Exam (elaborations)
Nursing Care of Persons with Obsessions and Compulsions
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Nursing Care of Persons with Obsessions and Compulsions
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Nursing Care of Persons withObsessions and Compulsions
Acceptance and Commitment Therapy for OCD - ANSWER--Nurses may have clients
who are engaged in acceptance and commitment therapy (ACT), which is a form of
CBT
-ACT is, however, somewhat different than CBT or ERP in that it focuses more on
altering obsessional thinking and the way it is experienced
-Strategies here help the person accept thoughts and anxiety without allowing them to
interfere with life
-Better functioning can be achieved without changing the frequency or severity of
symptoms
-ACT was particularly helpful for patients who relapsed after a course of ERP or CBT
-While reports are positive, this CBT-based therapy is still under investigation
Administering and Monitoring Medications for OCD - ANSWER--Antidepressants used
to treat persons with OCD are often given in higher doses than those normally used to
treat depressed patients
-The most common route of administration is oral
-For refractory OCD, high dose, intravenous treatment with antidepressant drugs may
be indicated to bring the symptoms quickly under control
-Medication effects must be closely monitored, including being alert to signs of toxicity,
to provide safe and adequate care
Age of Onset for OCD - ANSWER--The onset of the illness has a bimodal peak—in
early adolescence and early adulthood
-Males were thought to have a higher rate of childhood onset, but it may be that males
experience greater symptom severity at a younger age for which they seek treatment
-Occurrence over the age of 35 is rare
-While subclinical symptoms may not lead to a formal diagnosis of OCD, they may still
be troubling and contribute to some level of impairment
-Obsessional thinking styles might have an effect on cognitive performance, and
knowing this could help tailor cognitive-behavior therapy (CBT) for those with subclinical
symptoms
Behavioral Factors for OCD - ANSWER--Behavioral explanations for OCD stem from
learning theory
-From this viewpoint, obsessions are seen as conditioned stimuli
-Though being associated with noxious events, stimuli that are usually considered
neutral become anxiety provoking
-The individual then engages in activities to escape or avoid the anxiety
-Compulsions develop as the individual discovers behaviors that successfully reduce
the obsessional anxiety
,-As the principles of operant conditioning indicate, the more the behaviors decrease the
anxiety, the more likely the individual is to continue using them
-However, the rituals or behaviors preserve the fear response because the person
avoids the initial stimuli and thus never extinguishes the compulsion
-Interrupting this cycle is the focus of behavioral therapy in treating an individual with
OCD
-Nurses often use behavioral approaches to reinforce and encourage acceptable
behaviors, to set limits, and to impose structure on the environment to make people feel
safe, which can reduce anxiety and confusion
Behavioral Interventions and Interactions for OCD - ANSWER--Although most patients
with OCD are treated in outpatient settings, some are hospitalized with comorbidities
and are unable to care of themselves or pose a substantial risk of harm to self or others
-Some general behavioral-based strategies that can be used in any setting include the
following:
1. Unit routines must be carefully and clearly explained to decrease fear of the unknown
2. Assess and monitor the level of anxiety and disability
3. Monitor for psychiatric comorbidities and suicide risk
4. At least initially, do not prevent the individual from engaging in rituals because the
person's anxiety level will increase
5. Recognize the significance of the rituals to the person and empathize with the
person's need to perform them
6. Make reasonable demands and set reasonable limits, avoid situations that provoke or
increase frustration
7. Encourage discussions that identify disturbing topics that may relate to underlying
anxiety or fear
8. Assist the individual in arranging a schedule of activities that not only incorporates
some private time but also integrates the person into normal unit activities
9. Help the person recognize triggers to obsessive thoughts and ritualistic behaviors
and the relationship between them
10. Give positive reinforcement for non-ritualistic behavior and to acknowledge the
person's progress, strengths, and accomplishments
11. Reinforce the use of cognitive strategies, including constructive self-talk and
cognitive restructuring
Biochemical Theories for OCD - ANSWER--Biochemical theories address imbalances of
chemicals in the brain, but there is no persuasive evidence that any mental illness is
caused by a single biochemical imbalance
-Serotonin has been the most extensively studied neurotransmitter in relation to OCD,
largely through challenge tests in which serotonin agonists were administered to
persons with OCD and with control subjects
-The most convincing evidence for serotonin's role is that serotonin-specific
antidepressants relieve the symptoms of OCD for about 40% to 60% of those who take
them
,-Conventional and novel antipsychotic medications and mood stabilizers are used in
conjunction with serotonin-targeting medications to treat refractory symptoms, indicating
that other biochemical processes exist
-When chemical balances are identified, it is still difficult to understand how they relate
to precise mechanisms of OCD, nor is it possible to know if the chemical changes
caused the symptoms or presented because of the symptoms (chicken and egg
confound)
-Prolonged treatment with selective serotonin reuptake inhibitor (SSRI), combined with
CBT or with exposure and response prevention (ERP) therapy, is the most effective
treatment
-New treatments for refractory OCD are needed, and likely candidates will be based on
pharmacogenetics
Biologic Theories for OCD - ANSWER-Genetic, neuropathologic, and biochemical
research, suggests that OCD has a biologic basis involving several neuroanatomic
structures
Body Dysmorphic Disorder - ANSWER--Individuals with BDD focus on real (but slight)
or imagined defects in appearance, such as a large nose, thinning hair, or small genitals
-Preoccupation with the perceived defect causes significant distress and interferes with
their ability to function socially
-They feel so self-conscious that they avoid work or public situations
-Some fear that their "ugly" body part will malfunction
-Surgical correction of the problem by a plastic surgeon or a dermatologist does not
correct their preoccupation and distress
-BDD is an extremely debilitating disorder and can significantly impair an individual's
QOL
-BDD usually begins in adolescence and continues throughout adulthood
-These individuals are not usually seen in psychiatric settings unless they have a
coexisting psychiatric disorder or a family member insists on psychiatric attention
-This disorder occurs in men and women, with a prevalence of 2.4% in the United
States
-The risk of depression, suicide ideation, and suicide is high
-The suicide risk in BDD is increased by the presence of other disorders such as
substance use disorder, major depressive disorder, eating, and personality disorders
-People with comorbid OCD-BDD have high morbidity, a decrease in insight, and poor
psychosocial functions
-No single theory explains the cause of BDD
-Unrealistic cultural expectations and genetic predisposition most likely underlie this
disorder
Clinical Course for OCD - ANSWER--OCD follows a chronic waxing and waning course
-Symptoms of OCD (nonclinical or subclinical) often begin in childhood, but many
receive treatment only after the disorder has significantly affected their lives
-In preschool-age children, OCD is often misdiagnosed as separation anxiety disorder
-Onset in early or middle childhood is associated with a better outcome than later onset
, -Subclinical symptoms can be distressing and cause some impairment
-Escalation of subclinical symptoms takes on average 7 years
-Predisposition to escalation is associated with being a male, younger age of symptom
assessment, being in a new romantic relationship, having more severe sexual/religious
symptoms, and having low rates of hoarding
-Individuals with OCD may become incapacitated by their symptoms and spend most of
their waking hours locked in a cycle of obsessions and compulsions
-They may even become unable to complete a task as simple as walking through a door
without performing rituals
-Interpersonal relationships suffer, and the person may actively isolate and withdraw
from contact with others
-Individuals with OCD often engage in dissociative absorption, a tendency to become
excessively absorbed in fantasy (movies, online gaming), leading to decreased self-
awareness and inattention to their surroundings
-Dissociative absorption may predict the onset of obsessive-compulsive symptoms,
though this possible link is still being investigated
Clinical Course for Trichotillomania Disorder - ANSWER--The onset of trichotillomania
occurs among children before the age of 5 years and in adolescents
-For the young child, distraction or redirection may successfully eliminate the behavior
-The behavior in adolescents may begin a chronic course that may last well into
adulthood
Clinical Judgment for OCD - ANSWER--Patients with OCD may present with various
problems, depending on the particular obsession and the compulsions that have
evolved to cope with that obsession
-As a result, nursing priorities could run the gamut from psychologic issues related to
anxiety, poor self-concept, and loneliness to physical issues such as skin integrity
-Outcomes are determined collaboratively after the issues have been identified
-Do not forget that a suicide assessment is an essential part of care, and an emergency
plan for that contingency as well as for other possible adverse events (medication side
effects) should be in place before a client leaves the acute care setting
-Recovery plans may take longer to generate, but the acute care nurse can collaborate
and begin to develop a recovery plan
-The patient should be encouraged to commit to follow-up for long-term treatment and
recovery
Common SSRI Side Effects - ANSWER-Autonomic
-Dry mouth
-Sweating
Central/Peripheral nervous system
-Headache
-Sedation
-Psychiatric
-Somnolence
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