9.5 Obsessive – Compulsive Disorder

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

Historically, the relationship of OCD with anxiety disorders was strongly emphasized. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) classifies OCD under a separate group of disorders called “Obsessive-Compulsive and Related Disorders” due to the presence of obsessions and compulsions.^[2] A systematic review found that lifetime psychiatric comorbidities were present in 69% of individuals with OCD, with anxiety disorders the most common comorbidity in children, and depressive disorders being the most common comorbidity in adults. ^[3] 

Signs and Symptoms

Symptoms of OCD can interfere with all aspects of life, such as work, school, and personal relationships. Symptoms may come and go, ease over time, or worsen.^[4] See Figure 9.7^[5] for an artist’s depiction of obsessive thoughts related to OCD.

Obsessions are repeated thoughts, urges, or mental images that cause anxiety. Common obsessions are as follows^[6]:

• 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^[7]:

• Excessive cleaning and/or handwashing
• Ordering and arranging things in a particular, precise way
• Repeatedly checking on things, such as repeatedly checking to see if the door is locked or that 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^[8]:

• 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 their daily life due to these thoughts or behaviors

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.

Some individuals with OCD also have a tic disorder. Motor tics are sudden, brief, repetitive movements, such as eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking. Vocal tics include repetitive throat-clearing, sniffing, or grunting sounds.^[9]

People with OCD may try to cope by avoiding situations that trigger their obsessions or use alcohol or drugs to calm themselves. Although most adults with OCD have good insight and recognize what they are doing doesn’t make sense, some may not realize that their behavior is out of the ordinary (i.e., they demonstrate “poor insight”). Most children do not have good insight into their thoughts and behaviors, so parents or teachers typically recognize OCD symptoms in children.

Risk Factors

The causes of OCD are unknown, but risk factors include genetics, brain structure and functioning, and environmental factors such as adverse childhood events (ACEs).^[10]

Genetics

Twin and family studies have shown that people with first-degree relatives (such as a parent, sibling, or child) who have OCD are at a higher risk for developing OCD. The risk is higher if the first-degree relative developed OCD as a child or teen.^[11]

Brain Structure and Functioning

Imaging studies have shown differences in the frontal cortex and subcortical structures of the brain in patients with OCD, but the connection with symptoms is not clear. Research is still underway because understanding potential causes may help determine specific, personalized treatments to treat OCD.^[12]

Environment

Research has found an association between childhood trauma (otherwise known as adverse childhood events (ACEs) and obsessive-compulsive symptoms. Some studies also found that children may develop OCD symptoms following a streptococcal infection, referred to as Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). Children with PANDAS have a very sudden onset or worsening of their symptoms after a streptococcal infection, followed by a slow, gradual improvement.^[13]

Treatment

OCD is typically treated with medication, psychotherapy, or a combination of both. Although most patients with OCD improve with treatment, some patients continue to experience symptoms. Individuals with OCD may also have other mental health disorders, such as anxiety, depression, and body dysmorphic disorder (a disorder in which someone mistakenly believes that a part of their body is abnormal). It is important to consider these other comorbid disorders when planning interventions related to treatment.^[14]

Medication

Selective serotonin reuptake inhibitors (SSRIs) are used to help reduce OCD symptoms. SSRIs often require higher daily doses in the treatment of OCD than of depression and may take 8 to 12 weeks to start working. If symptoms do not improve with SSRIs, research shows that some patients may respond well to an antipsychotic medication, especially if they also have a tic disorder.^[15]

Psychotherapy

Psychotherapy can be an effective treatment for adults and children with OCD. Research shows that certain types of psychotherapy, including cognitive behavior therapy (CBT) and other related therapies (such as habit reversal training), can be as effective as medication for many individuals. Research also shows that a type of CBT called Exposure and Response Prevention (EX/RP) is effective in reducing compulsive behaviors in clients with OCD. 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 when SSRIs do not effectively treat OCD symptoms.^[16]

Other Treatment Options

In 2018 the FDA approved transcranial magnetic stimulation as an adjunct in the treatment of OCD in adults. Repetitive Transcranial Magnetic Stimulation (rTMS) uses a magnet to activate the brain. Unlike electroconvulsive therapy (ECT), in which electrical stimulation is more generalized, rTMS can be targeted to a specific site in the brain. A typical rTMS session lasts 30 to 60 minutes and does not require anesthesia. During the procedure, an electromagnetic coil is held against the forehead near an area of the brain that is thought to be involved in mood regulation. Short electromagnetic pulses are administered through the coil. The magnetic pulses easily pass through the skull and cause small electrical currents that stimulate nerve cells in the targeted brain region. The magnetic field is about the same strength as that of a magnetic resonance imaging (MRI) scan. The person generally feels a slight knocking or tapping on the head as the pulses are administered. The muscles of the scalp, jaw, or face may contract or tingle during the procedure, and mild headaches or brief light-headedness may result after the procedure. It is also possible that the procedure could cause a seizure, although this adverse effect is uncommon. Because the treatment is relatively new, long-term side effects are unknown.^[17]

Psychoeducation

In addition to teaching clients about the symptoms of OCD, prescribed medications, and other treatments, nurses should teach clients how to manage stress and anxiety associated with OCD:

• Create a consistent sleep schedule
• Make regular exercise a part of your routine
• Eat a healthy, balanced diet
• Seek support from trusted family and friends