This ppt for MSc Nursing Students of Psychiatric Nursing Specialty

1. PRESENTATION
ON
OBSESSIVE COMPULSIVE DISORDERS
PRESENTED BY:
RUCHI RANA
M.Sc(N)2ND YEAR
3/17/2021
1

2. INTRODUCTION
• Obsessions- Obsessions are recurrent , persistent,
intrusive and unwanted thoughts, images or urges that
cause anxiety or distress.
3/17/2021
2

3. FOUR POINTS OF OBSESSION
• Own thoughts
• Repeat
• Resist
• Distress
3/17/2021
3

4. Common obsessive thoughts in OCD
Fear of being contaminated by germs or dirt or
contaminating others.
3/17/2021
4

5. Common obsessive thoughts in OCD
Fear of losing control and harming yourself or
others
3/17/2021
5

6. Common obsessive thoughts in OCD
Intrusive sexually explicit or violent thoughts and
images.
3/17/2021
6

7. Common obsessive thoughts in OCD
Excessive focus on religious or moral ideas.
3/17/2021
7

8. COMPULSIONS
Compulsions- These are behaviors or rituals that
person feel driven to act out again and again.
Usually compulsions are performed in an attempt to
make obsessions go away.
3/17/2021
8

9. Example
• If person afraid of contamination, he might develop
elaborated cleaning rituals. However, the relief never
lasts . In fact the obsessive thoughts usually come
back stronger and the compulsive rituals and
behavior often end up causing anxiety themselves as
they become more demanding and time- consuming.
3/17/2021
9

10. 3/17/2021
10

11. Common compulsive behaviors in OCD
Excessive double-checking of things, such as
locks, appliances and switches
3/17/2021
11

12. Common compulsive behaviors in OCD
Counting, tapping, repeating certain words or
doing other senseless things to reduce anxiety.
3/17/2021
12

13. Common compulsive behaviors in OCD
Repeatedly checking in on loved ones to make sure
they are safe.
3/17/2021
13

14. Common compulsive behaviors in OCD
Spending a lot of time washing or cleaning.
3/17/2021
14

15. Common compulsive behaviors in OCD
Praying excessively or engaging in rituals
triggered by religious fear.
3/17/2021
15

16. Common compulsive behaviors in OCD
Accumulating “junk” such as old newspaper or
empty food containers.
3/17/2021
16

17. DEFINITION
Obsessive- compulsive disorder is characterized by
the undesirable repetitive obsessions (distressing ,
persistent thoughts or images) and compulsions
(desires to perform specific acts or rituals)
3/17/2021
17

18. HISTORY
• 14th & 15th century –Obsessions and compulsions
came into usage-Scrupulosity
• They thought that people were possessed by the devil
and treated by exorcism.
• 17th century thought people were cleansing their
guilt.
• 20th century began treating with behavioral
techniques.
3/17/2021
18

19. EPIDERMIOLOGY
• OCD affects around 3% of the population worldwide.
• Among adults, men and women are equally likely to
be affected.
• Among adolescents, boys are more commonly
affected than girls.
• The mean age of onset is about 20 years .
• Men having slightly earlier age of onset (mean about
19 years) than women (mean about 22 years)
3/17/2021
19

20. EPIDERMIOLOGY
• Overall, the symptoms of about 2-3rd of affected persons have
an onset before age 25 years.
• The symptoms of fewer than 15% have an onset after age 35.
• Single persons are more frequently affected with OCD than
are married persons
• The risk of death by suicide in people with OCD
approximately 10 times higher than in the general population
and the risk of attempting suicide was 5 times higher.
• In India, Prevalence of mental morbidity due to OCD is 0.76%
(NHMS survey 2016)
3/17/2021
20

21. 3/17/2021
21

22. Clinical features of OCD
The DSM-5 diagnostic criteria for obsessive-
compulsive disorder include the presence of
obsessions , compulsions or both.
Obsessional thoughts
Compulsive behaviors
Ruminations
Cognitive rituals
Compulsive motor rituals
Obsessional Doubts
Obsessional images of fear and impulses
3/17/2021
22

23. OBSESSIONAL THOUGHTS
The person experiences recurrent and persistent thoughts,
impulses, images that are disturbing inappropriate and
usually triggered by anxiety.
E.g-Repeated thoughts about contamination (e.g may
lead to fear of shaking hands or touching objects).
3/17/2021
23

24. COMPULSIVE BEHAVIOR
Mental acts that a person feels compelled to
perform. The behaviors are typically aimed at
reducing anxiety or preventing some feared
situation from occuring.
e.g- excessive hand washing or house cleaning.
3/17/2021
24

25. RUMINATIONS
Unreasonable worry about a particular topic,
associated with threatening speculation
(thoughts).
3/17/2021
25

26. COGNITIVE RITUALS
Complicated series of mental acts where the client
feels forced to complete.
3/17/2021
26

27. COMPULSIVE MOTOR RITUALS
Complicated habits of everyday functioning such
as grooming , dressing , eating , washing.
3/17/2021
27

28. OBSESSIONAL DOUBTS
Having excessive doubts that specific task or action
have not being completed.
e.g checking doors or appliances again and again.
3/17/2021
28

29. OBSESSIONAL IMAGES OF FEAR AND
IMPULSES
The person experiences recurrent and persistent vivid
images, impulses and fear that are disturbing,
inappropriate and usually triggered by anxiety.
3/17/2021
29

30. OCD WITH FOLLOWING CATEGORIES
• Washers
• Checkers
• Doubters and sinners
• Counters and arrangers
• Hoarders
3/17/2021
30

31. 3/17/2021
31

32. Pure-O, OCD
• OCD sometimes manifests without overt
compulsions. Rather than engaging in
observable compulsions, the person with this
subtype might perform more covert, mental
rituals, or might feel driven to avoid the
situations in which particular thoughts seem
likely to intrude.
3/17/2021
32

33. Comorbidity with OCD
• Depression is extremely prevalent among suffers
of OCD or any other anxiety disorder may feel
depressed because of an “out of control” type of
feeling and having high risk of suicide.
3/17/2021
33

34. 3/17/2021
34

35. DIAGNOSTIC CRITERIA OF OCD
According to DSM-5
Obsessions are defined by:
1. Recurrent and persistent thoughts , urges or images
that are experienced as intrusive, unwanted and
cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such
thoughts, urges, or images or to neutralize them
with some thought or action(ie. By performing a
compulsion)
3/17/2021
35

36. DIAGNOSTIC CRITERIA OF OCD
Compulsions are defined by:
• Repetitive behaviors(e.g, hand washing. Ordering
checking) or mental acts (eg, praying, counting,
repeating words silently) in response to an
obsessional thoughts.
• The behaviors are aimed at preventing or reducing
distress or preventing some dreaded event or
situation.
3/17/2021
36

37. DIAGNOSTIC CRITERIA OF OCD
• The obsessions or compulsons are time
consuming(e.g, take more than 1 hour or day) or
cause clinically significant distress or imparement in
social , occupational, or other important areas of
functioning.
• The disturbance is not due to other mental disorders,
physiological effects of a substance or general
medical conditions.
3/17/2021
37

38. • Some researchers have estimated that the disorder is
found in as many as 10 % of outpatients in
psychiatric clinics. These figures make OCD the 4th
most common psychiatric diagnosis after phobias,
substance-related disorders and major depressive
disorder.
3/17/2021
38

39. Classification of OCD
Obsessive compulsive and related disorders are
classified within the following subcategories under
DSM-5
Obsessive Compulsive and related disorders
Obsessive compulsive disorder(OCD)
Body dysmorphic disorder (BDD)
Hoarding disorder
Trichotillomania
Excoriation(skin picking) disorder
3/17/2021
39

40. Cont..
Substance /Medication- induced obsessive-
compulsive and related disorder.
Obsessive-compulsive and related disorder due to
another medical condition
Other specified obsessive-compulsive and related
disorder
Unspecified obsessive- compulsive and related
disorder
3/17/2021
40

41. Body dysmorphic disorder (BDD)
The perception of having physical defects that other
people can not see .
Body dysmorphic disorder affects 1.7% to 2.4% of the
general population about 1 in 50 people.
The average age of getting BDD under the age of 16-17
3/17/2021
41

42. 3/17/2021
42

43. 3/17/2021
43

44. HOARDING DISORDER
People with hoarding disorder often save random items and store them
haphazardly.
In most cases, people save items that they feel they may need in the future, are
valuable or having sentimental value.
Some may also feel safer surrounded by the things they save.
Current estimates indicate that 14% of the population will engage in hoarding
behaviors sometime in the life course.
3/17/2021
44

45. TRICHOTILLOMANIA
A disorder that involves recurrent, irresistible
urges to pull out body hair.
The urges involves pulling out hair from the
scalp, eye brows and other areas of the body.
3/17/2021
45

46. SKIN PICKING DISORDER
Skin picking disorder also referred to as chronic excoriation disorder
or dermatillomania, is a mental illness related to obsessive
compulsive disorder.
It is characterized by repeated picking at one’s own skin which
results in skin lesions and cause significant disruption in one’s life.
Dermatillomania affects upto 1.4 % of the total population and
approximately 75% of those affected are females.
3/17/2021
46

47. Etiology of OCD
• There are several theories about the cause of OCD ,
but none have been confirmed:
• Biological theory: Neurobiological and biochemical
disturbances seems to play a role in obsessive-
compulsive disorder.
• Neurotransmitters: It is speculated that the under
stimulation of serotonin receptors is associated with
the symptoms of OCD.
3/17/2021
47

48. Cont..
• Psychodynamic theory: Freud stated that obsessive-
compulsive characterstics developed due to fixation
at anal stage of development and subsequent
regression from the anal stage.
• Psychosocial theory: Erikson,s relate OCD with the
stage of autonomy versus shame and doubt. The
obsesional behavior is developed to fulfill the need of
approval by being excessively tidy and controlled.
3/17/2021
48

49. Cont..
• Behavioral Theory: Stated that OCD is a learn
behavior of an individual where obsessions are
triggered by fear associated with stimuli (e.g,
unwashed hands, obsessional thoughts). The
compulsive rituals (e.g, hand washing) decreases the
anxiety and fear hence more likely to occur in future
because of it reinforced by anxiety reduction.
3/17/2021
49

50. PSYCHODYNAMICS OF OCD
Child fall in mastering bowel and bladder control.
Fixation in anal stage
Precipitating factors: loss of loved object or situational crisis (real or
imaginary) in later life
Dostorted cognitive appraisal (delayed ego, conflict between id and
superego).
Ineffective coping : Isolation, undoing , reaction formation and
regression + week ego
OCD
3/17/2021
50

51. 3/17/2021
51

52. 3/17/2021
52

53. • A study was conducted in Denmark, states that
COVID-19 has triggered and worsened the state of
obsessive compulsive disorder in children and young
adults.
3/17/2021
53

54. • A 2011 study found that anger is a common
symptom of OCD. It affects approximately half of
people with OCD . Anger may result from frustration
with your inability to prevent obsessive thoughts and
compulsive behaviors, or from having someone or
something interfere with your ability to carry out or
ritual.
3/17/2021
54

55. • Studies also indicate that obsessions can transform
into delusions and that OCD and symptoms of OCD
can be associated with the development of psychotic
disorder over time. An increase prevalence of OCD in
patients with first- episode psychosis has also been
found .
3/17/2021
55

56. • A new prospective analysis of over 3 million people
in Denmark Proposes that OCD may be a risk factor
for schizophrenia. This study found that a prior
psychiatric diagnosis of OCD was associated with
approximately a fivefold increased risk of developing
schizophrenia.
3/17/2021
56

57. ASSESSMENT TECHNIQUES
• The Anxiety disorder interview schedule- Revised
(ADIS-R)
• The Yale – Brown obsessive compulsive symptoms
checklist (Y-BOC)
• ..04-Y-BOCS-w-Checklist.pdf
3/17/2021
57

58. Management of OCD
• OCD is generally treated with psychotherapy ,
medication and supportive interventions, ECT, Self
help and coping
3/17/2021
58

59. Medications
1. Selective serotonin reuptake inhibitor (SSRI)
2. Tricyclic antidepressants
3. Benzodiazepines (alprazolam, diazepam,
lorazepam)
3/17/2021
59

60. Sertraline
• Brand Name-(Zoloft)
• For adult and children 6 yrs and older
• Adult dose-50 mg orally once a day
• Pediatric dose
• 6-12 yrs 25 mg orally once a day
• 13-17 yrs 50 mg orally once a day
3/17/2021
60

61. Paroxetine
Brand Name – Paxil,Seroxat
Take paroxetine once a day, in the morning .
Its best to take it with food so it does not upset
pt,s stomach
Adult dose-20 mg
Maximum dose 60 mg per day
Child dose- Not recommended for children
Older people-20 mg
3/17/2021
61

62. Side effects of SSRIs
• Feeling agitated, anxious
• Feeling or being sick
• Diarrhoea/Constipation
• Dizziness
• Sleeping problems (Insomnia)
• Headaches
3/17/2021
62

63. Tricyclic antidepressants
• Tricyclic antidepressants effect serotonin and
nor-adrenaline in the brain.
• Improvement is usually seen in 2 to 6 weeks.
• Example-Clomipramine
3/17/2021
63

64. Clomipramine
• Brand Name-Anafranil
• Drug Class- Antidepressants , TCAs
• Clomipramine helps to decrease persistent/
unwanted thoughts and it helps reduce the urge to
perform repeated tasks (Compulsions such as hand
washing, counting, checking) that interfere with
daily life.
• Adult dose- 25 mg orally/ day initially.
• Maximum dose-250 mg/ day at bedtime
• Children 10 yrs and older: 25 mg orally once/day
initally
3/17/2021
64

65. Side Effects of Tricyclic antidepressants
• Lightheadedness
• Sleepiness
• Dry mouth
• Constipation
• Difficulty urinating
• Weight Gain
• Low blood pressure
3/17/2021
65

66. BENZODIAZEPINES
• Benzodiazepines are generally prescribed to
patient with OCD who have not much
improvement while using SSRIs.
• These are frequently used as a sedation and anti-
anxiety medication for GAD. Because of the
sedating effects, it mostly beneficial if OCD is
affecting the patient,s ability to relax and sleep .
• Example-Alprazolam.
3/17/2021
66

67. Psychological Therapies
• Psychotherapies help the person to learn different
ways of thinking, behaving and reacting to situations
in less anxious an fearful manner.
• Exposure and response prevention
• Cognitive therapy
• Family Therapy
• Group therapy
3/17/2021
67

68. Exposure and Response Prevention
(ERP)
• The most widely practised therapy for OCD is
called Exposure and response prevention.
• There are two components:
• -Exposure Treatment
• -Response Prevention Treatment
• Treatment start with exposure to situations that
cause the least anxiety.
• As the patient overcomes these, they move on to
situations that cause more anxiety
3/17/2021
68

69. Exposure Treatment
• Controlled exposure (dirt or imagined) to objects
or situations that trigger obsessions while
raising anxiety levels.
• Over time the exposure leads to less anxiety and
over a long period of time it leads to very little
anxiety at all.
3/17/2021
69

70. Response Prevention Treatment
• The ritual behaviors that people with OCD
engage in to reduce anxiety
• Patient learn to resist the compulsion to perform
rituals and are eventually able to stop engaging
in these behaviors.
3/17/2021
70

71. Common Difficulties During ERP
• Non- Compliance with response prevention
instructions.
• Continued passive avoidance.
• Arguing about exposure/ response prevention
requirements
• Emotional Overload
• Family reactions
3/17/2021
71

72. Group Therapy Family therapy
3/17/2021
72

73. NURSING ASSESSMENT
• Assessment should focus on the collection of
physical , psychological and social data.
• The nurse should be particularly aware of the impact
of obsessions and compulsions on physical
functioning, mood, self- esteem and normal coping
ability.
3/17/2021
73

74. Nursing Management
• Nursing Assessment
• The psychiatric history of a patient with this disorder
• Mental status examination
• Personality assessment determines the patient’s
personality type.
3/17/2021
74

75. Nursing Diagnosis-1
• Severe anxiety related to obsessional thoughts, fear,
images as evidence by repetitive action (eg, hand –
washing), recurrent thoughts (eg, dirt and germs) and
decreased social and role functioning.
3/17/2021
75

76. Expected outcome: Client will:
• Demonstrate ability to cope effectively with
situations without resorting to obsessive thoughts or
compulsive behaviors
• The patient will reduce the amount of time spent each
day on obsessing and ritualizing.
3/17/2021
76

77. INTERVENTIONS RATIONAL
1. Approach the patient unhurriedly.
2. Provide an accepting atmosphere.
3. Allow the patient time to carry out the
ritualistic behavior (unless it is
dangerous)
4. Provide for basic needs, such as rest ,
nutrition and grooming.
5. Fulfills the reasonable demands and set
reasonable limits; make their purpose
clear.
6. Listen attentively and offering
feedback.
7. Engage the patient in activities.
8. Encourage diversional activities.
9. Limit the number of times patient may
indulge in obsessive behavior) ,
Gradually shorten the time allowed.
10.Maintain consistency approach.
1. This improves patient’s confidence in
nurse.
2. Help to develop IPR with the patient.
3. Blocking the behavior raises anxiety.
4. Rituals may lead to inadequate food
/fluid intake, exhaustion and self-
neglect.
5. This decreases the patient’s frustration
and anger.
6. To convey respect and caring to the
patient.
7. To raise the patient’s self –esteem and
confidence.
8. To divert attention from the unwanted
thoughts.
9. To develop more effective coping skills
by setting limits on unacceptable
behavior.
10.To avoid boundary violation.
3/17/2021
77

78. Nursing Diagnosis-2
• Self –care deficit related to excessive ritualistic
behavior and excessive anxiety as evidence by
impaired ability to perform or complete activities of
daily living (ADL) independently.
• Expected Outcomes
• Client will verbalize desire to take control of self-
care activities.
• Client will be able to take care of own ADLs and
demonstrate a willingness to do so.
3/17/2021
78

79. Nursing Interventions Rationale
Encourage the client to perform normal
ADL to his level of ability.
Encourage independence and intervene
only when the client is unable to perform.
Offer positive reinforcement for
independent accomplishments.
Successful performance of independent
activities enhances self-esteem.
Safety and comfort of the client are
nursing priorities.
Positive reinforcement enhances self-
esteem and encourages repetition of
desired behaviors.
3/17/2021
79

80. NURSING DIAGNOSIS-3
Ineffective coping related to underdeveloped ego,
punitive superego: avoidance learning : possible
biochemical changes as evidenced by ritualistic
behavior or obsessive thoughts
Expected Outcomes
Client will demonstrate ability to cope effectively
without resorting to obsessive compulsive behaviors
or increased dependency.
3/17/2021
80

81. Nursing Interventions Rational
1. Work with client to determine type s of
situations that increase anxiety and
result in ritualistic behaviours.
2. Initially meet the client’s dependency
needs as required .Encourage
independence and give positive
reinforcement for independent
behaviors.
3. In the beginning of treatment, allow
plenty of time for rituals .Do not be
judgement or verbalize disapproval of
the behavior.
4. Provide structured schedule of activities
for client, including adequate time for
completion of rituals.
5. Give positive reinforceent for
nonritualistic behaviors.
1. Recognition of precipitating factors is
the first step in teaching the client to
interrupt the escalating anxiety.
2. Sudden and complete elimination of all
avenues for dependency would create
intense anxiety on the part of the client.
Positive reinforcement enhances self-
esteem and encourages repetition of
desired behaviors.
3. To deny client this activity may
precipitate panic anxiety.
4. Structure provides a feeling of security
for the anxious client.
5. Positive reinforcement enhances self-
esteem and encourages repetition of
desired behaviors
3/17/2021
81

82. NURSING DIAGNOSIS-4
• Ineffective role performance related to need to
perform rituals as evidenced by inability to fulfill
usual patterns of responsibility.
Expected Outcome
Client will able to resume role related responsibilities
3/17/2021
82

83. Nursing Interventions Rationale
1. Determine client’s previous role within
the family and extent to which this role
is altered by the illness. Identify roles of
other family members.
2. Discuss client’s perception of role
expectations.
3. Encourage client to discuss conflicts
evident within the family system.
Identify client and other family
members have responded to this
conflict.
4. Explore available options for changes or
adjustments in role. Practice through
role-play.
5. Give client lots of positive
reinforcement for ability to resume role
responsibilities by decreasing need for
ritualistic behaviors.
1. This is important assessment data for
formulating an appropriate plan of
care.
2. Determine if client’s perception of his
or her role expectations are realistic .
3. Identifying specific stressors, as well as
adaptive and maladaptive responses
within the system, is necessary before
assistance can be provided in an effort
to create change.
4. Planning and rehearsal of potential role
transitions can reduce anxiety.
5. Positive reinforcement enhances self-
esteem and promotes repetition of
desired behaviors.
3/17/2021
83

84. CONCLUSION
• In conclusion , OCD is a tough disorder to live
with. We all may think that OCD can have an
easy fix and that it really is not that hard to live
with. But , the real is that it is not, as it affects
almost every aspect of the persons life , whether
it be interactions with family or friends or simple
every day tasks that we all take for granted.
3/17/2021
84

85. REFERENCES
• Mary C. Townsen D, Psychiatric Mental health Nursing
.Concept of care in Evidence based parctice .7th edition.
Jaypee Brother Medical Publishers (P)Ltd .2012 p.631-
658
• Bharat Pareek, Sandeep Arya ,Textbook of Mental Health
& Psychiatric Nursing ,published by Vision Health
Science Publisher,2nd edition .2020.p.198-204
• MS Bhatia,Essentials of Psychiatry ,7th edition .CBS
Publishers & distributors PVT .LTD ,2013.P 110-120.
• D.Elakkuvana. Bhaskara Raj , Debr,s Mental health
Nursing, EMMESS Medical Publishers.2017.p444-471
3/17/2021
85

86. 3/17/2021
86