Obsessive compulsive disorder

AORN Journal, August, 2007 by Nancy R. Cyr

Have you ever left home and immediately wondered, "Did I lock the door?" or "Did I unplug the coffee pot?" Have you ever turned around to go back home and check on these items? These kinds of events periodically happen to all of us. Consider, however, a person who cannot stop checking the door locks or who must check every lock in the house in a certain order for a prescribed number of times and who must start the process over again if he or she is interrupted. Or consider a person who cannot leave home because of a complex routine of handwashing or cleaning in response to fear of germs or disease. These kinds of routines or rituals often are components of obsessive compulsive disorder (OCD), which can remain undetected and untreated for many years.(1) Perioperative nurses can play an important role in recognizing symptoms of this disorder and can refer patients affected with OCD for appropriate treatment.

The Diagnostic and Statistical Manual of Mental Disorders defines obsessions as

   recurrent and persistent thoughts, impulses,
   or images that are experienced as
   intrusive and inappropriate and that
   cause marked anxiety or distress; not
   simply excessive worries about real life
   problems. The person attempts to ignore
   or suppress the obsessions, or to neutralize
   them with other thoughts or actions;
   the obsessions are recognized as a
   product of his/her own mind. (2(P422423))

Compulsions are defined as

   repetitive behaviors (for example, hand washing, ordering,
   checking) or mental acts (for example, praying, counting, repeating
   words silently) that the person feels driven to perform in response
   to an obsession or according to rules that must be applied
   rigidly.(2(p423))

Obsessive compulsive disorder is a very common mental disorder, exceeded in occurrence only by depression. It affects 1% to 3% of the population and may be correlated to other anxiety disorders such as Tourette's syndrome; trichotillomania (ie, hair loss caused by compulsive pulling and/or twisting); or tic disorders. (1,3,4) The word obsession comes from a Latin word meaning besieged--a feeling very often reported by those with this disorder. (5) The obsessions most frequently center around a fear of germs or contamination and the resultant development of a disease or a fear that something awful is about to happen. (5) The nature of these kinds of obsessional thoughts causes individuals to perform certain acts or rituals (eg, handwashing to relieve the anxiety associated with the thoughts of contamination or disease). These compulsive acts, however, provide only short-term relief, necessitating continued compulsive acts. Some examples of compulsive acts or rituals might include hoarding items or food, washing, silently praying, straightening, or silently counting or repeating specific words or phrases. (5)

Individual experiences with OCD are quite different, so stereotyping of symptoms should be avoided. For instance, one woman may fear contracting a disease after touching something and use eight rolls of paper towels to clean her hands. Another person may count backwards from 100 to one to avoid the urge to shout obscenities, while another may feel that he needs to check the knobs on the oven seven times before leaving the room, repeating the ritual if it is not completed accurately. Conversely, some people feel they need to get dressed in exactly the same order each day and have to start over if they are interrupted or when they make a "mistake." Commonly, these people recognize that their actions are unreasonable and irrational; however, they are driven to continue performing them in order to manage their anxiety. (5)

An individual's underlying anxiety usually is caused by an unresolved emotional conflict, which typically is unconscious (ie, the person is unaware of the underlying emotional issue). The obsessions and compulsions, however, can become all consuming, reducing a person's existence to repeated rituals such as handwashing or checking door locks to the point that the person cannot leave home or function adequately. On the surface, these people may appear to lead orderly lives. The hidden disorder, however, causes them shame and embarrassment, often about the content of their obsessions or their inability to function as a result of the time taken to perform the compulsive acts. (1)

Unfortunately, this disorder is not easily diagnosed. Often it requires several visits to a physician over a period of many years to find answers before it is diagnosed accurately. (1) One reason for the low diagnosis rate lies in the hesitancy of people to discuss their symptoms with anyone, especially health care providers. There also is a lack of recognition of these symptoms by health care providers. People suffering from OCD can be so severely affected by this condition that it impairs their functional ability and quality of life. (1)

ETIOLOGY

Almost half of the people suffering from OCD begin experiencing their behaviors before the age of 15, and OCD is more common in boys at this age. (5) The incidence of OCD in adults is equally distributed between males and females. (5) Researchers have found that OCD often is accompanied by major depression or other anxiety disorders, and there appears to be a genetic component to it, with approximately 20% of close relatives experiencing symptoms of OCD. In identical twins, when one twin has been diagnosed with OCD, 50% to 80% of the time the other twin also suffers from the disorder. (6) A recently published study further suggests that brain abnormalities may be a contributing factor to OCD. (7)