Obsessive-compulsive disorder
Obsessive-compulsive disorder: Excerpt from Handbook of Diseases
Obsessive thoughts and compulsive behaviors represent recurring efforts to control overwhelming anxiety, guilt, or unacceptable impulses that persistently enter the consciousness. The word obsession refers to a recurrent idea, thought, impulse, or image that is intrusive and inappropriate and causes marked anxiety or distress.
A compulsion is a ritualistic, repetitive, and involuntary defensive behavior. Performing a compulsive behavior reduces the patient’s anxiety and increases the probability that the behavior will recur. Compulsions are commonly associated with obsessions.
Patients with obsessive-compulsive disorder are prone to abuse psychoactive substances, such as alcohol and anxiolytics, in an attempt to relieve their anxiety. In addition, other anxiety disorders and major depression commonly coexist with obsessive-compulsive disorder.
Obsessive-compulsive disorder is typically a chronic condition with remissions and flare-ups. Mild forms of the disorder are relatively common in the population at large.
Causes
The cause of obsessive-compulsive disorder is unknown. Some studies suggest the possibility of brain lesions, but the most useful research and clinical studies base an explanation on psychological theories. Several studies show brain abnormalities, such as decreased caudal size and decreased white matter, but results are inconsistent and remain under investigation. In addition, major depression, organic brain syndrome, and schizophrenia may contribute to the onset of obsessive-compulsive disorder.
Signs and symptoms
The psychiatric history of a patient with this disorder may reveal the presence of obsessive thoughts, words, or mental images that persistently and involuntarily invade the consciousness.
Some common obsessions include thoughts of violence (such as stabbing, shooting, maiming, or hitting), thoughts of contamination (images of dirt, germs, or feces), repetitive doubts and worries about a tragic event, and repeating or counting images, words, or objects in the environment. The patient recognizes that the obsessions are a product of his own mind and that they interfere with normal daily activities.
The patient’s history also may reveal the presence of compulsions, irrational and recurring impulses to repeat a certain behavior. Common compulsions include repetitive touching, sometimes combined with counting; doing and undoing (for instance, opening and closing doors or rearranging things); washing (especially hands); and checking (to be sure no tragedy has occurred since the last time he checked). The patient’s anxiety is often so strong that he’ll avoid the situation or the object that evokes the impulse.
When the obsessive-compulsive phenomena are mental, observation may reveal no behavioral abnormalities. However, compulsive acts may be observed, although feelings of shame, nervousness, or embarrassment may prompt the patient to try limiting these acts to his own private time.
You’ll need to evaluate the impact of obsessive-compulsive phenomena on the patient’s normal routine. He’ll typically report moderate to severe impairment of social and occupational functioning.
Diagnosis
Questionnaires, such as the Yale-Brown Obsessive Compulsive scale, may be used to help make the diagnosis. For characteristic findings in patients with this condition, see Diagnosing obsessive-compulsive disorder.
Treatment
Treatment usually involves a combination of medication and cognitive behavioral therapy. Other types of psychotherapy may also be helpful.
Effective medications include clomipramine; tricyclic antidepressants; selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, sertraline, and fluvoxamine; and clonazepam, a benzodiazepine .
Behavioral therapies — aversion therapy, thought stopping, thought switching, flooding, implosion therapy, and response prevention — have also proved effective. (See Behavioral therapies.)
Special considerations
❑ Approach the patient unhurriedly.
CLINICAL TIP: Provide an accepting atmosphere; don’t appear shocked at, amused by, or critical of the ritualistic behavior.
❑ Keep the patient’s physical health in mind. For example, compulsive hand washing may cause skin breakdown, and rituals or preoccupations may cause inadequate food and fluid intake and exhaustion. If the patient becomes involved in ritualistic thoughts and behaviors to the point of self-neglect, provide for basic needs, such as rest, nutrition, and grooming.
❑ Let the patient know you’re aware of his behavior. For example, you might say, “You’ve made your bed three times today; that must be very tiring.”
❑ Help the patient explore feelings associated with the behavior. For example, ask him, “What do you think about while you are performing your chores?”
❑ Make reasonable demands and set reasonable limits, explaining their purpose clearly. Avoid creating situations that increase frustration and provoke anger, which may interfere with treatment.
❑ Explore patterns leading to the behavior or recurring problems.
❑ Listen attentively, offering feedback.
❑ Engage the patient in activities and coversaton to create positive accomplishments and raise his self-esteem and confidence.
❑ Encourage active diversionary activities to divert attention from the unwanted thoughts and to promote a pleasurable experience.
❑ Help the patient develop new ways to solve problems and more effective coping skills by setting limits on unacceptable behavior. Gradually shorten the time allowed. Help him focus on other feelings or problems for the remainder of the time.
❑ Identify insight and improved behavior (reduced compulsive behavior and fewer obsessive thoughts). Evaluate behavioral changes by your own observations and the patient’s reports.
❑ Identify disturbing topics of conversation that reflect underlying anxiety or terror.
❑ Help the patient identify progress and set realistic expectations of himself and others.
❑ Explain how to channel emotional energy to relieve stress (for example, through sports and creative endeavors). In addition, teach the patient relaxation and breathing techniques to help reduce anxiety.
❑ Work with the patient and other treatment team members to establish behavioral goals and to help the patient tolerate anxiety in pursuing these goals.
Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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» Next page: Personality disorders (Handbook of Diseases)
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