OCD, Nursing Diagnosis for OCD, and Nursing Interventions for OCD

OCD, Nursing Diagnosis for OCD, and Nursing Interventions for OCD

This article is about OCD, nursing diagnosis for OCD, and nursing interventions for OCD. It can be used to create nursing care plans for OCD.

OCD

What is OCD?

Opinion | It's time to talk about OCD - The Pitt News

Have you ever wondered regarding the unusual behaviour of some persons when they do certain acts repeatedly seemingly without any logical reason like someone repeatedly washing hands, cleaning again and again when it is not needed, taking unusually long time like hours in bathing, taking unusually long time like hours in getting ready, extremely particular about things being arranged or about symmetry , or someone reports getting repetitive thoughts that he or she doesn’t want to think for e.g. violent or sexual thoughts or images  etc, then the person should get himself or herself evaluated by a psychiatrist as these may be the symptoms of Obsessive Compulsive Disorder(OCD).

There are certain other disorders which are quite similar to OCD in having Obsessive preoccupation leading to significant anxiety and certain repetitive behaviours or mental tasks they do to somehow reduce that anxiety and hence they are also recently considered in the obsessive compulsive spectrum of disorders, e.g.

  • Hoarding disorder (extreme difficulty in parting with possessions)
  • Body dysmorphic disorder (extreme dissatisfaction with body shape/part etc)
  • Trichotillomania or hair pulling disorder (Picking up ones hair and sometimes eating them)
  • Excoriation or Skin picking disorder.
  • The lifetime prevalence of OCD in general population in 2-3%, that means 2-3 persons in every hundred persons have OCD in their lifetime. It affects men and women equally.
  • It usually starts at 20 years of age however it can occur at any age including as early as 2 years of age in children.
  • OCD is often found to occur with other disorders like Depression, Social Phobia and Tourett’s disorder.

Remember OCD is a treatable disorder so seek help as soon as possible if you doubt you or someone you know may be having the symptoms suggestive of it.

What are the Symptoms of OCD?

  1. Recurrent intrusive thoughts and images (Obsessions) which generate a lot of worry apprehension or fear.
  2. Rituals or behaviour or mental acts done repeatedly (Compulsions) aimed to neutralize or reduce the anxiety.

Happening alone or in combinations

An example would be a person getting repeated thoughts of hands being dirty (Obsession) generating a lot of anxiety leading to repeated act of hand washing(Compulsion) to reduce the anxiety.

A person having OCD experiences severe anxiety and may be found indulging in

  • Excessive washing or cleaning, repeated checking, extreme hoarding.
  • Avoiding particular numbers (e.g. Even or odd numbers) or obsession with certain numbers.
  • Rituals such as opening and closing a door a certain number of times or doing certain other activity a particular number of times.
  • A person with OCD may also experience preoccupation with and being distressed by repeated sexual, violent or religious thoughts which he/she doesn’t want to think.

These symptoms are often recognized as irrational by the sufferers and they are further distressed by the fact that they fail to stop or control them. They feel alienated and the symptoms consume a lot of their time resulting in severe emotional, social, financial and other difficulties.

  • These symptoms must be consistent and continuing, consuming more than one hour a day and should not be secondary to any underlying medical disorder or the effect of a drug or substance of abuse, for a definitive diagnosis of OCD to be made.

Body Dysmorphic Disorder: The person suffering from body dysmorphic disorder harbors the idea of a perceived or imagined defect in body shape or shape or any specific part and indulges in repetitive behaviors or mental acts in response to preoccupations with perceived defects or flaws in physical appearance.  For e.g. a person believing that his/her nose is deviated to one side although no such defect is visible to others.

Hoarding disorder: The person suffering hoarding disorder finds it extremely difficult to part with possessions regardless of their value or utility resulting in emotional, physical social, financial, or even legal problems for the person himself and the family members. It is different from usual hobby some people have to collect certain items, in this disorder, they accumulate a large number of things filling up and cluttering active living areas of the home or workplace to the extent that the place cannot be used for the purpose it was meant for.

Trichotillomania or Hair pulling disorder: A person having hair pulling disorder gets the urge to pull one’s hair and experiences a lot of anxiety if he tries to resist it and a decrease in anxiety when he/she pulls the hair leading to gradual development of a visible loss of hair from the head. Sometimes the person additionally eats up the hair after pulling it. They are often brought to medical attention because of either unexplained loss of hair or stomach pain.

Excoriation (Skin-Picking) DisorderThis disorder is characterized by constant and recurrent picking at your skin resulting in skin lesions. The person fails to control the urge despite trying many times to reduce or stop it. This often results in medical complications like infections, scarring and physical disfigurement.

What are the causes of OCD?

OCD & related disorders are a result of complex multi factorial Bio-psycho-social causes. They are complex disorders like heart disease or Diabetes mellitus type-1 and the current research says they are a result of complex interaction of genetic, biological, psychological, social and developmental factors.  So one can have an OCD and related diorder because of a combination of the following factors.

  • Imbalance of the certain chemicals in the brain called the neurotransmitters namely Serotonin, Nor-epinephrine and GABA.
  • Over activity or under activity of certain areas of brain responsible for emotional or mood regulation or generating fear response.
  • Genetic factors are involved as relatives of patients with OCD have three to five fold increased risk of having OCD or related disorders or Obsessive Compulsive features.
  • Some research suggests the role of an infection in childhood by Group A beta hemolytic streptococci.
  • Stressful situations usually result in initiation or increase in symptoms of OCD and related disorders.
  • Psychoanalytic school sees OCD & related disorders to be related to multiple unconscious psychological conflicts at various developmental stages especially related to anal psychosexual phase of development while behavioral theories suggest Obsessions as a conditioned stimuli while compulsions are developed as learned behaviors to reduce the anxiety induced by the obsessions.

Nursing Diagnosis for OCD

OCD Diagnosis: Tests, Screenings, Criteria
Nursing Diagnosis for OCD

How do you diagnose for OCD?

Obsessive Compulsive disorder & related disorders can be diagnosed by

  1. Ruling out any underlying medical condition and any drug or substance of abuse which may give rise to OCD and related disorders like symptoms.
  2. Psychiatric evaluation based on clinical symptoms, detailed history and mental status examination.

Nursing Interventions for OCD

What are interventions for OCD?

Obsessive compulsive and related disorders are treatable and majority of patients lead a quality life with proper and regular treatment.

The management of OCD and related disorders vary as per the specific disorder a person is suffering from, its severity, and patient profile e.g. (age/sex/body weight/social support/psychological mindedness/past history/family history/other physical or mental health disorders patient is suffering from). The outcome of treatment is best when medicines are used along with behavior therapy.

In general the therapeutic management comprises of a combination of

1.Medications: These include various anti anxiety and antidepressant drugs.

SSRIs (Selective serotonin reuptake inhibitors) e.g. Fluoxetine, Fluvoxamine, Sertraline, Paroxetine etc.

  • These are currently considered the drug of choice for moderate to severe OCD and related disorders.
  • The dosage used are often higher than what works for Depression or anxiety in general.
  • They modulate the neurotransmitter serotonin in the brain and show their efficacy in 2-3 weeks.
  • They should only be taken under specialist guidance and any unwanted side effect or worsening of symptoms should be reported immediately.
  • In general SSRIs are relatively safer drugs as compared to the older antidepressants and the usual side effects are mild and usually self limiting e.g. headache, nausea, heart burn, nervousness etc, but you should immediately talk to your doctor if any unwanted side effect/change is noticed in body or mind.
  • Patient should never start or stop the medicines on their own as it may lead to worsening of the problem, discontinuation syndrome or even a paradoxical increase in anxiety or suicidal tendency.
  • Depending on the disease severity the medicine may have to be taken for longer periods.
  • SSRIs and other antidepressants and anti anxiety medicines are not habit forming drugs.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIS). Desvenlafaxine, Venlafaxine, Duloxetin are also antidepressants may be useful in some OCD related disorders as add on therapy.

TCAs (Tricyclic antidepressants) e.g. especially Clomipramine

This is an older antidepressant and once was used to be considered as the drug of choice for OCD and they act on other neurotransmitters as well apart from serotonin. Currently not used as first line drugs but still is quite useful in some patients or sometimes as a second drug at lower dosage to augment the treatment.

Benzodiazepines(BZDs)

Clonazepam, Lorazepam, Etizolam, Diazepam, Oxazepam, Chordiazepoxide.

  • BZDs are also used to treat OCD and related disorders in the acute and short term. They are often prescribed along with SSRIs to provide short term relief from anxiety till the time SSRIs take their effect.
  • They are habit forming drugs and have abuse potential so they should be used in the short term under specialist supervision only.

Serotonin dopamine agonists SDAs: e.g. Risperidone is useful in some patients as an add on therapy to augment the treatment or in patients who do not have insight into their OCD and related disorder or have co-morbid psychotic symptoms.

Electro-convulsive therapy ECT: at times can be helpful in patients not responding to medications.

Repetitive Trans Cranial Magnetic Stimulation rTMS: initial research seems promising in improving symptoms in some patients, more research is needed.

Psychosurgery: Sometimes in extremely treatment unresponsive cases cingulotomy and capsulotomy is helpful, surgery may not cure the condition but it may help it become treatment responsive.

Deep brain stimulation is another technique under research for treatment of OCD.

Others like Buspirone, Bupropion Hydrochloride, Mirtazapine, Valproate, Carbamazepine and Lithium are used as add on medicines in some patients.

2.Psychotherapies

A. Cognitive behavioural therapy: This form of psychotherapy is very effective in the treatment of OCD & related disorders and it involves the therapist using various techniques to help the patient understand and manage the factors that contribute to their disorder. Cognitive errors are corrected and behavioural techniques are used to reduce or stop undesired behaviour and relaxation techniques like deep breathing are used to control the bodily manifestations of anxiety.

B. Supportive psychotherapy: In this psychotherapeutic approach a variety of psychotherapeutic techniques are used to foster a healthy mental state in the patient through a supportive therapeutic relationship with the patient.

C. Family therapy: Family psychotherapy can help family members better understand their loved one’s OCD and learn new ways of communication and interaction that do not reinforce the OCD and related disorder and associated dysfunctional behaviours and this in turn ensures treatment compliance and improves the outcome.

D. Group therapy: In this the psychotherapy is done with a group of unrelated individuals all having OCD and related disorder and it’s a very useful way of providing effective treatment and generating support.

Others adjunctive therapies like Music therapy, art therapy and various meditation styles and breathing relaxation techniques can also help some patients in addition to the first line treatment.

How can OCD be prevented?

Nursing Interventions for OCD

OCD & related disorder cannot be entirely prevented but definitely the complications can be prevented and the course and outcome can be improved by adopting a healthy physical and mental life style right from childhood and learning to deal with stress in a better way. It includes

  • Exercising daily
  • Learning problem solving
  • Time management
  • Learning to prioritize things in life
  • Sleep hygiene
  • Assertiveness training
  • Eating healthy food
  • Inculcating hobbies e.g. Music, Dance, Arts etc
  • Investing in and nurturing the social support system.
  • Having close people to talk one’s heart out.
  • Providing stable and secure home environment to kids helps make them emotionally stable and secure thus reducing vulnerability to develop OCD & related disorders.
  • The awareness of OCD & related disorders is vital as it leads to early recognition and treatment thus preventing the further complications and improving the outcome.

So for prevention of further worsening and to have a better treatment response there is a need to identify problem at an early stage. It can be done through…

  • Sensitizing community regarding the importance of mental health.
  • Stressing the fact that mental health is as vital to a human being as physical health.
  • Reducing the stigma attached to being a mentally ill patient, this can be done through community participation and awareness programs.
  • As caretakers and patient one can minimize the further worsening and complications by ensuring compliance to treatment and regular participation in it.

Remember: For mental health problems the early the intervention the better the outcome and quality of life.

Majority of OCD & related disorders patients can lead a quality life with proper management.

Example of a Nursing Care Plan for OCD

May Be Related to

  • Earlier life conflicts(may be reflected in the nature of the repetitive actions and recurring thoughts)

Evidenced by

  • Repetitive action (e.g., hand-washing)
  • Recurring thoughts (e.g., dirt and germs)
  • Decreased social and role functioning

Desired Outcomes

  • Verbalize understanding of significance of ritualistic behaviors and relationship to anxiety.
  • Demonstrate ability to cope effectively with stressful situations without resorting to obsessive thoughts or compulsive behaviors.
Nursing Action Rationale
Establish relationship through use of empathy, warmth, and respect. Demonstrate interest in client as a person through use of attending behaviors. Anything about which the client feels anxious will serve to increase the ritualistic behaviors. Establishing trust provides support and communicates that the nurse accepts the client as a person with the right to self-determination.
Acknowledge behavior without focusing attention on it. Verbalize empathy toward client’s experience rather than disapproval or criticism. Better to say,” I see you undress 3 times every morning. That must be tiring for you,” rather than “Try to dress only 1 time today.” Lack of attention to ritualistic behaviors can diminish them. As anxiety is reduced, the need for behaviors is reduced. Reflecting the client’s feelings may reduce the intensity of the ritualistic behavior
Use a relaxed manner with the client; keep the environment calm. Any attempts to decrease stress will help the client to feel less anxious, which may reduce the intensity of the ritualistic behaviors.
Assist client to learn stress management, (e.g., thought-stopping, relaxation exercises, imagery). Stress-management techniques can be used, instead of ritualistic behaviors, to break habitual pattern.
Identify what the client perceives as relaxing (e.g., warm bath, music). Engage in constructive activities such as quiet games that require concentration, as well as arts and crafts such as needlework, woodworking, ceramics, and painting. Planned activities allow the client less time forward bath, music). Engage in constructive activities such as quiet games that require concentration, as well as arts and crafts such as needle work, woodworking, ceramics, and painting.
Encourage participation in a regular exercise program. Exercise therapy can help relieve anxiety. Note: Exercise does not need to be aerobic or intensive to achieve the desired effect.
Give positive reinforcement for non-compulsive behavior. Avoid reinforcing compulsive behavior. Help significant other(s) learn the value of not focusing on the ritualistic behaviors. This approach will prevent the client from obtaining secondary gains from the maladaptive behaviors.
Assist client to find ways to set limits on own behaviors. At the same time allow adequate time during the daily routine for the ritual(s). Encourages client to problem-solve ways to limit own behaviors while recognizing that behaviors cannot be stopped by others without increasing anxiety. If the time required for performing the ritual(s) is not considered in planning care, client will feel rushed and anxious while performing behaviors. A mistake in compulsive behavior is more likely to be made if client feels rushed, and the whole ritual will have to be started again, resulting in increased anxiety — possibly to an unmanageable level.
Limit the amount of time allotted for the performance of rituals. Encourage client to gradually decrease this time. Provides initial control of maladaptive behaviors until client can enforce own limits and substitute more adaptive response(s) to stress.
Encourage client to explore the meaning and purpose of behaviors; to describe the feelings when the behaviors occur, intensify, or are interrelated ;and to examine the precipitating factors to the performance of the rituals This exploration provides an opportunity to begin to understand the process and gain control over the obsessive-compulsive sequence. When the opportunity for ritualistic behavior does not occur, the client fears that something bad will happen. Recognizing precipitating factors allows client to interrupt escalating anxiety.
Discuss home situation, include family/SO as appropriate. Involve in discharge plan. Returning to unchanged home environment Increases risk that client will resume compulsive behaviors.
Administer medications as indicated,e.g.:Fluvoxamine(Luvox),clomipramine(Anafranil),fluoxetine (Prozac) These drugs help balance serotonin levels, decreasing feelings of anxiety, reducing need for ritualistic behavior(s), and allowing client to learn of other methods of stress reduction. Note: Luvox is classified as a selective serotonin reuptake inhibitor and has fewer side effects than tricyclics.
Administer Buspirone (BuSpar) and lithium (Eskalith) ,Sertraline (Zoloft), venlafaxine (Effexor)medications as indicated. Clients who are refractory to antidepressants may require combination therapy (e.g., buspirone and fluoxetine or lithium and clomipramine).

 

References:

Saddock BJ., Saddock VA. (2005) Obsessive compulsive disorder in Comprehensive textbook of Psychiatry (8th ed.) 1773-1777 Philadelphia, PA, Lipppincott Williams & Wilkins.

Sadock BJ, Sadock VA. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th ed.). 604-612 Philadelphia, PA, Lippincott, Williams & Wilkins; 2007.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA:  American Psychiatric Publishing.

OCD, Nursing Diagnosis for OCD, and Nursing Interventions for OCD

 

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