7.9 Obessesive-Compulsive Disorder (OCD)

Obsessive-compulsive disorder (OCD) is a common chronic disorder in which a person has obsessive thoughts and/or behaviors they feel the urge to repeat over and over called compulsions. These compulsions often temporarily relieve the stress/tension of the obsession.^[1]

Obsessions are uncontrollable, reoccurring thoughts, urges, or mental images that cause anxiety. Common obsessions are as follows:

• Fear of germs or contamination
• Unwanted forbidden or taboo thoughts involving sex, religion, or harm
• Aggressive thoughts towards self or others
• Having things symmetrical or in a perfect order

Compulsions are repetitive behaviors that a person with OCD feels the urge to do in response to an obsessive thought. Compulsions often match the obsession and include the following:

• Excessive cleaning and/or handwashing
• Ordering and arranging things in a particular, precise way
• Repeatedly checking on things, such as if the door is locked or the oven is off
• Compulsive counting

Not all rituals or habits are compulsions; everyone double-checks things sometimes. For example, many people double-check that their doors are locked as they exit the vehicle. However, a person with OCD generally exhibits the following characteristics:

• Spends at least one hour a day on these thoughts
• Can’t control their thoughts or behaviors, even when those thoughts or behaviors are recognized as excessive
• Does not experience pleasure when performing the behaviors or rituals, but may feel relief from the anxiety the obsessive thoughts cause
• Experiences significant problems in work, school, or personal relationships due to these thoughts or behaviors

Adults with OCD may have good “insight,” meaning they recognize the beliefs surrounding their behaviors are untrue, whereas others have “poor insight” or delusions that the beliefs are true.^[2] Sometimes compulsions are accompanied by a fear of potential consequences if they are not carried out. For this reason, an individual with OCD may become distressed if not able to complete a compulsive act. People with OCD may also try to cope by avoiding situations that trigger their obsessions or use alcohol or drugs to calm themselves.

See Figure 7.5^[3] for an artist’s depiction of obsessive thoughts related to OCD.

Research has found an association between childhood trauma, otherwise known as adverse childhood events (ACEs), and obsessive-compulsive symptoms. Review information about adverse childhood events (ACEs) in “Basic Concepts of Mental Health and Mental Illness” in the “Mental Health Concepts” chapter.

Assessment (Recognizing Cues)

Nurses recognize and document signs and symptoms of obsessions and compulsions and their effect on a person’s ability to function in daily life^[4]:

• Recurrent and persistent thoughts, images, urges, or images that are intrusive and unwanted and cause anxiety or distress
• Performing compulsive, excessive behaviors or mental acts to reduce anxiety or distress from the obsessive thoughts, images, or urges, such as excessive handwashing, placing things in a specific order, or repeatedly rechecking things like if a door is locked, or silently repeating words. Compulsions are time-consuming and take more than one hour per day or cause significant distress in work, social, or other areas of functioning

A mental health professional diagnoses OCD based on the presence of obsessions and compulsions and the effect on their daily life.

OCD in Children and Adolescents

Children and adolescents with OCD may display compulsive behaviors without well-defined obsessions and may display rituals other than the typical washing or checking, such as blinking and breathing rituals. Obsessions often center on a fear of a catastrophic family event such as the death of a parent. Symptoms may be of mild to moderate severity, wax and wane over time, be prominent in one setting and not another, and be kept secret from others, including family members.^[5]

Treatment of OCD

OCD is typically treated with medication, psychotherapy, and/or other medical treatments like transcranial magnetic stimulation (TMS). Read about TMS in the “General Treatments for Mental Health Conditions” section.

Medications

Selective serotonin reuptake inhibitors (SSRIs) are often prescribed to help reduce OCD symptoms. It may take up to 8-12 weeks and high doses to show effectiveness. If SSRIs are not effective, antipsychotic medication may be prescribed. Review information about these classes of medications in the “Psychotropic Medications” sections of this chapter.

Psychotherapy

A type of CBT used to reduce compulsive behaviors in OCD is called exposure and response prevention (EX/RP). EX/RP includes spending time in the very situation that triggers compulsions (for example, touching dirty objects) but then being prevented from undertaking the usual resulting compulsion (handwashing). For many clients, EX/RP is an add-on treatment with a therapist when SSRIs do not effectively treat OCD symptoms.

Nursing Interventions

In addition to teaching clients about the symptoms of OCD, treatments, and medications and their side effects, nurses teach clients how to manage stress and anxiety associated with OCD using positive coping strategies. Review the “Applying the Nursing Process to Promote Healthy Coping” in the “Mental Health Concepts” chapter for more information about stress management and positive coping strategies.