Obsessive-compulsive disorder (OCD)

Obsessive-Compulsive Disorder

• Obsessions are recurring, persistent, intrusive thoughts or impulses that cause anxiety.
• Compulsions are ritualistic or repetitive behaviors or mental acts performed to neutralize anxiety caused by obsessions (intrusive thoughts).
• Trying to suppress the obsessive thought or image makes it more intense.
• Performing compulsive behaviors relieves anxiety, while not performing them escalates anxiety.
• Rituals are repetitive, meaningless, and difficult to correct.
• Rituals interfere with normal routines and are time-consuming.
• Common obsessions include losing control, religious concerns, harm, unwanted sexual thoughts, perfectionism, violence, contamination, and superstitions.
• Corresponding compulsions can be behaviors like avoiding church, repeatedly checking things, ritualistically locking doors, working excessively, avoiding certain people, excessive cleaning, or adding/deleting items from lists.

Clinical Vignette: OCD

• The example shown is of a person showering. The person scrubs with a washcloth vigorously over every inch of his body repeatedly to get off germs,.
• The person takes 30 minutes scrubbing and scrubbing, and is careful to step on the clean bath towel.
• He dries himself making sure the towel does not touch the floor or sink.
• He then believes he is not clean and gets back in the shower to start again.

Treatment of OCD

• Treatment involves a combination of medications and therapy.
• First-line medications are selective serotonin reuptake inhibitors (SSRIs) like fluvoxamine and sertraline.
• Second-line medications are serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine.
• Second-generation antipsychotics such as risperidone and aripiprazole may be use for treatment-resistant OCD.
• Behavioral therapy includes exposure, which involves deliberately confronting situations and stimuli that the client usually avoids.
• An example of exposure is touching a doorknob in a public place.
• Response prevention involves delaying or avoiding performing rituals to tolerate the thoughts and anxiety.
• These therapies should happen at a gradual approach, and are not done immediately.

OCD and Nursing Process Application

• Therapeutic communication is key, encouraging clients to discuss their feelings and validating those feelings to help them regain control.
• Managing rituals/compulsions is an important part of treatment.
• Initiate a gradual approach: Do not stop the ritual initially.
• Incorporate the time a client spends on rituals into their daily routine and then allow patient to perform rituals / compulsions.
• Gradually decrease the time used for rituals; for instance, reducing hand washing from 1 hour to 50 minutes, then progressively decreasing the duration.
• Treatment is considered effective when OCD symptoms no longer interfere with the client's ability to fulfill responsibilities.
• While symptoms may persist over time, the focus is on enabling the patient to successfully manage their responsibilities despite the presence of these symptoms.

Related Compulsive Disorders

• Self-soothing behaviors: Excoriation (skin-picking), trichotillomania (hair-pulling), onychophagia (chronic nail-biting)
• Body dysmorphic disorder (BDD)
• Hoarding disorder
• Kleptomania
• Oniomania
• Body identity integrity disorder (BIID)

Self-Soothing Behaviors

• Excoriation (skin-picking): Focuses on the face, head, cuticles, back, arms, legs, hands, and feet, using fingers, fingernails, teeth, nail cutters, or tweezers, and can lead to pain, sores, scabs, and infections.
• Trichotillomania (hair-pulling): Focuses on hair of the head, eyebrows, eyelashes, pubic hair, and axillae, causing varied amounts of hair removal, and sometimes involves tricophagia (swallowing pulled hair), which occurs commonly in trichotillomania and can lead to abdominal obstruction.
• Onychophagia (chronic nail-biting): Can lead to complications involving the nails and oral cavity

Body Dysmorphic Disorder

• Individuals with BDD have a normal appearance but are preoccupied with an imagined defect or the exaggeration of a minor defect in their body.
• People with BDD blame all of their problems on their conceived "flawed" appearance.
• Body dysmorphic disorder can lead to compulsive mirror checking, camouflaging, and elective surgeries.
• Higher prevalence in women, men focused on body build and genitals, and women focused on skin, stomach weight, breast, buttocks, thighs, legs and hips.
• There is a higher incidence in patients seeking cosmetic surgery, dermatology treatment, adult orthodontia, and oromaxillofacial surgery.

Body Identity Integrity Disorder (BIID)

• BIID is used to describe people who feel "overcomplete" or alienated from a part of their body
• Individuals describe feelings of anguish due to their intact bodies and desire amputation.
• Those with BIID feel relieved and natural after an amputation. Terms for this include amputee identity disorder, apotemnophilia, or amputation love.
• Few surgeons agree to perform amputations due to ethical concerns, so patients resort to actions that cause severe damage to their limbs until amputation becomes a medical necessity.

Hoarding Disorder

• Hoarding involves excessive acquisition of animals or apparently useless items, cluttered living spaces that become uninhabitable, and significant distress or impairment for the individual.
• Family or visitors can no longer visit.
• Hoarding is associated with indecisiveness and more common in females.
• Hoarding occurs most commonly between the ages of 20 to 30.

Reward-Seeking Behaviors

• Kleptomania is compulsive stealing that's common in females.
• This is a repeated failure to resist urges to steal objects not needed for personal use or monetary value.
• Reward in kleptomania is the thrill of not being caught, not the stolen item itself and is different from stealing.
• Oniomania is compulsive buying, common in females and college students.
• Pyromania is defined by repeated deliberate fire setting, experiences excitement and or pleasure in setting fire or witnessing fire.
• Fire setting is done solely to bring this relief and/or pleasure and not for other reasons, such as to conceal a crime and is more common in males.