Obsessive–compulsive disorder (OCD)

o was previously classified as an anxiety disorder due to the sometimes-extreme anxiety that
people experience.

o Certain disorders characterized by repetitive thoughts and/or behaviors, such as OCD, can be
grouped together and described in terms of an obsessive–compulsive spectrum.

o The spectrum approach includes repetitive behaviors of various types: self-soothing

behaviors, such as trichotillomania, dermatillomania, or onychophagia; reward-seeking
behaviors, such as hoarding, kleptomania, pyromania, or oniomania; and disorders of body
appearance or function, such as body dysmorphic disorder (BDD).

o Obsessions

o are recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses

that cause marked anxiety and interfere with interpersonal, social, or occupational
function.

o Compulsions

o are ritualistic or repetitive behaviors or mental acts that a person carries out
continuously in an attempt to neutralize anxiety.

o Common compulsions include the following:

▪ Checking rituals (repeatedly making sure the door is locked or the coffee pot
is turned off)

▪ Counting rituals (each step taken, ceiling tiles, concrete blocks, or desks in a
classroom)

▪ Washing and scrubbing until the skin is raw

▪ Praying or chanting

▪ Touching, rubbing, or tapping (feeling the texture of each material in a

clothing store; touching people, doors, walls, or oneself)

▪ Ordering (arranging and rearranging furniture or items on a desk or shelf

into perfect order; vacuuming the rug pile in one direction)

▪ Exhibiting rigid performance (getting dressed in an unvarying pattern)

▪ Having aggressive urges (for instance, to throw one’s child against a wall)

o OCD is diagnosed only when these thoughts, images, and impulses consume the
person or he or she is compelled to act out the behaviors to a point at which they
interfere with personal, social, and occupational functions.
Onset and Clinical Course

- OCD can start in childhood, especially in males. In females, it more commonly begins in the 20s.
Overall, distribution between the sexes is equal.

- Onset is typically in late adolescence, with periods of waxing and waning symptoms over the
course of a lifetime.

- Individuals with early-onset OCD (average age of 11) and those with late- onset OCD (average
age of 23) differ in several ways.

- Early onset is more likely to affect males, has more severe symptoms, more comorbid diagnoses,
and a greater likelihood of a family history of OCD

Related Disorders

1. Excoriation disorder, skin-picking, also known as dermatillomania, is categorized as a self-

soothing behavior; that is, the behavior is an attempt of people to soothe or comfort
themselves, not that picking itself is necessarily a positive sensation.

➢ It may be necessary to involve medicine, surgery, and/or plastic surgery, as well as

psychiatry on the treatment team.

➢ Alternative therapies, such as yoga, acupuncture, and biofeedback, are helpful when
included in the treatment plan (Torales, Barrios, & Villalba, 2017).

2. Trichotillomania, or chronic repetitive hair-pulling, is a self-soothing behavior that can cause

distress and functional impairment.

➢ Onset in childhood is most common, but it can also persist into adulthood with
development of anxiety and depression. It occurs more often in females than in males.
Trichotillomania can be successfully treated with behavioral therapy, although results
are mixed and long-term outcomes are not well documented (Cison, Kus, Popowicz,
Szyca, & Reich, 2018).

3. Body Dysmorphic Disorder is a preoccupation with an imagined or slight defect in physical

appearance that causes significant distress for the individual and interferes with functioning in
daily life. The person ruminates and worries about the defect, often blaming all of life’s problems
on his or her “flawed” appearance, that is, the appearance is the reason the person is
unsuccessful at work or finding a significant other, for feelings of unhappiness, and so forth.

4. Hoarding disorder is a progressive, debilitating, compulsive disorder only recently diagnosed on

its own. Hoarding had been a symptom of OCD previously but differs from OCD in significant
ways. Diagnosis most commonly occurs between the ages of 20 to 30.

5. Onychophagia, or chronic nail-biting, is a self-soothing behavior.

➢ Typical onset is childhood, with a decrease in behavior by age 18.

 ➢ However, some nail-biting persists into adulthood.

➢ It may lead to psychosocial problems or cause complications involving the nails and oral
cavity.

➢ SSRIs have proven effective in the treatment of onychophagia (Halteh, Scher, & Lipner,
2017).

6. Kleptomania, or compulsive stealing, is a reward-seeking behavior. The reward is not the stolen
item, but rather the thrill of stealing and not getting caught.

➢ Kleptomania is different than stealing items needed for survival, such as a parent
stealing food for a hungry child.

➢ Kleptomania is more common in females with frequent comorbid diagnoses of

depression and substance use.

➢ It is associated with significant legal repercussions.

➢ There is a lack of standardized treatment for kleptomania, but it seems that longer term
therapy, as opposed to limited 10 or 12 sessions, may be needed (Grant & Chamberlain,
2018).

7. Oniomania, or compulsive buying, is an acquisition type of reward- seeking behavior. The

pleasure is in acquiring the purchased object rather than any subsequent enjoyment of its use.

➢ Approximately 80% of compulsive buyers are females with onset of the behavior in the
early 20s; it is often seen in college students. Compulsive shopping runs in families who
also have a high comorbidity for depression and substance use (Leite & Silva, 2016).

8. Body identity integrity disorder (BIID) is the term given to people who feel “overcomplete,” or
alienated from a part of their body and desire amputation. This condition is also known as
amputee identity disorder and apotemnophilia or “amputation love.”

➢ People describe feelings of anguish and distress with their intact bodies and report
feeling “natural, like they were intended to be” after an amputation.

Etiology

- The etiology of OCD is being studied from a variety of perspectives. Different studies show
promise but have yet to definitively explain how or why people develop OCD.

- Cognitive models of OCD arise from Aaron Beck’s cognitive approach to emotional disorders.

➢ The cognitive model describes the person’s thinking as

o (1) believing one’s thoughts are overly important, that is, “If I think it, it will
happen,” and therefore having a need to control those thoughts;

o (2) perfectionism and the intolerance of uncertainty; and

 o (3) inflated personal responsibility (from a strict moral or religious upbringing)
and overestimation of the threat posed by one’s thoughts.

➢ The cognitive model focuses on childhood and environmental experiences of growing

up. However, environmental influences are not solely responsible for the development
of OCD (Stein & Lochner, 2017).

Treatment

- Optimal treatment for OCD combines medication and behavioral therapy.

✓ SSRI antidepressants, such as fluvoxamine (Luvox) and sertraline (Zoloft), are first-line
choices, followed by venlafaxine (Effexor).

✓ Treatment-resistant OCD may respond to second-generation antipsychotics such as

risperidone (Risperdal), quetiapine (Seroquel), or olanzapine (Zyprexa).

✓ Children and adolescents with OCD also respond well to behavioral therapy and SSRI
antidepressants, even when symptoms are treatment refractory (Casale et al., 2018).

✓ Exposure involves assisting the client in deliberately confronting the situations and
stimuli that he or she usually avoids.

✓ Response prevention focuses on delaying or avoiding performance of rituals.

NURSING INTERVENTIONS

• Offer encouragement, support, and compassion.

• Be clear with the client that you believe he or she can change.

• Encourage the client to talk about feelings, obsessions, and rituals in detail.

• Gradually decrease time for the client to carry out ritualistic behaviors.

• Assist the client in using exposure and response prevention behavioral techniques.

• Encourage the client to use techniques to manage and tolerate anxiety responses.

• Assist the client in completing daily routine and activities within agreed-upon time limits.

• Encourage the client to develop and follow a written schedule with specified times and activities.

CLIENT AND FAMILY EDUCATION

• For OCD

o For Clients

▪ Teach about OCD.

 ▪ Review the importance of talking openly about obsessions, compulsions, and
anxiety.

▪ Emphasize medication compliance as an important part of treatment.

▪ Discuss necessary behavioral techniques for managing anxiety and decreasing

prominence of obsessions.

▪ Tolerating anxiety is uncomfortable but not harmful to health or well- being.

o For Families

▪ Avoid giving advice such as, “Just think of something else.”

▪ Avoid trying to fix the problem; that never works.

▪ Be patient with your family member’s discomfort.

▪ Monitor your own anxiety level, and take a break from the situation if you need
to.

Dissociative disorders involve problems with memory, identity, emotion, perception, behavior and sense
of self. Dissociation is a subconscious defense mechanism that helps a person protect the emotional self
from recognizing the full impact of some horrific or traumatic event by allowing the mind to forget or
remove itself from the painful situation or memory.

Risk factors

• People who experience chronic physical, sexual or emotional abuse during childhood are at
greatest risk of developing dissociative disorders.

• Children and adults who experience other traumatic events, including war, natural disasters,
kidnapping, torture and invasive medical procedures also may develop these conditions.

Kind of Dissociative Disorders

 Dissociative Amnesia

• person is unable to remember important personal information, which is usually associated

with a traumatic event in his/her life

• the loss of memory creates gaps in this individual's personal history

• Memory loss that's more extensive than normal forgetfulness

• hallmark à can't be explained by a physical or neurological cond

 Dissociative Fugue

• Person impulsively wanders or travels away from home and upon arrival in the new location is
unable to remember his/her past.
 • The individual's personal identity is lost because that person is confused about who he/she is.

• The travel from home generally occurs following a stressful event.

• The person in the fugue appears to be functioning normally to other people. However, after the
fugue experience, the individual may not be able to recall what happened during the fugue
state. The condition is usually diagnosed when relatives find their lost family member living in
another community with a new identity.

 Dissociative Identity Disorder

• “multiple personality disorder”

• characterized by "switching" to alternate identities when you're under stress.

• When a person intermittently experiences two or more identities.

• While experiencing a new identity, a separate personality takes control, and the person is
unable to remember important and personal information about himself/herself.

• Each personality has its own personal history and identity and takes on a totally separate
name.

• you may feel the presence of one or more other people talking or living inside your head.

• Each of these identities may have their own name, personal history and characteristics,
including marked differences in manner, voice, gender and even such physical qualities as
the need for corrective eyewear.

• There often is considerable variation in each alternate personality's familiarity with the
others.

• People with dissociative identity disorder typically also have dissociative amnesia.

 Depersonalization disorder

• characterized by a sudden sense of being outside yourself, observing your actions from a
distance as though watching a movie.

• client describes self as “detached from my body” or “being in a dream” or “watching themselves
on a movie screen”

• may be accompanied by a perceived distortion of the size and shape of your body or of other
people and objects around you. Time may seem to slow down, and the world may seem unreal.
Treatments:

Psychotherapy

- primary treatment for dissociative disorders.

- talk therapy

- counselling psychosocial therapy

Creative art therapy

-uses the creative process to help people who might have difficulty expressing their thoughts and
feelings.

-help you increase self-awareness, cope with symptoms and traumatic experiences, and foster positive
changes.

-includes art, dance and movement, drama, music and poetry.

Dissociative Amnesia

• therapy aimed at helping the client/patient restore lost memories as soon as possible

Dissociative fugue

• Hypnosis is often used in the treatment of. Hypnosis can help the client/patient recall
his/her true identity and remember the events of the past. Psychotherapy is helpful for
the person who has traumatic, past events to resolve.

Dissociative Identity Disorder

• involves long-term psychotherapy that helps the person merge his/her multiple
personalities into one. The trauma of the past has to be explored and resolved with
proper emotional expression. Hospitalization may be required if behavior becomes
bizarre or destructive.

Depersonalization

• thorough therapeutic exploration of the trauma in the individual's past and the
expression of the emotions associated with that trauma.

Disorders of Sleep and Wakefulness

INTRODUCTION

- Sleep and wakefulness disorders can be organized into five categories:

1. insomnia,

2. hypersomnia,
 3. sleep-related breathing disorders,

4. circadian rhythm disorders, and

5. parasomnias.

1. INSOMNIA DISORDER

➢ The primary element of insomnia is the dissatisfaction with sleep quantity or quality. The person
has difficulty falling asleep, maintaining sleep, and/or early-morning wakening with inability to
return to sleep. Subtypes of insomnia disorder include the following:

o Inadequate sleep hygiene—Engaging in behaviors not conducive to sleep or interfering

directly with sleep. Included are consuming caffeine or nicotine before bed time,
excessive emotional or physical stimulation just prior to bedtime, daytime naps, and
wide variations of daily sleep–wake routines.

▪ Treatment modalities include sleep hygiene measures include sleep hygiene

measures cognitive–behavioral techniques, and medication.

o Psychophysiological insomnia—Involves conditioned arousal associated with the

thought of sleep (i.e., the bed, the bedroom). It is often associated with stress and
anxiety. Characteristics include excessive worry about sleep problems, trying too hard to
sleep, rumination, increased muscle tension, and other anxiety symptoms.

▪ Relaxation therapy, sleep hygiene measures, and stimulus control therapy

o Paradoxical insomnia—When the individual thinks he or she is awake or is not sleeping

even though brain wave activity is consistent with normal sleep. It is usually due to
ruminative worrying that continues into sleep but causes the individual to believe he or
she is awake.

▪ An interruption of rumination and diminished worry about not sleeping usually

diminishes or eliminates the problem.

o Idiopathic insomnia—A lifelong inability to obtain adequate sleep. It is thought to be a

neurologic deficit in the sleep–wake cycle and is, therefore, chronic and lifelong.

▪ Treatment consists of improved sleep hygiene, relaxation therapy, and the long-
term use of sleep-inducing medication.

o Insomnia due to a mental disorder, medical condition, or drug or substance use—

Primary treatment of the underlying cause is helpful but may not eliminate the insomnia
altogether.

▪ Use of medications for sleep, sleep hygiene measures, and the avoidance of
stimulants, including caffeine, and of medications that interfere with sleep are
also effective.
2. HYPERSOMNOLENCE DISORDER

➢ Excessive sleepiness for at least 1 month that involves either prolonged sleep episodes or daily
daytime sleeping that causes significant distress or impairment in functioning.

➢ Major sleep episodes may be 8 to 12 hours long, and the person has difficulty waking up.

➢ Daytime naps leave the person unrefreshed upon awakening. It may be due to sleep regulation
dysfunction in the brain.

o Treatment with stimulant medication is often effective.

3. NARCOLEPSY

➢ Chronic excessive sleepiness characterized by repeated, irresistible sleep attacks. After sleeping
10 to 20 minutes, the person is briefly refreshed until the next sleep attack.

o Sleep attacks can occur at inopportune times, such as during important work activities or
while driving a car.

➢ People with narcolepsy may also experience cataplexy (sudden episodes of bilateral, reversible
loss of muscle tone that last for seconds to minutes) or recurrent intrusions of REM sleep in the
sleep–wake transitions, manifested by paralysis of voluntary muscles or dream-like
hallucinations.

o Treatment includes stimulant medication, modafinil (Provigil), and behavioral

structuring, such as scheduling naps at convenient times.

4. SLEEP-RELATED BREATHING DISORDERS

➢ Sleep disruption leads to excessive sleepiness or, less commonly, insomnia, caused by
abnormalities in ventilation during sleep.

➢ These sleep-related breathing disorders include

o obstructive sleep apnea (repeated episodes of upper airway obstruction),

▪ commonly seen in obese individuals.

o central sleep apnea (episodic cessation of ventilation without airway obstruction), and

▪ more common in the elderly,

o central alveolar hypoventilation (hypoventilation resulting in low arterial oxygen levels).

▪ commonly seen in obese individuals.

➢ The primary treatments for sleep-related breathing disorders are surgical, such as tracheotomy,
and use of a continuous positive-airway pressure machine during sleep.

5. CIRCADIAN RHYTHM SLEEP–WAKE DISORDERS

➢ Persistent or recurring sleep disruption resulting from altered functioning of circadian rhythm or
a mismatch between circadian rhythm and external demands.
 o Subtypes include

▪ delayed sleep phase (person’s own circadian schedule is incongruent with

needed timing of sleep, such as an individual being unable to sleep or remain
awake during socially acceptable hours as a result of a work schedule or the
like),

▪ jet lag (conflict of sleep–wake schedule and a new time zone),

▪ shift work (conflict between circadian rhythm and demands of wakefulness for
shift work), and unspecified (circadian rhythm pattern is longer than 24 hours
despite environmental cues, resulting in varying sleep problems).

o Sleep hygiene measures, melatonin, and bright light therapy can be effective treatments.

o Bright light therapy consists of being exposed to bright light when wakefulness is
initiated and avoiding bright lights when sleep is desired.

6. PARASOMNIAS

➢ Parasomnias are disorders characterized by abnormal behavioral or psychological events

associated with sleep, specific sleep stages, or sleep– wake transition. These disorders involve
activation of physiological systems, such as the autonomic nervous system, motor system, or
cognitive processes, at inappropriate times, as during sleep.

o Nightmare disorder—Repeated occurrence of frightening dreams that lead to waking

from sleep. The dreams are often lengthy and elaborate, provoking anxiety or terror and
causing the individual to have trouble returning to sleep and to experience significant
distress and, sometimes, lack of sleep.

o Sleep terror disorder—Repeated occurrence of abrupt awakenings from sleep associated

with a panicky scream or cry. Children with sleep terror disorder are confused and upset
upon awakening and have no memory of a dream either at the time of awakening or in
the morning. Initially, it is difficult to fully awaken or console the child.

o Sleepwalking disorder—Repeated episodes of complex motor behavior initiated during

sleep, including getting out of bed and walking around. Persons appear disoriented and
confused and on occasion may become violent. Usually, they return to bed on their own
or can be guided back to bed.

SLEEP HYGIENE MEASURES

• Establish a regular schedule for going to bed and arising.

• Avoid sleep deprivation, and the desire to “catch up” by excessive sleeping.

• Do not eat large meals before bedtime; however, a light snack is permissible, even helpful.

• Avoid daytime naps, unless necessitated by advanced age or physical condition.

• Exercise daily, particularly in the late afternoon or early evening, as exercise before retiring
may interfere with sleep.

• Minimize or eliminate caffeine and nicotine ingestion.

• Do not look at the clock while lying in bed.

• Keep the temperature in the bedroom slightly cool.

• Do not drink alcohol in an attempt to sleep; it will worsen sleep disturbances and produce
poor-quality sleep.

• Do not use the bed for reading, working, watching television, and so forth.

• If you are worried about something, try writing it down on paper and assigning a designated
time to deal with it—then, let it go.

• Soft music, relaxation tapes, or “white noise” may be helpful; experiment with different
methods to find those that are beneficial for you.