DIRECTORATE OF NURSING AFFAIRS PSYCHIATRIC NURSING MANUAL

OBSESSIVE THOUGHTS
AND COMPULSIVE BEHAVIOR

Obsessive thoughts are persistent thoughts that are usually troublesome to the
patient. Compulsions are ritualistic behaviors, usually repetitive in nature, and may
be attempts to contain or diminish obsessive thoughts (Kneisl and Wilson, 1984).
Obsessive thoughts and compulsive behaviors are a means of dealing with
excessive anxiety; the patient engages in repetitive acts to control anxiety and deal
with the obsessive thoughts. Compulsive behavior is a defense that is perceived by
the patient as necessary to protect him- or herself from anxiety or impulse that are
consciously unacceptable.

In early treatment, do not prevent the patient from performing compulsive acts.
Interventions should be limited at first to harmful and dangerous situations or
practices. Drawing undue attention to or attempting to forbid compulsive behaviors
will increase the anxiety that the patient is feeling. Initial nursing care should allow
the patient to be undisturbed in performing his or her rituals. Nursing care should
reduce anxiety and build self-esteem.

The particular obsessive thoughts and compulsive behaviors may be symbolic of the
patient’s anxieties or conflicts. Many obsessive thoughts are religious or sexual in
nature. The obsessive thoughts may also be destructive or delusional (the patient
may be obsessed with the thought of killing his or her significant other, or may be
convinced that he has cancer or that she is pregnant). The patient may also be
placing rigid standard on him- or herself and others that are unrealistic or
unattainable.

Many people have some obsessive thoughts or compulsive behaviors. The patient
comes to treatment when the thought or behaviors impede or inhibit his or her overall
ability to function.

ASSESSMENT DATA

• Obsessive thoughts (may be destructive or delusional

• Compulsive, ritualistic behavior (such as repeated hand washing)
• Difficulty eating or refusal to eat
• Difficulty sleeping
• Ambivalence (difficulty making or carrying out decisions)
• Disturbances in normal functioning due to obsessions or compulsive behaviors
(loss of job, loss of or alienation from family members, etc.)
• Self-mutilation or other physical problems (such as damage to skin from
excessive washing)
• Aggression toward others
• Anxiety
• Feared loss of control
• Overemphasis on cleanliness and neatness
• Rigidity or extremely high standards; inability to tolerate any deviation from
standards
• Guilt feelings
• Fears

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 DIRECTORATE OF NURSING AFFAIRS PSYCHIATRIC NURSING MANUAL

• Rumination
• Low self-esteem, feelings of worthlessness
• Lack of insight
• Denial of feelings
• Difficulty or slowness in completing daily living activities or tasks because of
ritualistic behavior
• Suicidal feelings or ideas

NURSING DIAGNOSES

Increased anxiety, fears or guilt related to:

• Obsessive thoughts
• Internal conflicts
• Delusions
• Feelings unacceptable to the patient
• Extremely high standards for him- or herself

Decreased adaptation to stress related to:

• Anxiety
• Fears
• Low self-esteem

Decreased ability to express feelings related to:

• Guilt
• Denial of feelings
• Lack of insight
• Anxiety

Low self-esteem related to

• Obsessive thoughts
• Extremely high standards for him- or herself
• Guilt
• Feelings of worthlessness

Potential self-inflicted injury related to:

• Compulsive behaviors (mutilation or excessive bathing)

• Obsessive thoughts
• Delusions
• Refusal to eat
• Suicidal feelings or ideas

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 DIRECTORATE OF NURSING AFFAIRS PSYCHIATRIC NURSING MANUAL

Potential for injury to others related to:

• Hostility or aggression
• Increased anxiety (i.e. when prevented from performing compulsive behaviors)

Potential for disrupted homeostasis related to:

• Refusal to eat
• Difficulty in completing tasks of daily living

Disturbance in balance or rest, sleep, and activity related to:

• Difficulty sleeping
• Anxiety
• Preoccupation with compulsive behaviors or obsessive thoughts

INTERMEDIATE GOALS

The patient will:

• Be free of self-inflicted harm
• Identify stresses, anxieties, and conflicts
• Verbalize feelings of fears, anxiety, guilt and so forth
• Decrease anxiety, fears, guilt, rumination, and aggressive behavior
• Develop or increase feelings of self-worth
• Establish and maintain adequate nutrition, hydration and elimination
• Develop independence in completion of daily living activities
• Identify alternative methods of dealing with stress and anxiety

NURSING OBJECTIVES & INTERVENTIONS RATIONALE

١. Decrease the patient’s anxiety, fears, guilt, or

rumination.
• At first, do not attempt to prevent or call Prevention or attending to compulsive
attention to the patient’s compulsive acts. acts may increase the patient’s anxiety.

• Encourage the patient to verbally identify his
or her concerns, life stresses, anxieties,
fears, and so forth.
• Encourage the patient to vent his or her
feelings in ways that are acceptable to the
patient (through talking, crying, physical
activities, etc.)
Addressing feelings directly may help
diminish the patient’s anxiety and thus
diminish obsessive thoughts, rumination,
and compulsive acts.
The patient may be uncomfortable with
some ways of expressing emotions or
find them unacceptable initially.

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 DIRECTORATE OF NURSING AFFAIRS PSYCHIATRIC NURSING MANUAL

NURSING OBJECTIVES & INTERVENTIONS RATIONALE

• If the patient is ruminating (perhaps on his or Withdrawing attention may help decrease
her worthlessness), acknowledge the rumination by not reinforcing that
patient’s feelings, but then try to redirect the behavior. Redirecting the patient to focus
interaction in a positive direction. Discuss the directly on emotions may help diminish
patient’s specific perceptions of why he or anxiety and rumination.
she feels this way and possible ways to deal
with these feelings. If the patient continues to
ruminate, withdraw your attention at that time
(tell the patient that you will discuss other
things and state when you will return or when
you will be available for interaction again).

• If the patient has delusional fears, do not
argue with him or her about the logic of these
fears. Acknowledge the patient’s feelings,
interject reality briefly (like “Your tests shows
that you are not pregnant”), and move on to a
concrete subject for conversation.
Delusions are strong beliefs; often the
patient can give “logical” support for
them. Arguing about delusions can
reinforce delusional beliefs. Providing a
concrete subject for interactions can
reinforce reality for the patient.

• At first, allot specific time periods, such as

ten minutes every hour, when the patient can
focus on his or her obsessive thoughts or
ritualistic behaviors. Require the patient to
attend to other feelings or problems for the
rest of the hour. Gradually decrease the time
allowed (from ten minutes per hour, to ten
minutes every two hours).
Setting time limits recognizes the
significance of these thoughts and acts in
the patient’s life, but still encourages him
or her to focus on other feelings and
problems.

٢ . Decrease or eliminate the patient’s

obsessive thoughts and/or compulsive
behaviors. Decrease his or her
ambivalence and the overemphasis on
order or cleanliness

NURSING OBJECTIVES & INTERVENTIONS RATIONALE

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 DIRECTORATE OF NURSING AFFAIRS
• As the patient’s anxiety decreases (by identifying
and expressing feelings) and as a trust
relationship builds, talk with the patient about the
patient’s feelings and behavior, and about the
patient’s feelings regarding them. Help the
patient identify alternative behaviors and
methods for dealing with increased anxiety.
• Encourage the patient to attempt to
decrease the frequency of compulsive
behaviors gradually. The patient (or staff
members) may identify a baseline
frequency and then keep a record of the
decrease.
• Talk with the patient about other
symptoms as appropriate (ambivalence,
frustration, rigidity). Help the patient
develop satisfactory coping mechanisms
to decrease frustration.
• Give the patient verbal support for
attempts to decrease the need for
ritualistic behavior and to decrease its
frequency.
٣. Promote the patient’s self-esteem.
• Help the patient increase his or her self- Your presence and interest in the patient
esteem by demonstrating an honest interest conveys your acceptance of the patient
and concern (do not flatter the patient or be as a worthwhile person. Patients with low
otherwise dishonest).
NURSING OBJECTIVES & INTERVENTIONS
OBSESSIVE THOUGHTS AND COMPULSIVE BEHAVIOR 6 - 9 -5
PSYCHIATRIC NURSING MANUAL
The patient may need to learn ways
to manage anxieties so that he or
she can deal with it directly. This will
increase his or her confidence in
managing anxiety and other feelings.
Gradually reducing the frequency of
compulsive behaviors and replacing
them with new behaviors will
minimize the patient’s anxiety in the
transition and encourage success
and independence.
Decreasing the patient’s frustration
will also decrease his or her
anxieties, lessening the need for
ritualistic behaviors.
Positive feedback provides
reinforcement for new behaviors.
self-esteem do not benefit from flattery or
undue praise. Sincere and genuine praise
that the patient has earned can foster
self-esteem.
RATIONALE
The patient may be limited in his or her
 DIRECTORATE OF NURSING AFFAIRS PSYCHIATRIC NURSING MANUAL

• Support the patient for participation in ability to deal with complex tasks,
activities, treatment, and interactions. Provide activities, or stimuli, and in his or her
opportunities for the patient to participate in ability to relate to others. Activities that
activities that are easily accomplished or the patient can accomplish and enjoy can
enjoyed by the patient. enhance self-esteem.

٤. Help the patient maintain adequate nutrition,

hydration, elimination, sleep, and normal
activities of daily living.

• Observe the patient’s eating, drinking, and The patient may be unaware of physical
elimination patterns and assist the patient as needs or may ignore feelings of thirst,
necessary. hunger, the urge to defecate, and so
forth.
• Assess and monitor the patient’s sleep Limiting noise and other stimuli will
patterns and prepare him or her for bedtime encourage rest and sleep. Comfort
by decreasing stimuli, giving a backrub and measures and sleeping medications will
other comfort measures or medications. enhance the patient’s ability to relax and
sleep.
• You may need to allow extra time or the The patient’s thoughts or ritualistic
patient may need to be verbally directed to behaviors may interfere with or lengthen
accomplish the normal activities of daily living the time necessary to perform activities.
(personal hygiene preparation for sleep).

٥. Decrease or eliminate the patient’s self-

mutilation and aggression.
• The patient have to be restrained or The patient’s physical safety, health, and
otherwise protected from self-mutilation. well being are priorities.
Treat any existing injury (provide cream for
reddened skin, protection for eyes).
• Try to substitute physically safe behavior Substitute behaviors may satisfy the
(even if it is compulsive or ritualistic) to patient’s need for compulsive behavior
decrease harmful acts. If the patient is cutting but protect the patient’s safety and
himself or herself, direct him or her toward provide a transition toward decreasing
tearing paper, for example. these behaviors.

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