Care of Clients with Maladaptive Patterns of

Behavior, Acute and Chronic

INSTRUCTOR’S GUIDE BS NURSING / THIRD YEAR
Session # 19

LESSON TITLE: OBSESSIVE-COMPULSIVE AND Materials:

RELATED DISORDERS Textbook, Notebook, Bondpaper, Pen, and Paper

LEARNING OUTCOMES:
References
At the end of the lesson, the nursing student can:

1. Recognize and describe the symptoms, behaviors, Bhandari, S. (2020). Skin Picking Disorder.
and diagnostic criteria for obsessive-compulsive and Retrieved from
related disorders [Link]
2. Create holistic care plans for patients with obsessive- picking-disorder
compulsive and related disorders
3. Critically assess the outcomes of various treatment Videbeck, S. L. (2014). Mental and Psychiatric
modalities Health Nursing. 6th Edition. Lippincott, Williams
4. Assess how these disorders affect a patient’s ability to and Wilkins. Philadelphia, PA.
perform daily activities
[Link]
clinical

LESSON REVIEW / PREVIEW& HOOK ACTIVITY (10 minutes)

Instruction: Look at the photo posted below closely. Describe what you see in the picture. What do you plan to do with
those colored pencils?

MAIN LESSON (50 minutes)

OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

A. Obsessive-Compulsive Disorder (OCD)

➢ Recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that cause marked anxiety and
interfere with interpersonal, social, or occupational function. The person knows these thoughts are excessive or
unreasonable but believes he or she has no control over them.

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 ➢ Obsessions are fixed, recurrent thoughts that a person believes in such as obsession over germs or cleanliness.
These cause a person’s anxiety.
➢ Compulsions are ritualistic, repetitive behaviors that a person performs continuously in an attempt to relieve the
anxiety.
➢ OCD is diagnosed if the thoughts, impulses, images consume the person and he/she becomes compelled to act
out the compulsions to a point where they interfere with personal, social, and occupational functions such as a
man no longer able to attend to work because he spends most the day arranging and rearranging things in his
desk
➢ Onset is gradual, in males it starts in childhood while in females it commonly begins in the 20s

Common obsessions
1. Contamination
2. Safety
3. Doubting one's memory or perception
4. Scrupulosity (need to do the right thing, fear of committing a transgression, often religious)
5. Need for order or symmetry
6. Unwanted, intrusive sexual/aggressive thought

Common Compulsions
1. Checking rituals – checking repeatedly if the door is locked or appliances are turned off
2. Chanting or praying
3. Washing and scrubbing until the skin is raw and red
4. Ordering, arranging and rearranging items, furniture and appliances
5. Rigid performance – performing a daily activity in an unvarying pattern
6. Counting rituals – how many tiles on the floor, steps taken, desks in the office
7. Hoarding items – fear throwing away items

Treatment
1. Behavior Therapy
a. Exposure – involves assisting the client to deliberately situations or stimuli that he/she avoids
b. Response Prevention – involves delaying or avoiding performance of rituals (compulsions)

Nursing Interventions
1. Offer encouragement, support, and compassion.
2. Be clear with the client that you believe he or she can change.
3. Encourage the client to talk about feelings, obsessions, and rituals.
4. Gradually decrease time for the client to carry out ritualistic behaviors.
5. Assist client to use exposure and response prevention behavioral techniques.
6. Encourage client to use techniques to manage and tolerate anxiety responses.
7. Assist client to complete daily routine and activities.

B. Body Dysmorphic Disorder (BDD)

➢ Is preoccupation with an imagined defect in appearance or disproportionate concern with a slight physical
anomaly.
➢ By definition, BDD causes significant distress or impairment in important areas of functioning.
➢ Common areas of perceived imperfections:
• Skin; face; nose; mouth; hair; eyelids; wrinkles; excessive greasiness; acne; excessive facial hair; nasal size
and shape; teeth; bite of jaw; breasts; genitals; buttocks; lips

Assessment:
1. Ritualistic behaviors aimed at confirming the “defect” or avoiding its recognition by others
2. Need for constant reassurance from others
3. Expenditure of considerable time (1 hour or more, sometimes as much as 8 hours) daily on thoughts and behaviors
relating to the “defect”
4. Repeated seeking of dermatologic or cosmetic referral for correction of the “defect”

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Asking the following 4 questions may be helpful:
1. Are you worried about how you look? (Yes/No); if you are, do you think about your appearance problems a lot and wish
you could think about them less? (Yes/No)
2. How much time per day, on average, do you spend thinking about how you look?
(a) Less than 1 hour a day
(b) 1-3 hours a day
(c) More than 3 hours a day
3. Is your main concern with how you look that you aren’t thin enough or that you might become too fat? (Yes/No)
4. How has this problem with how you look affected your life?
(a) Has it often upset you a lot? (Yes/No)
(b) Has it often gotten in the way of doing things with friends, your family, or dating? (Yes/No)
(c) Has it caused you any problems with school or work? (Yes/No)
(d) Are there things you avoid because of how you look? (Yes/No)

Clients are likely to have BDD if they give the following answers:
• Question 1 - Answer of “yes” to both parts of the question
• Question 2 - Answer of (b) or (c)
• Question 3 - Whereas an answer of “yes” answer may indicate that BDD is present, it is possible that an
eating disorder is a more accurate diagnosis
• Question 4 - Answer of “yes” to any of the 4 parts of the question

Treatment:
1. SSRI: fluoxetine, fluvoxamine, escitalopram, and citalopram; these agents are generally preferred
2. Tricyclic antidepressants: clomipramine in particular
3. Neuroleptics: pimozide
4. Lithium
5. Monoamine oxidase inhibitors (MAOIs)
6. Psychotherapy

C. Hoarding Disorder
➢ Characterized by a person’s irrational, persistent difficulty in discarding or parting with possessions regardless of
their actual value.
➢ Discarding refers to giving away, throwing away, recycling, or selling things one no longer needs (or sometimes,
even want)

Assessment:
People with hoarding disorder feel a strong need to save their possessions. Other symptoms include:
1. Inability to get rid of possessions
2. Extreme stress about throwing out items
3. Anxiety about needing items in the future
4. Uncertainty about where to put things
5. Distrust of others touching possessions
6. Living in unusable spaces due to clutter
7. Withdrawing from friends and family

Treatment:
1. Cognitive-behavioral Therapy
2. Exposure Therapy

D. Trichotillomania
➢ More commonly known as hair-pulling disorder, it involves an individual recurrently pulling hair from any part of
his/her body – the head, eyelashes, eyebrows, beard, underarms, chest, legs, or other area. Scalp is the most
common area.
➢ Similar to other OCDs, the person feels a compulsion to pull hair and feelings of satisfaction from the act.
➢ Pulling hair can be an avoidance or coping mechanism.

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 ➢ According to the DSM-5, the condition can develop in childhood or adulthood but onset is usually around 9 to 13
years of age.
➢ Many people who have TTM experience a high level of anxiety and/or depression, although happy people also
engage in hair-pulling activity.

Treatment:
1. Antidepressants
2. Anxiolytics
3. Cognitive-behavioral Therapy

E. Excoriation (Skin-picking) Disorder

➢ Involves conscious creation of neurotic excoriations through repetitive scratching. Neurotic excoriations can be
initiated by some minor skin pathology (e.g. insect bite, folliculitis, or acne), but it can also be independent of any
pathology.

Specific DSM-5 criteria for excoriation disorder are as follows:

1. Recurrent skin-picking, resulting in lesions
2. Repeated attempts to decrease or stop skin picking
3. The skin picking causes clinically significant distress or impairment in important areas of functioning
4. The skin picking cannot be attributed to the physiologic effects of a substance or another medical condition
5. The skin picking cannot be better explained by the symptoms of another mental disorder

Management for Excoriation

1. Setting limits for the protection of both the physician and patient
2. Creating an accepting, empathic, and nonjudgmental environment
3. Closely supervising symptomatic dermatologic care
4. Attempting to develop a therapeutic relationship in which psychological issues may be addressed and which may permit
referral to a psychiatrist as appropriate
5. Avoidance of issues of etiology (confrontation is counterproductive)

Treatment:
1. Pharmacotherapy may include the following:
a. Antipsychotic agents
b. Antianxiety agents
c. Antidepressants
d. Topical cortisone agents
e. Antiepileptic agents

2. Habit reversal training. The therapist helps the client identify the situations, stresses, and other factors that trigger the
skin picking. The therapist helps the client find other things to do instead of skin picking, such as squeezing a rubber
ball. This will help ease stress and occupy hands.

3. Stimulus control. This therapy involves making changes to the environment to help curb skin picking. For example, you
wearing gloves or Band-Aids to help prevent feeling the skin and getting the urge to pick or cover mirrors if seeing facial
blemishes or pimples brings on picking behavior.

CASELET: Hoarding Disorder

Background

In a quiet neighborhood in Iloilo, a 50-year-old woman named Lorna lives alone in a spacious house that once belonged to
her parents. Lorna works as a librarian at a local university but has struggled with Hoarding Disorder for many years. Her
home is filled with stacks of books, newspapers, and various items she has accumulated over the years.

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The Case of Lorna

Lorna's hoarding behavior is influenced by several unique factors:

1. Cultural Significance of Family and Inheritance: Lorna inherited the family home, which holds sentimental value
and represents her family's legacy. The fear of letting go of items, even if they are not useful, is tied to her cultural
beliefs about inheritance and preserving family history.
2. Historical Events and Collecting Behavior: Lorna's interest in history and Philippine culture has led to an
extensive collection of vintage newspapers, magazines, and memorabilia. She feels a deep connection to these
items, seeing them as a tangible link to the past, including historical events like the People Power Revolution of
1986.
3. Stigma and Shame: Lorna feels ashamed of her cluttered home and avoids inviting guests over, fearing judgment
and criticism.
4. Financial Constraints: Despite her job as a librarian, Lorna struggles financially. She sometimes buys items
impulsively, believing they will be valuable someday, which exacerbates her hoarding behavior.
5. Community Support: Lorna's neighbors are concerned about the state of her home and have expressed worry
about fire hazards and vermin infestations. They have tried to help by offering to clean or organize her home, but
she becomes defensive and refuses their assistance.

Questions

1. How can nurses approach Lorna about her hoarding behavior in a way that would match Lorna’s case?
2. What nursing interventions can be used to help Lorna declutter her home and manage her hoarding
tendencies?
3. How can nurses collaborate with Lorna's family and community to provide support and encourage her to
accept help, despite her reluctance?

CHECK FOR UNDERSTANDING (20 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to the correct
answer and another one (1) point for the correct rationale. Superimpositions or erasures in your answer/rationale are not
allowed. You are given 20 minutes for this activity:

Multiple Choice

1. A woman is 5'7", 160 lbs, and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically
reduce my feet." This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet
under a table or chair. Which problem is likely?
A. Social anxiety disorder
B. Body dysmorphic disorder
C. Separation anxiety disorder
D. Obsessive-compulsive disorder due to a medical condition
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. A client with obsessive-compulsive disorder is hospitalized on an inpatient unit. Which nursing response is most
therapeutic?
A. Accepting the client’s obsessive-compulsive behaviors
B. Challenging the client’s obsessive-compulsive behaviors
C. Preventing the client’s obsessive-compulsive behaviors
D. Rejecting the client’s obsessive-compulsive behaviors
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________

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_________________________________________________________________________________________________

3. What intervention does the nurse implement to enable the client with repetitive behavior to complete daily activities?
A. Involve the family in the therapy
B. Increase stimulus to distract client
C. Give the client as much time he wants in a therapy
D. Direct and guide the client in a therapy
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. Akara, a 20-year-old female client believes that doorknobs are contaminated and refuses to touch them, except with a
paper tissue. Akara has symptoms of a client with:
A. Obsessive-Compulsive Disorder
B. Hoarding Disorder
C. Body Dysmorphic Disorder
D. Excoriation Disorder
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. Miss K, a celebrity socialite, spends 4 hours every day to check on her body. She claims that she has a “small butt”
and that part of her lacks curves that must be enhanced so she can flaunt her body. Miss K is manifesting what
disorder?
A. Obsessive-Compulsive Disorder
B. Hoarding Disorder
C. Body Dysmorphic Disorder
D. Excoriation Disorder
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. Habit reversal as a therapy is used in clients with:

A. Obsessive-Compulsive Disorder
B. Hoarding Disorder
C. Body Dysmorphic Disorder
D. Excoriation Disorder
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. A client in the psychiatric ER admitted a client with baldness. The client appears socially impaired and admits to pull her
hair to relieve her tension that started 2 years ago when she her boyfriend died. Which of the following best describes her
condition?
A. Obsessive-Compulsive Personality Disorder
B. Hoarding Disorder
C. Trichotillomania
D. Body Dysmorphic Disorder
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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8. A nurse in the Psych unit is assigned to a client with OCD. The nurse identifies all of the following manifestations of OCD
clients except:
A. Arranging & Re-arranging
B. Hearing voices in a silence place
C. Waking up in at night several times to check if doors are locked
D. Making sure clothes are inside the closet are color coded
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Which of the following is a behavioral symptom of as client with OCD?

A. Doubting one’s memory
B. Intense Fear
C. Checking rituals
D. Scrupulosity
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. Marky loves to go to the mall with his friends. But often, he has the tendency to avoid the lines on the floor tiles which
makes him odd among his friends. Avoiding the lines as Marky steps on the floor is a:
A. Obsession
B. Compulsion
C. Illusion
D. Gratification
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE-TO-FACE INTERACTION)

The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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2. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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3. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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4. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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 _____________________________________________________________________________________________

5. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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6. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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7. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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8. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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9. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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10. ANSWER: _____

RATIONALE: __________________________________________________________________________________
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LESSON WRAP-UP (30 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: PATIENT EDUCATION PLAN

Instructions:
1. You will select and create a Client Teaching Plan for a client diagnosed with any of the following diseases: OCD, BDD,
Hoarding or Trichotillomania using the format shown.
2. The patient education plan must be written in a short bondpaper using the required format provided and attached to
the SAS during the submission.

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Format:

Topic:

General Objective:

Specific Objectives Teaching Strategies Teaching Resources Evaluative Method

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