UNM COC:  Your Healthcare Primer for Long Term Care

 
Obsessive-Compulsive Disorder (OCD)

Analissa Watkins, LPN

Definition and Introduction

Most of us have worries, doubts and superstitious beliefs and these are common in everyday life. But when these thoughts become so excessive and lead to such behaviors as hours of hand washing or cleaning the same area of the house over and over and over in the same day then a diagnosis of OCD is made. In OCD, it is as though the brain gets stuck on a particular thought or urge and just can’t let go. Some people describe the symptoms like a case of mental hiccups that won’t go away. The disorder is not the result of a "weak" or unstable personality.

Diagnosis

A person with OCD usually has both obsessions and compulsions although the disorder can be present with having only obsessions or compulsions.

Obsessions are defined as:

1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause increased anxiety or distress

2. the impulses, thoughts, or images are not simply excessive worries about real-life problems

3. the person will often try to ignore or suppress these thoughts, impulses , or images, or to stop them with some other thought or action

Obsessions are accompanied by uncomfortable feelings, such a fear, disgust, doubt, or a sensation that things have to be done in a way that is "just so."

Compulsions are defined as:

1. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly

2. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to stop or prevent or are clearly excessive

Unlike compulsive drinking or gambling, OCD compulsions do not give the person pleasure. Rather, the rituals are performed to obtain relief from the discomfort caused by the obsessions.

Most people with OCD recognize at some point that their obsessions are coming from within their own minds and are not just excessive worries about real problems, and that the compulsions they perform are excessive or unreasonable. If the person does not recognize that the obsessions and compulsions are excessive or unreasonable then this is described as OCD with poor insight.

The symptoms of OCD tend to wax and wane over time. Some of these symptoms may be little more than background noises; others may produce extremely severe distress.

OCD can start at any time from preschool age to adulthood (usually by age 40).

Many of the adult with OCD (one third to one half) report that the symptoms were present during childhood. Unfortunately, the disorder often goes unrecognized.

OCD symptoms can cause a great deal of stress by taking up a lot of time (more than an hour a day), or interfering with work, social life, and relationships. It is important to seek help from a professional such as a psychiatrist or psychologist to accurately diagnose and treat the disorder.

Prevention

There is no single, proven cause of OCD and no known way to prevent the disorder.

Although no specific gene has been identified for OCD, research suggests that in some cases genes do play a role in the development of the disorder. For instance, childhood onset OCD tends to run in families. When a parent has OCD, there is a slightly increased risk that a child will develop OCD, although the risk is low. On the other hand, when OCD runs in families, it is the general nature of OCD that seems to be inherited, not the specific symptoms. So a child may have checking rituals, while the mother washes her hands compulsively.

Treatment

Treatment for OCD involves education for the patient and family and medication if indicated. Effective treatments have only been developed within the last 20 years. The two effective treatments for OCD are cognitive-behavioral therapy (CBT) and medications with a serotonin reuptake inhibitor (SRI).

Cognitive behavioral therapy is the psychotherapeutic treatment of choice for children, adolescents, and adults with OCD. Behavior therapy is designed to help people learn to change their thoughts and feelings by first changing their behavior. This type of therapy involves exposure and response prevention.

• Exposure is based on the fact that anxiety usually decreases after enough contact the something that is feared. Therefore, people with obsessions about germs are told to stay in contact with "dirty" objects (e.g., handling money) until their anxiety is extinguished. Eventually with repeated exposure the person’s anxiety tends to decrease until he or she no longer fears the contact.

• Response or ritual prevention needs to be combined with exposure for the therapy to be the most helpful. Response prevention involves blocking the person’s rituals or avoidance behaviors. An example of this is a person who worries excessively about germs must not only stay in contact with "dirty" things but must also refrain from ritualized washing.

Generally exposure is more helpful in decreasing anxiety and obsessions. Response prevention is more helpful in decreasing compulsive behaviors.

The other part of CBT is cognitive therapy. This type of therapy is often added to exposure and response prevention to help reduce the ill thinking and exaggerated sense of responsibility often seen in those with OCD. For instance, a teenager with OCD may believe that his failure to remind his little brother to wear a helmet while riding his bike will cause him to die that day by being hit by a car. Cognitive therapy can help him question the faulty assumptions in this obsession.

This type of therapy is relatively free of side effects but all patients will usually have some anxiety during treatment. Most important to remember is that people react differently to psychotherapy just as they do to medicine.

Research has clearly shown that the serotonin reuptake inhibitors (SRI’s) are effective treatments for OCD. This type of medication increases the concentration of serotonin, a chemical messenger in the brain. Currently there are five SRI’s available by prescription in the US that are being used in the treatment of OCD:

• Clomipramine (Anafranil, manufactured by Ciba-Geigy)

• Fluoxetine (Prozac, manufactured by Lilly)

• Fluvoxamine (Luvox, manufactured by Solvay)

• Paroxetine (Paxil, manufactured by Smith-Kline Beecham)

• Sertraline (Zoloft, manufactured by Pfizer)

• Citalopram (Celexa, marketed by Forest Laboratories, Inc.)

Prozac, Luvox, Paxil, Zoloft, and Celexa are categorized as selective serotonin reuptake inhibitors (SSRI'’) because they primarily affect only serotonin. Anafranil is a nonselective SRI. This means is affects many other neurotransmitters besides serotonin. This also means that it may have a more complicated set of side effects than the SSRI’s.

An important point to remember when using these medications is that they don’t work right away. It usually takes 3 to 4 weeks before the patient notices some benefit from the medication. Maximum benefit should occur after 10 to 12 weeks of treatment on an adequate dose of medication. If symptoms are still persistent after an adequate dose and length of time, most experts recommend switching to another SSRI.

Side effect from each medication can vary. In general, most people tolerate the SRI’s well. The four SSRI’s (Paxil, Zoloft, Prozac, Celexa) have similar side effects which include nervousness, insomnia, restlessness, nausea, and diarrhea. The most common side effects of Anafranil are dry mouth, sedation, dizziness, and weight gain. All five medications can cause sexual problems but on average this side effect is a bit more common with Anafranil. Anafranil is also more likely to cause problems with blood pressure and irregular heartbeats. Patients with preexisting cardiac disease must have electrocardiograms before beginning the medication and then at regular intervals during treatment.

Emergency Situations - What Can Go Wrong

It is important to inform your physician of any side effects that you may be experiencing during treatment. Many of the side effects may be relieved by adjusting the dose or taking the medication at a different time of day. Medications should never be stopped abruptly unless your physician advises you to do so. All SRI’s except Prozac should be tapered and stopped slowly because of the possibility of the return of symptoms and withdrawal reactions.

Conclusion

Treatment for OCD is very individual and no single approach works best for everyone. The choice of treatment will ultimately depend on the patient’s preference. It is important to remember that OCD is a treatable disorder.

References

DSM-IV (Diagnostic and Statistical Manual of Mental Disorder Fourth Edition) American Psychiatric Association, Washington DC, October 1, 1996, pp 417-423

Analissa Watkins, LPN