Obsessive-compulsive disorder
Obsessive-compulsive disorder: Excerpt from Professional Guide to Diseases (Eighth Edition)
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’s intrusive and inappropriate, causing 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 (OCD) 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 OCD.
OCD is typically a chronic condition with remissions and flare-ups. Mild forms of the disorder are relatively common in the population at large.
Causes and incidence
The cause of OCD is unknown. Some studies suggest the possibility of brain lesions, but the most useful research and clinical studies base an explanation on psychological theories. In addition, major depression, organic brain syndrome, and schizophrenia may contribute to the onset of OCD. Some authorities think that OCD is closely related to some eating disorders.
OCD affects 2% to 3% of Americans — about 7 million people. Symptoms usually are noticed between ages 20 and 30, with 75% of patients displaying symptoms before age 30.
Signs and symptoms
The psychiatric history of a patient with OCD 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.
ELDER TIP In the older patient, any environmental change, such as transfer to a nursing home or a visit from a stranger in the patient’s home, may trigger a need for treatment. A distraction from the patient’s ritual activity may provoke anxiety or agitation.
The patient’s history may also 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). In many cases, the patient’s anxiety is so strong that he will 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. Feelings of shame, nervousness, or embarrassment may prompt the patient to try limiting these acts to his own private time.
Also 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
For characteristic findings in patients with this condition, see Diagnosing obsessive-compulsive disorder.
Treatment
OCD is tenacious, but improvement occurs in 60% to 70% of patients who obtain treatment. Current treatment usually involves a combination of medication and cognitive behavioral therapy. Other types of psychotherapy may also be helpful.
Effective medications include clomipramine, a tricyclic antidepressant; selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, sertraline, and fluvoxamine; and the benzodiazepine clonazepam.
Behavioral therapies — aversion therapy, thought stopping, thought switching, flooding, implosion therapy, and response prevention — have also been effective. (See Behavioral therapies, page 468.)
Special considerations
❑ Approach the patient unhurriedly.
❑ Provide an accepting atmosphere; don’t appear shocked, amused, or critical of the ritualistic behavior.
❑ Keep the patient’s physical health in mind. For example, compulsive hand washing may cause skin breakdown; rituals or preoccupations may cause inadequate food and fluid intake and exhaustion. Provide for basic needs, such as rest, nutrition, and grooming, if the patient becomes involved in ritualistic thoughts and behaviors to the point of self-neglect.
❑ Let the patient know that you’re aware of his behavior. For example, you might say, “I noticed you’ve made your bed three times today; that must be very tiring for you.” Help the patient explore feelings associated with the behavior. For example, ask him, “What do you think about while you’re 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.
❑ Encourage the use of appropriate defenses to relieve loneliness and isolation.
❑ Engage the patient in activities to create positive accomplishments and raise his self-esteem and confidence.
❑ Encourage active diversionary activities, such as whistling or humming a tune, to divert attention from the unwanted thoughts and to promote a pleasurable experience.
❑ Help the patient develop new ways to solve problems and cultivate more effective coping skills by setting limits on unacceptable behavior (for example, by limiting the number of times per day he may indulge in compulsive 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.
❑ When interventions don’t work, reevaluate them and recommend alternative strategies.
❑ 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: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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