NCP Obsessive Compulsive Disorder

DSM-IV

300.3 Obsessive-compulsive disorder

An obsession is an intrusive/inappropriate repetitive thought, impulse, or image that the individual recognizes as a product of his or her own mind but is unable to control. A compulsion is a repetitive urge that the individual feels driven to perform and cannot resist without great difficulty (severe anxiety). Most common obsessions are repetitive thoughts about contamination, repeated doubts, a need to have things in a specific order, aggressive or horrific impulses, or sexual imagery. The individual usually attempts to ignore or suppress such thoughts or to neutralize them with some other thought or action (compulsion).

ETIOLOGICAL THEORIES

Psychodynamics

Freud placed origin for obsessive-compulsive characteristics in the anal stage of development. The child is mastering bowel and bladder control at this developmental stage and derives pleasure from controlling his or her own body and indirectly the actions of others.

Erikson’s comparable stage for this disorder is autonomy versus shame and doubt. The child learns that to be neat and tidy and to handle bodily wastes properly gains parental approval and to be messy brings criticism and rejection.

The obsessional character develops the art of the need to obtain approval by being excessively tidy and controlled. Frequently the parents’ standards are too high for the child to meet, and the child continually is frustrated in attempts to please parents.

The defensive mechanisms used in obsessive-compulsive behaviors are unconscious attempts by the client to protect the self from internal anxiety. The greater the anxiety, the more time and energy will be tied up in the completion of the client’s rituals. First, the client uses regression, a return to earlier methods of handling anxiety. Second, the obsessive thoughts are either devoid of feeling or are attached to anxiety. Thus, isolation is used. Third, the client’s overt attitude toward others is usually the opposite of the unconscious feelings. Thus, reaction formation is being used. Last, compulsive rituals are a symbolic way of undoing or resolving the underlying conflict.

Biological

Although biological and neurophysiological influences in the etiology of anxiety disorders have been investigated, no relationship has yet been established. The mind-body connection is well accepted, but it is difficult to establish whether the biological changes cause anxiety or the emotional state causes physiological manifestations. However, recent findings suggest that neurobiological disturbances may play a role in obsessive-compulsive disorder, with physiological and biochemical factors also playing significant roles.

Family Dynamics

The individual exhibiting dysfunctional behavior is seen as the representation of family system problems. The “identified patient” (IP) is carrying the problems of the other members of the family, which are seen as the result of the interrelationships (disequilibrium) between family members rather than as isolated individual problems.

Multiple factors contribute to anxiety disorders.

CLIENT ASSESSMENT DATA BASE

(Also refer to CPs: Generalized Anxiety Disorder; Panic Disorders/Phobias.)

Activity/Rest

Difficulty relaxing

Pleasurable activities causing anxiety

Ego Integrity

May be very controlled from within

Pre-onset stressors (e.g., family death, pregnancy/childbirth, sexual failures) may be present

Hygiene

Characteristic rituals may influence/include repetitive hand-washing, intensive cleanliness, activities of daily living (e.g., dressing and undressing a number of times, placing articles in a specific order)

Neurosensory

Obsessive thoughts may be destructive or delusional, with most frequent themes, including contamination/dirt, health/illness, orderliness or need for symmetry, aggression, morality/religion, sex (e.g., shameful/degrading acts)

Thinking processes are rigid, intellectual, and sharply focused toward tasks; may express belief that nonpurposeful and nondirected activity is unsafe and bad

Repetitive mental acts (e.g., praying, counting, repeating words silently)

Impaired problem-solving ability

Ritualistic speech often noted

Social Interactions

More frequent occurrence in upper-middle class, with higher levels of intellectual functioning

Interference with normal routines, occupational functioning, social activities/relationships

May focus on details but be unproductive in work situations because of narrow scope and rigidity of ideas

Teaching/Learning

Most often seen in adolescence and early adulthood (average age of onset is 20)

DIAGNOSTIC STUDIES

(Refer to CPs: Generalized Anxiety Disorder, Panic Disorder/Phobias.)

NURSING PRIORITIES

1. Assist client to recognize onset of anxiety.

2. Explore the meaning and purpose of the behavior with the client.

3. Assist client to limit ritualistic behaviors.

4. Help client learn alternative responses to stress.

5. Encourage family participation in therapy program.

DISCHARGE GOALS

1. Anxiety decreased to a manageable level.

2. Ritualistic behaviors managed/minimized.

3. Environmental and interpersonal stress decreased.

4. Client/family involved in support group/community programs.

5. Plan in place to meet needs after discharge.

(Refer to CP: Generalized Anxiety Disorder for needs/concerns in addition to the following NDs.)