Professional Documents
Culture Documents
DSM-IV
300.3 Obsessive-compulsive disorder
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.
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.)
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
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 opportunity for ritualistic behavior does not
occur,
performance of the rituals. the client fears that something bad will happen.
Recognizing precipitating factors allows client to
interrupt escalating anxiety.
Discuss home situation, include family/SO as Returning to unchanged home environment
appropriate. Involve in discharge plan. increases risk that client will resume compulsive
behaviors.
Collaborative
Administer medications as indicated, e.g.:
Fluvoxamine (Luvox), clomipramine (Anafranil), These drugs help balance serotonin levels,
fluoxetine (Prozac); decreasing feelings of anxiety, reducing need for
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).
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