Case Study I
Mary works as an administrative assistant to a company CEO. She is known for being meticulous at her work and very organized. She makes sure the CEO’s office and the waiting room are perfectly put together. “Everything is in its place,” she says. Everyone who enters the office must use hand sanitizer before they can approach her desk. She becomes visibly upset when someone walks in and does not “clean” themselves first.
Jack is a college student. He does not have many friends, as his routine will not allow for usual things college students do. He walks the same path every day to his classes and counts the steps there and back to his dorm. He has his meals at designated times and wears certain clothes on particular days of the week. His mother tells him he is very predictable, but he likes it that way. One day on his way to class, the sidewalk was torn up to repair a water pipe. He was so upset that he could not continue to class and instead walked back to his dorm and paced the rest of the day.
Mary and Jack suffer from what is called obsessive-compulsive disorder or OCD. OCD is a common and very disabling disorder. It is characterized by uncontrollable thoughts, the obsession and repetitive behaviors, the compulsion (APA, 2013). The behaviors are an attempt to alleviate the anxiety caused by the thoughts or obsessions.
How Common is OCD?
Once thought to be a rare disorder, obsessive-compulsive disorder is now known to be one of the most common mental health disorders. Just under 2% of the population have OCD (NIMH, 2016). In fact, according to the World Health Organization, OCD is one of the highest ranked disorders for disability worldwide for ages 15-44 (WHO, 2001; Kessler, et al, 2012). OCD symptoms can vary in degree, type, frequency, and severity. Unfortunately, the cause of OCD is not well known. It is suggested that OCD is caused by both genetic and environmental factors (Markarian et al, 2010). There are some studies, according to the National Institute of Health (2016), that have identified serotonin issues.
Other studies have linked female hormone fluctuation with OCD (Pinkerton,2010). Still more studies have suggested links between OCD and rheumatic fever that involves the body’s immune response possibly affecting the central nervous system (Murphy, Kurlan, & Leckm
an, 2010). Typically, a person with OCD also has other disorders or co-morbidities such as anxiety, mood disorders or another mental health issues.
It is estimated that OCD affects roughly 2.2 million Americans in any given year (Kessler et al 2012). OCD affects men and women equally, and the prevalence seems to be similar across all races and ethnicities (Grohol, 2015). The median age of onset is 19 (NIMH, 2016). Younger onset seems to be associated with more severe symptoms and higher rates of comorbidities including ADHD, Tic disorder, and anxiety disorders (Mancebo, et al, 2014).
OCD has a significant effect on daily activities including work, school, and personal relationships (Markarian, et al, 2010). Patients typically report issues with their family life leisure activities and friendships. They may also avoid social situations recognizing the increased anxiety. Carrying out the compulsive acts is extremely time-consuming and interferes with other normal activities. Some studies have linked severity of OCD to a decreased quality of life (NIMH, 2016).
Symptoms of OCD
The first thing to note is that OCD tends to come and go. Although OCD was previously considered an anxiety disorder, it is now classified in the DSM-5 as a disorder on its own, separate from anxiety (APA,2013). OCD involves obsessions and or compulsions that cause anxiety and interfere with functioning. Typically, the person has obsessive thoughts that are only relieved by specific actions or compulsions. People with OCD are generally aware of their obsession and compulsions occurring and that they are unreasonable, which causes more anxiety. Think of this as the brain not able to turn off.
According to the DSM 5, OCD has four criteria (APA, 2013). First is the presence of either obsessions or compulsions. Obsessions are re-current persistent thoughts, urges, or images that are intrusive and unwanted and cause distress to the individual (Nichols, 2015). The person tries to ignore or suppress the obsessions or stop them with specific actions.
The second criteria are the compulsions which are repetitive behaviors that the person feels driven to do in response to the obsessive thoughts. The person believes these rules are very strict and must be done to alleviate the thoughts (Nichols, 2015). The acts are done to relieve or reduce anxiety or prevent a bad situation from happening. However, the acts are not a realistic way to stop the anxiety. Third, the obsessions and compulsions must interfere with daily life to be considered a diagnosis (APA, 2013). Finally, the acts must take up more than an hour per day and interfere with functioning (APA, 2013).
Some common themes for obsessions include germs, dirt, contracting a disease, making a mistake, religion, causing harm to others or sexual in nature (Nichols, 2015). Common compulsions include cleaning, washing hands, checking a task, counting, arranging objects, making lists, or repeating words or phrases (Nichols, 2015). Patients may have multiple thoughts and multiple compulsions usually fitting into one theme.
An example is:
Theme: Germs
Obsession: Not wanting to be touched due to fear of getting sick from germs.
Compulsion: Excessive handwashing especially when touching things. May have to wash hands a certain number of times a day.
Rumination may also be mental compulsion. Ruminations or excessive thoughts also occur in OCD and usually center around past events or self-worth (Darr & Iqbal, 2015). A rumination is simply a train of thought that is undirected and does not lead to a solution. Ruminations typically revolve around religion, philosophy, or metaphysical topics such as death or mortality (OCD-UK, 2015). An example is the person questions what the meaning of religion is. They think about all the theoretical possibilities, philosophies and scientific studies about religion. The person would dwell on this thought for long periods of time. They would appear preoccupied and distracted.
Normal Versus Abnormal; What to report
Although normal routines and rituals are a part of everyday life, for someone who suffers from OCD the rituals and routine does not have a purpose and can be harmful. It is important to assess if the obsessions are aggressive or violent in any way. If the patient has thought to hurt themselves or others or the compulsions are violent acts, the nurse needs to have a full report. Also if the patient begins to describe hopelessness or panic is observed, it is also important to tell the nurse. If the obsession or compulsions will not stop and it appears that the patient is becoming more agitated and unable to control the thoughts and acts, the nurse will need a full report. Be sure to report the content of the thoughts or obsession as well as what acts are carried out. Note if there is a pattern to the compulsions or thoughts (Clark, 2015). Also notice the mood or affect as well as appearance and gestures. Take note of how the client reacts and interacts with patients and staff. Nonverbal body language also speaks to how the person is feeling and if the patient is becoming agitated or not (Clark, 2015). For example, if the patient is stating they are fine but they are pacing and wringing their hands, they are probably becoming agitated. It is important to intervene with the nurse at the beginning stages of agitation to keep the patient and others safe.
If the patient becomes increasingly agitated or violent, including verbalizing aggressive thoughts or actions, make sure you remain calm, speak slowly, softly, and call for help (Hegner, Acello & Caldwell, 2009). Monitor body language of yourself and the patient. For example, do not put your hands on your hips as that may be taken as a challenge. Position yourself at a right angle to the person. Do not stand directly in front of them. Maintain a distance of 3 to 6 feet when possible (Hegnar, Acello & Caldwell, 2009). Avoid sudden movements. And make sure that the exit is accessible. Do not let the person come between you and the door. Listen to what the person is saying so that you can report it to the nurse. Acknowledge that you understand that the patient is upset. Never argue or become defensive.
How to Work with a Patient with OCD
When working with the patient suffers from OCD remember that you are playing an important role in their daily functioning. Supporting the patient by helping them manage anxiety, obsessions, and compulsions is important as well as helping them find solutions to decrease anxiety and triggers. If there are triggers, attempt to identify and remove the triggers in the patient’s environment (Hegner, Acello, & Caldwell, 2009).
First, acknowledge the patient’s anxiety, rituals, and compulsions without judging them. Usually, a patient with OCD has a great deal of shame about their condition. Approached the patient calmly and slowly. Never show shock, or criticism of their behaviors. Let the patient know that you are aware of their anxiety. For example, you might say “I notice that you had to turn the light switch on and off three times today. That must be exhausting.” This will help to establish trust and build a therapeutic relationship (RNspeak, 2012). Also reflecting the client’s feelings can reduce the anxiety the patient feels. If the patient needs to act out their compulsion allow them to do so as long as it is safe. Not allowing the patient to act on their compulsion can cause increased anxiety and even panic. Encouraging the patient to talk about why they have to do the behavior and what it means, can also help them to relieve anxiety (RNspeak, 2012).
You might suggest a diversional activity such as singing or drawing to help move attention away from the unwanted thoughts. If possible, engage the patient in groups to distract them. Planned activities such as groups or other activities that require concentration, can help to relieve anxiety. Also assess the patient’s needs carefully. For example, do they need to rest or do an activity that is less strenuous? Monitor the patient’s eating habits and drinking habits making sure they are hydrated and have the nutrition they need. In addition, make sure they are using the bathroom and are cleaning themselves using a shower or bed bath.
Focus on the patient’s strengths when planning care. Remember that all behaviors have meaning and are meeting the needs of that person; be accepting. Help the patient set limits for themselves suggesting alternate activities or expression of feelings. Remember that the therapeutic relationship and communication is one of the most important interventions to offer. Also, be an attentive and active listener. Identify the patient’s feelings and level of anxiety while they are completing compulsive task or having intrusive thoughts. Report to the nurse any harmful thoughts or the inability to control themselves.
These patients will most likely be on medications to help control their disorder. Be aware of side effects and try to help keep the patient comfortable. Most of the side effects will disappear after a few weeks. The patient may complain of nausea, insomnia, dry mouth, headache, diarrhea or agitation (Kizior & Hodgson, 2015). Make sure the patient is eating well and getting the fluids they need. If agitation is seen, attempt to distract the patient with tasks or an activity that requires concentration. For insomnia, a quiet relaxing environment can help. Also, make sure the patient does not drink caffeine later in the day (Mayo Clinic, 2013). Be sure to tell the nurse of any side effects you notice.
Let’s Review
Obsessive Compulsive disorder is a debilitating disease that impacts the persons daily functioning. Typically the patient exhibits uncontrollable obsessive thought or ruminations about a particular topic. They then try to relieve the thoughts by completing an act or a compulsion. Although the act may or may not temporarily relieve the obsessive thoughts, it is important, as a caregiver, to understand and be patient. The patient is aware of their thoughts and acts and may be shameful or frustrated. Never attempt to stop them from completing the act and never argue with them. Chances are there is a treatment plan in place to limit the compulsive acts or distract the patient. Be sure to follow the treatment plan to help the patent overcome anxiety and symptoms. Be aware of any excessive activity or harmful thought to report to the nurse.
Case Study II
Mr. J has been assigned as your patient today. In the report, you are told he has been acting oddly since being admitted yesterday. You are told he likes to count things and gets agitated when he is not allowed to finish counting. As you walk into the room to introduce yourself, you notice he has his finger in the air moving it as though he is counting something. You stay in the door for a minute then walk toward him smiling. “Hello, Mr. J” you say watching him closely. When he does not respond, you begin to observe that he has not washed recently, and his gown is stained. You assume that his bed sheets also have not been changed, as they are wrinkled and dirty. Mr. J still does not respond to you. You also notice that his tray of eggs and juice are untouched. “Mr. J,” you try again, “I am your nursing assistant today, Jenny. Can I get you something else for breakfast?” Mr. J stops what he is doing and turns to you. Angrily he yells, “No, get out now! Get out!” Mr. J picks up the cup of juice and throws it at you. What do you do?
First assess the environment and make sure that Mr. J is safe and not a danger to himself. Make a mental note of his appearance, his actions and how he reacted to you. Next, find the nurse and report your observations. “Should I have allowed Mr. J to continue counting? What if it took all day?” you ask the nurse. The nurse tells you that Mr. J suffers from Obsessive Compulsive Disorder. She tells you that patience and communication are very important when working with Mr. J. Along with the nurse, you come up with a plan of care for Mr. J.
The first plan is to try some distraction. Upon your suggestion that Mr. J needs to wash and get on some clean clothes, the nurse suggests that you try giving Mr. J a washcloth if he will not move into the bathroom. Ask him to wash his face with five strokes, his arms and legs with five strokes each. Since he threw something, it might be a good idea to keep the tub of water away from him. You can rinse the washcloth when needed. Since Mr. J likes to count, see if he will go to the common room where there are puzzle pieces for him to count. He may want to count the steps to the common room, and that is ok. Perhaps if he will calm down, he can attend a group today where he can concentrate on something else. Once he is settled in the common room, you can attend to his bedding.
You feel that this is a good plan and start working with Mr. J, remembering what the nurse told you about being patient with him. You understand his disorder better after talking more with the nurse, and feel you can work with Mr. J to get him to the common room where he calmed down and participated in the groups.
References
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