mg/day, was

the first drug used effectively in the treatment of OCD.

• Antipsychotics; Occasionally used in low doses in the

treatment of severe, disabling anxiety. E.g. haloperidol,

risperidone, aripiprazole, pimozide

• Buspirone has also been used beneficially as an adjunct

for augmentation of SSRIs.

Psychotherapy

• Psychoanalytic psychotherapy to those patients

who are psychologically oriented.

• Supportive psychotherapy to the clients as well

as the family members.

Behavior therapy

• Exposure and Response Prevention (ERP)

• Thought stoppage

• Relaxation technique

• Systematic desensitization

• Modeling

• Aversive conditioning techniques

• Exposure and Response Prevention (ERP):

It involves repeated exposure to the source of patient’s

obsession. Then the patient is asked to refrain from the

compulsive behavior that the patient usually performed

to reduce the anxiety.

For example, compulsive handwashers are encouraged

to touch contaminated objects and then refrain from

washing in order to break the negative reinforcement

chain.

• Thought stoppage: It help an individual to learn to stop

thinking unwanted thoughts. Steps are,

– Ask client to sit comfortably and ask to bring the

unwanted thoughts into the conscious mind at a rate

of one at a time.

– As soon as the thought forms, give the command

‘STOP’. Follow this with calm and deliberate

relaxation of muscles and diversion of thought to

something pleasant.

– Repeat the procedure to bring the unwanted thought

under control.

• Relaxation technique: Includes deep breathing

exercise, Progressive Muscle Relaxation, meditation,

imagery, music etc.

• Modeling- The person is exposed to a model behavior

and is induced to copy it.

• Aversive conditioning techniques- Pairing of pleasant

stimulus with unpleasant response, so that even in

absence of unpleasant response, the pleasant

stimulus becomes unpleasant by association.

Systematic desensitization-

It is based on work of Joseph Wolpe.

Desensitization (also known as exposure

therapy), is a cognitive-behavioral therapy in

which people are gradually exposed to the

frightening object or event until they become used

to it and their physical symptoms decrease.

Components of Desensitization

• Relaxation

• Hierarchy construction

• Visualizations

• Item presentation

• In vivo assignments

Procedure

• Teach progressive relaxation.

• The client is asked to outline an anxiety or phobia hierarchy, a step by step approximation of the feared situation in which the client, with guidance from the therapist, lists the lowest anxiety situation to the highest. This is called hierarchy construction.

• During visualization training, a client imagines himself in a variety of situations.

• In item presentations client relaxes and then

imagines himself in each of phobic situations on the

hierarchy he was created. It should be done in a slow

and systematic fashion: one item at a time.

• The client is advised to signal whenever anxiety is

produced. With each signal, he is asked to relax. After a

few trials, the client is able to control his anxiety.

• Thus gradually the hierarchy is climbed till the

maximum anxiety-provoking stimulus can be faced in

absence of anxiety.

Electroconvulsive therapy

• Indicated in patients with severe depression,

suicidal risk etc.

Psychosurgery

• The procedures used are Stereotactic limbic

leucotomy and Stereotactic subcaudate

tractotomy.

• It is available only at very few centers in the world.

NURSING MANAGEMENT

Assessment

• Collection of physical, psychological and social data

• Know the impact of obsessions and compulsions on

physical functioning, mood, self-esteem and

normal coping ability

• Identify defense mechanisms used, thought

content, potential for suicide, ability to function,

and social support system available.

Nursing diagnosis 1

• Severe Anxiety related to earlier life conflicts as evidenced by repetitive action (e.g., hand-washing), recurring thoughts (e.g., dirt and germs), decreased social and role functioning

Goals

• Demonstrates ability to cope effectively with stressful situations without resorting to obsessive thoughts or compulsive behaviors.

Interventions

• Establish relationship through use of empathy, warmth,

and respect.

• Verbalize empathy toward client’s experience rather than

disapproval or criticism.

• Assist client to learn stress management, (e.g., thought-stopping, relaxation exercises, imagery).

• Identify what the client perceives as relaxing (e.g.warmbath, music).

• Engage in constructive activities such as quiet games that require concentration.

• Encourage participation in a regular exercise program.• Give positive reinforcement for non-compulsive

behavior. Avoid reinforcing compulsive behavior. • Assist client to find ways to set limits on own behaviors.

At the same time allow adequate time during the daily routine for the ritual(s).

• Limit the amount of time allotted for the performance of rituals. Encourage client to gradually decrease this time.

• Discuss home situation, include family in discharge plan.

Nursing diagnosis 2

• Ineffective individual coping related to underdeveloped ego, punitive superego, avoidance learning, possible biochemical changes, evidenced by ritualistic behavior or obsessive thoughts.

Goal

• Demonstrates ability to cope effectively without resorting to obsessive-compulsive behaviors.

Interventions

• Work with patient to identify the situations that increase anxiety and result in compulsive acts.

• Encourage independence in patient and give positive reinforcement for independent behaviors.

• In the beginning of treatment, give plenty of time for ritualistic behavior. Do not be judgmental or verbalize disapproval of behavior.

• Support patient’s efforts to explore the meaning and purpose of behavior.

• Provide structured schedule of activities for the patient, including adequate time for completion of rituals.

• Gradually limit the amount of time allotted for ritualistic behavior as patient becomes more involved in unit activities.

• Give positive reinforcement for non-ritualistic behaviors.

• Help patient to learn techniques like thought stopping, relaxation and exercise.

Nursing diagnosis 3

• Impaired social interaction related to inability to control thoughts, images and impulses in a purposeful, voluntary manner.

Goal

• Verbalizes understanding that thoughts, impulses and images are involuntary and may worsen with stress.

Interventions

• Approach client in a calm, direct, non-authoritarian manner, using a soft tone of voice.

• Listen actively to the client’s obsessive themes no matter how absurd or incongruent they may seem.

• Assist client to gain control of overwhelming feelings and impulses through verbal interactions.

• Protect the client who is at the risk for suicide.

• Assist client in planning the rest periods between planned activities and rituals.

• In the beginning of treatment, give plenty of time for ritualistic behavior. Do not be judgmental or verbalize disapproval of behavior.

• Gradually limit the amount of time allotted for ritualistic behavior as patient becomes more involved in unit activities.

• Activate the client toward activities that will reduce stress or anxiety (warm bath, taking walk, listening to music etc.)

• Ask client to stay connected to family and friends.

• Ask client to choose one or two ‘worry periods’ each day,

time he can devote to obsessing. Choose a set and place.

During this time, focus only on negative thoughts or

urges. Don’t try to correct them. At the end of worry

period, take a few calming breaths, let the obsessive

thoughts or urges go, and return to normal activities. The

rest of the day, however, is to be designated free of

obsessions and compulsions. When thoughts or urges

come into patient during the day, write them down and

‘postpone’ them to worry period.

Nursing diagnosis 4

• Ineffective role performance related to the need to perform rituals, evidenced by inability to fulfill usual patterns of responsibility.

Goal

• Client resumes role-related responsibilities.

Interventions

• Determine patient’s previous role within the family and the extent to which this role is impaired by the illness.

• Encourage patient to discuss conflicts evident within the family system. Identify the responses of patient and family members.

• Explore available options for changes in role. Practice through role-play.

• Give patient lots of positive reinforcement for ability to resume role responsibilities by decreasing need for ritualistic behaviors.