Obsessive compulsivedisorder

OCD (mhn )

1. Obsessive compulsivedisorder mr .pritesh d patel msc nursing in MHN

2. INTRODUCTION • obsessive-compulsive disorder is a mental disorder whose main symptoms include obsessions and compulsions, driving the person to engage in unwanted, often-times distress behaviors or thoughts. The obsessions are usually related to a sense of harm, risk or injury. The common Obsessions include concern about contamination, doubt, fear of loss or letting go, fear of physically injuring someone.It’s treatment is done through a combination of psychiatric medications and psychotherapy.

3. DEFINITIONS Obsessions: Obsessions are recurrent and persistent thoughts, impulses, or images that cause distressing emotions such as anxiety or disgust. These intrusive thoughts cannot be settled by logic or reasoning. Typical obsessions include excessive concerns about contamination or harm, the need for symmetry or exactness, or forbidden sexual or religious thoughts.

4. COMPULSIONS Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing distress or a feared situation. Although the compulsion may bring some relief to the worry, the obsession returns and the cycle repeats over and over. Some of the common compulsions include cleaning, repeating, checking, ordering and arranging , Mental compulsions e.t.c

5. DEFINTION OF OCD Obsessive-Compulsive Disorder:- (OCD) is a common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over. An obsession is defined as an idea, impulse, or image which intrude into the conscious aware repeatedly.

6. CAUSES OF THE DISORDER Biological Factors: • People with a first degree relative (parent or sibling) with OCD have a 5 times greater risk of having the illness. • identical twins have more chances of developing OCD as compared to dizygotic twins.

7. Psychoanalytical Theory : According to the Frued’s psychoanalytical theory OCD arises when unacceptable wishes and impulses from the id are only partially repressed. They cause anxiety. Ego defence mechanisms are used to reduce the anxiety. These defence mechanisms are used unconsciously in the form of acts, such as hand washing. These acts are thought to be symbolically undo the unacceptable id impulses. Behavior Theory: This theory explains Obsessions as a conditioned stimulus to anxiety. Compulsions have been described as learned behavior that decreases the anxiety associated with the Obsessions. This decrease in anxiety positively reinforces the compulsive acts and they become stable learned behavior.

8. Neuroanatomical Factors: • there is evidence of abnormal brain structure and activity in patients with OCD. • these abnormalities are found in the pathway linking the lobes (responsible for judgement) with the basal ganglia (which are part of the system frontal for planning behaviour) • Serotonin deficiency – OCD sufferers have too little serotonin for their nerve cells to communicate effectively

9. CLASSIFICATION OF OCD ICD-10 classifies OCD into 3 clinical subtypes according to the symptoms: 1. Predominantly absessive thought or rumination 2. Predominantly compulsive acts. 3. Mixed Obsessional thoughts and acts.

10. CLINICAL FEATURES OF OCD 1. Washers (obsessional rituals) This is the most common type. Here the obsession is of contamination with dirt,germs, body excretions and the like. The compulsion is washing of hands or thewhole body, repeatedly many times a day. It usually spreads onto washing of clothes, bathroom, bedroom, door knobs and personal articles, gradually. The person tries to avoid contamination but unable to, so washing becomes a ritual.

11. 2. Checkers (obsessional doubt) In this type the person has multiple doubts that the activities may not have been completed adequately. for example the door has not beenlocked, kitchen gas has been left open, counting of money was not exact and etc.the compulsion, of course, is checking repeatedly to remove the doubt. Anyattempts to stop the checking leads to mounting anxiety before one doubt has been cleared, other doubts may creep in. 3. Pure obsessions (intrusive thoughts) This syndrome is characterized by repetitive intrusive thoughts, impulses or images which are not associated with compulsive acts. The distress associated with these obsessions is dealt usually by counter thought for e.g praying, undoing actions et.c a. Obsessional thoughts: these are words . ideas and beliefs ghat intrude forcibly into the patients mind. They are usually unpleasant and shocking to the patient and may be obscene and blastophemous. E.g. Orderliness, sexual imagery repeated doubts et.c.

12. b. Obsessional images: These are vividly imaginary scenes often of a violent or disgusting kind involving abnormal sexual practice c. Obsessional impulses: These are the urges to perform acts usually of a violenyt or embarrassing kind, such as injuring a child, shouting in church etc c. Obsessional ruminations: These involve internal debates in which arguments for and against even the simplest everyday actions are reviewed endlessly. 4. Primary obsessive slowing (symmetry) It is characterized by several obsessive ideas and or extensive compulsive rituals , in the relative absence of manifested anxiety. this leads to marked slowness in daily activity. usually the person demand on being need for symmetry and precise arranging so in order to neutralize it they will continue ordering, arranging, balancing, straightening until "just right" or perfect in their eyes.

13. DIAGNOSIS OF OCD • Suggested by demonstration of realistic behavior that is irrationl or excessive. • MRI and CT shows enlarged Basal Ganglia in some patients. • PET(Positron emisaion Tomography) shows incresed glucose metabolism in part of the basal ganglia. • ICD-10 criteria

14. TREATMENT MODALITIES 1. Psychotherapy • Psychodynamic psychotherapy • Cognitive Behavior therapy • Supportive therapy 2. Phrmcologicl treatment 3. ECT 4. Self help and coping 5. Psychosurgery 18. PSYCHODYNAMIC PSYCHOTHERAPY This can be used for the patients who are psychologically oriented. The therapy is based on psychoanalysis in which the patient is made conscious about their unconscious thoughts and motivations thus gaining insight.

15. PSYCHODYNAMIC PSYCHOTHERAPY A woman comes to therapist stating that she is chronically late and has done everything that she can to change this through a variety of organizational tools and methods but to not avail. Her behavior is interfering with her work and relationships. The therapist and client discover that being early or even on time put her at risk of waiting for the person that she was meeting. Waiting evoked uncomfortable needful feelings, especially when she was waiting for someone on whom she was reliant. This in part had roots in traumatic experiences in her childhood around being forgotten by her parents and having to wait for them: in those situations she had felt helpless, frightened and dependent. With the help of her therapist, she gradually grew to tolerate her needful and dependent feelings and with that, no longer needed to eliminate these feelings either by being late or through other problematic behaviors.

16. COGNITIVE BEHAVIOR THERAPY During treatment sessions, patients are exposed to the situations that create anxiety and provoke compulsive behavior or mental rituals. Through exposure, patients learn to decrease and then stop the rituals that consume their lives. They find that the anxiety arising from their obsessions lessens without engaging in ritualistic behavior. This technique works well for patients whose compulsions focus on situations that can be re-created easily.2 2. PHARMACOLOGICAL TREATMENT 1. Benzodiazepines • Alprazolam(0.5-1mg/day) • Clonazepam(0.25-0.5 mg/day) 2. Antidepressants Clomipramine(75-300mg/day) Fluoxetine(20-80mg/day) Fluvoxamine(50-200mg/day) 3. Antipsychotics- these are occassionally used in low doses in the treatment of severe anxiety e.g. Haloperidol,Risperidine, Olanzepine.

17. 3. ELECTRO-CONVULSIVE THERAPY Electroconvulsive Therapy (ECT)In the presence of severe depression with OCD, ECT may be needed. ECT is particularly indicated when there is a risk of suicide and/or when there is a poor response to the other modes of treatment. 4. SELF-HELP AND COPING Keeping a healthy lifestyle and being aware of warning signs and what to do if they return can help in coping with OCD and related disorders. Also, using basic relaxation techniques, such as meditation, yoga, visualization, and massage, can help ease the stress and anxiety caused by OCDPSYCHO SURGERY In severe chronic incapacitating cases, where all other treatment have failed, Streotactile site speciefic brain surgery hs been reported to be successful. These surgery includes: 1. Anterior cigulotomy 2. Capsulotomy 3. Limbic leucotomy These surgery involve the separation of the frontal cortex from deep limbic structure.

18. NURSING MANAGEMENT . NURSING ASSESSMENT • Social impairment • Obsessive thought (repetitive worries, repeating and counting images or words) • Compulsive behaviour (repetitive activity, like touching, counting, doing or undoing) NURSING DIAGNOSIS 1. Severe anxiety related to absessional thoughts and impulses as evidenced by repetitive actions and decresed social functioning. 2. Ineffective individual coping relted to under developed ego, punitive super ego, avoidance learning, possible biochemical changes as evidenced by realistic behavior. 3. Altered role performance related to the need to perform rituals, as evidenced by inability to fulfill usual patterns of responsibility

19. 4. Chronic low self-esteem relted to the obsessiinal thoughts and rituals s evidenced by social isolation and low self confidence. 5. Sleep pttern disturbnces related to the obsessional doubts and fears s mnifested by repetitive checking of doors nd not sleeping prope . TO REDUCE ANXIETY • Establish relationship through use of empathy,warmth, and respect. • Acknowledge behavior without focusing attention on it. Verbalize empathy toward client’s experience rather than disapproval or criticism. • Assist client to learn stress management, (e.g.,thought- stopping, relaxation exercises, imagery) • Give positive reinforcement for noncompulsive behavior. • Assist client to find ways to set limits on own behaviors.

20. 2 . TO REDUCE OBSESSIVE COMPULSIVE BEHAVIOR • Work with ptient to determine the type of situations that increase anxiety and result in such behvior. • Meet the patient dependency needs. • Provide positive reinforcement. • Support patients efforts to explore the meaning and purpose of behavior. • Provide structured schedule activities for patient, including adequte time for performing rituals. • Help the ptient lern wys of interrupting absessive thoughts. 31. 3. IMPROVE ROLE RELTED RESPONSIBILITIES • Determine patients previous role within the family nd the extent to which the role is altered by the illness. • Encourge patient to discuss conflicts evident within the family system. • Explore availble options for changes for djustment in the role. • Practice through role play. • Provide positive reinforcement. 32. DIFFERENCE FROM OTHER ANXIETY DISORDERS • phobias – the stimulus that provokes the anxiety comes from an external object or situation. • panic disorder or generalised anxiety disorder – panic attacks are unpredictable and not linked to obsessional thoughts.