SRI LAKSHMI COLLEGE OF NURSING

Case study on OCD

Mr Suman bera

OCD sufferers do not actively want to perform their

compulsive tasks, and experience no pleasure from doing so. OCD is placed in
the anxiety class of mental illness, but like many chronic stress disorders it can
lead to clinical depression over time. The constant stress of the condition can
cause sufferers to develop a deadening of spirit, a numbing frustration, or sense
of hopelessness. OCD's effects on day-to-day life—particularly its substantial
consumption of time—can produce difficulties with work, finances and
relationships.
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INTRODUCTION

As part of the clinical practice of MSc psychiatric nursing I was poste in

NIMHANS for duration of 2 months. During this tenure I selected Master Suman
Bera, 18 years old with diagnosis of OCD for my case study. Mr Suman showed
classic symptoms of OCD with clear obsessive thoughts and compulsions of dirty
hands and body and repeated actions of cleaning himself at an alarming rate of
multiples of 5 is astonishing.
The patient was very cooperative and rapport establishing and maintenance was
not difficult which also aided proper history taking and mental status examination.
It would be my pleasure to help him cope with his situations and return to his pre-
morbid condition as early as possible.
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History of the patient

Identification data
Name: Mr Suman Bera Age: 18 years
Sex: Male Marital status: Single
Religion: Hindu Education: 10+2
Occupation: Student Date of admission: 6th December 2008
Mode of Direct IPNO: 1059208
admission:
Ward: Male open ward Diagnosis: OCD
Informant: Self and father Reliability: Reliable and
adequate

Chief complaints
Increased obsession
Increased compulsion
Anxiety
Decreased concentration since 4 months
Decreased sleep
Decreased appetite

History of present illness

Onset: insidious
Precipitating factors: Patient was apparently asymptomatic until few months back
(April 08). He was staying in the hostel provided by engineering college when his
obsession and compulsive behavior aggravated suddenly. He started getting
obsessive thoughts of dirt and contamination of hands feet and cloths. In order to
release from anxiety due to the obsessive thoughts, and washed hands for hours
and bathe 10 to 12 hours a day. He will take bath in a particular pattern that is
multiples of five while pouring water. That is he starts be 5 then 10 and then 15
then 20 and so on. He washes his hands in a specific pattern that is from his little
fingers of left and gradually come up. If during the routine he leaves a part to
wash, he starts all over again. The whole process would be repeated if he misses a
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count. To avoid any obsessions of dirtiness he will not take breakfast, and defecate
only twice in a week. He would miss classes on the compulsion of washing hands.
Course of illness: continuous
Past history of illness:
Medical: Nothing relevant is mentioned
Surgical history: Patient has no relevant surgical history.
Psychiatric history: first episode of OCD started in the year 2003. He refused the
parents who tried to stop the action. And this affected his academic performance.
On January 2006 he was agina brought to NIMHANS for obsessive behavior.

Negative history
No significant negative history has been mentioned

Family history

45 36years
years arthritis

male
18 Years OCD
female
patient
disease other than pshychiatric
expired member
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Father—45 years old studied up to BSc a farmer by vocation from a rural

background he earns not more than 4000 per month. He is not suffering from any
illness. Maintain good relation with the client
Mother—she is 36 years old and studied up to 10 th standard and is a home maker.
She suffers from arthritis since 3 years and is on medication for the same reason.
There are no other medical or surgical or psychiatric problems. She has a good
relation with the client.

Personal history
Birth and early development
Full term normal delivery at hospital and Cried soon after birth antenatal and
postnatal period uneventful. There were No infections elicited
Childhood:
Developmental milestones where normal. No neurotic traits of bed wetting or
thumb sucking . No nail biting
Schooling:
Joined school at 04 years. Had many friends. Studying in an engineering college .
Had good IPR with teachers and classmates.
Sexual history:
He never had any sexual exposure. But retains adequate knowledge of sex.
Pre-morbid personality:
Intra personal relationship:
The client has good relationship with his family members and enjoys an even
closer relationship with his mother.
General temperament:
He is a calm and cool person, and cools down quickly when he is angry. Mr Suman
is very sociable, and cares a lot for his parents.
Intellectual activities:
He is a brilliant student scored 86 in his PUC, at the same time he is an artist.
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Habits:
There are no bad habits reported and love sleeping.

Physical examination:
General appearance:
Nourishment: well nourished
Body built: athletic
Health: healthy
Activity: normal activity
Posture
Body curves: normal
Gait: normal
Height and weight:
Skin condition
Colour: wheatish
Texture: dry
Temperature: warm
Lesions: none
Head and face:
Scalp: clean
Face: no deformities seen
Eyes: pupils equally reacting, wears spectacles
Ear: normal and bilateral
Nose: no structural deformity
Mouth: no dentures hygiene is maintained
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Neck: normal range of motion and no enlargement of lymph nodes

Chest
Thorax: normal bilateral symmetrical expansion
Breath sounds: normal, no wheezing or crepitation heard
Heart: normal, no cardiac murmur, Heart rate 66 beats per second
Respiration: rate—20 per minute,

Blood pressure— mmHg

Abdomen: normal bowel sounds, normal appetite, bowel and bladder movements
normal
Extremities: all joints have normal range of motion, power and tone adequate, no
scars and wounds seen
Genitals: no significant infections
CNS: conscious oriented with normal speech
Mental status examination
General appearance and behavior:
Attitude-cooperative rapport established and sustained
Grooming- well groomed
Facial expression- eye to eye contact maintained, expression appropriate to
situation
Posture- relaxed
Gait carriage- body erect normal
Body built- athletic
Psychomotor activities:
Compulsions present repetitive actions of cleaning hands and bathing
Speech:
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Tone: normal
Tempo: normal
Volume: normal
Spontaneity: spontaneous
Productivity: normal
Reaction time: normal
Coherent: coherent
Relevance: relevant
Mood and affect:
Subjective: “I am fine”
Objective: Euthymic
Range: broad
Labiality: not labile
Congruence: congruent
Appropriateness: appropriate
Perception:
Hallucination: not present
Illusion: not present
Thinking:
Stream: no flight of ideas and circumstantialities
Content: obsession present regarding dirt
Form: no formal thought disorder
Cognitive functions:
Attention and concentration:
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Digit span test up to 6 digits forward and backward

Serial subtraction could subtract 100-7 up to 10 times
Inference attention and concentration adequate
Orientation:
What time of the day it is?
10:30 Am
What place is this?
NIMHANS
Who am i?
Nursing student
Inference—oriented to place time and person
Memory:
Up to 8 articles the patient could tell when told to repeat
Yesterday what time did we talk?
About 11:30 am you took my interview
When did you get admitted in the hospital?
14th December 2008
Intelligence:
General information:
Who is the prime minister of India?
Dr Manmohan Singh
Inference: general knowledge adequate
Comprehension:
What will you do when it rains on the way?
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I will stand by the shelter or use an umbrella

Inference-comprehension inract
Arithmetic:
Addition: 23+25=48
Subtraction:87-17=70
Multiplication:14x4=56
Division:88/11=8
Inference: arithmetic functions are intact
Abstraction:
Similarities between TV and Radio?
Both are used for entertainment and listening news.

Dissimilarities: difference between table and chair?

Table is used for writing and the other is used for sitting

Proverb: patient himself told: “success is hard earned” which means to succeed in
life one has to work very hard.
Inference: abstraction present at the concrete level
Judgment:
Personal: what will you do after getting discharged?
I’ll continue my studies and then get a good job.
Inference:- personal judgment intact
Social: social judgment intact as he maintains good communication and is well
mannered
Test: what will you do if your catches fire.
Patient: I will try to extinguish it using water.
Insight:
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Are you ill? What is the problem you are having?

Yes I’m having OCD
What is the cause of illness?
Some problem in the chemicals in brain
Do you need medication?
Yes, I need medication to recover.
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Formulation
Mr. Suman Bera, aged 18, unmarried, years from a Hindu religion, who is pursuing
an engineering course was admitted to the male open ward on 6 th December 2008
with chief complaints of
Increased obsession
Increased compulsion
Anxiety
Decreased concentration since 4 months
Decreased sleep
Decreased appetite

There is no significant family history of any psychiatric ailments and had a very
acceptable personality prior to the disease. On MSE of the patient, it was revealed
that Mr Suman had compulsive behavior of washing hands several times and
taking bath for hours which originated from his obsessive thoughts of un-
cleanliness and dirty hands. The patient retains insight. The client is diagnosed as
OCD.
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Investigation:
Investigation Result Normal Remark
value
Glucose 110mg/dl 90-140mg/ Normal
dl
Urea 15 mg/dl 10-40 mg/dl Normal

Creatinine 1.1 mg/dl 0.6-1.4 Normal

mg/dl
Total 0.5 mg/dl 0.3-1.2 Normal
bilurubin mg/dl
Alkaline 120 U/L 40-129 U/L Normal
phosphate
SGOT 21 U/L 8-40 U/L Normal

SGPT 16 U/L 6-40 U/L Normal

Sodium 140 meq/dl 135-140 Normal

meq/dl
Potassium 4.6 meq/dl 3.5-5.2 Normal
meq/dl
Chloride 103 meq/dl 95-106 Normal
meq/dl
Hb 15gm% 12-16gm% Normal

Treatment:
Drug: Tab Clomipramine
Route & dose:
Adult:Oral starts with 25mg and gradually increases over 4 weeks to a dosage of
75-300mg / day in divided doses.
Available forms: capsules of 25,50,75mg
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Indications: OCD, depression, Dyspharia , Anxiety, Agoraphobia, and other

phobias
Side effects:
CNS- Dizziness, tremors, mania, seizures, aggressiveness
CV- hypotension, tachycardia, cardiac arrest,
Endocrine- Galactorrhea, hyperprolactinemeia
GI- constipation, dry mouth, nausea, dyspepsia
GU- delayed ejaculation, anorgasmy, retention
Hematological- agranulocytosis, neutropnia,
Integumatary system diaphoresis

Contraindications: hypersensitivity to any tricyclic drug, concominent with MAO

inhibitor, recent MI, lactation, myelography within previous 24 hours or scheduled
within 48 hours.
Therapeutic action: Inhibits the presynaptic uptake of neuro-transmitters
norepinephrine and serotonin, anticholinergic and increases dopamine metabolism
Pharmacokinetics:
Route: oral; Onset: slow; duration 1-6 weeks
Metabolism: hepatic.
T ½ 21-31 hr
Distribution: crosses placenta, enters breat milk.
Excretion: bile and feces
Nursing role:
Assessment
History: hypersensitivity to any tricyclic drug, concomitant with MAO inhibitor,
recent MI, lactation, myelography within previous 24 hours or scheduled within 48
hours, lactation, EST, preexisting CV disorders angle closure glaucoma, increased
intraocular pressure, urinary retention, ureteral or urethral spasm. Seizure
disorders, hyperthyroidism, impaired hepatic renal function, psychiatric patient
elective surgery.
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Physical examination:
Weight, skin color, lesions orientation, affect, reflexes, vision and hearing, Pulse
and blood pressure, perfusion bowel sounds, urine output, liver functions, sexual
functions, frequency of menses, scrotal and breast examination, urine analysis
CBC and ECG.
Implementation:
 Limit depressed a potentially suicidal patients’ access to drug
 Administer in divided doses with meals to reduce GI side effects while
increasing dosage to therapeutic levels.
 Give maintenance dose at hs to decrease day time sedation.
 Reduce dose if minor side effects develop, discontinue drug if serious side
effects occur
 Arrange for CBC if patient develops fever, sore throat and other sign of
infection.
Instructions to the client:
Instruct the client to take this drug as prescribed and not to stop taking abruptly or
without consulting health care provider. Avoid alcohol, sleep inducing drugs, OTC
drugs. Avoid prolong exposure to sun or sunlamps; use sunscreen or protective
garments if exposure to sun is unavoidable. Inform that the following side effects
may occur: headache, dizziness, drowsiness, weakness, blurred vision, nausea,
vomiting, anorexia, dry mouth, nightmares, inability to concentrate altered sexual
function. Also instruct the client to report excessive sedation dry mouth and if
there is difficulty in urinating.
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OBSESSIVE COMPULSIVE DISORDER

Obsessive-compulsive disorder (OCD) is a mental disorder most commonly

characterized by intrusive, repetitive thoughts resulting in compulsive behaviors
and mental acts that the person feels driven to perform, according to rules that must
be applied rigidly, aimed at preventing some imagined dreaded event. In severe
cases, it affects a person's ability to function in every day activities. The disorder is
often debilitating to the sufferer's quality of life. Also, the psychological self-
awareness of the irrationality of the disorder can be painful. For people with severe
OCD, it may take several hours a day to carry out the compulsive acts.

Experts believe OCD is related to levels of a normal chemical in the brain called
serotonin. When the proper flow of serotonin is blocked, the brain's "alarm system"
overreacts. Danger messages are mistakenly triggered. Instead of the brain filtering
out these unnecessary thoughts, the brain dwells on them—and the person
repeatedly experiences unrealistic fears and doubts.

Diagnostic criteria

To be diagnosed with OCD, a person must have either obsessions or compulsions

alone, or obsessions and compulsions, according to the DSM-IV-TR diagnostic
criteria. The Quick Reference to the diagnostic criteria from DSM-IV-TR (2000)
states six characteristics of obsessions and compulsions:

Obsessions

1. Recurrent and persistent thoughts, impulses, or images that are experienced

as intrusive and that cause marked anxiety or distress.
2. The thoughts, impulses, or images are not simply excessive worries about
real-life problems.
3. The person attempts to ignore or suppress such thoughts, impulses, or
images, or to neutralize them with some other thought or action.
4. The person recognizes that the obsessional thoughts, impulses, or images are
a product of his or her own mind, and are not based in reality.

Compulsions
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1. Repetitive behaviors or mental acts 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 are not actually connected to the issue, or they are excessive.

In addition to these criteria, at some point during the course of the disorder, the
individual must realize that his/her obsessions or compulsions are unreasonable or
excessive. Moreover, the obsessions or compulsions must be time-consuming
(taking up more than one hour per day), cause distress, or cause impairment in
social, occupational, or school functioning. OCD often causes feelings similar to
those of depression.

According to ICD 10
F42 Obsessive-Compulsive Disorder

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.
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. 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 may develop obsessional
thoughts during their episodes of depression. In either situation, increases or
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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.

Includes:
* anankastic neurosis
* obsessional neurosis
* obsessive-compulsive neurosis

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,
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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.

Epidemiology

There is a lifetime prevalence rate of OCD for both sexes is 2.5 percent.
Education also appears to be a factor. The lifetime prevalence of OCD is lower for
those who have graduated high school than for those who have not (1.9 percent
versus 3.4 percent). However, in the case of college education, lifetime prevalence
is higher for those who graduate with a degree (3.1 percent) than it is for those who
have only some college background (2.4 percent). As far as age is concerned, the
onset of OCD usually ranges from the late teenage years until the mid-20s in both
sexes, but the age of onset tends to be slightly younger in males than in
females.Violence is very rare among OCD sufferers, but the disorder is often
debilitating to their quality of life. Also, the psychological self-awareness of the
irrationality of the disorder can be painful. For people with severe OCD, it may
take several hours a day to carry out the compulsive acts. To avoid perceived
obsession triggers, they also often avoid certain situations or places altogether. It
has been alleged that sufferers are generally of above-average intelligence, as the
very nature of the disorder necessitates complicated thinking patterns

Causes

Scientists studying obsessive-compulsive disorder generally agree that both

psychological and biological factors play a role in causing the disorder, although
they differ in their degree of emphasis upon either type of factor.

Psychological

In the early 1910s, Sigmund Freud attributed obsessive-compulsive behavior to

unconscious conflicts which manifested as symptoms. [ Freud describes the clinical
history of a typical case of "touching phobia" as starting in early childhood, when
the person has a strong desire to touch an item. In response, the person develops an
"external prohibition" against this type of touching. However, this "prohibition
does not succeed in abolishing" the desire to touch; all it can do is repress the
desire and "force it into the unconscious".
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The cognitive-behavioral model suggests that the behaviour is carried out to

remove anxiety-provoking intrusive thoughts. Unfortunately this only brings about
temporary relief as the thought re-emerges. Each time the behaviour occurs it is
negatively reinforced (see Reinforcement) by the relief from anxiety, thereby
explaining why the dysfunctional activity increases and generalises (extends to
other, related stimuli) over a period of time. For example, after touching a door-
knob a person might have the thought that they may develop a disease as a result of
contamination. They then experience anxiety, which is relieved when they wash
their hands. This might be followed by the thought "but did I wash them properly?"
causing an increase in anxiety once more, the hand-washing once again rewarded
by the removal of anxiety (albeit briefly) and the cycle being repeated when
thoughts of contamination re-occur. The distressing thoughts might then spread to
fear of contamination from e.g. a chair (someone might have touched the chair
after touching the door handle).

Biological

There are many different theories about the cause of obsessive-compulsive

disorder. The majority of researchers believe that there is some type of abnormality
with the neurotransmitter serotonin, among other possible psychological or
biological abnormalities; however, it is possible that this activity is the brain's
response to OCD, and not its cause. Serotonin is thought to have a role in
regulating anxiety, though it is also thought to be involved in such processes as
sleep and memory function. In order to send chemical messages, serotonin must
bind to the receptor sites located on the neighboring nerve cell. It is hypothesized
that OCD sufferers may have blocked or damaged receptor sites that prevent
serotonin from functioning to its full potential. This suggestion is supported by the
fact that many OCD patients benefit from the use of selective serotonin reuptake
inhibitors (SSRIs)—a class of antidepressant medications that allow for more
serotonin to be readily available to other nerve cells. [For more about this class of
drugs, see the section about potential treatments for OCD.

It has been theorized that a miscommunication between the orbitofrontal cortex,

the caudate nucleus, and the thalamus may be a factor in the explanation of OCD.
The orbitofrontal cortex (OFC) is the first part of the brain to notice whether or not
something is wrong.[ When the OFC notices that something is wrong, it sends an
initial "worry signal" to the thalamus. When the thalamus receives this signal, it in
turn sends signals back to the OFC to interpret the worrying event. The caudate
nucleus lies between the OFC and the thalamus and prevents the initial worry
signal from being sent back to the thalamus after it has already been received.
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However, it is suggested that in those with OCD, the caudate nucleus does not
function properly, and therefore does not prevent this initial signal from recurring.
This causes the thalamus to become hyperactive and creates a virtually never-
ending loop of worry signals being sent back and forth between the OFC and the
thalamus. The OFC responds by increasing anxiety and engaging in compulsive
behaviors in an attempt to relieve this apprehension. This overactivity of the OFC
is shown to be attenuated in patients who have successfully responded to SSRI
medication. The increased stimulation of the serotonin receptors 5-HT2A and 5-
HT2C in the OFC is believed to cause this inhibition. [5]

Some research has discovered an association between a type of size abnormality in

different brain structures and the predisposition to develop OCD. Through the use
of magnetic resonance imaging (MRI), researchers were able to discover
distinctive patterns in the brain structure of individuals with OCD and their close
family members. According to learning theory there are two stages in OCD. The
stage 1 anxiety is classically conditioned to a specific environmental
event( classical conditioning). The person then engages in compulsive rituals
(escape and avoidance response) in order to decrease anxiety. The compulsive
behavior is more likely to occur in future. Higher order conditioning occurs when
other neutral stimuli like words, images or thoughts are associated with the initial
stimulus and associated anxiety is diffused. Some rituals lead to an increase in
anxiety and cannot be understood in this way.

Some OCD sufferers exhibit what is known as overvalued ideas. In such cases, the
person with OCD will truly be uncertain whether the fears that cause them to
perform their compulsions are irrational or not. After some discussion, it is
possible to convince the individual that their fears may be unfounded. It may be
more difficult to do ERP therapy on such patients, because they may be, at least
initially, unwilling to cooperate. For this reason OCD has often been likened to a
disease of pathological doubt, in which the sufferer, while not usually delusional, is
often unable to realize fully what sorts of dreaded events are reasonably possible
and which are not. There are severe cases when the sufferer has an unshakeable
belief within the context of OCD which is difficult to differentiate from psychosis.

Differential diagnosis

People with OCD may be diagnosed with other conditions, such as generalized
anxiety disorder, anorexia nervosa, social anxiety disorder, bulimia nervosa,
Tourette syndrome, Asperger syndrome, compulsive skin picking, body
dysmorphic disorder, trichotillomania, and (as already mentioned) obsessive-
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compulsive personality disorder. There is some research demonstrating a link

between drug addiction and OCD as well. Many who suffer from OCD also suffer
from panic attacks. There is a higher risk of drug addiction among those with any
anxiety disorder (possibly as a way of coping with the heightened levels of
anxiety), but drug addiction among OCD patients may serve as a type of
compulsive behavior and not just as a coping mechanism. Depression is also
extremely prevalent among sufferers of OCD. One explanation for the high
depression rate among OCD populations was posited by Mineka, Watson, and
Clark (1998), who explained that people with OCD (or any other anxiety disorder)
may feel depressed because of an "out of control" type of feeling.

Some cases are thought to be caused at least in part by childhood streptococcal

infections and are termed PANDAS (Pediatric Autoimmune Neuropsychiatric
Disorders Associated with Streptococcal infections). The streptococcal antibodies
become involved in an autoimmune process. Though this idea is not set in stone, if
it does prove to be true, there is cause to believe that OCD can to some very small
extent be "caught" via exposure to strep throat (just as one may catch a cold).
However, if OCD is caused by bacteria, this provides hope that antibiotics may
eventually be used to treat or prevent it.

Management

According to the Expert Consensus Guidelines for the Treatment of obsessive-

compulsive disorder, behavioral therapy (BT), cognitive therapy (CT), and
medications are first-line treatments for OCD. Psychodynamic psychotherapy may
help in managing some aspects of the disorder, but there are no controlled studies
that demonstrate effectiveness of psychoanalysis or dynamic psychotherapy in
OCD.

Behavioral therapy

The specific technique used in BT/CBT is called exposure and ritual prevention
(also known as "exposure and response prevention") or ERP; this involves
gradually learning to tolerate the anxiety associated with not performing the ritual
behavior. At first, for example, someone might touch something only very mildly
"contaminated" (such as a tissue that has been touched by another tissue that has
been touched by the end of a toothpick that has touched a book that came from a
"contaminated" location, such as a school.) That is the "exposure". The "ritual
prevention" is not washing. Another example might be leaving the house and
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checking the lock only once (exposure) without going back and checking again
(ritual prevention). The person fairly quickly habituates to the anxiety-producing
situation and discovers that their anxiety level has dropped considerably; they can
then progress to touching something more "contaminated" or not checking the lock
at all—again, without performing the ritual behavior of washing or checking.

Exposure ritual/response prevention has been demonstrated to be the most

effective treatment for OCD. It has generally been accepted that psychotherapy, in
combination with psychotropic medication, is more effective than either option
alone. However, more recent studies have shown no difference in outcomes for
those treated with the combination of medicine and CBT versus CBT alone.

Medication

Medications as treatment include selective serotonin reuptake inhibitors (SSRIs)

such as paroxetine (Seroxat, Paxil, Xetanor, ParoMerck, Rexetin), sertraline
(Zoloft, Stimuloton), fluoxetine (Prozac, Bioxetin), escitalopram (Lexapro), and
fluvoxamine (Luvox) as well as the tricyclic antidepressants, in particular
clomipramine (Anafranil). SSRIs prevent excess serotonin from being pumped
back into the original neuron that released it. Instead, serotonin can then bind to the
receptor sites of nearby neurons and send chemical messages or signals that can
help regulate the excessive anxiety and obsessive thoughts.

Benzodiazepines are also used in treatment. It's not uncommon to administer this
class of drugs during the "latency period" for SSRIs or as synergistic adjunct long-
term. Although widely prescribed, benzodiazepines have not been demonstrated as
an effective treatment for OCD and can be addictive.

Serotonergic antidepressants typically take longer to show benefit in OCD than

with most other disorders which they are used to treat, as it is common for 2–3
months to elapse before any tangible improvement is noticed. In addition to this,
the treatment usually requires high doses. Fluoxetine, for example, is usually
prescribed in doses of 20 mg per day for clinical depression, whereas with OCD
the dose will often range from 20 mg to 80 mg or higher, if necessary. In most
cases antidepressant therapy alone will only provide a partial reduction in
symptoms, even in cases that are not deemed treatment-resistant.

Low doses of the newer atypical antipsychotics olanzapine (Zyprexa), quetiapine

(Seroquel), ziprasidone and risperidone (Risperdal) have also been found to be
useful as adjuncts in the treatment of OCD. The use of antipsychotics in OCD must
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be undertaken carefully, however, since, although there is very strong evidence

that at low doses they are beneficial (most likely due to their dopamine receptor
antagonism), at high doses these same antipsychotics have proven to cause
dramatic obsessive-compulsive symptoms even in those patients who do not
normally have OCD. This is most likely due to the antagonism of 5-HT2A
receptors becoming very prominent at these doses and outweighing the benefits of
dopamine antagonism. Another point that must be noted with antipsychotic
treatment is that SSRIs inhibit the chief enzyme that is responsible for
metabolising antipsychotics—CYP2D6—so the dose will be effectively higher
than expected when these are combined with SSRIs. Also, it must be noted that
antipsychotic treatment should be considered as augmentation treatment when
SSRI treatment does not bring positive results.

Alternative drug treatments

Certain vitamin and mineral supplements may aid in such disorders and provide
the nutrients necessary for proper mental functioning.

Recent research has found increasing evidence that opioids may significantly
reduce OCD symptoms, though the use of them is not sanctioned for treatment and
considered an "off-label" use, factors being physical dependence and long term
drug tolerance. Anecdotal reports suggest that some OCD sufferers have
successfully self-medicated with opioids such as tramadol (Ultram) and
hydrocodone (Vicodin, Lortab), though the off-label use of such painkillers is not
widely accepted, research on this has been limited. Tramadol is an atypical opioid
that may be a viable option as it has a low potential for abuse and addiction, mild
side effects, and shows signs of rapid efficacy in OCD. Tramadol not only provides
the anti-OCD effects of an opiate, but also inhibits the re-uptake of serotonin (in
addition to norepinephrine). This may provide additional benefits, but should not
be taken in combination with antidepressant medication unless under careful
medical supervision due to potential serotonin syndrome.
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Psycho-surgery: For some, neither medication, support groups nor psychological

treatments are helpful in alleviating obsessive-compulsive symptoms. These
patients may choose to undergo psychosurgery as a last resort. In this procedure, a
surgical lesion is made in an area of the brain (the cingulate bundle). In one study,
30% of participants benefited significantly from this procedure.[14] Deep-brain
stimulation and vagus nerve stimulation are possible surgical options which do
not require the destruction of brain tissue, although their efficacy has not been
conclusively demonstrated.
Transcranial magnetic stimulation: Though in its early stages of research,
Transcranial magnetic stimulation (TMS) has shown promising results. The
magnetic pulses are focused on the brain's supplementary motor area (SMA),
which plays a role in filtering out extraneous internal stimuli, such as ruminations,
obsessions, and tics. The TMS treatment is an attempt to normalize the SMA's
activity, so that it properly filters out thoughts and behaviors associated with OCD.
 Case study on OCD
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Comparative study

Book picture Patient picture

Etiology Genetic factors
Absent
Family predisposition
Absent
Failing to use defense
mechanism Absent
Organic factors
Absent
More in first born and only
Epidemiology child Present
More in intelligent and
exceptionally talented Present
Chronic illness
Course Present, onset from 2006
Incomplete remission
Present
Episodic
Present
Obsessional doubts
Clinical Absent
features
Obsessional thoughts
Present(obsessions of dirt and
numerous multiplication)
Obsessional images
Absent
Obsessional rumination
Absent
Obsessional impulses
Absent
Obsessional fears
Present(dirt and contamination)
Obsession of miscellaneous
form Absent
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Compulsions to the
obsessions Present( hand washing repeatedly
and bathing for long hours
Behaviour therapy(exposure
Treatment and reaction therapy) Done
Analytic drugs
Given
Antidepressants
Given
Mood stabilizers
Not prescribed
Psychotherapy
Supportive psychotherapy given
Psychosurgery
Not done
Transcranial magnetic
stimulation Not done
Normal good premorbid
Prognosis:good personality Present
Mild symptoms including
predominance of phobic Absent
symptoms
Short duration of symptoms
Absent
Obsesssional premorbid
Bad prognosis personality Absent
Early age of onset
Absent
A clinical picture showing
severe symptoms Present
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NURSING MANAGEMENT

Assessment
The nurses collects a detailed history and conducts a through physical and mental
status examination to reveal the following problems the client faces:
 Washing hands excessively
 Taking very long showers
 Complains of weight gain due to the effects of medication
 Being overly concerned about contamination and germs
 Fear of behaving improperly, such as making sexual advances, saying the
wrong thing, swearing
 Late for college, frequent absences

Nursing diagnosis

Based on the above problems the diagnosis is set according to the priorities

 Moderate anxiety related to feeling of discomfort due to obsessive thought

and compulsion as evidenced by washing hands excessively, taking very
long showers.
 Disturbed body image related to side effects of drugs as evidenced by
verbatim stating weight gain.
 Impaired social interaction related to fear of rejection secondary to
depression as evidenced by increased concern about contamination.
 Self esteem disturbance related to impaired cognition fostering negative
view of self as evidenced by fear of behaving improperly, such as making
sexual advances, saying the wrong thing and swearing.
 Ineffective coping related to academic responsibility as evidenced by delay
in reaching college and frequent absences.
 Knowledge deficit regarding medication and treatment regimen.
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Nursing care plan with application of the theory of interpersonal relationship

by Hildegard E Peplau

Peplau emphasized that problems in the patient can be solved by prominent

interpersonal relationship. According to Peplau there are our stages in the
relationship. They are

1. Orientation
2. During the orientation phase the individual has a felt need seeks professional
assistance. The nurse help the patient recognize and understand his problem
and determine his need for help.
3. Identification phase
The nurse idenmtifies with those who can help him. The nurse explores the
feelings of the patient to aid in coping with the undergoing illness as an
experience the reorients feelingsand strengths positive forces satisfaction.

4. Exploitation
During this phase the patient makes more demands than they did when they
were seriously ill. They make many minor requests, or may use other
attention getting techniques, depending on their individual needs. the nurse
use communication tools such as clarifying ,listening, accepting, teaching,
and interpreting to offer services to the patient. The patient then takes
advantage of the services offered based on his/her needs of interest. In this
phase, the nurse aids the patient to use the services to help solve the problem

5. Resolution
The patients needs have already been met by collaborative efforts between
the patient and the nurse. The patient and the nurse now need to terminate
the relationship and dissolve the links between them.

Nurses roles
Role of a stranger
Role of a resource person
Role of a teacher
Leadership C
Surrogate role
Counseling role D
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Energy transformation
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 Case study on OCD
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Assessment Diagnosis Planning and Evaluation

implementation

Orientatio Identificati Exploitatio Resoluti

n on n
on

The nurses collects a detailed history

and conducts a through physical and The client responds
Moderate anxiety Interventions are planned
mental status examination to reveal to the treatment and
to relieve anxiety, reduce
the following problems the client nursing management
Disturbed body obsessions and to control
faces: Washing hands excessively image and socialized more
compulsions. Positive
Taking very long showers Complains and involved in
of weight gain due to the effects of Impaired social feedback is emphasized.
group activity
medication Being overly concerned interaction Improved his
about contamination and germs Fear communication and
of behaving improperly, such as Self esteem socializing skills . taught
making sexual advances, saying the disturbance
him effective weight loss
wrong thing, swearing L ate for
Ineffective coping methods and requested
college, frequent absences . effective
rapport was established family support
 Case study on OCD
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ASSESSMEN NURSING PLANNING NURSING RATIOANLE EVALUAT

T DIAGNOSIS INTERVENTIONS ION
AND ITS
IMPLIMENTATION
Subjective: “I Moderate Short term: The client was secluded Deviation or The patient
don’t know anxiety related Demonstrates from the water tap. seclusion will demonstrat
why the to feeling of degreased Deviated the attention of enable to stop es
thought of dirt discomfort due anxiety, fear or the thought by the stream of decreased
comes again to obsessive guilt. interacting with the obsessive anxiety and
and again in thought and patient. Substituted a thoughts. compulsive
my mind to compulsion as Long term: physical safe behavior Substitute actions.
feel better I evidenced by Manage his rather than hand washing behaviors may
want to do washing hands anxiety eg tearing paper. The satisfy the
repeated hand excessively, client was encouraged to client needs for
washing” taking very verbalize his concerns of compulsive
Objective: the long showers. obsession and stress , the behaviors but
client anxiety, and fears in a protect the
verbalizes way he pleased like client safety
unpleasant and talking crying, physical and provides a
distressing activities. The client was transition
obsessions and taught the exposure towards
compulsions. response prevention decreasing
when client will get these
obsessive thoughts. He behaviors.
should not be compelled Addressing
to do the activities, doing feelings
 Case study on OCD
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so will increase his directly may

anxiety and gradually he help diminish
will compact his anxiety the anxiety and
and compulsion is thus diminish
prevented with time. obsession. The
procedure of
“exposure
response
prevention”
will help the
client to
manage his
anxiety level
and not to
perform the
compulsive
acts.

ASSESSMEN NURSING PLANNING NURSING RATIOANLE EVALUAT

T DIAGNOSIS INTERVENTIONS ION
AND ITS
IMPLIMENTATION
Subjective: “I Disturbed Short term: Teach the importance of The client will Patient
am putting on body image the client will healthy diet. Plan a menu have reports that
weight since I related to side understand the as per clients likings to preferences he
started taking effects of importance of follow in hospitals set up and by understands
medication. drugs as balanced diet. and at home. Eg: involving him what has
My present evidenced by Long term: breakfast—bread, egg a in the been taught
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Weight is 76 verbatim glass of milk. Lunch— preparation of to him and

Kg stating weight Demonstrate before eating meal have the menu will plans to
gain. constant lots of salads and then increase his maintain
Objective: the maintenance of have what he wants in self esteem and weight and
client weight. little amounts. Instructed self reliance. restrict his
verbalizes to drink lots of water per Improving his weight to 74
unpleasant day( 3-4L/day). Avoid hydration kg.
ideas of non vegetarian diet and maintains good
weight gain include more green leafy metabolism
vegetables. The client is and excretion.
instructed to avoid Non-vegetarian
beverages like cold diet have lots
drinks, junk food, and of calories
excessive sweet intake. which aids in
The client was taught the weight gain.
importance of physical Sweets
exercises on a daily basis beverages like
like brisk walking, cold drinks,
physical exertion junk food
through play. The client increases the
was encouraged to check weight by
his weight weekly. increasing
calorie intake.
By activities
that exert
physically will
result burning
of excessive
 Case study on OCD
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calories .

ASSESSMEN NURSING PLANNING NURSING RATIOANLE EVALUAT

T DIAGNOSIS INTERVENTIONS ION
AND ITS
IMPLIMENTATION
Subjective: “I Impaired social Short term: the Made brief frequent Demonstrating The client
don’t want to interaction clinet will contact with client daily. availability has started
talk to anyone related to fear communicate Initially interacted with will aid in trust to
I prefer to stay of rejection with others and him then gradually building and participate
alone. secondary to participate in involved him in a larger development of in the group
Objective: the depression as activities. group. Slowly rapport. The activities
patient is seen evidenced by Long term: the progressed to facilitating nurse social like exercise
observed to increased client will social interaction behavior and games
himself and concern about initiate between the client and provides a role and singing
does not contamination. interaction with others though games and model for the sessions.
interact with others and will talking. The client is client. A The client is
other patient assume taught social skills like gradual seen
or people. responsibility of eye contact, active increase in the interacting
dealing with listening nodding etc. the social with other
feelings. client is discussed the interaction will patients and
type of topics the client help him build their
can use for casual self confidence attendants.
interaction like local and master in
events. Encouraged the social skills,
 Case study on OCD
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client to show personal teaching him

interest like hobbies and these skills of
recreational activities. communication
Motivate the client in will aid in his
group activity social
participation like interaction
exercises and prayers which might be
that are conducted daily. the reason for
Give patient feed backs his reserved
of all signs of progress nature. Casual
on his initiation in all topics are
activities, means for easy
way
communication
. Recreational
activities
provides an
environment
for initiation of
such
relationships
and also makes
the interaction
fruitful and
enjoyable.
Participation in
such activities
improves his
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health and
sense of well
being. Giving
signs of
reinforcement
will will
validate and
build his
confidence.

ASSESSMEN NURSING PLANNING NURSING RATIOANLE EVALUAT

T DIAGNOSIS INTERVENTIONS ION
AND ITS
IMPLIMENTATION
Subjective: “I Self esteem Short term: the Encouraged the client to When the The client
can’t disturbance client will be become involved with client starts to interacts
concentrate in related to able to verbalize activities and participate focus on others with staff
my studies, I impaired increased in the programs or on and other
am worthless cognition feeling of self conducting with others integration members of
and useless fostering worth and and improved interactive with others the the ward
there is no negative view evaluate own skills. Involved the client pessimistic and
purpose in my of self as strengths that are pleasurable and thoughts are involves in
life. I might be evidenced by realistically recreations and creative. interrupted. the
a problem to fear of Long term: the The client was involved Involving him activities
others, my behaving client will in simple and in pleasurable consistently.
words might improperly, demonstrate uncomplicated activities activities and He
 Case study on OCD
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harm others, such as making consistent first and then progressed therefore verbalizes
especially sexual behavior with to give responsibilities. increased his that he s of
girls. I am advances, increased self Honest praise was given acceptance of worth and
afraid to talk” saying the worth and to the client for his company Any he
Objective: wrong thing prepare plans accomplishment. Helped task completed understands
patient tends and swearing. for the future. the client enumerate his provides and his strengths
to talk own personal strengths. opportunities that he is a
negatively to Help him recollect for positive good
himself and happiness and success he reinforcement listener and
others. He gets enjoyed in the past. and good good in
himself feedback to painting.
reserved most him and
of the time increases his
don’t initiate self regard and
or tries to improves his
sustain a self concept.
conversation Clients do not
with anybody. benefit from
flattering but
honest remarks
can change the
perspective.
Enumerating
self worth
counteracts
negative self
view and
increase self
 Case study on OCD
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worth.
Recollection of
success and
happiness
gives him
confidence and
more self
worth
ASSESSMEN NURSING PLANNING NURSING RATIOANLE EVALUAT
T DIAGNOSIS INTERVENTIONS ION
AND ITS
IMPLIMENTATION
Subjective: Ineffective Short term: The patient was asked to Exposure The client is
“I am not able coping related reduce the practice exposure response ready to
to concentrate to academic frequency of his response prevention and prevention will face his
on my studies responsibility compulsions as far as possible. The result in college days
and I am late as evidenced Long term: client was asked to plan reduced and plans to
to college by delay in will be able to methods for him to plan compulsions. attend
because of my reaching reach his his day like setting an Involving the college as
problem and I college and expectation in alarm clock or reminder client in soon as he
miss classes frequent his role as a in his mobile that remind planning will is
frequently.” absences. student him to do his help improve discharged.
Objective: the responsibility on time. his self concept Family
father of the He was asked to seek and members
client also help from his family confidence. have
verbalizes that members to remind him Involving his volunteered
he misses to leave for college family to help in
early. members also the process
 Case study on OCD
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will facilitate
class the back up
family support
systems.
Subjective: I Knowledge Short term: the Taught the client about The client may The client
don’t know deficit client will the occurrence of the have little or verbalizes
why this OCD regarding participate in disease, its prevalence no knowledge knowledge
happened to medication learning etiology treatment and about the about his
me. and treatment activities about out come of OCD. Its disease process illness,
Objective: the regimen. the disease signs and symptoms and and need for importance
client did not treatment and when to seek help. The recognizing of
respond to any safe use of client is informed about and seeking medication
of the medication and the importance of help in the and ways to
questions so will be able medication and the need future. It is cope with
asked to him to cope up with to continue the necessary for stress in a
regarding his illness medications as long as the client to healthy way
disease. Long term: prescribed. Helped him understand the
demonstrate to set a realistic goal for importance of
complete plans about his future. drug
compliance compliance for
with drugs and prevention of
will be able to relapse.
return to pre- Planning for
morbid the future gives
functioning of a sense of
living wrathfulness..
 Case study on OCD
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 Case study on OCD
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Health education
Regarding illness and medications
 Explained regarding the nature of illness, also the fact that this is a long term
disorder and that maintenance treatment therefore will require one or more
medication may have be taken for long time.
 Educated him regarding the medication, proper dose and time of
administration.
 Explained regarding the expected side-effects and toxic effects of the
prescribed medications as well as where to go in care of severe side effects.
 Enlisted the signs and symptoms of relapse that may came, also explained
the role of family members and others in preventing relapse.
 Advised not to take any pother medication with out the advise not to stop
drug abruptly with out psychiatric advise
Personal hygiene
 Educated the client the importance of bathing daily, brushing teeth daily,
grooming, weaning clean clothes, combing hair, cutting nails.
Nutrition
 Educated regarding importance of balanced diet. Regarding maintenance of
adequate weight. Educated the intake of 3-4 liters of water per day. Educated
the importance of fibers in diet. Physical activities which interest him.
Regular weighing.
Coping with illness
 Educated the patient and family members regarding how to cope up with
illness
 Advised them to avoid situations which causes anxiety to client and provide
calm and peaceful environment.
 Encouraged client to take responsibilities.
 Educated family members to encourage and appreciate even small tasks.
 Explained the importance of follow up. Advised to abstain from alcohol and
smoking.
 Case study on OCD
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Process recording
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Person Verbatim Nonverbal Inference and technique

communication used by the nurse.
Nurse Hello, what is your name? The nurse approached Introduction
near the bed and stood
looking at him
Mr Suman Hello. Suman you can see every thing is there Resilient and The client is not
Bera in the file. disinterested interested to talk.
Nurse Suman are you doing something? Still stands near the
patient
Mr Suman Nothing Looks at the nurse in an Impatient and anxious
Bera anxious manner.
Nurse Do you mind if I spend some time with you The nurse comes
speaking. I am a student and wish to speak to forward and leans .
you.
Mr Suman Ok please sit. Shows finger to a nearby Ready to talk.
Bera chair.
Nurse But you still feel tense here. He looks down and
answers quickly.
Mr Suman I am watched well here. What do you want to He stopped fro some
Bera know? time then he continued.
Mr Suman I have been here since 3 days many people He leaned towards the He understand that the
Bera come and asks lot of things I’m bored saying wall and then got up. He time for food and
the same thing over and over again. wanted to go as the wanted to stop the
lunch was getting ready conversation himself.
to serve
Nurse What do you do? The nurse leans forward
 Case study on OCD
Psychiatric department

Mr Suman I’m a engineering student Leans back at the wall

Bera and then sits near the
bed.
Nurse Do you know why you are here? The nurse leans
backward
Mr Suman Yes I have OCD. He retains the position Insight present
Bera
Nurse Do you take medication Retains the position

Mr Suman Yes I do , so that I can get better. And join my Retains the position
Bera classes as soon as possible
Nurse I did not see you for the exercise today Retains the position
morning. Where you were?
Mr Suman I prefer to be alone. I don’t want my hands to Retains the position
Bera get dirty. It is already dirty that’s what I feel.
And I don’t want to make others dirty too.
Nurse Why do you think you have this problem? Retains the position

Mr Suman I don’t know some chemical problem in the Sits erect

Bera brain
Nurse Did you have your food. Leans forward

Mr Suman No its getting served Gets up and moves and Disinterested and wants
Bera looks at the door. to go to get the food.
Nurse Can I speak to you some time later Gets up and moves away
from the bed
Mr Suman Yes anytime I am always here Goes to the door to get
Bera his food.
 Case study on OCD
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 Case study on OCD
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Summary
Mr. Suman Bera, aged 18, unmarried, years from a Hindu religion, who is pursuing
an engineering course was admitted to the male open ward on 6 th December 2008
with chief complaints of Increased obsession, Increased compulsion, Anxiety,
Decreased concentration, Decreased sleep, Decreased appetiteThere is no
significant family history of any psychiatric ailments and had a very acceptable
personality prior to the disease. On MSE of the patient, it was revealed that Mr
Suman had compulsive behavior of washing hands several times and taking bath
for hours which originated from his obsessive thoughts of un-cleanliness and dirty
hands. The patient retains insight. The client is diagnosed as OCD. The nurse
assessed the client and planned for care using the interpersonal approach of
Hildegard E Peplau. The client showed marked improvement during the stay in
the hospital and got discharged from the hospital on 10 th December 2008. The
nurse had educated regarding the follow up care and the need for medication. The
rapport was resolved successfully.

Conclusion

Obsessive convulsive disorder is an anxiety disorder different from behaviors such

as gambling addiction and overeating. People with these disorders typically
experience at least some pleasure from their activity; OCD sufferers do not
actively want to perform their compulsive tasks, and experience no pleasure from
doing so. OCD is placed in the anxiety class of mental illness, but like many
chronic stress disorders it can lead to clinical depression over time. The constant
stress of the condition can cause sufferers to develop a deadening of spirit, a
numbing frustration, or sense of hopelessness. OCD's effects on day-to-day life—
particularly its substantial consumption of time—can produce difficulties with
work, finances and relationships. There is no known cure for OCD as of yet, but
there are a number of successful treatment options available.

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