OBSSESSIVE COMPULSIVE
DISORDER
(OCD)(F42)
What is OCD?
• Is an anxiety disorder.
• They experience obsessions and compulsions
• Obsessions – unwanted thoughts, images or impulses that cause a lot of stress
and anxiety
• Compulsions – are behaviours or acts that are carried out to reduce the
anxiety
Epidemiology of OCD
In 2005 a study conducted by Bhattacharya S etal found that in 218
OCD subject 17% had major depression , 6% dysthymia and 7% any
anxiety disorder.
In 2003 a followup study of juvenile obsessive compulsive disorder
from India was done by Reddy JC etal and found that in a study of
58 children and adolescent all aged 16 years and below.
Contamination obsession were the commonest (62%),
followed by obsession related to aggression(57%),
symmetry(34%) sexual(22%), religion(22%),Somatic(12%)
and hoarding 7%.
Regarding compulsion cleaning and washing was the
commonest(69%) followed by repeating(52%),
checking(47%), ordering(29%), counting(15%) and
hoarding(7%).
In 2000 Reddy YC etal on co-morbidity in juvenile
obsessive compulsive disorder- a report from India found
that Juvenile OCD have high rates of co-morbid major
depression(10-73%), anxiety disorder (26-76%) and tic
disorder(17-59%).
According to National Mental Health Survey
2015-2016. The prevalence as per ICD 10.
F42 OBSESSIVE COMPULSIVE 0.76(0.75-0.78) 95% CI
DISORDER
F42.0 TO F42.8 OCD CURRENT 0.32(0.31-0.33) 95%CI
F42.9 OCD NOS 0.76(0.75-0.78) 95%CI
The essential feature of this disorder is recurrent obsessional
thoughts or compulsive acts. (For brevity, "obsessional" will
be used subsequently in place of "obsessive-compulsive"
when referring to symptoms.)
Obsessional thoughts are ideas, images or impulses that enter
the individual's mind again and again in a stereotyped form.
They are almost invariably distressing (because they are
violent or obscene, or simply because they are perceived as
senseless) and the sufferer often tries, unsuccessfully, to
resist them.
They are, however, recognized as the individual's own
thoughts, even though they are involuntary and often
repugnant.
Obsessions
• Obsessions are intrusive, distressing thoughts and mental
images which repeat over and over. They are ego-dystonic
(experienced as unpleasant).
• Common obsessions:
– Dirt and contamination
– Pathological doubt
– Need for symmetry
– Hoarding
– Sexual content (blasphemous religious thoughts.)
– Aggressive content
– Superstitious fears
Compulsions
Compulsive acts or rituals are stereotyped behaviours that are
repeated again and again. They are not inherently enjoyable,
nor do they result in the completion of inherently useful tasks.
The individual often views them as preventing some
objectively unlikely event, often involving harm to or caused
by himself or herself.
Usually, though not invariably, this behaviour is recognized by
the individual as pointless or ineffectual and repeated attempts
are made to resist it; in very long-standing cases, resistance
may be minimal.
Autonomic anxiety symptoms are often present, but
distressing feelings of internal or psychic tension without
obvious autonomic arousal are also common.
Compulsions
• Compulsions are repetitive behaviors (hand washing,
cleaning) or mental acts (praying, counting) that the person
feels driven to perform in response to an obsession.
• Common compulsions:
– Cleaning and washing
– Arranging until things are “just right”
– Hoarding
– Checking
– Mental rituals (prayers, counting etc.)
There is a close relationship between obsessional
symptoms, particularly obsessional thoughts, and
depression. Individuals with obsessive-compulsive
disorder often have depressive symptoms, and patients
suffering from recurrent depressive disorder (F33.-)
may develop obsessional thoughts during their episodes
of depression. In either situation, increases or decreases
in the severity of the depressive symptoms are
generally accompanied by parallel changes in the
severity of the obsessional symptoms.
Obsessive-compulsive disorder is equally common in
men and women, and there are often prominent
anankastic features in the underlying personality. Onset
is usually in childhood or early adult life. The course is
variable and more likely to be chronic in the absence of
significant depressive symptoms.
Diagnostic guidelines
For a definite diagnosis, obsessional symptoms or compulsive acts, or both,
must be present on most days for at least 2 successive weeks and be a source
of distress or interference with activities. The obsessional symptoms should
have the following characteristics:
(a)they must be recognized as the individual's own thoughts or impulses;
(b)there must be at least one thought or act that is still resisted
unsuccessfully, even though others may be present which the sufferer no
longer resists;
(c)the thought of carrying out the act must not in itself be pleasurable
(simple relief of tension or anxiety is not regarded as pleasure in this
sense);
(d)the thoughts, images, or impulses must be unpleasantly repetitive.
Differential diagnosis.
Differentiating between obsessive-compulsive disorder and a depressive disorder
may be difficult because these two types of symptoms so frequently occur
together. In an acute episode of disorder, precedence should be given to the
symptoms that developed first; when both types are present but neither
predominates, it is usually best to regard the depression as primary. In chronic
disorders the symptoms that most frequently persist in the absence of the other
should be given priority. Occasional panic attacks or mild phobic symptoms are
no bar to the diagnosis. However, obsessional symptoms developing in the
presence of schizophrenia, Tourette's syndrome, or organic mental disorder
should be regarded as part of these conditions. Although obsessional thoughts
and compulsive acts commonly coexist, it is useful to be able to specify one set
of symptoms as predominant in some individuals, since they may respond to
different treatments.
F42.0 Predominantly obsessional thoughts or ruminations
These may take the form of ideas, mental images, or impulses to act. They are
very variable in content but nearly always distressing to the individual. A woman
may be tormented, for example, by a fear that she might eventually be unable to
resist an impulse to kill the child she loves, or by the obscene or blasphemous
and ego-alien quality of a recurrent mental image. Sometimes the ideas are
merely futile, involving an endless and quasi-philosophical consideration of
imponderable alternatives. This indecisive consideration of alternatives is an
important element in many other obsessional ruminations and is often associated
with an inability to make trivial but necessary decisions in day-to-day living.
The relationship between obsessional ruminations and depression is particularly
close: a diagnosis of obsessive-compulsive disorder should be preferred only if
ruminations arise or persist in the absence of a depressive disorder.
F42.1 Predominantly compulsive acts [obsessional
rituals]
The majority of compulsive acts are concerned with cleaning
(particularly hand-washing), repeated checking to ensure that a
potentially dangerous situation has not been allowed to develop, or
orderliness and tidiness. Underlying the overt behaviour is a fear,
usually of danger either to or caused by the patient, and the ritual act
is an ineffectual or symbolic attempt to avert that danger.
Compulsive ritual acts may occupy many hours every day and are
sometimes associated with marked indecisiveness and slowness.
Overall, they are equally common in the two sexes but hand-washing
rituals are more common in women and slowness without repetition
is more common in men. Compulsive ritual acts are less closely
associated with depression than obsessional thoughts and are more
readily amenable to behavioural therapies.
F42.2 Mixed obsessional thoughts and acts
Most obsessive-compulsive individuals have elements of
both obsessional thinking and compulsive behaviour. This
subcategory should be used if the two are equally
prominent, as is often the case, but it is useful to specify
only one if it is clearly predominant, since thoughts and
acts may respond to different treatments.
F42.8 Other obsessive-compulsive disorders
F42.9 Obsessive-compulsive disorder, unspecified
Treatment
• Pharmacotherapy
• Cognitive-Behavioral Therapy
• Deep Brain Stimulation
SSRI
Monoamine Oxidase Inhibitors
– The monoamine oxidase inhibitors (MAOIs) are effective
antidepressants
– The two MAOIs available are phenelzine (Nardil) and
tranylcipramine (Parnate).
– The MAOIs are used to treat OCD only when SSRI
medications fail.
Psychotherapy
• Cognitive-Behavioral Therapy
• Exposure and Response Prevention
Exposure and Response Prevention
(ERP)
• The most widely practised behaviour therapy for OCD is called
exposure and response prevention.
• There are two components:
– Exposure Treatment
– Response Prevention Treatment
• Treatment starts with exposure to situations that cause the
least anxiety
• As the patient overcomes these, they move on to situations
that cause more anxiety
ERP
• Exposure Treatment
– Controlled exposure (direct or imagined) to objects or
situations that trigger obsessions while raising anxiety
levels
– Over time the exposure leads to less anxiety and over a
long period of time it leads to very little anxiety at all.
ERP
• Response Prevention Treatment
– The ritual behaviours that people with OCD engage in to reduce
anxiety.
– Patients learn to resist the compulsion to perform rituals
and are eventually able to stop engaging in these
Behaviours.
Common Difficulties During ERP
• Non-compliance with response prevention instructions.
• Continued passive avoidance.
• Arguing about exposure/response prevention requirements
• Emotional overload.
• Family reactions.
Deep brain stimulation disrupts action of cortico thalamic (hyperactive)
circuit
• Electrode is placed in anterior
limb of internal capsule
• Modulation of OFC, ACC, striatum,
thalamus and globus pallidus
activation noted
Nursing management
Short term goals
1. Identify stresses and anxiety
2. Ventilate feelings
3. Decrease anxiety, fear, guilt,or rumination
4. Build self esteem
5. Ensure adequate hydration, nutrition and elimination.
6. Promote independence in and completion of daily activities
7. Eliminate aggression or self mutilation
8. Care for existing injuries and other physical needs.
Long term goal.
Eliminate the needs for obsessive thoughts and compulsive
behaviour.
Reference
1. Khanna S, Gururaj G, Sriram TG. Epidemiology of obsessive-compulsive disorder in India.
Presented at the first international obsessive compulsive disorder congress.March 1993. pp 9-
11
2. Bhattacharya S, Reddy YC, Khanna S. Depressive and anxiety disorder comorbidity in
obsessive compulsive disorder. 2005 Nov-Dec;38(6):315-9.
https://www.ncbi.nlm.nih.gov/pubmed/16224205
3. Reddy YC, Srinath S, Prakash HM, Girimaji SC, Sheshadri SP, Khanna S, Subbakrishna DK.
A follow-up study of juvenile obsessive-compulsive disorder from India. 2003
Jun;107(6):457-64. https://www.ncbi.nlm.nih.gov/pubmed/12752023
4. ICD 10
5. Schultz JM, Dark LS. Manual of psychiatric nursing care plan. Pp149-151.
6. National mental health survey 2015-2016. Ministry of Health and Family Welfare
