Nursing Aspects of Working in an OutpatientTerm Paper

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¶ … nursing aspects of working in an outpatient capacity with young patients suffering from various levels of OCD. While the advent of new drugs has made a significant difference in the outcomes for some patients, existing and new forms of 'talk therapy,' in conjunction with drugs, have proven efficacious for most patients. It appears from a review of the literature that the more complex the OCD behaviors, the more likely that talk therapy is needed in order to supplement drug treatment.

This paper will analyze the literature on OCD treatment from a number of perspectives. There is a wide range of OCD-related mental illness, from the relatively benign, such as fear of flying, to life-threatening, such as anorexia. The common themes are that short- and long-term talk therapy, many times in conjunction with anti-depressants, can result in the patient's ability to better function in his/her environment, even if the OCD has not disappeared completely.

Literature Review

Which SSRI? A Meta-Analysis of Pharmacotherapy Trials in Pediatric Obsessive-Compulsive Disorder (Geller, 2003)

Many OCD disorders start in childhood or early adolescents. Until the past few years, there has been little in the way of randomized trials to analyze more modern drug treatment regimens for these young patients.

SSRI's have helped to transform OCD treatment for many with mild- to moderate OCD syndromes. This metastudy looked at the literature which pertains to pediatric and adolescent sufferers of OCD, which is a helpful expansion from earlier clinical work done on SSRI's with adults. The meta-study looked exclusively at well-conducted clinical trials, which were randomized, double-blinded, limited to patients 19 or under, and had a placebo or other sort of control. The study does not indicate whether all patients were analyzed on a prospective rather than a retrospective basis, which would be an additional claim of objectivity.

In all, the meta-study included 12 studies with 1,044 participants, an average of 87 patients per study. Given that four SSRI's were evaluated, it is difficult to draw statistically-significant conclusions from these studies -- many were simply underpowered, with some n's as low as 21, 7 and 11. This meta-study calculated a "fail-safe N," a number below which negative data would disprove the conclusions; this author would argue that the total number of participants was too close to the fail-safe N. To be able to draw statistically valid conclusions.

The paper found that across studies, there was a uniform improvement in Yale-Brown scores by 4 points for those who took SSRI's. The improvement was not universal: there was an overall effect size of 0.46. Some studies of Clomipramine were included, which demonstrated that the improvement was greater than with the average of SSRI's. The authors concluded that, despite the better results, Clomipramine had too many side effects to be warranted for general treatment, particularly arrhythmogenic effects.

This paper mentions a series of limitations which should be taken into account. Despite limiting to patients with true diagnosis of OCD according to APA criteria, the age, gender and severity of illness in the patients was quite wide. In particular, the studies were not well-powered enough to establish the effects of pre-pubescent and post-pubescent children, where the effects could be significantly different. Since dosing for children is not yet established, there were wide variances in dosage which could also have an effect on the outcomes.

Cognitive-Behavior Therapy, Sertraline, and Their Combination for Children and Adolescents With Obsessive-Compulsive Disorder (March, 2004)

Although new drugs have helped to reduce the symptoms of OCD with children, the underlying causes may be unchanged despite the reduction in patient problems. This study tested the use of sertraline, an SSRI, alone or in conjunction with CBT (cognitive behavioral therapy). This multi-center study (three hospitals) enrolled a total of 112 patients between 7 and 17 with a DSD Fourth Edition qualification for a diagnosis of OCD, and a Yale-Brown OCD score of 16 or higher. Enrollment took five years, from 1997 to 2002.

The results indicated an advantage of sertraline alone and CBT alone as compared with placebo. The small sample size made it difficult to attain P. Of less than.05, although the combined result was clearly statistically significant in indicating a reduction in OCD symptoms (P=.001) compared with the placebo.

One might expect that the remission rate for CBT-only patients is lower than for sertraline-only patients, as the former deals with underlying causes and uses aversion therapy to address those sources of OCD. The study found a statistically-significant reduction in remission for those who took the combined therapy or CBT alone, but a higher remission rate for those who took sertraline only. CBT plus placebo was not analyzed, but the effects of CBT alone have been well-established in previous trials.

The recruitment took five years, despite the low number of patients in the study who completed the entire 12-week cycle (n=97). The authors do not mention why the recruitment was so difficult, although they do mention that the exclusion criteria were kept to a minimum. One concern about such a long enrollment period and a low n is that the nature of treatment and the physicians and nursing staff can change over such a long period of time, making it difficult to compare patients that, say, were brought in 1997 to those brought in 2002.

While this study's impact was somewhat reduced by the low n and the long recruitment period, the overall conclusion is supported by other literature: that CBT and SSRI's, taken in concert, reduce not only short-term OCD symptoms, but also reduce longer-term remission rates. SSRI's alone have this effect on short-term symptoms, and may provide some longer-term relief for some patients. The longer-term effect of CBT may be due to its ability to impact the patient's underlying causes of his/her OCD.

Narrative Approach to Body Dysmorphic Disorder (Nelson, 2007)

Body dysmorphic disorder is one of the more extreme and even life-threatening subcategories of OCD. Unlike mild- to moderate cases of OCD, treatment by anti-depressant drugs alone does not appear to have a significant 'cure' rate for those with the worst forms of BDD. Talk therapy, in some cases with significant intervention and isolation of the patient, is necessary in many cases to reverse this disorder. Clinical trials using talk therapy are generally less common than those using accepted short-term techniques, such as CBT or aversion therapy, due to the customized nature of the approaches used. This paper deals with an approach to OCD in adolescents that help to treat a severe case of OCD.

This narrative approach was first developed in Australia, and explained by White in a series of papers from 1995 through 2004. The fundamental concept of narrative therapy is to help clients to replace their 'restraining' narratives, which may be the source of their dissatisfaction with their bodies, to 'more preferred' stories about their problems and how they lead their lives.

One element that narrative therapy seems to address particularly well is as a counter to cultural stereotypes which have been established about 'perfect' bodies and how one should behave. These stereotypes, or memes, become stories by which young teens determine their fit into society. One of the surprises about the stories of those with BDD is the extremely negative image that they have of themselves, and the idealized people with whom they compare themselves. The four stages of narrative therapy start with an externalization of the 'story,' which takes a rational look at the story that a teen tells about herself (most are young girls). In this phase, narrative therapy is similar to CBT, in that it seeks to help the client step outside of the image and use rationality to understand what is happening. Also, like CBT, the therapist seeks to empower the client by giving her an understanding of when and how feelings of inadequacy and imperfection arise, and how to deal with them.

This article is a good explanation of how narrative therapy is employed, including an in-depth case study of a specific patient and her course of treatment. It would have been helped by concentrating on one of the several different kinds of BDD, and including several examples of the application of this therapy to the specific patient differences. Since BDD is strongly associated with anorexia nervosa, and this disease has proven particularly resistant to several kinds of treatment, it would have been useful to focus on that syndrome and how to address it with narrative therapy.

Self-Injurious Behavior: A Bi-Modal Treatment Approach to Working with Adolescent Females (Stone, 2003)

Self-injurious behavior (SIB) affects 4% of the general population. It generally afflicts teenage girls, who may continue the behavior into adulthood. It is particularly prevalent amongst those with developmental problems, psychiatric disabilities, and amongst those in prison. It may be caused by poor parental care, and is used for attention-seeking, inward-turned aggression, or to reach out to others. The authors demonstrate that SIB is not a new diagnosis, and quote Karl Menninger who wrote, in 1938, "Local self-destruction is a form of partial suicide to… [END OF PREVIEW]

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