Obsessive Compulsive Disorder, Nursing Considerations, and Treatment - Research Paper Example

 Obsessive Compulsive Disorder in Adolescents Introduction Obsessive Compulsive Disorder or OCD is one of the chronic mental illnesses and is gaining recognition in recent times (Brasic, 2012). The disease causes severe mental exhaustion and distress. The individual typically has some obsessions and compulsions which are recurrent and persistent. They occur in a significant manner. They are inappropriate and also intrusive. The thoughts, images and impulses of the individual lead to actions. These cause so much distress in the individual that it impairs social functioning. OCD can occur in any age group. In majority of the cases, OCD develops in young adulthood or even adolescence, but the patient may seek help at an older age. Infact, it has been estimated that 1 in 200 children and adolescents suffer from OCD (AACAP, 2011). Traditionally, this condition was neglected, especially in children and adolescents. However, recent recognition of the condition has led to enhanced understanding of various treatment modalities (Piacentini and Bergman, 2000). OCD can be treated in majority cases especially if there is good family and social support. Family members, pediatricians, teachers and school counsellors play a major role in identifying the disorder and referring to child and adolescent psychiatrist for appropriate treatment. In this essay, various aspects of the disorder will be discussed with reference to suitable literature. Description of the disorder OCD is a chronic disorder which is associated with significant impairment in the functioning of the individual and leads to distress (Stum, 2009). The disorder is classified under anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (APA, 2000). The main characteristic features of this disorder are presence of intrusive obsessive thoughts that are distressing with or without compulsive acts that are repetitive (APA, 2000). The acts may be physical or mental and are significant clinically. The DSM-IV-TR criteria for obsessions are as follows (APA, 2000): 1. The person suffers from images, thoughts and impulses that are persistent and also recurrent. These occur in such significant manner as to causing anxiety and distress to the patient. They are intrusive and inappropriate. Some thoughts may not lead to actions, but the thoughts cause lot of disturbance to the patient and the patient may not be able to discuss with other persons. 2. The images, thoughts and impulses are certainly not just about excessive worrying about problems in real life. 3. The persons make a definite attempt to suppress such thoughts images or impulses, but they fail to do so. They also try to neutralize them by other acts or thoughts. 4. The person believes and recognizes that the thoughts, images and impulses are that of oneself only and are not imposed by others. The DSM-IV-TR criteria for compulsions are as follow (APA, 2000): 1. In response to obsession, the individual performs mental acts like counting, muttering words silently or praying, or performs repetitive behaviors like checking and washing hands. Such acts are not effects of some physical illness or substance intake. 2. These mental acts or behaviors are mainly aimed to reduce or prevent distress or prevent the event that the person has dreaded. But, these, in reality do not serve the purpose or are applied in an exaggerated manner. The person itself realizes and recognizes that his or her obsessions/ compulsions are unreasonable or inappropriately excessive (AACAP, 2011). Epidemiology According to the Epidemiological Catchment Area Study, the lifetime prevalence of OCD is estimated to be 2.5 percent (Brasic, 2012). Prevalence is the same in both the sexes (Dell'Osso et al, 2006). However, childhood onset of the disorder is more common among males (Dell'Osso et al, 2006). Pregnancy and premenstrual period can exacerbate the symptoms of OCD in women. The symptoms usually begin in young age, between 10- 24 years (Dell'Osso et al, 2006). Prevalence, anytime during childhood is estimated to be 2-3 per 100 children (Brasic, 2012). There is no race predilection among adults. In children however, OCD is more prevalent among Whites. It is an unfortunate fact that though in more than half cases the onset of the disease is in childhood, it is often unrecognized and treatment is initiated very late (Brasic, 2012). Etiology and pathogenesis The exact etiology and pathogenesis of OCD is not fully understood. Majority of the trials have pointed to abnormalities in the neurotransmission of serotonin and this is supported by the evidence that patients with OCD respond very well to serotonin reuptake inhibitors (Castle and Phillips, 2006). There is also some evidence that dopaminergic transmission pathway abnormalities also can contribute to OCD. Anatomical parts of brain in which pathological changes have been seen are caudate and thalamus, orbitofrontal cortex and limbic structures. There is a trend towards predominance on right side. This information is based on positron emission tomography and magnetic resonance imaging studies on patients with OCD. These studies have revealed increased blood flow and increased metabolism in these regions. Some studies have shown that overactivity in these sites normalize after cognitive behavioral therapy and serotonin-reuptake inhibitors. The hypothesis driven from these findings is that the symptoms of OCD occur because of impairment in the inhibition of certain orbitofrontal-subcortical circuitry within the cortex leading to mediation of strong emotions and also autonomic responses to them. Based on this hypothesis, in severe and resistant cases of OCD a cingulotomy may be performed which causes interruption of the orbitofrontal-subcortical circuit. Another abnormality which merits importance is glutaminergic pathway defects (Castle and Phillips, 2006). There is remote evidence that acute group A streptococcal and herpes simplex infections can contribute to OCD due to CNS autoimmune response. OCD can also occur secondary to substance abuse, head injury and carbon monoxide poisoning. Parenting methods and stress do not cause OCD. OCD can run in families (AACAP, 2011). Studies on twins have revealed that OCD has a strong heritability factor. The genes which are affected are related to dopaminergic, serotonergic and glutaminergic pathway (Brasic, 2012). Symptoms Obsessive thoughts change over time in children and adolescents. For example, a younger child may have thoughts related to harm and an older child may have obsessions of contamination (AACAP, 2011). Adolescents and children frequently feel ashamed and also get embarrassed about their problem, although they might not realize that they have a disorder and need to seek medical help. It is very important for parents to establish good communication with their children to understand the problem and seek help as needed. Parental support is utmost important in the management of OCD in adolescents. It is worth seeking help from a pediatric psychiatrist who can understand the concepts of treatment in the age group better (AACAP, 2011). Common obsessions which the individual may present with are safety, contamination of food, hands or items, suspecting perception or memory, scrupulosity especially related to religion, need for symmetry, perfection and order, intrusive and unwanted thoughts of aggression or sexual acts. Some of the common compulsions include frequent cleaning, hand washing, checking stove, locks, plug points and safety of children, arranging objects, hoarding, making lists, touching objects and confession. These symptoms can have profound influence on social and interpersonal relations. The individuals perform poorly in academics despite high intelligence levels (NAMI, 2005). Comorbid conditions are common in OCD. Infact, some studies have reported that 75- 84 percent of children suffering from OCD have comorbid disorders (Freeman et al, 2007). Comorbid conditions in children and adolescents include attention deficit hyperactivity disorder and opposition disorders. Treatment becomes difficult when these comorbid conditions are present (Brasic, 2012). Assessment and diagnosis The diagnosis of OCD is mainly based on clinical presentation and history elaboration. It is very important to ascertain the age of onset and also history of tics, either in the present or in the past. The nature and severity of symptoms must also be evaluated. OCD in children and adolescents affects social development. Even school work and relationship with friends and members of the family are affected (NAMI, 2005). Individuals of this age may not realize that their thoughts and actions are unusual (NAMI, 2005). Some of the common obsessions in children and adolescents include fear of contamination, fear of harm and fixation on certain lucky numbers (NAMI, 2005). Some of the common compulsions in this age group are repeated washing, repeated cleaning, checking locks and counting numbers (NAMI, 2005). Due to embarrassment, the individuals my hide their rituals from others and hence undergo lot of stress and mental exhaustion. They may become so tired that they may not be able to concentrate in school or feel tired to play with friends (NAMI, 2005). Physical examination findings are often normal except for some findings in the skin due to compulsions. Excessive washing can lead to eczemas. Compulsive hair pulling can lead to hair loss and compulsive skin picking can lead to excoriation of the skin (Brasic, 2012). In many situations, physicians fail to make the diagnosis. Patients may come to the doctor for eczema or other skin problems and may not tell about OCD symptoms. Infact, the person may not realize that he or she has a problem which has to be dealt medically. OCD is commonly associated with other comorbid conditions and it is very important to identify even the comorbid conditions for effective clinical management. . Treatment The treatment is provided in an outpatient setting and the main stay of treatment is serotoninergic antidepressant treatment. Other forms of treatment include cognitive behavioral therapy, behavioral therapy and in very rare cases neurosurgery. Patients who have suicidal risk or complex comorbid conditions may require admission and management. The first line drugs are 5-HT reuptake inhibitors. Good examples of drugs in this category are clomipramine and SSRIs like fluvoxamine, sertraline, fluoxetine and citalopram. Other drugs include tricyclic antidepressants with norepinephrine and 5-HT reuptake inhibition and drugs like venlafaxine which is a serotonin norepinephrine reuptake inhibitor. Even in adolescents and children, the standard treatment is medication therapy, cognitive behavioural therapy or a combination of both (NAMI, 2005). The most well-tolerated treatments for OCD in children and adolescents are serotonin-reuptake inhibitors SSRI and CBT (Piacentini and Bergman, 2000). Early onset OCD has some unique features which are different from adult-onset or adolescent OCD, having some implications for treatment too (Freeman, 2007). The phenomenology is consistent across all age spans, however; traditional adult CT approaches have been modified to accommodate developmental differences which exist. OCD that manifests in early childhood can be pernicious in nature and can cause severe functional impairment and derailment of normal development (Choi, 2009). Early onset OCD coincides with the beginning of formal education and difficulties related to OCD during this period can have a devastating consequence on relationships with peers and academic performance (Freeman et al, 2007). Thus, it warranted to provide early and frequent intervention to facilitate development of coping skills and also to minimize the anxiety levels of the child that may interfere with learning. There is actually not much research pertaining to treatment of OCD in this age group (Williams et al, 2010). Because of this, it is very important to take into account the type of treatment that is most appropriate for children who are young. According to Expert Consensus Guidelines and AACAP, the beginning treatment for all children with OCD must be either CBT alone, or a combination of CBT and SSRI drug, depending of the severity of symptoms and comorbid conditions (Freeman, 2007). Though SSRI drugs have good outcomes for OCD symptoms, very few drugs have been approved by FDA for use in children less than 8 years of age. Also, the rates of adverse drug reactions and variables of duration of treatment and moderators are poorly understood. For these reasons, CBT, rather than pharmacotherapy or a combination of pharmacotherapy and CBT has been treatment of choice in younger children with OCD (Freeman, 2007). Promising results have been found in older children and adolescents with family based CBT. CBT models for adolescents and children with OCD mainly focus on providing skills that facilitate exposure with prevention of response or ritual. Whether manual therapy or therapy based on waiting list and whether family should be involved in therapy or whether just relaxation therapy must be provided for children is a much debated topic. Williams et al (2010) conducted a randomized controlled trial of CBT on children and adolescents with OCD. The trial compared 10 sessions of manualized CBT with 12-week waiting list for adolescents and children. Assessors of the study were blind to treatment and the age group of patient was 9-18 years. The group who received treatment improved more than a comparison group who waited for 3 months. Based on the results of the study, it was evident that CBT is useful to treat young people with OCD and the treatment must be initiated immediately without any waiting period. Holistic considerations Teachers, parents, pediatricians and school counsellors play an important role in the identification of OCD in children and referring them to a child psychiatrist in a timely manner (NAMI, 2005). Active support from parents and caregivers is crucial along with a calm and supportive environment (Brasic, 2012). Implications for nursing Nurses have a major role to play in the evaluation and management of patients with OCD. One of the important nursing priority is to help the patient realize the onset of anxiety. Nurses need to explore and evaluate the purpose and also the meaning of a particular behavior with the patient. They must help the patient to limit various compulsive ritualistic behaviors. They must teach the patient various alternative strategies to handle stress related to their thoughts. They must also educate and encourage the family of the patient to take part in the therapeutic program of the patient (Fleury et al, 2012). Prognosis The disorder is chronic and the range of symptoms is wide. The intensity of the symptoms can wax and wane. Spontaneous remission is rare. After initiation of treatment, improvement of symptoms is seen in about 70 percent patients. In about 15 percent patients, the symptoms deteriorate over time, despite adequate treatment. About 5 percent have complete remission. Relapse is common. The disorder has a course of remissions and relapses and needs close monitoring adjustment of treatment. Specific predictors for good prognosis are unknown. However, in those children and adolescents in whom they themselves have identified their obsessions and compulsions are useless, the success rates are higher because they have increased motivation (Brasic, 2012). Conclusion OCD with onset at a young age is distressing, can be persistent, can cause impairment of the functioning and proper development of the child. Hence it is necessary to administer such therapy that facilitates complete but safe resolution of symptoms. Family based and group interventions are better considering the age group ad the fact that family and familial influences are likely in early onset OCD. References American Psychiatric Association or APA. (2000). Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association. AACAP. (2011). Obsessive-Compulsive Disorder In Children And Adolescents. Retrieved on 5th March, 2013 from http://www.aacap.org/cs/root/facts_for_families/obsessivecompulsive_disorder_in_children_and_adolescents Brasic, J.R. (2012). Pediatric Obsessive-Compulsive Disorder. Emedicine from WebMD. Retrieved on 5th March, 2013 from http://emedicine.medscape.com/article/1826591-overview#showall Castle, D.J., Phillips, K.A. (2006). Obsessive-compulsive spectrum of disorders: a defensible construct?. Aust N Z J Psychiatry, 40(2), 114-20. Choi YJ. (2009). Efficacy of treatments for patients with obsessive-compulsive disorder: a systematic review. J Am Acad Nurse Pract., 21(4), 207-13. Dell'Osso, B., Altamura, A.C., Allen, A., Marazziti, D., Hollander, E. (2006). Epidemiologic and clinical updates on impulse control disorders: a critical review. Eur Arch Psychiatry Clin Neurosci., 256(8), 464-75. Freeman, J.B., Choate-Summers, M.L., Moore, P.S., Garcia, A.M., Sapyta, J.J., Leonard, H.L., Franklin, M.E. (2007). Cognitive behavioral treatment for young children with obsessive-compulsive disorder. Biol Psychiatry, 61(3), 337-43. Fleury G, Gaudette L, Moran P. (2012). Compulsive hoarding: overview and implications for community health nurses. J Community Health Nurs., 29(3), 154-62. NAMI. (2005). Child and Adolescent OCD. Retrieved on 5th March, 2013 from http://www.nami.org/Content/ContentGroups/Helpline1/Child_and_Adolescent_OCD_.htm Piacentini, J., Bergman, R.L. (2000). Obsessive-compulsive disorder in children. Psychiatr Clin North Am., 23(3), 519-33. Sturm, R. (2009). Obsessive-compulsive disorder in children: The role of nurse practitioners. J Am Acad Nurse Pract., 21(7), 393-401. Williams, T.I., Salkovskis, P.M., Forrester, L., Turner, S., White, H., Allsopp, M.A. (2010). A randomised controlled trial of cognitive behavioural treatment for obsessive compulsive disorder in children and adolescents. Eur Child Adolesc Psychiatry, 19(5), 449-56. Read More