Obsessive-Compulsive Disorder (OCD) | Types, Symptoms, Treatment, Therapies, Nursing Interventions.

INTRODUCTION

The term obsession and compulsive are sometimes used more broadly to characterize condition that is not true OCD although some activities, such as eating, sexual behavior ,gambling or drinking when engaged in excessively may be referred to as “compulsive” these activities are distinguished from true compulsion in that they are experienced as pleasurable and ego-syntonic although there consequence become increasingly unpleasant and ego-dystonic over a time .obsessive brooding rumination or preoccupations. typically characteristic of depression may be unpleasant but are distinguished from depression may be unpleasant but distinguished from true obsession .Early onset of onset consists of late 19th century .In 1895 Sigmund Freud describe with obsession subsequently the French physician Pierre Janet the first description conceit treatment of OCD.

DEFINITIONS

Obsessive-compulsive disorder (OCD) is an intriguing and often debilitating syndrome characterized by the presence of two distinct phenomena obsessions and compulsions. Obsessions are intrusive recurrent unwanted ideas and thoughts or impulses that are difficult to dismiss despite their disturbing nature. Compulsion is repetitive behavior either observable or mental that intended to reduce anxiety engendered by obsessions 

According to the ICD9, obsessive compulsive disorder is a state in which “outstanding symptoms is a feeling of subjective compulsion resisted which must be resisted to carry out some action, to dwell on an idea, to recall an experience, or ruminate on an abstract topic unwanted thought which includes the insistence of words or ideas perceived by patient to be inappropriate or nonsensical.

EPIDEMIOLOGY

• The study has found that OCD was the fourth most common psychiatric disorder (after phobias, substance abuse disorder, and major depressive disorder ) in India,the prevalence is 1.6% in 6months OCD is more common in unmarried males while in other countries no gender difference is reported . this is common in persons from upper social strata and with high intelligence the average age of onset is the late third decade in India while in the western countries the usually onset earlier in life . 
• Recent studies show that the lifetime prevalence of OCD to be high as 2-3% through Indian data . mean age is between 6&11 
• Around 80% adult, (OCD)cases have initial onset during childhood it's more in children whom often have embarrassing thoughts and behavior
• The onset is more in males than females

ETIOLOGY

I.Genetic Factors

• It is documented a fourfold increased frequency of OCD in first –degree relatives OCD.
• Twins studies has consistently found a significantly higher concordance rate for monozygotic twins than for dizygotic twins obsessive compulsive disorder is found in 5-7% or 35% of first-degree relatives of patients with OCD literature review says that concordance rate of 63% in monozygotic twins the parents or relatives with tic disorder & Gilles da la Tourette's syndrome it was much higher 40%than predicted general population 
• Preliminary findings from multisite obsessive genetic association study (OCGAS)the largest study to suggest linkage signal between chromosomes that is particularly on 14 is linked with compulsive disorder it may occur much secondary illness such as Von Economo’s encephalitis, basal ganglia lesions hypothalamic and third ventricle lesions . 

II. Biochemical influences 

• A number of studies suggest the dysregulation neurotransmission serotonin (5-HT) may be abnormal in individuals with obsessive-compulsive disorder whether serotonin is involved in the cause of OCD is not clear

• Abnormality in the neurotransmitters serotonin is blocked or damaged receptor sites that prevent serotonin from functioning to its full potential 

III. Psychodynamic Theory

Its views that OCD is residing on a continuum with obsessive-compulsive character pathology suggests that OCD develops when defence mechanism fails to contain obsessional character anxiety .in this model it involves fixation and subsequent regression from oedipal to the earlier developmental phase the fixation is presumably due to excessive investments in anal eroticism result in excessive frustration in anal phase 

The obsessive-compulsive patient thought to use the defence mechanism of isolation, undoing, reaction formation and displacement to control unacceptable sexual and aggressive impulse.

1. Regression:

In OCD, regression is theorized to take place from the genital oedipal phase to the early pregenital anal –sadistic phase, which has not been fully relinquished .the regression helps the patient to avoid genital conflicts and the anxiety associated with them. Themes characteristics of anal phase typically reflect conflicts surrounding ambivalence, control, dirt, order, and parsimony 

2.Ambivalence:

In normal development, aggressive impulses are neutralized and loving feeling predominate towards the significant object .In old strong aggressive impulses are thought to reemerge towards love object

3.Reaction Formation: 

The defence of reaction formation substitutes an unacceptable unconscious impulse with its opposite. Thus at moments of heightened anger, a person who has sadistic impulses to hurt people might behave in a passive manner

4.Undoing 

It's an attempt to magically reverse a psychological event, such as words, thoughts, gesture . A real or imagined act can be undone by performing or evoking its opposite.

5. Isolation

Isolation is an attempt to separate the feeling and effects from the thoughts fantasies or impulses that are associated with them 

IV. Behavioural Theory 

• The behavioural theory explains obsessions as conditioned stimuli to anxiety compulsion is described as learners behavior which decreases the anxiety associated with obsession this decrease in anxiety positively reinforces the compulsive act and they become stable as learned behavior
• It interplays between classical and operant conditioning paradigms
• The external aversive stimuli interact with the organism with previous learning such stimuli have acquired specific significance this results in stimuli gaining more strength result in sensitization. Ritual acts produce relief and thus through negative reinforcement increases the possibility of the phenomena. 

V. Mowers 2stage theory:

• the role of exposure and response prevention
• Neutral stimuli become associated with fear as it occurs within an event which provokes discomfort due this association various objects thoughts images also capable of causing discomfort
• Response that reduces discomfort are developed and maintained 
• According to Wolpe compulsion are anxiety elevating or relieving .obsession of thoughts to occur automatically in response to anxiety-evoking stimuli compulsion occurs as a reaction to anxiety and act as aimed at temporarily revealing compulsion

VI. Autoimmune responses to group A Streptococcal Infection

VII. Unconscious conflict manifested as OCD symptoms (Sigmund Freud)

VIII. Environmental factors 

 Misconception between the orbital frontal cortex the caudate nucleus and thalamus may be the factors 

CLASSIFICATION AS PER ICD-10

• F42 Obsessive-compulsive disorder
• F42.0 Predominantly obsessive thoughts or 

Rumination

• F42.1 predominantly compulsive acts 
• F42.2 Mixed obsession of thoughts and acts 
• F42.8 Other obsessive-compulsive disorder 
• F 42.9 obsessive compulsive disorder 

Unspecified 

• F42.0 Predominantly obsessive thoughts or 

Rumination

• These may be ideas thoughts mental images or impulses which are very distressing to an individual. e.g woman getting an idea to kill her child whom she loves 

• F42.1 predominantly compulsive acts
• For example, washing, checking, counting etc the underlying overt behavior is a fear the ritual act is a symbolic attempt to avert the danger of fear
• F42.2 Mixed obsession of thoughts and acts
• Majority of OCD individual will have both obsessions of thoughts and compulsive acts thoughts and acts responds differently to the treatment 

CLINICAL FEATURES

Obsession of thoughts: 

There are words ideas and belief that intrude forcibly into patient mind they are usually unpleasant and shocking to the patient and may become obscene 

• Contamination
• Repeated doubts
• Orderliness
• Impulses
• Sexual imagery

Obsession of images

These are vividly imagined scenes, often of a violent or disgusting kind involving abnormal sexual practices 

Obsessional ruminations:

These involves internal debates in which arguments for and against even the simplest everyday actions are reviewed endlessly 

Obsessional doubts

These may concern actions that may not have been completed adequately the obsession often implies some danger such as forgetting to turn off the stove or not locking a door, it may be followed by compulsive act such as the person making multiple trips back into house to check If the stove has been turned off sometimes these may take the form of doubting the very fundamental of beliefs such as doubting the existence of god and so on. 

Obsession of impulses 

These are the urge to perform usually of the violent or embarrassing kind, such as injuring a child, shouting in church etc.

Obsession of rituals 

These may include both mental activities such as counting repeatedly in a special way or reporting certain form of words and repeated senseless behaviors such as washing hands 20 times a day sometimes such compulsive act may be preceded by obsession of thoughts 

Obsessive slowness:

Severe obsession ideas or extensive compulsive rituals characterize obsessional slowness in the relative absence of manifested anxiety. This leads to marked slowness in daily activities 

• Lack of concentration ,and task completion
• Impaired social or work functioning 
• Repeated acts impulses , rituals such as washing hands, checking, rearranging things for perfect alignment
• Feeling of distress and anxiety 
• The compulsions are purely mental often called as secret illness
• Person suffering from OCD are often aware that their behavior is not rational and unhappy about their obsession but nevertheless feel compelled by them
• OCD is ‘ego dystonic’ this disorder is incompatible with the sufferer’s self-concepts 

DIAGNOSTIC EVALUATION

MENTAL STATUS EXAMINATION 

• Suggested by demonstrated of ritualistic Behavior that is irrational or excessive.
• MRI and CT show enlarged basal ganglia in some patients. 
• Positron-emission tomography scanning shows increased glucose metabolism in part of the basal ganglia. Especially the caudate and cingulum patient
• Differential Diagnosis
• Schizophrenia 
• Depression 
• Phobic disorder 

Course and Prognosis

More than half of all patients with OCD have a sudden onset of symptoms the onset of symptoms for about 50 to 70 percent of the patient occur after the stressful events, such as pregnancy sexual problem or the death of the relative .The course is usually long but some patient fluctuating course and other experience constant one a good prognosis is observed with treatment among the client who has the precipitating event and episodic nature of symptoms by improvement in personal social and occupational functioning.

Poor prognosis was noticed when OCD onset is in childhood and if major depressive disorder is coexisting about 20 to 30 percent of patient have significant impairment in their symptoms , and 40 to 50 percent have moderate improvement and the remaining 20 to 40 percent of patient either remain ill or see their symptom worsen 

MANAGEMENT

Pharmacotherapy

1. Benzodiazepines(e.g alprazolam,clonazepam)

Have a limited role in controlling anxiety 

2. Antidepressants some patient improve dramatically with specific serotonin reuptake inhibitors (SSRIs)

• Clomipramine (75-300 mg/day) a nonspecific serotonin reuptake first drug used in treatment of OCD
• Fluoxetine (20-80mg/day)is a good alternative to clomipramine 
• Fluvoxamine (50-200mg/day) marketed as anti-obsessional SSRI drug 
• Paroxetine (20-40 mg/day) 
• Sertraline(50-200mg/day)

3. antipsychotics they occasionally used as low doses (e.g haloperidol, risperidone, olanzapine, aripiprazole, pimozide ) in the treatment of severe disabling anxiety 

4.Buspirone has also been used beneficially for treatment 

Behavioural Therapy 

Behavioural modification is effective mode of therapy with success rate as high as 80% especially for compulsive acts 

The techniques are listed below 

• Systematic desensitization 
• Flooding 
• Modeling 
• Shaping
• Aversion therapy
• Reinforcement
• Positive reinforcement : suggestive measures emotional education 
• Negative practice- time out aversive training
• Emotional education
• Relaxation techniques e.g. deep breathing exercise progressive muscle relaxation meditation imagery music

Cognitive Therapy 

• Self-monitoring and control 
• Exposure and response prevention :
• Gradually learning to tolerate the anxiety by performing the ritual behavior
• Exposure involves deliberately facing the feared or avoided objects ,thoughts situation place 
• Response prevention involves delaying diminishing the anxiety-reducing rituals 
• The combination leads to gradual decrease in anxiety e.g. while going out checking the lock once (exposure)without going back and checking again (ritual prevention) 
• This exposure procedure combined with responses prevention techniques. ( compulsive hand washers are encouraged to touch contaminated objects and then refrain from washing in order to break the negative reinforcement chain 

Thought Stoppage

• Thought stopping is a technique to help an individual to learn to stop thinking unwanted thoughts. Following steps in thought stopping.
• Sit in a comfortable chair, bring to mind the unwanted thought concentrating only one thought per procedure 
• As soon as the thought forms, give command “stop” follow this with calm and deliberate relaxation of muscles and diversion of thought to something pleasant 
• Repeat the procedure to bring the unwanted thought under control. 

PSYCHOTHERAPY:

1. Psychoanalytical psychotherapy is used in certain selected patient who are psychologically oriented 

2. Supportive psychotherapy is an important mode treatment also needed by the family members 

ELECTROCONVULSIVE THERAPY

In presence of severe depression with OCD

Usage of ECT In OCD is controversial.

PSYCHOSURGERY 

Psychosurgery is used in treatment OCD that has been intractable and is not responding to any treatment 

The procedure are 

1. Stereotactic limbic leucotomy.

2. Stereotactic sub caudate tractotomy

NURSING MANAGEMENT / NURSING ASSESMENT

• Assessment should focus on collection of physical, psychological, and social data 
• The should be aware of the impact of obsession and compulsive on physical functioning, mood, self-esteem, and normal coping ability 
• The defense mechanism used thought content suicide and ability to function socially 

NURSING INTERVENTION

• Work with the patient to determine types of situation that increase anxiety and result in ritualistic behaviour 
• Initially, meet the patient’s dependency needs 
• Provide positive reinforcement for independent behavior 
• In beginning of treatment , allow plenty of time for rituals
• Gradually began to limit the time allotted ritualistic behaviour 

CONCLUSION

It a diverse group symptoms that include intrusive thoughts rituals preoccupation and compulsion it can cause severe distress to person a patient with OCD may have both through medication and psychotherapy 80% of people show improvement.

REFERENCES

• Mary C. Townsend, Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice, Sixth Edition, Philadelphia: F. A. Davis Company.
•  Sreevani R, A Guide to Mental Health and Psychiatric Nursing, Second Edition, Delhi: Jaypee Medical Publishers
• Neeraja KP, Essentials of Mental Health and Psychiatric Nursing, Volume 2, Delhi: Jaypee Medical Publishers
• Vyas JN, Ahuja Niraj, Textbook of Postgraduate Psychiatry, Second Edition, Delhi: Jaypee Medical Publishers. 
• Namboodiri VMD, Concise Textbook of Psychiatry 3^rd Edition, Gurgaon: Reed Elsevier India Pvt. Ltd 2009.

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