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Obsessive Compulsive Disorder (OCD): A Quick Overview

Contact Hours: 3

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Contact Hours: 3

This educational activity is credited for 3 contact hours at completion of the activity.

Course Purpose

The purpose of this course is to provide an overview of obsessive compulsive disorder (OCD), including its clinical presentation, etiology, diagnosis, treatment options, and long-term management strategies.

Overview

Obsessive Compulsive Disorder (OCD) is a debilitating chronic mental health condition that cuts across cultures and demographics, affecting an estimated 1.2% of the US population. While remission is possible in adulthood without intervention, individuals with OCD often live with difficulty to the extent that it impairs their daily functioning, relationships, and overall quality of life. This course aims to provide an overview of OCD, including its clinical presentation, etiology, diagnosis, treatment options, and long-term management strategies. It also examines nursing considerations based on the latest study findings and evidence-based practices to provide healthcare professionals with the fundamental knowledge and skills to foster better health outcomes for patients living with this challenging condition.

Course Objectives

Upon completion of this course, the learner will be able to:

  • Define obsessive compulsive disorder (OCD) per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
  • Review the relationship between obsessive compulsive disorder and generalized anxiety disorders (GAD), and other conditions that are associated with obsessive compulsive disorder.
  • Review the causes of obsession and compulsion symptoms, and neuroimaging findings regarding differences in the brain structure and functioning.
  • Review risk factors that may contribute to the development of OCD, including genetic, biological, temperamental, and environmental influences.
  • Distinguish between obsessive compulsive disorder as described by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and differential diagnoses, including anxiety disorders.
  • Understand the available treatment options and long-term management of those afflicted with obsessive compulsive disorder.

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

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Definitions
Adverse Childhood ExperiencesTraumatic events that happen between the ages of 1 and 17.
Anorexia NervosaThe restriction of nutrient intake relative to requirements, which leads to significantly low body weight.
Anterior Cingulate CortexThe front-most portion of the cingulate cortex.
AnxietyA feeling of fear, dread, and uneasiness.
Body Dysmorphic DisorderAlso known as  body dysmorphophobia, causes persistent, intense focus, shame and anxiety over perceived body defects.
Caudate NucleusThe upper of the two gray nuclei of the corpus striatum in the cerebrum of the brain.
Cognitive Behavioral Therapy (CBT)A structured, goal-oriented type of talk therapy. It can help manage mental health conditions and emotional concerns.
Deep Brain Stimulation (DBS)A treatment that involves an implanted device that delivers an electrical current directly to areas of the brain.
DepressionA mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities.
DopamineA type of neurotransmitter and hormone that  acts on areas of the brain to give feelings of pleasure, satisfaction and motivation.
ExcoriationSkin-picking disorder, also known as psychogenic excoriation, dermatillomania or neurotic excoriation, is characterized by the conscious repetitive picking of skin that leads to skin lesions and significant distress or functional impairment.
Exposure And Response Prevention Therapy (ERP)A therapy that encourages one to face fears and let obsessive thoughts occur without ‘putting them right’ or ‘neutralising’ them with compulsions.
Gamma-Aminobutyric Acid (GABA)A chemical messenger in the brain that slows down thebrain by blocking specific signals in the central nervous system.
Generalized Anxiety Disorders (GAD)Is a mental health condition that causes fear, worry and a constant feeling of being overwhelmed.
GlutamateAn excitatory neurotransmitter with several types of receptors found throughout the central nervous system.
Hoarding DisorderOccurs when someone acquires an excessive number of items and stores them in a chaotic manner, usually resulting in unmanageable amounts of clutter.
Humanitarian Device ExemptionThe FDA process of scientific and regulatory review to evaluate the safety and effectiveness of Class III medical devices.
Hypothalamic-Pituitary-Adrenal (HPA) Axis Major neuroendocrine system that controls reactions to stress and regulates many body processes.
Low-Dose Neuroleptics Low-potency, first-generation antipsychotics.
Motor TicsInvoluntary movements caused by spasm-like contractions of muscles, most commonly involving the face, mouth, eyes, head, neck or shoulders. 
Neuroendocrine SystemMade up of special cells called neuroendocrine cells.
NorepinephrineAlso known as noradrenaline, is both a neurotransmitter and a hormone that plays an important role in the body’s “fight-or-flight” response.
Nucleus AccumbensA subcortical brain structure known primarily for its roles in pleasure, reward, and addiction.
Obsessive Compulsive Disorder (OCD)A long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both.
Obsessive-Compulsive Personality DisorderA mental health condition that causes an extensive preoccupation with perfectionism, organization and control. 
Orbitofrontal Cortexprefrontal cortex region in the frontal lobes of the brain which is involved in the cognitive process of decision-making.
PhobiaAn uncontrollable, irrational, and lasting fear of a certain object, situation, or activity.
Polygenic DisorderOccurs when a condition requires multiple genetic factors to manifest.
PutamenThe outer part of the lentiform nucleus of the brain.
Repetitive Transcranial Magnetic Stimulation (rTMS)A form of brain stimulation therapy used to treat depression.  
Schizoaffective DisordersA chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression.
Selective Serotonin Reuptake Inhibitors (SSRIs)A class of antidepressants that help treat depression.
SerotoninA chemical that carries messages between nerve cells in the brain and throughout the body.
StriatumA critical component of the motor and reward systems; receives glutamatergic and dopaminergic inputs from different sources.
Tic DisordersInclude motor, vocal, and Tourette’s syndrome.
Tourette SyndromeA condition that causes a person to make involuntary sounds and movements called tics. 
Traumatic Brain Injury (TBI)Also known as closed head injury or blunt TBI, is caused by an external force strong enough to move the brain within the skull.
TrichotillomaniaAn uncontrollable urge to pull out hair, which can lead to hair loss, bald patches, and feelings of shame, and embarrassment.
Tricyclic Antidepressants (TCAs)A class of medications that help manage the symptoms of clinical depression.
Vocal TicsSounds uttered unintentionally.
Introduction

Obsessive Compulsive Disorder (OCD) is a debilitating chronic mental health condition that cuts across cultures and demographics, affecting an estimated 1.2% of the US population.2 Yet despite its prevalence, OCD is often misdiagnosed or complicated by the co-occurrence of other mental health disorders. Its symptoms typically manifest gradually from adolescence or early adulthood, with the mean age of onset being 19.5 years. However, approximately one-quarter of cases begin as early as age 14. While remission is possible in adulthood without intervention, individuals with OCD often live with difficulty to the extent that it impairs their daily functioning, relationships, and overall quality of life. Over half of those diagnosed with OCD are plagued with suicidal thoughts, with reports indicating suicide attempts in up to 25% of cases. The importance of early OCD diagnosis and intervention cannot be overstated, as timely recognition and treatment are crucial for mitigating the incapacitating effects of OCD and improving long-term outcomes. This course aims to provide an overview of OCD, including its clinical presentation, etiology, diagnosis, treatment options, and long-term management strategies. It also examines nursing considerations based on the latest study findings and evidence-based practices to provide healthcare professionals with the fundamental knowledge and skills to foster better health outcomes for patients living with this challenging condition.

Understanding Generalized Anxiety Disorders

To understand OCD, it is important to acknowledge generalized anxiety disorders (GAD), as there is a close relationship between these mental health conditions and overlapping symptoms.20 Anxiety disorders are a prevalent mental health concern characterized by excessive anxiety and worry about various events or activities. Studies show that 0.9% of adolescents and 2.9% of adults in the US struggle with GAD, with females being two times more likely to be affected than males. 2 Research has also shown that the  prevalence of generalized anxiety disorders peaks in middle age (45 – 60) before declining in later years. Unlike non-pathological anxiety, which is non-excessive, perceived as manageable, and may be put off, GAD is an uncontrollable, prolonged, distressing worry that is noticeably out of proportion to the actual likelihood or effect of the anticipated event.5 Those with GAD are often unable to control their apprehensions, which frequently shift from one concern to another, and typically struggle to focus on daily tasks due to intrusive thoughts. Adults with GAD are seen to worry about life circumstances such as health, job responsibilities, finances, and family matters, while children with GAD show excessive concern about their performance or competence. Physical symptoms of GAD include restlessness, difficulty concentrating, fatigue, muscle tension, irritability, and disturbed sleep.

While the precise cause of generalized anxiety disorders (GAD) remains elusive, several key contributors have been identified through research:5

  • Environmental factors
  • Genetics
  • Neurobiology and brain functioning
  • Psychological factors

Evidence suggests a genetic predisposition to GAD, as individuals with a family history of anxiety disorders are at increased risk of developing the condition. Dysfunction in neurotransmitter systems, particularly those involving serotonin, norepinephrine, and gamma-aminobutyric acid (GABA), has been implicated in the pathophysiology of GAD, and neuroimaging studies have also revealed functional and structural abnormalities in certain brain regions associated with emotion regulation and threat processing.14 Maladaptive cognitive processes, such as excessive rumination, intolerance of uncertainty, and cognitive biases toward threats, have also been shown to perpetuate anxiety symptoms. These cognitive vulnerabilities may interact with environmental stressors such as traumatic life events, chronic stress, and adverse childhood experiences to maintain and exacerbate persistent anxiety. Even without genetic or psychological predisposition, environmental stressors can exacerbate GAD symptoms over time. These factors have been shown to contribute to the development of dysfunctional coping strategies and heighten vulnerability to anxiety disorders.

Definition of Obsessive Compulsive Disorder (OCD)

As described by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), obsessive compulsive disorder is a mental health disorder that presents with obsessions, compulsions, or both that may fluctuate over time and worsen during periods of stress.2 Obsessions are intrusive and unwanted thoughts, urges, or images that cause marked anxiety or distress in an individual. Typically obsessions seen in cases of OCD revolve around specific themes, with the most common being: 2

  • Aggressive thoughts toward others or oneself
  • Doubting and difficulty with uncertainty
  • Fear of contamination
  • Fear of losing control over one’s behavior
  • Fear of losing, forgetting, or misplacing items
  • Forbidden, unwanted, or taboo thoughts involving sex
  • Harm
  • Religion
  • The desire to have things symmetrical or in perfect order

Compulsions are repetitive behaviors or mental acts that individuals feel driven to perform in response to their obsessions. Compulsions in OCD aim to reduce the anxiety of the obsession or prevent the occurrence of ill fate, despite no evidence to justify the correlation between the compulsion and the fearful outcome. However, these compulsions do not bring pleasure or joy. They only offer temporary relief. Examples of compulsions include hand-washing until skin becomes raw due to fear of contamination, repeatedly checking doors to make sure they’re locked, and persistently counting in certain patterns to ensure safety. While adults with OCD may recognize the irrationality of their behaviors, children may not fully understand and may fear dire consequences if they do not perform compulsive rituals.

It is important to note that not all repeated thoughts are obsessions, and not all rituals or habits are compulsions. 2 There is a fine demarcation between OCD and general eccentricities or quirky behaviors. Individuals with OCD struggle to control their obsessions or compulsions and experience physical symptoms similar to anxiety disorders. The constant worry and preoccupation with obsessions, as well as the urge to perform compulsions, can lead to heightened physiological stimulation and stress. This heightened state of activity can manifest as restlessness, muscle tension, irritability, and difficulty concentrating.23 Due to the chronic nature of OCD, the issues may compound and contribute to fatigue and disturbed sleep patterns, further exacerbating physical symptoms. Individuals with OCD also spend significant amounts of time dealing with the demands of the disorder. In severe cases, activities can interfere with daily life, and cause avoidance of situations that may trigger strategies or cause an individual to consider substance use to cope and deterioration of overall functioning. For example, obsessions centered on harm can permeate relationships, causing individuals to perceive interactions with family and friends as hazardous, straining relationships.21 Similarly, obsessions related to symmetry can disrupt academic or professional endeavors, as the individual may struggle to complete tasks to their satisfaction, resulting in academic failure or job loss. Those with contamination obsessions may avoid necessary medical settings due to fears of exposure to germs.

Within the spectrum of OCD, there are several other obsessive-compulsive-related conditions characterized by a fixation on a specific preoccupation, repetitive behaviors or mental acts.2 These disorders include:

  • Body dysmorphic disorder
  • Excoriation (skin-picking) disorder
  • Hoarding disorder
  • Obsessive-compulsive behavior due to another medical condition
  • Substance or medication-induced obsessive-compulsive disorder
  • Trichotillomania (hair-pulling disorder)

Many adults with OCD also have other comorbidities. Reports have revealed that up to 76% have an anxiety disorder, and of those, 63% have depressive or bipolar disorder, with major depressive disorder being the most common among them, affecting 41% of individuals with OCD. An estimated 30% of people with OCD also have a past or current tic disorder characterized by repetitive movements or sounds.23 Motor tics involve sudden, brief, repetitive movements like eye blinking, facial grimacing, shoulder shrugging, and head or shoulder jerking. Vocal tics include repetitive sniffing, throat-clearing, or grunting sounds.10 Tic disorders are most common in males with childhood-onset OCD, and the types of their OCD symptoms tend to differ from those without a history of tic disorders. It is not uncommon for individuals with OCD to have both a diagnosed mood disorder and an anxiety disorder. Despite the prevalence of these coexisting conditions, it is challenging to determine whether OCD is the precursor condition or the effect of other conditions.21

Causes of Obsession and Compulsion Symptoms

The exact causes of OCD are not fully understood, but ongoing research suggests that an amalgamation of genetic, environmental, neurological, and psychological factors may influence its development. 21,23 Numerous family and twin studies have provided compelling evidence for the heritability of OCD, with relatives of individuals with OCD being found to have a higher prevalence of the disorder compared to relatives of unaffected individuals. Specific genetic variations have yet to be identified with OCD, but it is believed OCD is a polygenic disorder where multiple genes contribute to its development.

Neuroimaging studies have isolated differences in the brain structure and functioning of individuals with OCD compared to those without the disorder. 21,23  In particular, abnormalities in the orbitofrontal cortex, anterior cingulate cortex, and striatum have been observed with dysfunction. The orbitofrontal cortex (OFC) is situated in the frontal lobes of the brain, playing a critical role in decision-making, reward processing, and behavioral inhibition. Abnormalities in this area may contribute to difficulties in evaluating the significance of thoughts and behaviors, leading to the persistence of obsessive-compulsive symptoms. The anterior cingulate cortex (ACC) is concerned with cognitive control, error detection, and emotional regulation. Studies have found structural and functional alternation in this area that may contribute to difficulties in regulating emotions and controlling intrusive thoughts and behaviors characteristic of OCD. The striatum is a subcortical structure located deep within the brain and is involved in reward processing, habit formation, and motor control. Abnormalities in the structure and functioning of the striatum, particularly the caudate nucleus and putamen, may contribute to the development of repetitive behaviors and rituals seen in OCD.

Environmental factors, such as trauma, stress, and early childhood experiences, may also contribute to the development of OCD.21,23 Traumatic events, such as neglect, physical or sexual abuse, exposure to violence, or the sudden loss of a loved one, can strongly impact an individual’s psychological well-being, disrupting the normal development of coping mechanisms. This can lead to lead to maladaptive responses to stress, which may manifest as obsessive-compulsive symptoms. Prolonged exposure to chronic stress can dysregulate the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis, leading to alterations in neurotransmitter levels, neuroendocrine function, and immune responses, as seen in OCD. Stressful life events also trigger maladaptive coping strategies, such as engaging in compulsive rituals or avoidance behaviors, to alleviate anxiety and regain a sense of control.

Certain psychological factors, such as personality traits and cognitive biases, may predispose individuals to developing OCD. 21,23 For example, individuals who are perfectionistic, conscientious, prone to anxiety, have an intolerance of uncertainty, or inflated responsibility beliefs may be more susceptible to developing obsessive-compulsive tendencies.2 Individuals with perfectionistic tendencies often set excessively high standards for themselves and others, striving for flawlessness in their thoughts, behaviors, and achievements. The unyielding pursuit of perfection can lead to obsessive concerns about making mistakes or failing to meet unrealistic expectations, fueling compulsive behaviors aimed at attaining perfection and preventing perceived errors. High levels of conscientiousness, characterized by organization, orderliness, and attention to detail, may predispose individuals to developing OCD symptoms, particularly those related to symmetry, precision, and control. The need for structure and predictability can drive compulsive rituals to maintain order and reduce uncertainty. Intolerance of uncertainty fuels obsessive concerns about potential risks, dangers, or negative outcomes and can lead to compulsive rituals aimed at neutralizing uncertainty and restoring a sense of security. These inflated responsibility beliefs compel individuals to engage in compulsive behaviors aimed at averting perceived threats or mitigating the consequences of imagined disasters. The overestimation of personal responsibility perpetuates the cycle of obsessions and compulsions, reinforcing maladaptive coping strategies.

Risk Factors

Several risk factors contribute to the development of OCD, spanning genetic, biological, temperamental, and environmental influences.23 Understanding the risk factors can help healthcare professionals identify individuals at higher risk for developing OCD and implement early intervention strategies to mitigate symptoms and improve outcomes. However, it is essential to recognize that not everyone with risk factors will develop OCD, as the disorder likely arises from a combination of multiple factors interacting with each other. Genetic predisposition plays a considerable role. Studies have consistently shown that individuals with a first-degree relative (parent or sibling) diagnosed with OCD are at a higher risk of developing the disorder themselves. This suggests a strong genetic component in OCD susceptibility. However, researchers have yet to identify the precise genes associated with OCD. Certain biological factors have been implicated in OCD. Noted variations in brain structures and dysfunctional neural circuits, and imbalances in neurotransmitters, such as serotonin and dopamine, may also increase the risk. Congenital defects in the brain, lesions of the brain, or a history of traumatic brain injury, especially in areas implicated in OCD, can increase the risk of developing the disorder.

Individuals with certain temperamental traits may be more predisposed to developing OCD. For example, individuals who exhibit reserved behaviors, perfectionism, or negative emotions from an early age may be at a higher risk. Childhood temperament characterized by high levels of anxiety or inhibition can also contribute to the development of OCD later in life. Individuals with comorbid mental health conditions, such as mood disorders such as depression, anxiety disorders, or tic disorders such as Tourette syndrome, are more likely to develop OCD. Environmental factors can also influence the onset or exacerbation of OCD symptoms. Childhood trauma, such as physical or emotional abuse, neglect, or significant life stressors, can increase the risk of developing OCD later in life. Major life transitions, such as moving to a new place, starting a new job, or experiencing relationship difficulties, can also precipitate the onset of OCD symptoms or exacerbate existing ones.

Diagnosis

Diagnosing OCD involves assessing the presence of obsessions, compulsions, or both, along with five specific criteria outlined in DSM-5:2

  • Compulsions aim to reduce anxiety, distress, or harm, but are not realistically connected to neutralizing or preventing the feared event.
  • Obsessions and compulsions are time-consuming, with individuals spending significant amounts of time each day engaging in behaviors.
  • Obsessions are intrusive, unwanted, and cause distress, leading individuals to attempt to ignore or suppress them through compulsions.
  • Symptoms are not attributable to the physiological effects of a drug, medication, other substance.
  • Symptoms are not better explained by another medical condition or mental disorder such as schizophrenia or autism.

Diagnoses in young children are typically more focused on compulsions rather than obsessions, as compulsions are observable, and children may have difficulty articulating their thoughts. Also, the pattern of symptoms is more variable in children, most likely reflecting their developmental stage. For example, higher rates of sexual and religious obsessions are seen in adolescents than in children. In comparison, higher rates of harm obsessions, such as fears of catastrophic events, such as death or illness to self or loved ones, are seen more in children and adolescents than in adults.

Another crucial aspect of diagnosing OCD involves assessing the individual’s self-awareness regarding their obsessive-compulsive behaviors and the dysfunctional beliefs that underlie them.2  This insight varies from good or fair insight, to poor insight, to absent insight. A majority of individuals with OCD have good or fair insight, which means they acknowledge their rituals may not be rational but still feel compelled to perform them. For instance, they may believe that their house will not burn down, but they are still compelled to check the oven 30 times. Those with poor insight believe strongly in the necessity of their rituals despite evidence to the contrary. For instance, they may believe the house will probably burn down if the oven is not checked 30 times. Less than 4% of cases show an absence of insight, holding delusional beliefs that their actions directly prevent catastrophic events. As insight can fluctuate over the course of the illness, it is critical to evaluate this aspect of the condition to determine its severity and guide treatment interventions.

Differential Diagnosis

Differential diagnosis is a crucial aspect of accurately identifying OCD and distinguishing it from other mental health conditions that may present with similar symptoms.2 Several disorders commonly considered in the differential diagnosis of OCD include anxiety disorders: 2  

  • Eating disorders
  • Major depressive disorder
  • Obsessive-compulsive personality disorder
  • Other compulsive-like behaviors
  • Psychotic disorders
  • Tics and stereotyped movements

Anxiety disorders present with recurrent thoughts, repetitive requests for reassurance, and avoidant behaviors.5 However, these manifestations are usually about real-life concerns without compulsions, whereas OCD obsessions are more irrational, including content that is odd in nature. Compulsions are also linked with these obsessions. Similarly, individuals with a specific phobia can have an irrational reaction to certain objects or situations, but this fear is much more bound, as opposed to worrying about it consistently, even in its absence.25 For example, in a social phobia, the fear is limited to periods of social interaction. In the case of major depressive disorder, the focus is primarily on mood and feelings as opposed to intrusive or distressing external stimuli, as seen in OCD.12 Also, these thoughts are not linked to specific compulsions. Obsessive compulsive disorder can be differentiated from eating disorders such as anorexia nervosa, as OCD is not limited to worries regarding food and weight.17

Tics and stereotyped movements are typically less complex than OCD compulsions and are not aimed at neutralizing obsessions.8 In most patients, a tic is a sudden, recurrent, rapid, non-rhythmic motor movement or vocalization such as eye blinking. In contrast, a stereotyped movement is a seemingly driven, repetitive, nonfunctional motor behavior such as body rocking. However, if these actions are more complex, they can be difficult to distinguish from compulsions. In such cases, it is important to consider the preceding factor. Tics are often preceded by premonitory sensory urges, whereas compulsions are usually preceded by obsessions.

Psychotic disorders like delusional disorders present with irrational beliefs similar to those seen in cases of OCD with poor insight.15 Psychotic disorders are without obsessions and compulsions. Schizoaffective disorders are characterized by symptoms such as hallucinations or formal thought disorder, which are not present in OCD. Certain behaviors are described as ”compulsive,” such as compulsive sexual behavior, gambling disorder, and substance abuse disorders, but they differ from the OCD compulsions such that pleasure is derived, and resistance is only due to its harmful consequences. Although obsessive-compulsive personality disorder and OCD have similar names, the clinical manifestations of these conditions are quite different. Obsessive-compulsive personality disorder does not feature invasive thoughts, images, urges or repetitive behaviors in response to these intrusions. Rather, it involves a pervasive and enduring maladaptive pattern of rigid control and excessive perfectionism.

Treatment Options

Treatment for OCD is available for individuals across a spectrum of severity, offering hope and relief from the debilitating symptoms associated with the disorder.21,23 While OCD cannot be cured, interventions such as psychotherapy, brain stimulation, medications, or a combination thereof can significantly alleviate distress and improve overall functioning and quality of life.

Psychotherapy

Specific forms of psychotherapy shown to be as effective for OCD includes cognitive behavioral therapy (CBT) and exposure and response prevention therapy (ERP). Cognitive behavioral therapy (CBT) is overwhelmingly regarded as the “gold standard” of treatment and is widely used to treat adults and children with varying severities of OCD.22 Using a structured approach to address both the cognitive (thought) and behavioral aspects of the disorder, CBT helps individuals identify and challenge their irrational thoughts. Through a practice called cognitive restructuring, individuals learn to recognize when their thoughts are unrealistic or exaggerated. They then work to replace those thoughts with more realistic and balanced perspectives. For example, someone with contamination obsessions may learn to challenge the belief that touching a doorknob will lead to serious illness by examining evidence to the contrary, recognizing that most doorknobs are not contaminated with harmful germs. Cognitive behavioral therapy also equips individuals with practical coping strategies to manage their obsessive thoughts without resorting to compulsive behaviors. These strategies include “thought stopping” to interrupt and redirect obsessive thought patterns, such as mentally saying “stop” or switching attention to a different activity, response prevention that teaches individuals they can tolerate the discomfort of obsessions without resorting to rituals, which may lead to decreased anxiety and improved functioning, and behavioral experimentation that encourages individuals to test the accuracy of their beliefs by exposing oneself to feared situations or triggers and observing the outcome without engaging in compulsive activities.

Exposure and response prevention therapy (ERP) is a specialized form of cognitive behavioral therapy that has proven to be highly effective, particularly for individuals who do not respond well to medication alone.In ERP, individuals are gradually exposed to situations or stimuli that trigger their obsessive thoughts or anxiety while simultaneously being prevented from engaging in their usual compulsive behaviors. For example, for an individual with contamination obsessions and fears of touching dirty objects, ERP systematically exposes them to touching such objects in a safe environment. It also prevents them from immediately washing their hands. Through repeated exposure to these feared stimuli, individuals gradually learn that their feared consequences do not materialize, thus leading to a reduction in anxiety over time. While initially, ERP may induce significant anxiety, especially during the exposure phase, research has consistently shown that compulsions tend to diminish as individuals persist with treatment. This process of systematic desensitization allows individuals to gain mastery over their OCD symptoms and regain control over their lives.

Brain Stimulation

Two forms of brain stimulation are used to treat OCD: 1

  • Repetitive transcranial magnetic stimulation
  • Deep brain stimulation

Repetitive transcranial magnetic stimulation (rTMS) is an innovative non-invasive procedure that involves the application of repetitive magnetic pulses to precise sections of the brain, aiming to normalize irregular brain functioning.1 Initially developed as a treatment for depression, rTMS gained food and drug administration (FDA) approval in 2018 for severe cases of OCD that have not responded well to other therapies. In these cases, rTMS targets brain areas implicated in obsessive-compulsive behaviors, such as the prefrontal cortex. By stimulating these brain regions, rTMS aims to modulate the neural circuits associated with OCD symptoms. While rTMS can be used as a standalone treatment, it is often integrated into a comprehensive treatment plan that includes medication and psychotherapy. By combining these approaches, clinicians can optimize outcomes and reduce OCD symptoms more effectively.

Deep brain stimulation (DBS) is a surgical procedure used to treat severe, treatment-resistant.11 It involves the implantation of electrodes into specific brain regions implicated in obsessions and compulsions, such as the anterior limb of the internal capsule or the nucleus accumbens. The electrodes deliver multiple electrical impulses aimed at modulating neural activity by interrupting dysfunctional neural circuits associated with OCD symptoms. While DBS has been FDA-approved for certain neurological disorders like Parkinson’s disease, its effectiveness for OCD is still undergoing active research.19 Under a Humanitarian Device Exemption, the FDA has granted approval for DBS to treat individuals with severe, treatment-resistant OCD who have exhausted other therapeutic options.6 However, it is important to note that DBS is a complex and invasive procedure with potential risks. Due to the limited number of select OCD cases suitable for DBS treatment, gathering enough evidence to establish its effectiveness remains challenging. Nevertheless, ongoing research continues to explore the potential benefits and risks of DBS in managing severe OCD symptoms, offering hope for those who have not responded to other treatments.

Medication

Medications used to manage obsessive-compulsive behaviors include selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs), both antidepressants.23 Serotonin reuptake inhibitors such as fluoxetine, sertraline and fluvoxamine, are considered the first-line treatment for OCD.16 These drugs increase the levels of serotonin, a neurotransmitter that is known to play a role in regulating mood, anxiety, and other mental processes. By enhancing serotonin levels, SSRIs can reduce the stress associated with OCD and diminish the invasive nature of obsessions. Tricyclic antidepressants are typically used in cases where SSRIs are ineffective or not tolerated. Examples of TCAs used to treat OCD include clomipramine and imipramine. Similar to SSRIs, TCAs increase levels of serotonin and norepinephrine, other neurotransmitters that regulate cognitive function, attention, and stress reactions. It is important to note that antidepressant treatment may take up to 12 weeks before OCD symptoms begin to improve, and maximum benefit may take as long as six months.

Approximately 60% of individuals with OCD see some improvement with antidepressant medications on their first try, while 20% do not see any improvement.16 However, less than 20% treated with medication alone will have a complete remission of obsessive-compulsive behaviors. Reports have indicated that these medications work best in combination with psychotherapy for substantial improvement. Selective serotonin reuptake inhibitors are generally well tolerated by most individuals, but given antidepressant doses for OCD are higher than those typically used for depression, side effects of the medications may be more prevalent. These side effects include nervousness, headaches, insomnia, restlessness, dizziness, nausea, and diarrhea. Usually, these effects decrease as the body becomes accustomed to the medication, which may take several weeks. Other medications that may benefit individuals with OCD include low-dose neuroleptics (antipsychotics), especially in OCD patients with a history of tic disorders, and glutamate modulators such as memantine, ketamine, and glycine. Glutamate modulators can aid in regulating glutamate, another neurotransmitter recent evidence suggests may also contribute to OCD behaviors. However, further investigation is necessary to determine the effectiveness of these experimental pharmacological agents.

Long-Term Management

Once OCD behaviors are eliminated or considerably reduced following an initial course of medication and psychotherapy, long-term management focuses on maintenance treatment to keep the gains achieved during active treatment, and prevent relapse.4 This is especially important because OCD is a chronic disorder, and relapse is common. Healthcare providers recommend monthly follow-up visits for at least the first six months after completing a successful course of treatment. The follow-up care should continue for at least one year before considering the discontinuation of medications or psychotherapy. Regular monitoring is critical for tracking symptom severity, insight, and functional impairment over time, allowing for timely intervention if symptoms worsen or relapse occurs. For a majority of individuals, continued psychotherapy is beneficial, though the frequency of sessions depends on the individual’s progress, stability, and ongoing need for support. Whether individualized or in a group setting, maintaining psychotherapy sessions can help individuals maintain the skills learned during active treatment, reinforce adaptive coping strategies, and address any residual symptoms or triggers.

Long-term management also involves healthcare providers adjusting medication dosages or changing medications based on individual response and tolerability.18 In some cases, individuals may experience noteworthy improvement in symptoms or achieve stable remission while on medication. In such instances, healthcare providers may consider gradually discontinuing medication. The general protocol for medication discontinuation involves reducing dosages by 25% at a time, with waiting periods of two months to monitor responses before further adjustments. A gradual approach helps minimize the risk of relapse and allows healthcare providers to closely monitor individuals for signs of symptom recurrence. However, for individuals who experience repeated episodes of OCD, such as 2 to 4 severe relapses or 3 to 4 milder relapses, long-term or even lifelong medication management may be necessary to prevent symptom exacerbation and maintain stability.

Adopting a healthy lifestyle can expressively contribute to long-term well-being.7 Regular exercise has been shown to reduce symptoms of anxiety and depression, which often coexists with OCD. Adequate sleep is vital for overall mental health, as sleep disturbances can exacerbate symptoms of OCD. Stress management practices such as deep breathing, mindfulness meditation, and relaxation exercises can help individuals cope with the anxiety and distress associated with OCD. Maintaining a balanced diet rich in nutrients also supports brain function and overall well-being. Engaging in meaningful activities, hobbies, and social connections can also play a vital role in managing OCD symptoms. Participating in deeds that bring joy and fulfillment can provide a sense of purpose and accomplishment, thereby reducing obsessive thoughts and compulsive behaviors. Social support from friends, family, or support groups can offer emotional support, encouragement, and understanding, which are invaluable in navigating the challenges of living with OCD. Distracting oneself from obsessive thoughts through enjoyable activities and interactions can help break the cycle of rumination and alleviate distress.

Family involvement plays a crucial role in the long-term management of OCD in children.21,23 Parents and caregivers should be actively engaged in a child’s treatment, participating in therapy sessions, implementing behavioral interventions at home, ensuring medication regimens are followed, and providing emotional support. Encouraging children to maintain a healthy lifestyle can support their overall well-being and help manage OCD symptoms. This includes promoting regular exercise, adequate sleep, nutritious eating habits, and stress-reduction techniques. Collaborating with school personnel is important to create a supportive environment for children. School accommodations, such as modified assignments, extra time for tasks, and access to support services can help children manage their symptoms effectively while participating in school activities. A child’s needs and experiences with OCD are known to change frequently over time, requiring flexibility and adaptation in their treatment approach. Healthcare providers should regularly reassess the child’s progress and modify treatment strategies accordingly to ensure continued symptom management and overall well-being.

Nursing Considerations

When treating or interacting with patients diagnosed with OCD, nurses play a crucial role in their management. For all patients diagnosed with OCD, holistic assessment is essential for comprehensive care. Nurses should consider various aspects of the patient’s physical, psychological, social, and environmental well-being to develop an effective treatment plan and provide appropriate support.13 Nurses should assess the patient’s physical health, including any medical conditions or medications that may impact OCD symptoms or treatment. During the physical assessment, nurses should assess the severity and nature of the patient’s OCD symptoms, including obsessions, compulsions, and related distress. They should also evaluate the patient’s insight into their condition, as well as any coexisting mental health issues such as anxiety, depression, or other disorders that may require attention. Exploring the patient’s social support system, including relationships with family, friends, caregivers, and living environment, can further help identify any stressors or triggers that may exacerbate OCD symptoms. Nurses should evaluate how OCD symptoms affect the patient’s ability to perform activities of daily living, work, study, and their ability to engage in social interactions. Understanding the functional impairment caused by OCD can guide treatment planning and goal-setting.

Cultural considerations must also be taken into account. Cultural beliefs, values, and practices may influence the patient’s experience of OCD and their attitudes, which in turn, can affect help-seeking behaviors, treatment preferences, and adherence to interventions. All assessments must be documented accurately. During interactions, nurses should always aim to establish a therapeutic relationship. Nurses should demonstrate empathy and understanding towards the patient’s struggles with OCD.21,23 This involves actively listening to their concerns, acknowledging their feelings, and validating their experiences. Maintaining a non-judgmental attitude towards OCD symptoms and behaviors is paramount. Patients may feel ashamed or embarrassed about their obsessions and compulsions, and criticisms or stigmatisms can exacerbate their symptoms. Nurses should offer reassurance and support, emphasizing that OCD is a health condition and seeking help is a sign of strength. By showing empathy, nurses can create a safe and non-judgmental environment where patients feel comfortable discussing their symptoms and seeking help.

Nurses should provide comprehensive education to both the patient and their family members about OCD.13 This includes explaining the symptoms of OCD, such as intrusive thoughts (obsessions) and repetitive behaviors (compulsions), and how these symptoms can impact daily functioning and quality of life. Patients and families should be informed about the potential causes and risk factors associated with OCD. This may include genetic predispositions, neurobiological factors, environmental influences, and psychological factors. Understanding the risk factors can help patients and families make sense of the condition and reduce feelings of shame or guilt. Various treatment options available for OCD, including medication, therapy, and other interventions, also need to be discussed in detail. Patients should be informed about the role of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and other medications in managing OCD symptoms. Additionally, the benefits of psychotherapy, such as cognitive-behavioural therapy (CBT) and exposure and response prevention (ERP), should be explained. 

During the treatment course, nurses actively participate in administering prescribed medications for OCD.24 They must closely monitor patients for any adverse or side effects of medications to ensure patient safety and well-being. To optimize outcomes, patients and families must be educated on the importance of treatment adherence, which is crucial. Nurses should emphasize the benefits of sticking to the prescribed treatment plan and address patients’ concerns or misconceptions regarding medications or therapies. Nurses are pivotal in providing crisis intervention and support during periods of heightened anxiety or distress for patients with OCD. Using de-escalation techniques, nurses help patients cope with OCD-related symptoms and prevent self-harm or harm to others. They create a calming environment and offer reassurance while implementing strategies to manage acute distress effectively. Continuous monitoring of the patient’s progress and response to treatment is also essential. Nurses should regularly assess the effectiveness of interventions and adjust the care plan as needed to optimize outcomes. Accurate documentation of observations, interventions, and outcomes in the patient’s medical record ensures continuity of care and facilitates communication among healthcare team members.

Conclusion

Obsessive compulsive disorder (OCD) is a complex mental health condition influenced by a myriad of factors, including genetic predispositions, biological vulnerabilities, temperamental traits, and environmental stressors. It severely affects individuals across various demographics and often complicates their daily lives, deteriorating their quality of life. Accurate diagnosis and differential diagnosis are essential for effective treatment planning, as OCD frequently presents with overlapping symptoms with other mental health disorders. While OCD is not curable, there are various treatment options available, including psychotherapy, brain stimulation, and medication, either alone or in combination, to alleviate distress and improve overall functioning.

Long-term management of OCD involves maintenance treatment to sustain gains achieved during active treatment and prevent symptom recurrence. Healthcare providers must closely monitor patients, adjust treatment plans as needed, and support patients in adopting healthy lifestyle practices to optimize long-term well-being. Nurses play a central role in managing OCD by conducting holistic assessments, providing education and support, administering medications, implementing crisis intervention, and collaborating with multidisciplinary teams to ensure comprehensive care. By employing a multidimensional approach that addresses the biological, psychological, social, and environmental aspects of OCD, healthcare professionals can empower individuals with OCD to manage their symptoms effectively, achieve greater stability, and enhance their overall quality of life.

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