OBSESSIVE-COMPULSIVE DISORDER

DSM-IV
300.3 Obsessive-compulsive disorder

An obsession is an intrusive/inappropriate repetitive thought, impulse, or image

that the individual recognizes as a product of his or her own mind but is unable to
control. A compulsion is a repetitive urge that the individual feels driven to perform
and cannot resist without great difficulty (severe anxiety). Most common obsessions
are repetitive thoughts about contamination, repeated doubts, a need to have things
in a specific order, aggressive or horrific impulses, or sexual imagery. The individual
usually attempts to ignore or suppress such thoughts or to neutralize them with
some other thought or action (compulsion).

ETIOLOGICAL THEORIES
Psychodynamics
Freud placed origin for obsessive-compulsive characteristics in the anal stage of
development. The child is mastering bowel and bladder control at this
developmental stage and derives pleasure from controlling his or her own body and
indirectly the actions of others.
Erikson’s comparable stage for this disorder is autonomy versus shame and
doubt. The child learns that to be neat and tidy and to handle bodily wastes properly
gains parental approval and to be messy brings criticism and rejection.
The obsessional character develops the art of the need to obtain approval by
being excessively tidy and controlled. Frequently the parents’ standards are too high
for the child to meet, and the child continually is frustrated in attempts to please
parents.
The defensive mechanisms used in obsessive-compulsive behaviors are
unconscious attempts by the client to protect the self from internal anxiety. The
greater the anxiety, the more time and energy will be tied up in the completion of
the client’s rituals. First, the client uses regression, a return to earlier methods of
handling anxiety. Second, the obsessive thoughts are either devoid of feeling or are
attached to anxiety. Thus, isolation is used. Third, the client’s overt attitude toward
others is usually the opposite of the unconscious feelings. Thus, reaction formation
is being used. Last, compulsive rituals are a symbolic way of undoing or resolving
the underlying conflict.

Biological
Although biological and neurophysiological influences in the etiology of anxiety
disorders have been investigated, no relationship has yet been established. The
mind-body connection is well accepted, but it is difficult to establish whether the
biological changes cause anxiety or the emotional state causes physiological
manifestations. However, recent findings suggest that neurobiological disturbances
may play a role in obsessive-compulsive disorder, with physiological and
biochemical factors also playing significant roles.

Family Dynamics
 The individual exhibiting dysfunctional behavior is seen as the representation of
family system problems. The “identified patient” (IP) is carrying the problems of the
other members of the family, which are seen as the result of the interrelationships
(disequilibrium) between family members rather than as isolated individual
problems.
Multiple factors contribute to anxiety disorders.

CLIENT ASSESSMENT DATA BASE

(Also refer to CPs: Generalized Anxiety Disorder; Panic Disorders/Phobias.)

Activity/Rest
Difficulty relaxing
Pleasurable activities causing anxiety

Ego Integrity
May be very controlled from within
Pre-onset stressors (e.g., family death, pregnancy/childbirth, sexual failures) may be
present

Hygiene
Characteristic rituals may influence/include repetitive hand-washing, intensive
cleanliness, activities of daily living (e.g., dressing and undressing a number of
times, placing articles in a specific order)

Neurosensory
Obsessive thoughts may be destructive or delusional, with most frequent themes,
including contamination/dirt, health/illness, orderliness or need for symmetry,
aggression, morality/religion, sex (e.g., shameful/degrading acts)
Thinking processes are rigid, intellectual, and sharply focused toward tasks; may
express belief that nonpurposeful and nondirected activity is unsafe and bad
Repetitive mental acts (e.g., praying, counting, repeating words silently)
Impaired problem-solving ability
Ritualistic speech often noted

Social Interactions
More frequent occurrence in upper-middle class, with higher levels of intellectual
functioning
Interference with normal routines, occupational functioning, social
activities/relationships
May focus on details but be unproductive in work situations because of narrow scope
and rigidity of ideas

Teaching/Learning
Most often seen in adolescence and early adulthood (average age of onset is 20)

DIAGNOSTIC STUDIES
(Refer to CPs: Generalized Anxiety Disorder, Panic Disorder/Phobias.)
 NURSING PRIORITIES
1. Assist client to recognize onset of anxiety.
2. Explore the meaning and purpose of the behavior with the client.
3. Assist client to limit ritualistic behaviors.
4. Help client learn alternative responses to stress.
5. Encourage family participation in therapy program.

DISCHARGE GOALS
1. Anxiety decreased to a manageable level.
2. Ritualistic behaviors managed/minimized.
3. Environmental and interpersonal stress decreased.
4. Client/family involved in support group/community programs.
5. Plan in place to meet needs after discharge.

(Refer to CP: Generalized Anxiety Disorder for needs/concerns in addition to the following NDs.)

NURSING DIAGNOSIS ANXIETY [severe]

May Be Related to: Earlier life conflicts (may be reflected in the
nature of the repetitive actions and recurring
thoughts)
Possibly Evidenced by: Repetitive action (e.g., hand-washing)
Recurring thoughts (e.g., dirt and germs)
Decreased social and role functioning
Desired Outcomes/Evaluation Criteria— Verbalize understanding of significance of
Client Will: ritualistic behaviors and relationship to anxiety.
Demonstrate ability to cope effectively with
stressful situations without resorting to obsessive
thoughts or compulsive behaviors.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Establish relationship through use of empathy, Anything about which the client feels anxious will

warmth, and respect. Demonstrate interest in client serve to increase the ritualistic behaviors.
as a person through use of attending behaviors. Establishing trust provides support and
communicates that the nurse accepts the client
as a
person with the right to self-determination.
Acknowledge behavior without focusing attentionLack of attention to ritualistic behaviors can
on it. Verbalize empathy toward client’s experience diminish them. As anxiety is reduced, the
need for
rather than disapproval or criticism. Better to say, the behaviors is reduced. Reflecting the
client’s
“I see you undress 3 times every morning. That feelings may reduce the intensity of the
ritualistic
must be tiring for you,” rather than “Try to dress behavior.
only 1 time today.”
Use a relaxed manner with the client; keep the Any attempts to decrease stress will help the
client
environment calm. to feel less anxious, which may reduce the
intensity of the ritualistic behaviors.
Assist client to learn stress management, (e.g., Stress-management techniques can be used,
thought-stopping, relaxation exercises, imagery). instead of ritualistic behaviors, to break habitual
pattern.
Identify what the client perceives as relaxing (e.g., Planned activities allow the client less
time for
warm bath, music). Engage in constructive activities compulsive behavior and distract her or
him in a
such as quiet games that require concentration, as manner that allows creativity and positive

well as arts and crafts such as needlework, feedback.

woodworking, ceramics, and painting.
Encourage participation in a regular exercise Exercise therapy can help relieve anxiety. Note:
program. Exercise does not need to be aerobic or intensive
to
achieve the desired effect.
Give positive reinforcement for noncompulsive This approach will prevent the client from
behavior. Avoid reinforcing compulsive behavior. obtaining secondary gains from the maladaptive
Help significant other(s) learn the value of not behaviors.
focusing on the ritualistic behaviors.
Assist client to find ways to set limits on own Encourages client to problem-solve ways to limit
behaviors. At the same time allow adequate time own behaviors while recognizing that
behaviors
during the daily routine for the ritual(s). cannot be stopped by others without increasing
anxiety. If the time required for performing the
ritual(s) is not considered in planning care, client

will feel rushed and anxious while performing

Limit the amount of time allotted for the
performance of rituals. Encourage client to
gradually decrease this time.
Encourage client to explore the meaning and
behaviors. A mistake in compulsive behavior is
more likely to be made if client feels rushed, and
the whole ritual will have to be started again,
resulting in increased anxiety—possibly to an
unmanageable level.
Provides initial control of maladaptive behaviors
until client can enforce own limits and substitute
more adaptive response(s) to stress.
This exploration provides an opportunity to begin

purpose of behaviors; to describe the feelings when to understand the process and gain
control over
the behaviors occur, intensify, or are interrelated;the obsessive-compulsive sequence. When
and to examine the precipitating factors to the
occur,
performance of the rituals.
Discuss home situation, include family/SO as
appropriate. Involve in discharge plan.
Collaborative
Administer medications as indicated, e.g.:
Fluvoxamine (Luvox), clomipramine (Anafranil),
fluoxetine (Prozac);
opportunity for ritualistic behavior does not
the client fears that something bad will happen.
Recognizing precipitating factors allows client to
interrupt escalating anxiety.
Returning to unchanged home environment
increases risk that client will resume compulsive
behaviors.
These drugs help balance serotonin levels,
decreasing feelings of anxiety, reducing need for

ritualistic behavior(s), and allowing client to learn

of other methods of stress reduction. Note:

Luvox
is classified as a selective serotonin reuptake
inhibitor and has fewer side effects than
tricyclics.
Buspirone (BuSpar) and lithium (Eskalith); Clients who are refractory to antidepressants
may
require combination therapy (e.g., buspirone and

fluoxetine or lithium and clomipramine).

Sertraline (Zoloft), venlafaxine (Effexor). These drugs are being used investigationally
with
some success for the treatment of obsessive-
compulsive behaviors.

NURSING DIAGNOSIS SKIN/TISSUE INTEGRITY, impaired/risk for

May Be Related to:
Possibly Evidenced by (Actual):
Desired Outcomes/Evaluation Criteria—
Client Will:
Repetitive behaviors related to cleansing, such
as hand-washing, brushing teeth, showering
Disruption of skin surfaces; destruction of skin
layers/tissues (e.g., mucous membranes)
Identify risk factors.
Verbalize understanding of treatment/therapy
regimen.
Engage in behaviors/techniques to prevent
skin/tissue breakdown.
Demonstrate timely healing/improvement in
condition of dermal layers.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess changes in skin/tissue (e.g., alterations in Repetitive behaviors, such as hand-washing with
skin turgor, edema, dryness, altered circulation, detergents or cleaning with caustic substances,
can
and presence of infections). damage the skin and underlying tissues.
Encourage use of mild soap and hand creams, while Helps to minimize tissue trauma until
other forms
using methods previously described in ND: Anxiety of therapy reduce damaging behaviors.
[severe] to decrease repetitive behaviors.
Discuss measures client can take during/after Protects skin and tissues in the presence of
cleaning behaviors (e.g., use of rubber gloves and constant hand-washing, use of caustic
substances.
application of antiseptic cream).

NURSING DIAGNOSIS ROLE PERFORMANCE, risk for altered

Risk Factors May Include: Psychological stress
Health-illness problems
Possibly Evidenced by: [Not applicable; presence of signs and symptoms
establishes an actual diagnosis.]
Desired Outcomes/Evaluation Criteria— Identify conflicts within work/family situations.
Client Will: Talk with family/SO(s) about situation and
changes that have occurred.
Maintain/resume role-related responsibilities.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Determine client’s role within family and extent to Identifies areas of concern and provides
accurate
which illness-related thoughts and actions affect information to formulate plan of care.
role relationships.
Discuss client’s perceptions of role, how obsessive- Client may deny extent of effect that
behaviors
compulsive behaviors affect role, and whether have on daily activities.
perceptions are realistic.
Identify conflicts that exist within the family system Knowing what stressors as well as what
adaptive
and specific relationships that are affected. Encourage and maladaptive responses are occurring
helps
family members to begin to discuss identified individuals begin the process of positive change.
problem areas.
Explore options for changes or adjustments in role Planning and rehearsal of potential role
transitions
and practice behaviors using role-play. can reduce anxiety.
Encourage participation by all family members in Likelihood of positive change increases when
problem-solving process and plans for change. family system is involved in resolution of
situations arising from client’s ritualistic
behaviors.
Provide positive reinforcement for movement Enhances self-esteem and promotes repetition of

toward resuming role responsibilities and decreasing desired behaviors.

ritualistic behaviors.