Obsessive Compulsive Disorder or OCD is a common neuro-psychiatric disorder and is considered the 4th most prevalent psychiatric disorder. This disorder is a household topic, used to tease that family member who has to clean that certain thing or organize something in a specific way. While these things are slightly obsessive or even borderline compulsive, it is usually limited to those few pet peeves individuals have. True OCD is marked by distressing, time-consuming, impairing or even disabling habits, rituals and thoughts that affected a persons daily life.
Obsessions are repetitive and persistent thoughts that become intrusive. These thoughts stress the person and as a response, they try to overcome them with compulsions. Compulsions are behaviors, words or specific actions that are used to combat or neutralize unwanted thought. For instance, a person may develop irrational thoughts surrounding germ transmission and disease that consumes them. This makes things like touching a doorknob or shaking a hand greatly troubling. A possible behavior this person may develop in response to this thought is compulsive hand washing or sanitizing after every interaction with a possible germ infested object. This is known as contamination OCD. While it is normal for a person to wash their hands, it is considered OCD behavior when these thoughts and/or actions consume the persons time for over an hour each day.
The cause of OCD is not yet fully identified. While there is some evidence that it can be inherited, studies do not prove so consistently. Therefore, there are no genetic or other medical tests that can definitively prove OCD is present in a patient. This is where behavior observation and reporting become vital in diagnosis. Unfortunately, OCD is often confused with depression or anxiety disorder. This is where a skilled clinician must understand what OCD is and is not on a deeper level. OCD is ruminations, obsessive thinking, and actions that one feels compelled to do in a similar fashion as mentioned above. OCD is not ruminations with a depressing theme, such as feelings of guilt. It is also important to note that obsessive thoughts associated with OCD are irrational while those associated with anxiety are usually focused on real-life problems related to performance, work or finances.
OCD affects people in different ways. Some cases can be considered mild due to the fact that the thoughts and subsequent actions do not interfere with the patients’ life in a major way. They are still able to get up, go to work and socialize. While the obsessions and compulsions are present, they are not absorbing large amounts of time. Then there are cases so progressed and exhausting to a patient that they may even require outside intervention to get out of bed in the morning. This avoidance of activities and people can affect the personal relationships and ability to function in the modern world so greatly that it may be necessary for public health organizations to intervene. Most of the time OCD is progressive, so a once mild case can easily become severe if left untreated.
Of course, the diagnosis, prescription of drugs, and referral for behavioral therapy are reserved for a doctor; but it is essential for a nurse to understand treatment modalities common to this condition.
A nurse may find themselves suspecting a patient is OCD for the first time because it is highly likely they may have been mistakenly diagnosed with anxiety or depression as previously mentions. Also, if they are properly diagnosed with OCD it is estimated that only approximately one-third of patients with OCD receive appropriate treatment. Therefore, an advocating nurse will state their recommendation for the following evidence-based treatment.
There are both pharmacological and psychological treatments for OCD that are supported by research. The first line pharmacological treatment is with selective serotonin reuptake inhibitors or SSRIs. These drugs increase levels of serotonin in the brain. Serotonin is a neurotransmitter that carries signals between brain cells. When the reuptake of serotonin is stopped or slowed down it allows more serotonin availability. The psychological treatment of OCD is cognitive-behavioral therapy or CBT. This is backed by numerous clinical trials and is used particularly with exposure and response prevention. Exposure to the object or trigger of obsession and compulsion coupled with the deliberate denial of the compulsive act on top of SSRI ‘s has been proven more helpful than pharmacological treatment alone.
If the patient is non-compliant with medication and CBT, or the case is so severe that this therapy is not giving the patient relief, there are alternative treatments. Deep-brain stimulation or ablative neurosurgery may be an option for those with severe, incapacitating OCD. A very small amount of patients with OCD qualify for this treatment. Although medical centers around the world offer ablative surgery, only deep-brain stimulation has been approved by the FDA for the treatment of OCD.
There is hope for other treatments in the future due to our expanding knowledge of how this disorder affects the brain. A recent study headed by Dr. Van Den Heuvel used brain scans to create detailed maps participant’s cortex. When comparing, they found that the surface area and thickness of certain regions of the cortex were smaller in people with OCD. They also found that an area of the brain thought to be in charge of planning, and response inhibition, the parietal lobe, was thinned in people with OCD. The team thinks that these brain abnormalities may be the cause, or contribute to the patients’ obsessions and compulsions. This could lead to more targeted medications or surgical intervention in the future that make better treat or cure OCD.
Nurses play an important role in caring for a patient with OCD. Unfortunately, care is often sought when the condition has begun to affect the patient on a daily basis and for extended periods of time. This can make signs and symptoms of the disorder pronounced, affecting coping skills. An appropriate NANDA nursing diagnosis would be ineffective coping. Once this nursing diagnosis has been initiated and proper doctor related pharmacologic and psychologist referral has been made, the nurse can assist the patient in the short term or long term using the following. The nurse can support the patient by acknowledging the patient’s rituals or compulsions without judging him or her. This can include helping the patient identify situations that trigger obsessions and compulsions. It’s important to avoid shaming the said obsessions or compulsions. The nurse must allow the patient to perform rituals if needed while they are in their care without disapproval, and encouraging the patient to verbalize the meaning of the behaviors they perform. The nurse must remember that this disorder is not treated quickly but over time and in collaboration with the patient. Part of that collaboration is deciding with the patient is how and when to begin to gently remind them to limit the time devoted to the behaviors. Another part of the collaboration is helping the patient acknowledge when their roles and responsibilities have been compromised and how to remedy that. Whether the patient is in the acute care setting or a long-term care facility the above method, used with tact and care, can improve patient understanding and strategies to control OCD. It is important for the nurse to implement this plan of care understanding that sometimes the patient may be so severely affected by their condition that treatment changes may become necessary as determined by the patient, the nurse, and the provider.
While OCD is a complex problem, that is not fully understood, modern medicine has made strides toward treatment and remission of symptoms. The use of medications and behavioral modification are effective and useful treatments. Many who seek treatment can expect to gain control of their symptoms within a few months.
There are still some improvements in care to be made. Community awareness and outreach are needed to bring awareness to the symptoms and why to seek treatment early. Medical personnel must become more familiar with the differences between this condition and depression or anxiety so that the proper treatment can be applied the first time. Cognitive behavioral therapy takes time and some patients, unfortunately, do not get enough time with a behavioral therapist due to insurance, financial and time constraints of modern life.
There are strides in research to be made as well. Most trials of medications have only been short-term and are found to be helpful in young adults but not as effective in children. The implications of the brain scan results have yet to be determined. More focused research must be conducted on prevention and better treatment in childhood.
Strides have been made in the treatment and management of obsessive-compulsive disorder. However, there is always room for improvement. Nurses play a vital role in recognition and advocacy for evidence-based treatment. Good nursing will bridge the gap between this disorder and science.
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