Obsessive Compulsive Disorder | Psychiatric Nursing | Juhin J

Obsessive-compulsive disorder (OCD) is a chronic and relapsing anxiety disorder that is characterized by persistent obsessive thoughts and/or repetitive compulsive actions that impair daily functioning. The repetitive actions can be mental or physical acts, either of which is perceived by the individual as reducing anxiety. Individuals with OCD might recognize the irrationality of their anxiety-driven patterns, they feel helpless to resist the compulsive urges that serve as dysfunctional coping mechanisms to reduce anxiety. Many patients prefer to keep ritualistic compulsions such as repetitive checking of locks or repeated hand washing a secret because they are ashamed of their illogical behavior.

Definition:
Obsession: Repetitive thoughts, images and doubts which make a person absolutely senseless and irrational. Individual tries to resist but finds unable to do so because that restriction might increase the level of anxiety.
Compulsion: Repetitive actions are performed followed by obsession in order to avoid the marked distress even though the client knows that behavior is unrealistic, senseless and irrational.

Etiology/ Predisposing factors:
I. Biological Theories:
a) Neurotransmitters:
Studies have suggested that changes in brain serotonin(5-HT) function may contribute to anxiety symptoms and anxiety type behaviors. Among anxiety disorders, the most compelling evidence implicating 5-HT exists for OCD.
OCD patients were found to have higher plasma free 3-methoxy-4-hydroxy-phenylglycol and plasma norepinephrine levels. The maximum number of binding sites (Bmax) for tritiated clonidine was significantly greater in OCD patients than in normal people. There was a blunted growth hormone, cortisol and ACTH response to clonidine in OCD.
b) Genetics:
Family studies: 35% of first-degree relatives of OCD clients might suffer from this disorder.
Twin studies: Monozygotic twins are more prone to it as compared to dizygotic twins.
c) Electrophysiological Studies:
Electroencephalography: Many of the earlier reports suggested EEG abnormalities in OCD. Temporal lobe spikes and increased theta waves have been reported in sleep EEG or OCD subjects.
Evoked Potentials: Higher N60 amplitudes were found in somatosensory evoked patients in OCD. Obsessional patients are characterized by reduced amplitudes and decreased latencies of late EP component.
d) Brain Imaging:
Cranial CT and MRI scans: An increase in ventricular-brain ratio was found in cranial CT in OCD. Subsequent studies have shown similar results in caudate nuclei. Earlier reports found non-specific abnormalities on Magnetic Resonance Imaging of the brains in OCD.

Management:
IV. Psychosurgery:
There are various procedures that have been used in treatment of OCD. They are as follows;
• Prefrontal leucotomy
• Transorbital leucotomy
• Biomedical leucotomy
• Orbital leucotomy
• Rostral leucotomy
• Limbic leucotomy
• Subcaudate tractotomy

1. JUHIN. J
2
nd
Year Msc(N)

2. OBJECTIVES:
At the end of this session, you’ll have clear understanding about;
Definition of OCD
Epidemiology
Onset and course
Classification of OCD
Etiologyof OCD
Clinical features of OCD
Psychopathology of OCD
Diagnostic criteria of OCD
Differential diagnosis of OCD
Management of OCD
Nursing process of OCD

3. INTRODUCTION
Obsessive-compulsive disorder (OCD) is a chronic and relapsing anxiety disorder
that is characterized by persistent obsessive thoughts and/or repetitive compulsive
actions that impair daily functioning.
The repetitive actions can be mental or physical acts, either of which is perceived
by the individual as reducing anxiety.
Individuals with OCD might recognize the irrationality of their anxiety-driven
patterns, they feel helpless to resist the compulsive urges that serve as
dysfunctional coping mechanisms to reduce anxiety.
Many patients prefer to keep ritualistic compulsions such as repetitive checking of
locks or repeated hand washing a secret because they are ashamed of their illogical
behavior.

4. DEFINITION
Obsession: Repetitive thoughts, images and doubts which make a person
absolutely senseless and irrational. Individual tries to resist but finds unable to do so
because that restriction might increase the level of anxiety.
Compulsion: Repetitive actions are performed followed by obsession in order to
avoid the marked distress even though the client knows that behavior is unrealistic,
senseless and irrational.

5. EPIDEMIOLOGY
•OCD was found to have a lifetime prevalence of 2.5%.
•The overall prevalence of OCD is equal in males and females.
•Symptoms of OCD usually begin in individuals aged 10-24 years.
•The incidence of OCD is higher in dermatology patients and cosmetic
surgery patients.
•OCD ranks tenth in leading causes of disability and, in the case of
women aged 15–44 years, it occupies the fifth position.

6. ONSET & COURSE
•OCD can start in childhood, mostly in males.
•Onset is usually gradual, although there have been cases of acute onset with
periods of waxing and waning symptoms.
•Nearly 30% of OCD patient have current or past tic disorder.
•Average time between onset and treatment is 11 years.
•Nearly one-third of patients with OCD refuse treatment, stop treatment, or
do not respond to treatment.
•Half of patients who have successful treatment experience residual
symptoms.
•Up to two-thirds of patients with OCD have suicidal thoughts at some point
and 10-13% attempt suicide.

7. CLASSIFICATION
According to ICD 10, OCD is classified into three; they are;
➢Predominantly Obsessional Thoughts
➢Predominantly Compulsive Acts (Obsessional rituals)
➢Mixed Obsessional Thoughts and Acts

8. ETIOLOGY/ PREDISPOSING FACTORS
The etiology of OCD is classified under few subheadings, they are;
Biological theories
oNeurotransmitters
oGenetics
oElectrophysiological studies
oBrain imaging
Behavioral theories
Psychodynamic theories

9. CLINICAL FEATURES
Obsessions include the following:
•Contamination
•Safety
•Doubting one's memory or perception
•Scrupulosity (Religious obsession)
•Need for order or symmetry
•Unwanted, intrusive sexual/aggressive
thoughts
Compulsions include the following:
•Cleaning/washing
•Checking (eg, locks, stove, iron, safety
of children)
•Counting/repeating actions a certain
number of times or until it "feels right"
•Arranging objects
•Touching/tapping objects
•Confessing/seeking reassurance
•List making

10. PSYCHOPATHOLOGY
OCD is thought to result from a disruption in the serotonin system
of the brain; abnormalities in dopaminergic transmission and overactivity of certain
brain regions (e.g., the orbitofrontal cortex) might also be involved. OCD can
coexist with or be part of a spectrum of other brain disorders, including Tourette
syndrome, and is often accompanied by depression, eating disorders, substance
use disorders, or other anxiety disorders.
Both OCD and generalized anxiety disorder (GAD) are characterized
by excessive worry and anxiety. The difference is that anxiety in GAD is typically
realistic but excessive, and in OCD the anxiety is typically unrealistic and irrational.

11. DIAGNOSTIC CRITERIA
The diagnostic criteria for OCD in DSM-5 require the presence of obsessions
and/or compulsions that are time consuming (e.g., take more than 1 hour per day) or cause
clinically significant distress or impairment in social, occupational, or other important areas
of functioning.
The signs and symptoms must not be better accounted for by substance
use/abuse or other mental health disorders such as an eating disorder, trichotillomania,
body dysmorphic disorder, tic disorder, Tourette syndrome, hypochondriasis, or paraphilia.

12. DIFFERENTIAL DIAGNOSIS
•It is important to distinguish the obsessional thinking of OCD from the
delusional thinking of schizophrenia or other psychotic disorders.
•Obsessions are usually unwanted, resisted, and recognized by patients as
coming from their own thoughts. whereas delusions are generally regarded as
distinct from patients' thoughts and are typically not resisted.
•For example, patients with depression often experience obsessive ruminations
that can be distinguished from obsessions because they are transient, not
considered unwanted, and not resisted.

13. MANAGEMENT
I. Pharmacological Management:
a)Benzodiazepines: -Clonazepam, Lorazepam, Alprazolam
b) Antidepressants:
Selective Serotonin Reuptake Inhibitors (SSRI)
•Fluoxetine 20-80 mg/ day
•Clomipramine 75-300 mg/day
•Fluvoxamine 50-200 mg/ day
•Sertraline 50-200 mg/ day
c) Antipsychotics: -Haloperidol, Olanzapine, Risperidone, Pimozide
d) Anti-anxiety: -Buspirone

14. MANAGEMENT
II. Non-Pharmacological Management:
a)Psychotherapy
b) Behaviortherapy
•Thought stopping technique
•Rubber band method
•Exposure and response prevention
•Systematic desensitization
•Modelling
Cont.

15. MANAGEMENT
III. Electro Convulsive Therapy:
•Refractory patients may benefit from a trial of 8-10 ECTs.
•Improvement is observed in patients, who have agitation
and lack of premorbid anankastic traits.
IV. Psychosurgery:
•Limbic Leucotomy
•Subcaudatetractotomy
Among psychiatric syndromes, OCD is the second-best responder to
stereotaticpsychosurgery. The first responder is sexual perversions.
Cont.

16. NURSING PROCESS
Risk for suicide
Panic Anxiety
Ineffective coping
Ineffective impulse control
Ineffective role performance

17. JOURNAL DISCUSSION
A study was conducted in Australia to find the association between OCD and eating disorders. 320
females with eating were selected as samples. Information was collected using semi-structured EATATE
interview and Eating Disorder Inventory-2. Results revealed that ascetism, social insecurity, ineffectiveness
and impulsivity had highest influence over OCD and eating disorders. (Giles et.al, 2022)
A study was conducted to investigate the differences in empathy, compassion, and Theory of
Mind in individuals with OCD as a possible cause for social functioning deficits. 64 individuals diagnosed
with OCD and 62 healthy individuals were selected as samples. Data collection was done using naturalistic
behavioral task(EmpaToM) and self-report measure(Interpersonal Reactivity Index). Results revealed that
people with OCD exhibited higher empathy levels like increased sharing of others suffering compared to
healthy individuals; Compassionate caring for others was high among OCD patients. (Salazar et.al, 2021)
A study was conducted in Brazil to describe the relationship between family accommodation of
relatives of OCD patients and their perceptions about the obsessions and compulsions of the patient. Data
was collected through interview method using Family Accommodation Scale for Obsessive-Compulsive
Disorder -Interviewer Rated (FAS-IR). Results revealed that the level of family accommodation was higher
in those family members who lived with the patient when compared to those who did not live with them.
(Matos et.al, 2020)

19. SUMMARY

20. REFERENCES
Books:
Lalitha.(2015). Mental Health and Psychiatric Nursing. P. 367-373
Mary C. Towsend.(2015). Psychiatric Mental Health Nursing (8th ed.). P. 543,878,909
Norman, Lee, Carol. Psychiatric Nursing (5th Edition). P. 396-403
Prakash.(2020). Mental Health and Psychiatric Nursing. P.229-231
Sheila L. Videbeck.(2015). Psychiatric -Mental Health Nursing (5th ed.). P. 243-245
Subash Indra Kumar.(2014). Psychiatry and Mental Health Nursing. P. 386-390
Journals:
European Eating Disorders Review, Bridging of childhood obsessive-compulsive personality disorder traits and
adult eating disorder symptoms: A network analysis approach, Vol 30(2), 2022, P. 110-123
Psychology and Psychotherapy: Theory, Research and Practice, Empathy, compassion, and theory of mind in
obsessive-compulsive disorder, Vol 95, Issue 1, 2021, P. 1-17
International Journal of Social Psychiatry, Family perception of the symptoms of obsessive-compulsive disorder
patient and the family accommodation, Vol 68(1), 2020, P. 73-81