The Basics of OCD

Obsessive compulsive disorder (OCD) is a chronic mental health condition in which the individual has recurring, unwanted thoughts or fears that cause a significant amount of stress that can only be relieved by performing ritualistic behavior. The recurring thoughts or fears are the individual’s obsessions.The ritualistic activity that alleviates the obsessive thoughts and their associated stress is the compulsion.

Compulsions are unique to each individual, and can include any kind of repetitive behavior such as hand washing, checking that the doors are locked, or counting in specific patterns. These thoughts and activities interfere with daily life and can be extremely debilitating.

OCD pathophysiology

Obsessive compulsive disorder has been shown to have multiple causative factors including genetics, brain physiology, and the individual’s environment during their formative years. Neuroimaging studies show that individuals with OCD have decreased motor inhibition, so they are unable to stop an action once it has been initiated. These studies show that individuals with OCD have increased blood flow and an increased metabolic rate in certain areas of the brain, including the frontal lobes and basal ganglia. Studies also show that decreased levels of serotonin can play a role in the development of OCD.

Additional imaging studies have shown imbalances of gray matter density in some areas of the brain in individuals with OCD along with increased activity in other areas while at rest and when the individual is exposed to the subject of their obsessions.

Who is Most at Risk for OCD?

Obsessive compulsive disorder is more common in males and typically begins to manifest in teens and young adults, though it can begin even earlier in some cases. It tends to begin gradually and worsens over time, with stressful situations causing an increase in symptoms. 

There are a variety of factors that place someone at higher risk for OCD. Substance abuse, traumatic life events, having a family history of OCD, and the presence of another mental health disorder such as depression or anxiety all increase the risk for developing OCD.

One interesting risk factor occurs in children. Studies show there is a link between OCD and streptococcal infections, which goes by the acronym PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections). In these patients, OCD or a tic disorder appear or worsen following a strep infection.

What Are the Complications of OCD?

One of the most impactful complications of OCD is the effect it has on the individual’s life. Compulsive behaviors can be so all-consuming that individuals spend a significant amount of time, even hours per day, completing their rituals. 

Mental health complications include depression and suicidal ideation. In fact, individuals with OCD have a 3 to 10 times higher risk of death by suicide than the rest of the population. Additionally, a 2020 study showed that 26% of patients with OCD had attempted suicide at least once and 20 to 46% had had thoughts of suicide at some point in their lives.

Individuals with OCD also suffer greatly in their social lives with many having difficulties with socializing and forming or maintaining meaningful relationships. 

Physical complications can include things like skin irritation from frequent hand washing or even serious dehydration and hypoglycemia when the compulsive behavior lasts for an extended period of time. It is not unheard of for an individual to fixate on their compulsion for 24 hours or more during an acute exacerbation and avoid food and drink during this time.

Now that you have some background understanding of OCD, it’s time to review nursing implications using the Straight A Nursing LATTE method.

L: How does the patient LOOK?

An individual with OCD will have both obsessions and compulsions. Common obsessions include:

• A need for items to be symmetrical and tidy (such as the labels on canned foods all facing the same way with equal distance between each object).
• Concerns about contamination and being afraid to touch objects.
• Intrusive thoughts about harming others or oneself (even though they have no desire to do so).
• Doubt about themselves or things they’ve done such as being unsure if they’ve locked a door or turned off the stove.

The individual will partake in ritualistic behavior patterns as a way to manage anxiety and quell the obsessive thoughts or fears. Common compulsions include: 

• Washing (washing hands is common and can occur so frequently that the individual suffers from skin irritation)
• Counting in routine patterns
• Maintaining a strict routine
• Arranging objects so they are symmetrical and face the same way
• Cleaning 
• Checking things over and over (such as checking that the door is locked repeatedly)

It’s important to note that individuals with OCD are often described as perfectionists and inflexible, though being a perfectionist is not diagnostic for OCD. Neither is double checking things occasionally, which we all do from time to time. In order for the behavior to be associated with OCD, they must be causing significant life impairment and distress in the individual. According to the National Institute of Mental Health (NIMH), the distinguishing features of OCD are: 

• An inability to control the thoughts or behaviors even when they know they are unnecessary or unreasonable
• Spending at least an hour per day on the obsessions or compulsions
• While the compulsions do not provide pleasure, the individual does experience less anxiety by doing them 
• The individual’s life is significantly affected by the intrusive thoughts and behaviors

In addition, some people with OCD may also display motor or vocal tics. Motor tics manifest as brief repetitive movements like blinking, grimacing, or jerking. Vocal tics can manifest as sniffing, clearing the throat, or making grunting sounds.

Because the condition’s severity can range from mild to severe, remember that not all individuals with OCD display overly noticeable behaviors. Many can and do lead what appear to be normal lives.

A: How do you ASSESS the patient with OCD?

An important nursing assessment involves asking the patient specific questions about their symptoms. These include:

• “Do you have recurring thoughts that are disturbing to you and that you cannot get out of your head?”
• “Do you frequently wash, clean, or continuously check things such as doors or locks?”
• “Are you unable to function adequately because of the time it takes to complete the checking or cleaning?”
• “Do you regularly think about specific things or engage in behaviors to help calm your  nerves?”

Other assessments for a patient with OCD include: 

• Ask the patient to rate their anxiety level while also observing the patient for signs of anxiety. These can manifest differently for each individual but can include restlessness, increased activity, an inability to focus, and irritability.
• Assist the patient in identifying situations or events that cause anxiety, which can lead to compulsive behavior. 

• Assess for signs of depression and suicidal ideation. When necessary, perform a suicide risk assessment, maintain 1:1 observation of the patient, and alert the MD immediately. A commonly used suicide risk screening tool is the SAD PERSONS scale which looks at ten factors and assigns a point to each. A score of 0 to 4 indicates low risk, a score of 5 to 6 indicates medium risk, and a score of 7 to 10 indicates high risk.
• Observe for complications associated with the individual’s specific compulsion. For example, if the individual washes their hands repeatedly, check for skin irritation and breakdown. If the individual has engaged in exceedingly long periods of ritualistic activity they could be at risk for dehydration and hypoglycemia due to lack of food intake.

T: What TESTS are conducted for a patient with OCD?

Because there is no specific test for OCD, evaluation and diagnosis is typically done by a psychiatrist and involves interviewing the patient about their symptoms. The criteria for OCD include:

• The presence of obsessions and compulsions
• The obsession or compulsive behavior cause distress and persist for more than one hour per day
• The obsession or compulsion interferes with daily life, including the ability to work effectively
• The individual’s symptoms are not a result of substance abuse, medications or an underlying medical or mental health condition

T: What TREATMENTS are utilized in OCD?

Obsessive compulsive disorder is treated with psychotherapy and pharmacology. The medication class most commonly used in the treatment of OCD are SNRIs and SSRIs. These medications are understood to work because they increase serotonin levels, which may be decreased in individuals with OCD.

• SNRI: venlafaxine (Effexor)
• SSRI: fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro) and paroxetine (Paxil). 

Individuals who do not achieve the desired response with these medications may have additional or different medications prescribed. These could include:

• Clomipramine (Anafranil) a tricyclic antidepressant
• Antianxiety agents such as buspirone or benzodiazepines such as clonazepam, alprazolam or lorazepam
• Antipsychotics such as risperidone and olanzapine (note that these medications have many unwelcome side effects including sedation, decreased libido and weight gain)
• Other antidepressants such as trazodone (which also affects serotonin levels)
• Gabapentin, which has mood stabilizing properties

Psychotherapy for OCD

Psychotherapy, specifically cognitive behavioral therapy (CBT), is also used to treat OCD either alone or in combination with the medications mentioned above. In cognitive behavioral therapy, the individual has a safe place to experience their distressing thoughts or beliefs while avoiding the compulsive behavior that they rely on to bring them short-term relief.

The practice of intentionally experiencing the stressor is called exposure therapy and it can be a key component of cognitive behavioral therapy for OCD. Over time, the goal of therapy is for the triggering stressor to cause less and less of an anxiety response. Treatment itself can be quite stressful and difficult for some patients to adhere to.

Another approach is response prevention (also called ritual prevention). With this approach, the patient works with their therapist to avoid engaging in their compulsive behavior when faced with their triggering stressor.

Regardless of which approach is used, the individual and therapist will work to address and reframe the underlying thoughts and fears that lead to anxiety-driven compulsive behaviors. In addition, if the individual also has depression, they may need treatment for depression prior to initiating CBT. This is because in order for CBT to be successful, the individual must have both the energy and internal motivation to engage in therapy.

E: How do you EDUCATE the patient about OCD?

Because OCD is a chronic condition, it’s important for patients and families to understand that the condition is managed by therapy and medication but will not be cured. As such, it is vitally important they understand their goals of therapy, how to take their medications, and coping mechanisms that don’t involve compulsive rituals. 

Some specific things to include in patient education about OCD include: 

• Therapy will require dedication and effort. They should understand that they can expect to experience short-term anxiety as they undergo therapy that should lessen over time as they stick with it.
• Teach the patient the importance of recognizing their specific OCD triggers.
• For patients taking an SNRI or SSRI, teach them that these medications can take up to 8 to 12 weeks to have an effect. They should also be informed that the sudden cessation of their medication can cause withdrawal symptoms and return of OCD symptoms.
• Teach the patient about potential side effects of their medication and strategies to mitigate them where applicable. For example, SSRIs can cause dry mouth, so chewing gum or sucking on hard candies can help.
• Educate the patient and family about the increased risk of suicidal thoughts and behaviors that is associated with many medications used for OCD. Ensure they understand that any suicidal ideation means the individual must receive immediate treatment and evaluation.
• Teach the patient and family the signs and symptoms of serotonin syndrome, which can occur with serotonin modulators. Serotonin syndrome can occur when an SNRI or SSRI is used on its own or if taken along with another medication that affects serotonin levels such as MAOIs, some antipsychotics, and dextromethorphan (which is in a lot of cold remedies). Early signs of serotonin syndrome include confusion, diarrhea, headache, tachycardia, hypertension, dilated pupils, restlessness, shivering, twitching and muscle rigidity.
• If the patient is taking a tricyclic antidepressant, educate them on the unpleasant side effects so they know what to expect. These can include constipation, urinary retention, tachycardia, blurred vision, orthostatic hypotension, and even weight gain. 

For more lessons on mental health conditions, click this link!

Take this topic on the go by tuning in to episode 301 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.

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