Our Lady of Fatima University

College of Nursing
MacArthur Highway, Valenzuela City

Obsessive compulsive
Personality Disorder

Submitted by:

Zacarias, McHarris

Submitted to:

Mr. Sam Raymundo RN

Obsessive-Compulsive Disorder (OCD) is the name given to a condition
where people are having uncontrollable and unreasonable obsessions or
compulsions that are excessive.

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).

Obsessions:

Intrusive or inappropriate recurring thoughts or impulses such as:

• Obsessing about dirt and contamination, fear of coming into contact

with germs or anything perceived as ‘unclean’.
• The sufferer has constant doubts about whether they have done
something or not — did they lock the door, turn of the taps, run over
somebody etc.
• They believe that things ‘must be kept tidy’, an endless quest for
orderliness.
• They have impulses or thoughts about doing something aggressive or
embarrassing which they may or may not contain.

Compulsions:
Repetitive behaviors or rituals that the sufferer feels compelled to do to
lower his or her anxiety levels. Relief is only temporary so the compulsions
are weaved into the person's daily routine and are not always directly related
to the obsessive thought, for example, a person who has aggressive
thoughts may count bricks or words in an effort to control the thought.

Common compulsions include:

• Cleaning — sufferers obsess about germs and contamination and

tend to clean constantly, either repeatedly washing their hands,
showering, or constantly cleaning their home;
• Checking — individuals may check whether they have done
something, locking doors for example, several or even hundreds of times
‘just to make sure;
 • Repeating — one form of OCD is when the person repeats a name,
phrase or action over and over;
• Going slow — some individuals take an excessively slow and
methodical approach to ordinary daily activities. They might, for example,
spend hours organizing and arranging objects, food or timetables;
• Hoarding — some OCD sufferers are unable to throw away useless
items, such as old newspapers, junk mail, even broken appliances;
sometimes the hoarding reaches the point that whole rooms are filled
with junk that they have to carve passages through.

Signs and Symptoms

Obsessions

The typical sufferer performs tasks, or compulsions, to seek relief from

obsession-related anxiety. Within and among individuals, the initial
obsessions, or intrusive thoughts, can vary in their clarity and vividness. A
relatively vague obsession could involve a general sense of disarray or
tension, accompanied by a belief that life cannot proceed as normal while
the imbalance remains.

A more articulable obsession could be a preoccupation with the idea of

violently hurting others or oneself. A survey of healthy university students
found that virtually all of them had these types of thoughts from time to
time. Like these students, OCD sufferers generally do not enact or even
enjoy these violent thoughts.

On the contrary, they are pathologically disturbedby these ideas—and

by the sense that they could inexplicably possess them. Other obsessions
concern the possibility that someone or something other than oneself—such
as God, the Devil, or disease—will harm either the sufferer or the people or
things that the sufferer cares about. Some people dread entire concepts,
fearing their materialization by causes that may seem implausible or
indiscriminate to others. For example, a generalized fear
of contamination might entail not only wariness of
bodily secretions or excretions, but also apprehension toward household
chemicals, radioactivity, newsprint, pets, or even soap.

Sexual obsessions may involve intrusive thoughts or images of

"kissing, touching, fondling, oral sex, anal sex, intercourse, and rape" with
"strangers, acquaintances, parents, children, family members, friends,
coworkers, animals and religious figures", and can include
"heterosexual or homosexual content" with persons of any age. As with other
intrusive, unpleasant thoughts or images, most people have some
disquieting sexual thoughts at times, but people with OCD may attach
extraordinary significance to the thoughts. For example, obsessive fears
about sexual orientation can appear to the sufferer, and even to those
around them, as a crisis of sexual identity. The doubt that accompanies OCD
leads to uncertainty regarding whether one might act on the troubling
thoughts, resulting in self-criticism or self-loathing.

Some people with OCD may sense that the physical world is qualified
by certain immaterial conditions. These people might intuit invisible
protrusions from their bodies or could feel that inanimate objects
are ensouled. These intuitions and feelings do not stem from socially
accepted religious or metaphysical convictions, such as animism; even a
child with OCD might find their obsessive notions ultimately silly. However,
even if the OCD sufferer understands that their notions do
not correspond with the external world, they feel that they must act as
though their notions were correct. For example, an individual who engages
in compulsive hoarding might be inclined to treat inorganic matter as if it
had the sentience or rights of living organisms, but such an individual might
find their consequent behavior irrational on a more intellectual level.
However, Insel and Akiskal (1986) noted that in severe OCD, obsessions can
shift into delusions when resistance to the obsession is abandoned and
insight into its senselessness is lost.

Compulsions

While some with OCD perform compulsive rituals because they

inexplicably feel they must, others act compulsively so as to mitigate the
anxiety that stems from particular obsessive thoughts. The sufferer might
feel that these actions somehow either will prevent a dreaded event from
occurring, or will push the event from their thoughts. In any case, the
sufferer's reasoning is so idiosyncratic or distorted that it results in
significant distress for the sufferer or for those around them.

Compulsions include counting specific things (such as footsteps) or in

specific ways (for instance, by intervals of two) and doing other repetitive
actions, often with atypical sensitivity to numbers or patterns. People might
repeatedly wash their hands or clear their throats, repeatedly check that
their parked cars have been locked before leaving them, turn lights on and
off, keep doors shut or closed at all times, touch objects a certain number of
times before exiting a room, or walk in a certain routine way like only
stepping on a certain color of tile.

People rely on compulsions as an escape from their obsessive

thoughts; however, they are aware that the relief is only temporary, that the
intrusive thoughts will soon come back. Some people use compulsions to
avoid situations that may trigger their obsessions. Although some people do
certain things over and over again, they don't necessarily perform these
actions compulsively. For example, bedtime routines, learning a new skill,
and religious practices are not compulsions. Whether or not behaviors are
compulsions depends on the context in which the behaviors are performed.
For example, arranging and ordering DVDs or videos for eight hours a day
would be expected of one who works in a video store, but would seem
abnormal in other situations.

For some people with OCD, these tasks, along with the attendant
anxiety and fear, can take hours of each day, making it hard for the person
to fulfill their work, family, or social roles. In some cases, these behaviors can
also cause adverse physical symptoms: People who obsessively wash their
hands with antibacterial soap and hot water (to remove germs) can make
their skin red and raw with dermatitis. To others, these tasks may appear
odd and unnecessary. But for the sufferer, such tasks can feel critically
important, and must be performed in particular ways. OCD sufferers are
aware that their thoughts and behavior are not rational, but they feel bound
to comply with them to fend off feelings of panic or dread.

OCD without overt compulsions

OCD sometimes manifests without overt compulsions. Informally

nicknamed "Pure-O",OCD without overt compulsions could, by one estimate,
characterize as many as 50 percent to 60 percent of OCD cases. Rather than
engaging in observable compulsions, the person with this subtype might
perform more covert, mental rituals, or might feel driven to avoid the
situations in which particular thoughts seem likely to intrude. As a result of
this avoidance, people can struggle to fulfill both public and private roles,
even if they place great value on these roles and even if they had fulfilled
the roles successfully in the past.

Moreover, a sufferer's avoidance can confuse others who do not know

its origin or intended purpose, as it did in the case of a man whose wife
began to wonder why he would not hold their infant child.

Pathophysiology

There are many factors that contributes to the development of obsessive

compulsive personality disorder, one of these are:

Psychodynamic
 Freud’s Psychosexual Erickson’s Psychosocial

Anal Stage Autonomy vs Shame and Doubt

Learns that neatness to Learns that to be

handle bodily wastes messy brings criticism
properly gains approval and rejection

The need to obtain approval by

being excessively tidy and

Parents’
standards are too
high for the child
to meet

Attempts to please parents

Defensive mechanism to
protect the self from internal

Regression Isolation Reaction formation Undoing

Return to Obsessive Client’s overt Resolving the

earlier thoughts are attitude toward underlying
methods of either devoid others is usually conflict
handling of feeling or the opposite of
are attached the unconscious
to anxiety
Freud placed origin feelings
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.

Medications

Pharmacotherapy
Clinical trials in recent years have shown that drugs that affect the
neurotransmitter serotonin can significantly decrease the symptoms of OCD.
This drugs include fluvoxamine, paroxetine, sertraline, clomipramine and
fluoxetine. All these serotonin reuptake inhibitors (SRIs) have proved
effective in treatment of OCD.
If a patient does not respond well to one SRI, another SRI may give a
better response. For patients who are only partially responsive to these
medications, research is being conducted on the use of an SRI as the primary
medication and one of a variety of medications as an additional drug (an
augmenter). Medications are of great help in controlling the symptoms of
OCD, but often, if the medication is discontinued, relapse will follow. Most
patients can benefit from a combination of medication and behavioral
therapy.
Behavior Therapy
Traditional psychotherapy, aimed at helping the patient develop
insight into his or her problem, is generally not helpful for OCD. However, a
specific behavior therapy approach called "exposure and response
prevention" is effective for many people with OCD. In this approach, the
patient is deliberately and voluntarily exposed to the feared object or idea,
either directly or by imagination, and then is discouraged or prevented from
carrying out the usual compulsive response. For example, a compulsive hand
washer may be urged to touch an object believed to be contaminated, and
then may be denied the opportunity to wash for several hours. When the
treatment works well, the patient gradually experiences less anxiety from
the obsessive thoughts and becomes able to do without the compulsive
actions for extended periods of time.
Studies of behavior therapy for OCD have found it to produce long-
lasting benefits. To achieve the best results, a combination of factors is
necessary: The therapist should be well trained in the specific method
developed; the patient must be highly motivated; and the patient's family
must be cooperative. In addition to visits to the therapist, the patient must
be faithful in fulfilling "homework assignments." For those patients who
complete the course of treatment, the improvements can be significant.
With a combination of pharmacotherapy and behavioral therapy, the
majority of OCD patients will be able to function well in both their work and
social lives. The ongoing search for causes, together with research on
treatment, promises to yield even more hope for people with OCD and their
families.
Nursing Interventions

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.

Nursing Intervention Rationale

Independent
Establish relationship through use of
empathy, warmth, and respect.
Demonstrate interest in client as a
person through use of attending
behaviors.
Acknowledge behavior without
focusing attention on it. Verbalize
empathy toward client’s experience
rather than disapproval or criticism.
Better to say, “I see you undress 3
times every morning. That must be
tiring for you,” rather than “Try to
dress only 1 time today.”
Use a relaxed manner with the client;
keep the environment calm.
Anything about which the client feels
anxious will serve to increase the
ritualistic behaviors. Establishing
trust provides support and
communicates that the nurse accepts
the client as a person with the right
to self-determination.
Lack of attention to ritualistic
behaviors can diminish them. As
anxiety is reduced, the need for
behaviors is reduced. Reflecting the
client’s feelings may reduce the
intensity of the ritualistic behavior.
Any attempts to decrease stress will
help the client to feel less anxious,

Assist client to learn stress
management, (e.g., thought-
stopping, relaxation exercises,
imagery).
Identify what the client perceives as
relaxing (e.g., warm bath, music).
Engage in constructive activities such
as quiet games that require
concentration, as well as arts and
crafts such as needlework,
woodworking, ceramics, and painting.
Encourage participation in a regular
exercise program.
Give positive reinforcement for
noncompulsive behavior. Avoid
This approach will prevent the client
reinforcing compulsive behavior. Help
from obtaining secondary gains from
significant other(s) learn the value of
the maladaptive behaviors.
not focusing on the ritualistic
behaviors.
Assist client to find ways to set limits
on own behaviors. At the same time
allow adequate time during the daily
routine for the ritual(s).
which may reduce the intensity of
the ritualistic behaviors.
instead of ritualistic behaviors, to
break habitual Stress-management
techniques can be used, pattern.
Planned activities allow the client less
time for compulsive behavior and
distract her or him in a manner that
allows creativity and positive
feedback.
Exercise therapy can help relieve
anxiety. Note: Exercise does not
need to be aerobic or intensive to
achieve the desired effect.
Encourages client to problem-solve
ways to limit own behaviors while
recognizing that behaviors 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 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.
Limit the amount of time allotted for
the performance of rituals.
Encourage client to gradually
decrease this time.
Performance of the rituals. To
examine the precipitating factors to
the and the behaviors occur,
intensify, or are interrelated; purpose
of behaviors; to describe the feelings
when Encourage client to explore the
meaning and
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);
Buspirone (BuSpar) and lithium
(Eskalith);
Sertraline (Zoloft), venlafaxine
(Effexor).
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 to understand
the process and gain control over the
obsessive-compulsive sequence.
When Opportunity for ritualistic
behavior does not occur, 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
level decreasing feelings of anxiety,
reducing need for ritualistic
behavior(s), and allowing client to
learn other methods of stress
reduction. Note: Luvox of is
classified as a selective serotonin
reuptake inhibitor and has fewer side
effects than tricyclics.
Clients who are refractory to
antidepressants may require
combination therapy (e.g., buspirone
and fluoxetine or lithium and
clomipramine).
These drugs are being used
investigationally with some success
for the treatment of obsessive-
compulsive behaviors.
Reaction

They say that each and every one of us is entitled to have personality
disorder. One of which is Obsessive Compulsive personality disorder.
Everyone has thoughts that are upsetting or do not make a lot of sense from
time to time; this is normal. Just having an unpleasant thought does not
mean you have obsessions. Similarly, it is not uncommon for people to
repeat certain actions, such as double-checking whether the door is locked.
However, these behaviors are not always compulsions. Some of the
manifestations of OCD is frequent hand washing, organizing things, etc are
essential to health care providers just like nurses, but excessive if it may
lead to diagnosis of obsessive compulsive disorder. I’ve learned that people
start to be OCD as young as 3 years old. I also have a somehow personality
disorder and I have a hard time figuring out how I will manage myself. That’s
why I understand how OCD patient relieved their anxiety by organizing or
repetitively doing their obsessions. Patients with obsessive compulsive
disorder are not that difficult to deal with, and having a experience in a
psychiatric ward is a sure help in gaining new knowledge and worth keeping
experience about the different personality disorders.