Obsessive-Compulsive Disorder

What is obsessive-compulsive disorder?

Obsessive-compulsive disorder (OCD) is a disorder characterized by compulsive behaviors that are meant to reduce the anxiety caused by obsessive thoughts.

Obsessions are recurrent and persistent thoughts, impulses, or images experienced as intrusive and stressful. They are recognized as being excessive and unreasonable despite being a product of one’s mind. The thought, impulse, or image cannot be expunged by logic or reasoning.

Compulsions are repetitive, ritualistic behavior or thoughts, with the purpose of preventing or reducing distress, or preventing a dreaded event or situation. The individual feels driven to perform such actions in response to an obsession or according to rules that must be applied rigidly, even though the behaviors or thoughts are recognized to be excessive or unreasonable.

OCD is a highly disabling disorder with a lifetime prevalence of 1-2%. OCD peaks between ages 7-12 (boys more susceptible) and around age 21 (women more susceptible).

What does OCD look like?

Signs & Symptoms

Examples of obsessions:

Fear of being contaminated by touching objects others have touched
Doubts that you've locked the door or turned off the stove
Intense stress when objects aren't orderly or facing a certain way
Images of driving your car into a crowd of people
Thoughts about shouting obscenities or acting inappropriately in public
Unpleasant sexual images
Avoidance of situations that can trigger obsessions, such as shaking hands

Examples of compulsions:

Hand-washing until your skin becomes raw
Checking doors repeatedly to make sure they're locked
Checking the stove repeatedly to make sure it's off
Counting in certain patterns
Silently repeating a prayer, word, or phrase
Arranging your canned goods to face the same way

DSM-5 Criteria

Criterion A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e. by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

Criterion B. The obsessions or compulsions are time-consuming (e.g. take more than 1 hour a day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion C. The obsessive-compulsive symptoms are not attributable to the direct physiological effects of a substance or another medical condition.

Criterion D. The disturbance is not better explained by the symptoms of another mental disorder.

Subtypes & Specifiers

Obsessions

Can be external (environment-based) or internal (self-based), such as:

Contamination: Concerns about dirt, germs, illness, or body waste
Symmetry: Needing things to be "just so", even, or lined up in a certain arbitrary way
Aggressive: Focus on inadvertent harm, or thoughts or images of deliberately harming others
Sexual: Disturbing sexual thoughts that are not consistent with an individual's orientation or cultural norms, or unwanted inappropriate sexual thoughts about children
Religious: Examples include thoughts about selling someone's soul to the devil, deliberately thinking inappropriate thoughts about major religious figures, or committing sins
Somatic: Exaggerated fears of contracting a serious illness, such as a brain tumor, despite the absence of any identifiable risk

Compulsions

Can be physical/behavioral (actions) or mental/cognitive (thought-based), such as:

Washing: Excessive hand-washing, showering, or cleaning
Checking: Repeatedly turning the stove on and off, rereading all emails to ensure content is appropriate, driving around the block to ensure no one is hit, or asking for repeated reassurance
Ordering: Folding clothes a specific way, or arranging items to be positioned in specific ways
Counting: Performing actions a certain arbitrary number of times, such as tapping a finger on the doorframe 3 times every time when leaving a room
Repeat: Repeatedly going up and down the stairs or flushing the toilet; typically done until it feels "right" or cancels out a negative thought

Risk Factors

Highly heritable - half of affected individuals have a family history of OCD
Environmental factors such as infections and post-infectious autoimmune syndromes

Prognosis

OCD is chronic and fluctuating; however, children may experience remission by early adulthood
Factors associated with poor prognosis: early onset, poor insight, schizotypal features, thought/action compulsions

Differential Diagnosis

Substance/medication-induced obsessive compulsive symptoms
Specific phobia
Social anxiety disorder
Major depressive disorder
Body dysmorphic disorder
Trichotillomania
Hoarding disorder
Eating disorders
Psychotic disorders
Tic disorders and Tourette's
Obsessive-compulsive personality disorder

How is OCD investigated?

Labwork: anti-streptolysin O (ASO) and anti-DNAse B titres for acute or dramatic onset, or exacerbation of symptoms

Thorough history of the client's obsessions and compulsions.

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

Clinician/client rater
10-item scale with symptom severity rankings

Florida Obsessive Compulsive Inventory (FOCI)

Client rater
Can be used to monitor OCD symptoms

How is OCD treated?

Cognitive behavioral therapy (CBT) is the first line treatment for obsessive-compulsive disorder, especially in children. Medication can be considered if CBT alone is not effective. It's important to keep in mind that all forms of treatment for OCD takes commitment and longer time to see improvements.

Selective serotonin reuptake inhibitors (SSRI)
Other antidepressants
Some antipsychotics as adjunctive therapy

Nursing Management

Ineffective coping

Causes & Behaviors:

Situational or maturational crises
Fear of failure
Ritualistic behavior or obsessive thoughts
Inability to meet basic needs
Inability to meet role expectations
Inadequate problem solving

Interventions:

Investigate the types of situations that increase anxiety and result in ritualistic behaviors
Increasingly encourage independence and give positive reinforcement for independent behaviors to enhances self-esteem and encourage repetition of desired behaviors over undesired behaviors
Gradually limit the amount of time allotted for ritualistic behavior as client becomes more involved in unit activities
Encourage the client to recognize situations that provoke obsessive thoughts or ritualistic behaviors
Provide positive reinforcement for adaptive, nonritualistic behaviors

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Krebs, G., Isomura, K., Lang, K., Jassi, A., Heyman, I., Diamond, H., Advani, J., Turner, C., & Mataix-Cols, D. (2015). How resistant is "treatment-resistant" obsessive-compulsive disorder in youth? The British Psychological Society, 54, 63-75.

[4] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.