Download 2- obsessive compulsive disorders DSM 5

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Obsessive-Compulsive & Related
Disorders (DSM 5)
Obsessive – compulsive disorder
Body dysmorphic disorder
Hoarding disorder
Trichotillomania (hair pulling) disorder
Excoriation (skin picking) disorder
Obsessive-Compulsive Disorder
Obsessive Compulsive disorder
Either obsession or compulsion or both and as defined
• The preoccupation with recurrent and persistent
thoughts , urges or images that are experienced- at
some time during the disturbance- as being
intrusive, senseless and unwanted and cause
marked anxiety (obsession).
– Not excessive worry about daily life problems.
• The individual tries to cope with it by ignoring or
suppressing such thoughts, urges or images or try to
neutralize them with some other thought or action
(i.e., performing a compulsion)
• The person recognizes that the thoughts and images
are of ones own mind not imposed on him.
– Compulsion
• Repetitive behavior (e.g., hand washing,
ordering things …etc) or mental acts (e.g.,
praying, counting, repeating words silently) that
the individual feels driven to perform as a
response to an obsession or according to rules
that must be followed rigidly.
• The behaviors or mental acts are aimed at
preventing or reducing anxiety or distress or
preventing some dreaded event or situation;
however, these behaviors or mental acts are
not connected in a realistic way with what they
are designed to neutralized or prevent or are
clearly excessive
• The obsessions or compulsion are time
consuming (take more than 1 hour per day) or
cause clinically significant distress or impairment
in social, occupational or other important areas
of functioning
• The OCD symptoms are not attributable to the
physiological effects of a substance (drug abuse
or medication) or another medical disorder
• The disturbance is not explained by symptoms of
another mental disorder
Specification of OCD
• Specify be:
– With good or fair insight: obsessive beliefs
not true
– With poor insight: obsessive belief probably
– With absent insight/ delusional beliefs:
be;iefs & compulsions really true
• Specify by:
– Tic-related: person has currently or past tic
Checking …………………………..63%
Washing ………………….….……50%
Body fears………................... 36%
Insisting on symmetry……….. 31%
aggressive behaviors ………..28%
Body Dysmorphic Disorder
Body Dysmorphic Disorder
• A. Preoccupation with one or more perceived
deficits or flaws in physical appearance that are
not observable or appear slight to others
• B. At some point the course of the disorder, the
individual has performed repetitive behaviors
(mirror checking, excessive grooming, skin
picking, reassurance seeking) or mental acts
(comparing his or her appearance with that of
others) in response to the appearance
Body Dysmorphic Disorder
• C. The preoccupation causes clinically
significant distress of impairment in social,
occupational or other important functioning
• D. The appearance preoccupation is not
explained by concerns of body fat or weight in
an individual whose symptoms meeting
diagnostic criteria for an eating disorder
• Mr. Adham a 28 year old cook at a resturent presents
to the ER worried that his chapped hands may have
become infected.
• Mr. Adham has been obsessed with thoughts of
infection and spends several hours each day scrubbing
his hands each time he touches the kitchen tools. He
said “ I am so distressed from these thoughts and it is
making it difficult for me to do my work, I am missing a
lot of days at work and I got fired”. Mr. Adham also
admitted that he is being afraid of leaving the stove on
accidently (obsession) and he checks his stove 29 times
before leaving the house or going to bed (compulsion),
Mr. Adham acknowledges that his behavior is senseless
but is unable to control it
• Physical exam: severely damaged skin with mild
bleeding over both hands.
• Normal tests
Nursing Diagnosis: Ineffective Coping
 Related to:
◦ Biochemical changes (OCD)
◦ Repressed anxiety, unmet dependency needs
(Somatic symptoms disorder)
◦ Severe psychosocial stressors or substance abuse and
repressed severe anxiety (Dissociative disorder)
• Evidenced by:
– Ritualistic behavior, obsessive thoughts (OCD)
– Verbalization of numerous physical complaints, self
centered, presence of physical symptoms with no
path-physiology (Somatic symptoms disorders)
– Sudden travel away from home with inability to
recall previous identity (dissociative disorders)
Ineffective coping (OCD, Dissociative, & somatic
symptoms disorders
• Long Term Goals:
– Client will demonstrate the use of healthy coping
strategies without resorting to previous unhealthy
 Short Term Goals:
◦ Client will decrease participation in ritualistic behavior
by half within 1 week
◦ Client will verbalize understanding of correlation
between physical symptoms or dissociative behavior
& anxiety or stressful psychosocial stress
◦ Client will verbalize more adaptive ways of coping in
stressful situations than resorting to dissociation or
physical complaint or symptoms
Ineffective coping (OCD, Dissociative, & somatic symptoms
• Develop trust relationship through
communicating acceptance, understanding,
respect ….
• Reassure the client for safety & security by
your presence -due to memory loss(dissociative)
• Accept client’s behavior (physical complaint)
& do not deny client’s feelings
• Give space and allow ritualistic behavior of
complaint at the beginning of treatment
without judgment
Ineffective coping (OCD, Dissociative, & somatic
symptoms disorders
• Initially meet the client’s dependency needs
as required, & encourage independence &
give positive rewards for independent
• Identify factors or stressors that precipitate
severe anxiety
• Support client & help him/her to verbalize &
explore meaning & purpose the exhibited
behavior (OCD, dissociative or physical
Ineffective coping (OCD, Dissociative, & somatic
symptoms disorders
 Provide structured schedule to divert from the
unwanted behavior (ritualistic or physical
complaint) – allow some time for ritualistic
behavior then decrease the allocated time for
it gradually Explain that new physical complaint will be
referred to the physician with no further
 Help client to learn ways to interrupt
unhealthy behaviors (ritualistic, complaining
of physical symptoms)
Ineffective coping (OCD, Dissociative, & somatic symptoms
• Discuss possible alternative coping strategies
to use in response to stress – relaxation,
exercise, imagery …• Give positive reinforcement for use of healthy
coping strategies
• Help client identify ways of getting
recognitions from others without resorting to
physical symptoms
• Identify community resources for support to
prevent unhealthy coping behaviors from
Nursing Diagnosis: Ineffective Role Performance
• Related to:
– Need to perform rituals
• Evidenced by:
– Inability to fulfill usual patterns of responsibility
• Long Term Goal
– Client will be able to resume role related
responsibilities by discharge
• Short Term Goal:
– Client will verbalize understanding that rituals
interfere with role performance in order to
decrease anxiety
Nursing Diagnosis: Ineffective Role Performance
 Assess extent of role alteration by exploring
client’s role and other family members’ roles
 Discuss client & family (work) members
perception of the role and determine if it is
 Encourage the client to discuss conflict within
family system (work) in order to produce
change in family system if needed
◦ Identify specific stressors
◦ Identify adaptive or maladaptive responses of both
client & family (work) members
Nursing Diagnosis: Ineffective Role Performance
• Explore available options for changes or
adjustments in role
• Plan & rehearse through role play, of potential
role transition this will help to decrease
• Encourage the participation of family
members who are directly involved in
planning and helping client to work through
the changes
• Give the client positive reinforcement for
ability to resume role responsibilities
Nursing Diagnosis: Disturbed Body Image
• Related to:
– Repressed anxiety
• Evidenced by:
– Preoccupation with imagined or real defect, verbalizations
that are out of proportion to any actual physical
abnormality that may exist, numerous visits to
dermatologists to seek help
• Long Term Goal:
– Client will verbalize perception of own body that is realistic
to actual structure or function by discharge
• Short Term Goal:
– Client will verbalize understanding that changes in bodily
structure or function is exaggerated (specific time)
Nursing Diagnosis: Disturbed Body Image
 Assess client’s perception of his/her body image,
keep in mind that body image is real for the client
 Help client to see that his/her body image is
distorted and exaggerated recognition is
necessary before accepting reality
 Encourage verbalization of fears & anxieties
associated with life situations-verbalization help
the client to come to term with unresolved issues
 Discuss alternative coping strategies
 Involve client in activities that reinforce positive
self image –to develop self satisfaction based on