CHAPTER 15: OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Chapter 15: Obsessive-Compulsive and Related Disorders

Key Terms:
o Compulsions: ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an
attempt to neutralize anxiety
o Dermatillomania/ Excoriation: compulsive skin picking, often to the point of physical damage; an
impulse control disorder
o Exposure: behavioral technique that involves having the client deliberately confront the situations and
stimuli that he or she is trying to avoid
o Obsessions: recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that cause
marked anxiety and interfere with interpersonal, social, or occupational function
o Oniomania: compulsive buying; possessions are acquired compulsively without regard for cost or need
for the item
o Onychophagia: compulsive nail biting
o Response Prevention: behavioral technique that focuses on delaying or avoiding performance of rituals in
response to anxiety- provoking thoughts
o Tricotillomania: compulsive hair pulling from scalp, eyebrows, or other body parts; leaves patchy bald
spots that the person tries to conceal
Learning Objectives:
o Discuss etiologic theories of obsessive-compulsive disorder (OCD)
Etiology is being studied from a variety of perspectives
Cognitive Model:
Arises from Aaron Becks cognitive approach to emotional disorders
Has long been accepted as a partial explanation for OCD, particularly since CBT is a
very successful treatment
Describes the persons thing as:
o Believing ones thoughts are overly important, this is, if I think it, it will
happen, and therefore having a need to control those thoughts
o Perfectionism and the tolerance of uncertainty
o Inflated personal responsibility (from a strict moral or religious upbringing) and
overstimulation of the threat posed by ones thoughts
Focuses on childhood and environmental experiences of growing up
Genetic Model:
Identified the influence of the SLC1A1 gene in twin studies, which has ben successfully
replicated
Involves chromosomal region 9p24. This contains the gene encoding the neuronal
glutamate transporter, SLC1A1. SLC1A1 represents a gene for OCD based on evidence
from neuroimaging and animal studies that altered glutamatergic neurotransmission is
implicated in the pathogenesis of OCD
Immune Model:
Immune markers were identified and measured
Recent studies support the presences of immune abnormalities in OCD
Several groups agree that there is a subset of patients with OCD (perhaps 10%) for
whom there is a clear streptococcal trigger, namely, D8/17 and anti-brain antibodies,
which suggest the presence of similar immune abnormalities, even in idiopathic cases
o Describe related compulsive disorders, including self-soothing and reward-seeking behaviors and
disorders of body appearance and function
OCD previously classified as an anxiety disorder due to the sometimes-extreme anxiety that
people experience
Classified as an anxiety disorder, but with unique manifestations in the way patients attempt to
decrease or control their anxiety

UNIT 4: NURSING PRACTICE FOR PSYCHIATRIC DISORDERS

CHAPTER 15: OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
Certain disorders characterized by repetitive thoughts and/or behaviors, can be grouped together
and described in terms of an obsessive-compulsive spectrum
Some of the disorders on spectrum havent been accepted by the American Psychiatric
Association as official diagnoses
DSM-5 Diagnoses: OCD, body dysmorphic disorder, hoarding disorder, trichotillomania,
excoriation, and disorders due to substances, medication or other origins
Common compulsions:
Checking rituals (repeatedly making sure the door is locked or the coffee pot is turned
off)
Counting rituals (each step taken, ceiling tiles, concrete blocks, or desks in a class room)
Washing and scrubbing until the skin is raw
Praying or chanting
Touching, rubbing, or tapping (feeling the texture of each material in a clothing store;
touching people, doors, walls, or oneself)
Ordering (arranging and rearranging furniture or items on a desk or shelf into perfect
order; vacuuming the rug pile in one direction)
Exhibiting rigid performance (getting dressed in an unvarying pattern)
Having aggressive urges (for instance, to throw ones child against the wall)
Diagnosed only when thoughts images and impulses consume the person or they are compelled
to act out the behaviors to a point at which they interfere with personal, social, and occupational
functions
Person realizes that the thought/ behaviors are unreasonable, but cannot stop/control them
Can be manifested through many behaviors, all of which are repetitive, meaningless, and
difficult to conquer
Obsessive thoughts or compulsive behaviors help to decrease/control anxiety
Obsessions and compulsions are a source of distress and shame to the person, who may go to
great lengths to keep them a secrete
Symptoms wax and wane with stress level
Self-soothing behaviors:
Dermatillomania:
o Can cause significant distress to the individual and may also lead to medical
complications and loss of occupational functioning
o May be necessary to involve medicine, surgery and/or plastic surgery, as well as
psychiatry on the treatment team
Onychophagia:
o Typical onset is childhood with decrease in behavior by 18, however can persist
into adulthood
o SSRI anti-depressants have proven effectiveness in treatment
Trichotillomania:
o Childhood onset most common, also persists into adulthood, with development
of anxiety and depression
o Pediatric can be successfully treated with behavior therapy with mixed results
Reward-seeking behaviors:
Kleptomania: compulsive stealing
o Reward isnt the stolen item, its the thrill of stealing and not getting caught
o More common in females with frequent comorbid diagnoses of depression and
substance abuse
o Lack of standardized treatment, seems that long term therapy may be needed
Oniomania:
o Approximately 80% are females with onset of the behavior in early 20s, often
seen in college students
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CHAPTER 15: OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
o Runs in families who also have high comorbidity for depression and substance
abuse
Hoarding: progressive, debilitating, compulsive disorder only recently diagnosed on its
own
o Been a symptom of OCD previously but differs in significant ways
o Affects 2-5% of population
o More common in females with parent or first-degree relative with hoarding as
well
o Involves excessive acquisition of animals or apparently useless things, cluttered
living environment that become uninhabitable, and significant distress or
impairment of individual
o Can seriously compromise quality of life, and become a health, safety, or public
health hazard
o Medications, cognitive-behavioral therapy (CBT), self-help groups, or
involvement with community agencies has been helpful
Pyromania: fire setting
Disorders of body appearance and function:
Body Dysmorphic Disorder (BDD): preoccupation with an imagined or slight defect in
physical appearance that causes significant distress for the individual and interferes with
functioning in daily life
o Elective cosmetic surgery is sought to fix the flaw, after surgery person is still
dissatisfied or finds another flaw in appearance
o Vicious cycle
o Overlap with anxiety, depression, social anxiety disorder, and excoriation
disorder
Body Identity Integrity Disorder: feelings alienated from a part of the body to the extent
seeking amputation of the identified body part
o AKA amputee identify disorder and apotemnophilia or amputation love
o People resort to packing limb in dry ice until damage is so advanced that
amputation becomes a medical necessity or amputation is done with power tools
by non-medical professional, leaving a physician to the save the persons life
and deal with the damage
o Apply the nursing process to the care of clients and families with OCD
Assessment:
Yale-Brown Obsessive-Compulsive Scale Box 15.1 pg 259
History
General appearance, motor behaviors- do they appear tense, anxious, embarrassed
Mood, affect
Thought process, content- are obsessions out of nowhere
Judgement, insight- are obsession irrational but patient cant stop them
Self-concept the patient may feel powerlessness over control of obsessions
Roles, relationships- how are they being affected
Physiologic, self-care considerations
Outcome Identification:
Client will complete daily routine activities within realistic time frame
Client will demonstrate effective use of relaxation technique
Client will discuss feelings with another person
Client will demonstrate effective use of behavior therapy techniques
Client will spend less time performing rituals
Intervention:
Therapeutic communication
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CHAPTER 15: OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
Relaxation techniques
Behavioral techniques
Daily routine completion
Dairy/log
Patient, family education
Evaluation: treatment has been effect when OCD symptoms no longer interfere with the clients
ability to carry out responsibilities
o Provide education to clients, families, caregivers, and community members increase knowledge and
understanding of OCD and related disorders
Teach family to avoid giving advise
Teach family to avoid trying to fix the problem
Teach family to be patient with their own discomfort
Teach family to monitor own anxiety level
Give family permission to take a break: for the situation, as needed
o Treatment, Cultural Considerations, and Self-Awareness issues
Treatment:
Medications:
o First Line: SSRIs fluvoxamine (Luvox) , sertraline (Zoloft)
o Second Line: SNRI venlafaxine (Effexor)
o Treatment Resistant: second generation antipsychotics risperidone (Risperdal),
quetiapine (Seroquel), olanzapine (Zyprexa)
Therapy:
o Cognitive Behavioral Therapy: treatment focuses on examining the relationships
between thoughts, feelings, and behaviors
o Exposure Therapy
o Response Therapy
Cultural Considerations:
Self-Awareness Issues:
Need to understand how, why OCD behavior works
OCD is a chronic condition involving bizarre thoughts/behaviors
OCD treatment is dependent upon meds, daily structure, and long-term behavior therapy
Avoid trying to fix patients problem

UNIT 4: NURSING PRACTICE FOR PSYCHIATRIC DISORDERS