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What is OCD?
 A type of anxiety that
happens when there is a
problem with the way the
brain deals with normal
worrying and doubts
 A person has recurrent and
unwanted ideas or impulses
and an urge to do something
to relieve the discomfort
caused by the obsession.

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 What are obsessions?
 Ideas, images, and impulses
that run through the
person’s mind over and over
again.
 Fear of dirt or germs
 Disgust with bodily waste or
fluids
 Concern with order,
symmetry and exactness

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 What are compulsions?
 Behaviors that people
with OCD do to try to
get rid of nervous and
afraid feelings
according to “rules” that
they make up for
themselves
 Compulsions are also
called rituals

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 What are common obsessions?
 Worrying that  Need for constant
something has been reassurance
done poorly when they
know it wasn’t
 Fear of harming a
family member or friend
 Fear of thinking evil or
sinful thoughts
 Thinking about certain
sounds, images, words,
or numbers all the time

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 What are common compulsions?
 Cleaning and grooming over  Ordering and arranging
and over again items in certain ways
 Checking drawers, door  Counting over and over to a
locks, and appliances to certain number
make sure they are shut,  Saving things such as
locked, or turned off newspapers, mail, or
 Repeating things several containers when they are no
times longer needed
 Seeking constant
reassurance and approval

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 How common is OCD?
 It was thought to be rare
for many years
 Recent studies show
that as many as 3
million Americans ages
18-54 may have it

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 1% of young people – adults often report
experiencing first symptoms in childhood.
 Onset can be at any age. Mean age is late
adolescence for men, early twenties for women
 2-3 % of the population will suffer from OCD (in the
lifetime)
 Equally common in males and females
 In children, washing, checking, and ordering are
common presentations (as in adults).

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 What causes OCD?
 A single proven cause
has not been found
 Research shows that it
could have to do with
chemicals in the brain
that carry messages
from one nerve cell to
another
 A person who has OCD
may not have enough
Serotonin.
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Contributory Factors to OCD:- Genetics
 OCD proposed to be a spectrum of disorders (subtypes?)

that share some of the same genes.

 No specific genes identified.

 MZ twins more likely than DZ twins to exhibit OCD

symptoms.
 Those with OCD more likely to have parents and

children with OCD or OC behaviors than those without

OCD
 Roughly 40% of those with OCD have a biological

relative with OCD

 Within families, many different specific OC behaviors

—so not likely learned

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Contributory Factors to OCD:- Environmental
 Brain Injury (damage basal ganglia and connections to

frontal lobes)
 Caused by anoxia, toxic exposure (e.g., CO

poisoning), brain infection (e.g. viral encephalitis),

substance abuse
 Bacterial Infection (again, damage to basal ganglia)

 PANDAS: pediatric autoimmune neuropsychiatric

disorders associated with streptococcal infections

 Sydenham’s chorea

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 Contributory Factors to OCD:-
Structures/Functioning
 Basal Ganglia-
 Animal studies: Basal ganglia damage leads to

repetitive behaviors (like compulsive rituals)

 Patients with Parkinson’s, Huntington’s chorea, or

other diseases involving basal ganglia deterioration

are at increased risk of developing OCD symptoms
 Hyperexcitability of basal ganglia pathways seen in

OCD

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Contributory Factors to OCD:- Environmental
 Amygdala-
 Increased activity when exposed to pictures of contaminated

environments
 Responds differently in those with OCD than in controls

when exposed to fearful or neutral stimuli

“Most theories concerning OCD’s etiology include some type of
abnormal function in the neural circuits between the frontal lobe
and the basal ganglia within the brain. Serotonin and dopamine
are the primary neurotransmitters for the neural circuits that
connect these areas.”
(Steketee & Pigott, 2006; p. 59)

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 Contributory Factors to OCD:- Psychoanalytical theory
Disturbed development in
Early normally disguised by
anal sadistic phase
childhood
fixation in development Obessional
Reaction
Personality
formation
traits
Anxiety r/t
Odipal Regression reinforcement of anal/aggressive impulses
conflicts
in the presence of fixation
at anal sadistic phase
New defenses

needed as reaction formation isn’t enough

Isolation of affect Displacement

undoing

Obsessional thought Phobias

Compulsive acts
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 What other illnesses are associated
with OCD?
 People often have other
kinds of anxiety like
phobias or panic attacks
 They may have
depression, ADHD, and
eating disorder or a
learning disorder such
as dyslexia

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 What are the risk factors of you
getting OCD?
 the risk of you getting
OCD is slightly higher
if your parents or other
family members have
OCD.

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 How do doctors diagnose OCD?
 There is no laboratory test
to diagnose OCD but your
doctor may ask you
questions about your
obsessions, compulsions,
and emotional well- being
 Your doctor may also talk to
your friends and relatives
about your behavior

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 Diagnostic criteria:-
A. Either obsessions or compulsions:
Obsessions as defined by 1, 2, 3, & 4
i. Recurrent & persistent thoughts, impulses or images that are
experienced at some time during the disturbance as intrusive &
inappropriate & that cause marked anxiety or distress.
ii. The thoughts, impulses or images are not simply excessive
worries about real life problems
iii. The person attempts to ignore or suppress such thoughts,
impulses or images or to neutralize them with some other
thoughts or action.
iv. The person recognizes that the obsessional thoughts, impulses or
images are a product of his own mind (not imposed from
without as in thought insertion)
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Compulsions are defined by 1 & 2
i. Repetitive behavior (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

ii. The behaviors or mental acts are aimed at preventing

or reducing 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

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B. At some point of during the course of the disorder, the person has
recognized that the obsessions or compulsions are excessive or
unreasonable, note: this doesn’t apply to children
C. The obsessions or compulsions cause marked distress, are time
consuming (take more than 1 hr/day), or significantly interfere with the
person’s normal routine, occupational (or academic) functioning or
usual social activities or relationships.
D. If another axis I disorder is present, the content of the obsessions or
compulsions is not restricted to it (e.g. preoccupation with food in the
presence of an eating disorder, hair pulling in the presence of body
dimorphic disorder, preoccupation with drugs in the presence of a
substance use disorder, preoccupation of having a serious disease in the
presence of hypochondriasis,etc
E. The disturbance is not due to the direct physiological effects of a
substance (e.g. a drug of abuse, a medication) or a general medical
condition

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 How is OCD treated?
 Many medications are clomipramine
available: clomipramine
( Anafranil), fluoxetine
( Prozac), sertraline
(Zoloft), paroxetine (Paxil), fluoxetine
and fluvoxamine (Luvox)
 Behavioral therapy can also
be used under the guidance
of a trained therapist
sertraline

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 Assessment:-
 Routinely consider and explore the possibility of comorbid
OCD for people:- at higher risk of OCD, such as those
with symptoms of:
 depression
 anxiety
 alcohol or substance abuse
 BPAD
 an eating disorder
 attending dermatology clinics
 Ask direct questions about possible symptoms

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 Assessment :- For any person diagnosed with OCD:

 assess risk of self-harm and suicide (particularly if depression

already diagnosed).

 include impact of compulsive behaviours on patient and

others in risk assessment.

 consider other comorbid conditions or psychosocial factors

that may contribute to risk.

 consult mental health professional with specific expertise in

OCD if uncertain about risks associated with intrusive
sexual, aggressive or death-related thoughts. (These themes
are common in OCD and are often misinterpreted as
indicating risk.)
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 Treatment options for adults
with OCD
Mild functional Moderate functional Severe functional
impairment impairment impairment

Offer choice of: Inadequate

Brief CBT (+ERP) response at 12
more intensive CBT weeks
< 10 therapist hours
(+ERP)
(individual
>10 therapist hours
or group Multidisciplinary
or
formats) review
course of an SSRI
Offer combined
treatment of
CBT (+ERP)
and an SSRI
Patient cannot engage in/CBT
(+ERP) is inadequate

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 Treatment options for adults

Severe functional impairment:

• offer combined treatment with CBT (including ERP) and an SSRI

Offer either: a different SSRI or clomipramine

*
Refer to multidisciplinary team with expertise in OCD
*
Consider:
• additional CBT (including ERP), or cognitive therapy
• adding an antipsychotic to an SSRI or clomipramine
• combining clomipramine and citalopram

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 Psychological interventions - adults

 CBT (including ERP) is the mainstay of psychological

treatment-
 Consider CBT (including ERP) for patients with
obsessive thoughts without overt compulsions
 Consider cognitive therapy adapted for OCD:
- as an addition to ERP to enhance long-term
symptom reduction
- for people who refuse or cannot engage with
treatments that include ERP

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 Psychological interventions - adults

 If a family member/carer is involved in compulsive

behaviours, avoidance or reassurance seeking, treatment
plans should help them to reduce their involvement in a
supportive way
 The intensity of intervention is dependent upon the
degree of functional impairment and patient preference

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What is CBT?
 Cognitive-Behavioral Therapy
 Focuses on thought patterns/perspectives

 “Cognitive Distortions”
 “Metacognition” –thinking about thinking
 Focuses on behavioral modification
 What can one do differently to feel better?
 Example behavioral strategies in CBT:
assertiveness training, task management, behavioral
activation, relaxation training, exercise,
reinforcement, environmental change, social support
seeking . . .

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What is ERP?
 Exposure with Response Prevention
 Exposure = “Face the Fear”
 Experience the obsessive thought
 Come into contact with the feared situation
 Response Prevention = Don’t do the compulsive,
“neutralizing” or preventive, behavior (rituals)
 Just feel the anxiety! It will diminish naturally.

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 Nursing management:-
I. Nursing assessment
II. Nursing diagnosis-
 Impaired skin integrity r/t repeated washing.
 Ineffective coping r/t underdeveloped ego, punitive
superego.
 Ineffective role performance r/t need to perform rituals.
 Disturbance in self esteem r/t lack of perceived strengths.
 Diversional activity deficit r/t pre-occupation with
performance of rituals.

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Impaired skin integrity r/t repeated washing.
Goal-to maintain normal skin integrity
Intervention Rationale
Provide a good quality -to make the skin healthy &
soap to the patient prevent easy dryness
In winter provide warm

water
Encourage patient to use
-it prevents dryness of skin
cold cream or Vaseline, & cracking.
wear gloves after washing.
Gradually set limit on no.
-it reduces frequency of
of times he washes hands. washing hands. 31
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