At age 27, Arthur has worked at no less than four jobs each year since graduating from high school. He has been divorced three times. Arthur is meticulous in attire, his hair neatly groomed. His fastidious nature drowns his few friends when they visit his home — they are required to remove their shoes at the door; glasses are snatched out of their hands and washed before they’re done drinking. Nothing is out of place, and when anything is disrupted, such as the stacking order of the magazines on the coffee table or positioning of the couch pillows, Arthur becomes visibly upset.
Melissa has been to her gynecologist seven times this year, concerned about “getting infected,” despite having only one sexual partner and consistent use of condoms. Although she has no symptoms to suggest a sexually transmitted disease, she insists on cultures and an HIV test at each visit, “just to be sure.”
Alicia’s preschool teacher has already labeled the 3-year-old as a “difficult” child. Alicia does the same things every day, in the same way, and any attempt to change her actions results in loud tantrums until she is permitted to continue her routine. She insists on washing her hands immediately after touching any of her classmates. Her sweater must be folded and placed in her backpack, not hung on the coat hooks with the other children’s. After naptime, she insists that her socks and shoes be placed on one foot at a time, not both socks first and then shoes. Not well accepted by her classmates, Alicia spends most of the day alone in quiet play.
These three people share a bond — OCD. Nurses also share a bond: They are quite likely to encounter these patients in any setting.
Defining the disorder
OCD is a common, disabling condition characterized by uncontrollable thoughts and disruptive behaviors. Once thought rare, it is now recognized as one of the five most common causes of mental health disability worldwide.1 About 2.3% of the U.S. population ages 18 to 54 — approximately 3.3 million Americans — has OCD in a given year.1 Perhaps an increase in recognition and treatment-seeking has been sparked in recent years by a number of highly successful programs and movies that feature a character with OCD, such as the USA Network television show Monk and Jack Nicholson’s character Melvin Udall in As Good as it Gets.
Ranked below depression, substance abuse, and phobia, OCD is the fourth most common mental health diagnosis in the world.2 And it’s complicated: OCD has a neurobiological basis in which serotonin plays a significant role.3
Although genetic predisposition is strongly implicated, parental influence also plays a role.4,5 In one study, individuals with OCD were more likely to have fathers whom they perceived to be rejecting them or parents who expressed low levels of emotional warmth.5
OCD symptoms include a combination of anxiety-producing intrusive thoughts (obsessions), with or without rituals performed to decrease anxiety (compulsions). Patients are often aware of their abnormal actions, yet unable to control them. Some patients with OCD experience only obsessions; most experience both obsessions and compulsions.
The Diagnostic and Statistical Manual of Mental Disorders defines obsessions as intrusive and time-consuming thoughts, impulses, or images that cause marked anxiety or distress that interfere with normal social or occupational activities.6 For example, some people may be obsessed with germs, religion, their safety, or simply ordering things. The manual delineates compulsions as repetitive behaviors that a person feels driven to perform in response to an obsession or in accordance with rigidly applied rules. For example, a person who is obsessed with germs may compulsively engage in repetitive handwashing or avoiding physical contact with other people. The compulsions are aimed at preventing or reducing distress; however, they are not connected in a realistic way with the thoughts they are trying to neutralize or prevent, and they are truly excessive.7
Performing these rituals provides only temporary relief from the obsessions, yet not performing them markedly increases anxiety.
Some actions may appear to be purposeful behaviors compelled by rational reasoning, but they are primarily aimed at reducing anxiety, not accomplishing a task. Common themes associated with the obsessions and compulsions of OCD are listed in the sidebar, “Common OCD Themes.”
The signs and symptoms of OCD are chronic and unremitting, and if left untreated, they usually grow progressively worse in both intensity and frequency. Many patients with OCD are unable to work or, with low self-esteem or poor work performance, become underachievers in the work environment. Social isolation, impaired social functioning, impaired family life, and difficulties with activities of daily living can all result in diminished quality of life as a potential outcome for those with severe and untreated OCD.8
Sounds alike, but not the same
Obsessive-compulsive personality disorder is often confused with OCD. However, OCPD differs from OCD in that affected patients, who are more often men, are preoccupied with order, lists, rules, goals, and perfection. Generally, OCD impairs function much more than OCPD. Patients with OCPD may be highly successful achievers, often at the expense of personal and professional relationships. Many times, they are also described as driven “type A” personalities. Unlike those with pure OCD, individuals with OCPD may accomplish many things despite their preoccupations, inflexibility, and drive for perfection. But they can also be inefficient, leaving out important steps or crucial pieces of information that would only be included at the expense of changing accepted ritualistic behaviors. These people rationalize the connection between their obsessions and their compulsions as a means to achieve order or accomplishments. Many people with OCD have OCPD, which together, drastically diminish their ability to function.9
Incidence and diagnostic features
Overall, OCD occurs equally among men and women. The mean age of onset is 20 years although the same symptoms can occur in children as young as two years old. The onset differs with gender, occurring in females in their 20s, and in males during childhood and adolescence.4 Family members of people with OCD have a greater risk of OCD. The risk for the general public is approximately 2%.10
Scientists at the National Institutes of Health have identified a genetic variation associated with the reuptake of serotonin that doubles an individual’s risk for OCD. The genetic deficit is responsible for the inhibition of connections between emotions and repetitive behaviors.2
Evidence is also emerging from research that links exacerbation of OCD symptoms with female reproductive hormonal fluctuation. Menopause, pregnancy, and the premenstrual time period have been linked to an increase in the severity of OCD symptoms in some studies. In other studies, pregnancy was associated with an improvement of OCD symptoms.11
A link has also been established between the incidence of OCD and streptococcus infections that have led to rheumatic fever. This link is theorized to be the result of an immune response that impacts the central nervous system.12 Similar research among individuals with irritable bowel syndrome (IBS) supports that an immune response is associated with OCD incidence. In one study, 35% of patients with OCD also were diagnosed with IBS.13 Researchers are investigating the role of reducing immune triggers, perhaps with antibiotic prophylaxis, as a means to reduce the incidence of developing OCD or reducing its severity when diagnosed early.14
Healthcare providers may have difficulty identifying OCD symptoms, although they are the same in both children and adults. Secrecy and shame often complicate the diagnosis.1 For example, some patients may not readily admit to OCD symptoms, such as fear of germs, touch, death, or illness. Others who come to healthcare settings with common OCD-related complaints may be labeled as hypochondriacs. Also, the severity and intensity of OCD symptoms can fluctuate, depending on the presence of stressful situations or a depressed mood. This is particularly true for individuals who perform handwashing or hoarding as a component of their OCD.15
Coexistent disorders also make the diagnosis difficult. For example, up to two-thirds of these patients also have depression.4 Up to 75% of individuals with OCD are also diagnosed with other psychological disorders, including panic disorder, social phobia, eating disorders, schizophrenia, attention deficit disorder/attention deficit hyperactivity disorder, substance abuse, and Tourette syndrome. In Tourette, the OCD may not be so easily diagnosed because it often has a later onset than the classic tics.16 OCD may also coexist with temporal lobe epilepsy, traumatic head injury, and drug-induced conditions. Women with OCD are also more likely to report a history of sexual abuse.17
Nevertheless, psychiatric screening tools, such as the Yale-Brown Obsessive Compulsive Scale, can facilitate diagnosis by identifying thought processes and behavior patterns common to OCD.18 The 10-item Y-BOCS rates the severity of OCD by measuring time spent on, interference from, distress from, resistance to, and control over obsessions and compulsions. The test not only aids diagnosis, but also can periodically track therapeutic progress. Separate versions address adults and children.
One of the cardinal features of OCD is that it is an ego-dystonic disorder, that is, the symptoms are unacceptable to the person. Therefore, the patient tries to ignore or suppress symptomatic thoughts and behaviors. Although patients recognize the abnormality of the symptoms, they cannot stop them.18 Worrying and sadness, as well as somatic complaints of fatigue and pain may develop in these patients. Soft neurological signs, such as involuntary limb movements or twitching and visual/spatial deficits (poor hand-eye coordination), occur in almost all patients with OCD.4 MRI scans that are sensitive to the orbitofrontal cortex-striatal circuit, the area of the brain responsible for initiating hand-eye coordination, have even confirmed abnormal neurological activity when patients with OCD are challenged with cognitive learning tasks.19
Issues surrounding treatment
Treatment of OCD is complex, individualized, and multimodal. It aims to diminish the frequency of obsessions and compulsions as well as reduce the reward that these behaviors provide. Because OCD has an impact on marriage and other interpersonal relationships, employment, and academic performance, treatment also affects those around the patient.8 While many people with OCD believe their behaviors are well concealed, they are often obvious and affect those around them. Early detection and aggressive treatment of OCD in children can result in significant long-term improvement. It is especially important because an earlier age of onset often results in poor outcomes, particularly among men.20
Clinicians need to remember that the support system of those with OCD may already be strained. People with OCD often have difficulty maintaining relationships. Older patients are less likely to be married, and if so, they are typically highly dependent on their spouses. Screening for substance abuse is important in treatment. Although coexisting disorders are often treated simultaneously with OCD, alcohol and substance abuse must be dealt with before therapy for OCD is instituted.14
Treatment modalities
Treatment combining pharmaco- and psychotherapies results in a better outcome than when either is used alone.
Medications: The tricyclic antidepressant clomipramine (Anafranil) is one of the first medications approved for OCD. This drug must be used with caution, particularly with depressed patients who may be suicidal, because an overdose can be lethal.21 Selective serotonin reuptake inhibitors are now the preferred agents.21 They include fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac). Fluoxetine is the only SSRI currently available in liquid form, so it’s used for those with swallowing difficulties or for young children. The Food and Drug Administration has also approved fluvoxamine, sertraline, paroxetine, and clomipramine for use in children with OCD, however, the use of antidepressants among children is increasingly associated with concerns over suicidal ideation.21 Therapy with SSRIs or clomipramine requires careful monitoring and instruction.
Combination pharmacotherapy is common, particularly when other disorders are present. Buspirone (BuSpar) may be used along with an SSRI in patients diagnosed with both OCD and generalized anxiety. When OCD coexists with a bipolar disorder, mood stabilizers, such as lithium, carbamazepine (Tegretol), or valproic acid (Depakene, Depakote), may be used in combination with SSRIs.21
Success for treatment-resistant OCD has also been shown with the combination of the mood stabilizer topiramate (Topamax) and the SSRI paroxetine.22
Many of the medications used for OCD have unpleasant adverse effects, including drowsiness, dry mouth, dyspepsia, sexual dysfunction, insomnia, headache, diarrhea, constipation, and the potential for interactions with other drugs.21 Dosage timing adjustment should be considered for patients who experience daytime drowsiness from medication; taking medication at night may help promote sleep.
Patients need to know not to abruptly stop SSRI medications; instead, the dosage should be tapered.21 Abrupt discontinuation can trigger a flu-like withdrawal syndrome in up to 25% of patients, which may include a wide variety of symptoms, including fatigue, lethargy, myalgia, chills, dizziness, vertigo, ataxia, nausea and vomiting, numbness and tingling in the hands and face, insomnia, crying, anxiety, agitation, irritability, mood changes, inability to concentrate, and memory impairment.21 The risk for withdrawal increases with age and duration of treatment. The potential for withdrawal syndrome varies among the SSRIs, but it is greatest for paroxetine and fluvoxamine, and the least for citalopram, fluoxetine, and sertraline.21
Nurses are often responsible for explaining medications to patients. When SSRI therapy is used for OCD, patients need to know that the response is not immediate, and, in fact, additional medications may be needed, including atypical antipsychotics, such as quetiapine (Seroquel) and olanzapine (Zyprexa).21 This is especially true when OCD and Tourette’s co-exist.16 Standard dosages used for depression treatment may not be effective with OCD, and higher doses may be needed, particularly when OCD occurs with other disorders, such as Tourette’s syndrome, bipolar disorder, or anxiety. Patients respond differently to SSRIs, depending on the type of OCD.21
Some patients with OCD are young and sexually active. They may discontinue pharmacotherapy because of unfavorable sexually related adverse effects, particularly with SSRIs, carbamazepine, lithium, alprazolam (Xanax), and buspirone. Providers should address this potential problem before therapy is started. Of the medications used for OCD, the lowest incidence of sexually related adverse effects has been reported with clomipramine.21
Adherence to medication regimens can be related to adverse effects, the need for multiple daily doses, the persistence of compulsions, the length of time the disorder has been present, the patient’s age, cost of medical care, chronic illness, shame, or coexistent disorders. Patient and healthcare provider attitudes also play an important role. Establishing a trusting environment that fosters open communication should be a goal for any nurse caring for these patients.
When medication therapy is used as a component of OCD treatment, a collaborative approach is best. Obtaining consent to speak with family members and other individuals close to the patient cannot only be therapeutic, but can be life-saving, especially when medications with known specific risks are used, including antidepressants and antipsychotics.23
The majority of antidepressant medications now carry “black-box warnings” and closer observation is recommended, especially at the beginning of drug therapy and when the dose is adjusted. Behavioral symptoms to watch for include anxiety, agitation, irritability, hostility, panic attacks, and impulsivity. Physical signs for concern can include insomnia and extreme restlessness. Stressful social situations that occur during SSRI therapy, and especially with paroxetine, may increase the risk for suicidal behavior — one research study showed that nearly all suicidality occurred when a social stressor was present.23
The second-generation antipsychotics including clozapine (Clozaril), olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal), quetiapine (Seroquel), and ziprasisone (Geodon), along with a combination antipsychotic/SSRI medication, Symbyax (olanzapine and fluoxetine) also carry “black-box warnings” for increased incidence of heart failure. When patients are prescribed these strong medications for resistant OCD, it’s important to alert them to the signs of diminished cardiac function including monitoring for edema and shortness of breath.21
Many of the atypical antipsychotics are also associated with hyperglycemia that may make blood glucose monitoring or frequent laboratory monitoring necessary. Patients and their caregivers may require education about dietary choices and the warning signs of hyperglycemia.
Treatment beyond the medicine cabinet
In extreme cases, electroconvulsive therapy may be used for treatment-resistant individuals, and those who also have severe depression. Severe OCD has even been treated with the psychosurgical intervention cingulotomy, in which an electrode needle burns a lesion in the cingulum, bundled nerve fibers that link the centers of emotion and thought on the cortex of the brain. In one study, OCD improvement with cingulotomy was 48%, and studies of cognitive function at 12 and 24 months after the procedure did not reveal and significant adverse cognitive decline.24
Another surgical modality initially used for individuals with Parkinson’s Disease, deep brain stimulation (DBS) has also emerged as an effective treatment for OCD.25
Psychotherapeutic modalities: Psychotherapy for OCD may include behavioral, cognitive, or group therapy. The success rate with a combination of psychotherapy and medication is high. Psychotherapy alone, however, has a lower success rate of 14% to 26% when used alone or when other psychological disorders are present.18
Behavioral therapy focuses on exposure and response prevention; patients are encouraged to participate in feared activities and refrain from acting out compulsions. This therapy is intended to reduce and eventually eliminate ritualistic responses as a means to reduce anxiety. It has been shown to be especially effective with children and adolescents.26
Cognitive therapy provides a way for patients to confront their irrational or faulty belief systems, while paying special attention to their need for perfection and certainty as a comfort measure. The goal is to examine the underlying beliefs, rather than individual obsessive thoughts that are expressed.27
Group therapy provides mutual support and decreased social isolation. Mutual understanding and a sense of belonging are fostered, and coping mechanisms are shared.18
Advances in technology have also impacted the way in which psychological and behavioral therapy for OCD is delivered, with promising results for those who are unable or unwilling to attend sessions in-person. One study of 72 patients with OCD attending 10 weekly sessions of cognitive behavioral therapy either in person or via telephone revealed that the therapy was equally effective for those attending sessions via phone.28
Supportive counseling for family members and significant others is often helpful, because these individuals may require guidance in how to respond to the patient and provide reinforcement. Family members need to understand that obsessions and compulsions cannot simply be willed away and that the presence of OCD is as frustrating for the patient to live with as it is for the family members around them to endure.29 Family therapy can help them cope with their own frustration and teach them how to support their loved one through changes directed toward more positive and healthy behaviors.18
Family therapy does not involve using the family members to distract from the ritualistic behaviors or take on the role of the therapist. Only trained clinicians should attempt to initially modify ritualistic behavior patterns. However, in time, therapists may guide and use family members as therapeutic helpers in exposure and response prevention.
Yoga meditation is one alternative treatment approach currently being used with OCD. The special techniques of Kundalini yoga induce a meditative state, energize, and decrease emotional stress, anxiety, and mental tension. In a review of two small trials, improvement from 50% to 70 % was demonstrated among participants with OCD.30
Although relaxation techniques are another alternative treatment modality, behavior therapy guided by clinicians or computer programs has shown more promise in treating OCD.31
The extent to which an effective treatment for OCD is desired might be evidenced by the reports of two studies investigating the use of psychedelic agents and powerful anti-androgenergic drugs for OCD treatment.32,33 One study evaluated the short-term use of psilocybin among nine individuals with a marked decrease in symptoms noted.32 The other evaluated six male patients with OCD who were given a treatment for prostate cancer — a long-acting gonadotropin-releasing hormone analogue, triptorelin (Trelstar), with considerable improvement noted.33 Don’t expect to see strong hormonal therapy or pharmaceutically-engineered mushroom juice used anytime soon for OCD, however, as safety data after long-term use must first be cautiously evaluated.
Where do nurses fit in?
Nursing management of OCD varies with specialty. It may focus on the observation and documentation of ritualistic behaviors or shared thoughts, which can lead to diagnosis and treatment. After establishing a trusting relationship, nurses should encourage individuals with OCD to seek care and follow their treatment plans. Nurses also reinforce therapeutic concepts and provide support for significant others. A psychiatric nurse clinician or nurse practitioner may provide medication management. To review an evidenced-based practice, go to www.nice.nhs.uk/page.aspx?o=cg031&c=mental.
The most significant contribution a nurse can make to patients with OCD is maintaining an open and honest relationship, keenly assessing for OCD signs and symptoms, and referring individuals for early treatment. Nurses play a vital role in reinforcing continued therapy and adherence with continuing medication. Educating patients and their family members to have realistic expectations is also crucial. While OCD has no cure, nurses can help patients and those around them to cope with what can be a debilitating psychological disorder. |
