TOPIC. Identification and management of obsessive-compulsive disorder (OCD).
PURPOSE. To increase advanced practice clinicians' awareness of the prevalence, screening tools, diagnostic criteria, differential diagnosis, and therapeutic management of OCD.
SOURCES. Published literature.
CONCLUSIONS. Nurses have a pivotal role in teaching self-management techniques to people with OCD.
Search terms: Anxiety disorders, obsessivecompulsive disorder
Anxiety disorders pose significant mental health problems and impair social functioning and quality of life, despite significant progress in understanding and treating anxiety disorders, such as obsessive-compulsive disorder (OCD). Anxiety disorders are one of the two most common types of psychiatric disorders, yet scant attention has been focused on treatment of OCD, the fourth most common psychiatric disorder in the United States (Rasmussen & Eisen, 1992). The traditional example of obsessive compulsive disorders is Lady Macbeth, who obsessed about her guilt and repeatedly washed her hands and intoned, "Out, out damned spot."
OCD is a treatable and biological disease in which serotonin metabolism plays a major role. It is an anxiety disorder with persistent thoughts and repeated rituals to control those thoughts. Anxiety is a hyperalert state causing excessive autonomic arousal and diminished coping that can be crippling and can seriously interfere with a person's life, increase health concerns, and absorb costly medical services. Approximately 4 million Americans suffer from anxiety disorders such as OCD, but only one in four is accurately diagnosed and treated (Rasmussen & Eisen, 1992).
The purpose of this article is to increase advanced practice clinicans' awareness of the prevalence, screening tools, diagnostic criteria, differential diagnosis, and therapeutic management of OCD. Effective management of anxiety disorders rests on sound scientific knowledge, which can enable advanced practice nurses to reduce anxiety and prevent complications. Failure to detect and diagnose OCD among many anxious patients leads to costly urgent care visits and other consequences such as suicide risk, depression, or chemical dependency. Diagnosis can be missed when medical care focuses on the chief physical complaint without considering anxiety disorders. Detecting OCD is a challenge when patients do not automatically report anxiety and OCD symptoms.
Incidence and Prevalence
Anxiety and mood disorders are the most frequent psychiatric disorders in America. In the Economic Catchment Area Survey, the 6-month prevalence of OCD was 1.6%; lifetime prevalence was 2.5% (Greist & Jefferson, 1995, 1998). OCD interferes with the quality of life and performance of more than 5 million Americans. OCD occurs more than twice as often as panic disorder or schizophrenia. Approximately equal numbers of females (53%) and males (47%) have OCD (Greist & Jefferson). The prevalence of OCD in the United States is similar to rates in Canada, Europe, Taiwan, and Africa. According to Greist and Jefferson, most people seek treatment from a medical or primary care provider but not a psychiatrist. Onset typically occurs during childhood or teenage years for males and during the 20s for females (Greist & Jefferson).
Historically, OCD developed among people who had biological disorders such as Von Economo's disease, warrelated head injuries, and Gilles de la Tourette's syndrome. About 55% to 74% of people with Tourette's syndrome have OCD symptoms, and 6 out of 10 sufferers meet the diagnostic criteria for OCD (Coffey et al., 1998; Rasmussen & Eisen, 1992; Steketee & Frost, 1998). This pattern of OCD following a neurological disorder suggests that OCD is related to neuroanatomical deviations. Family and twin studies also suggest a genetic susceptibility to OCD. Monozygotic twin pairs were 63% concordant for OCD symptoms, and 1 in 4 to 5 family members had OCD when a family history of the disorder existed (Carey & Gottesman, 1981). According to Freud (1923/1966) "sufferers from this illness are able to keep their affliction a private matter. Concealment is made easier by the fact that they are quite well able to fulfill their social duties during part of the day, once they have devoted a number of hours to their secret doings, hidden from view" (p. 196).
Anxiety and OCD may arise from a malfunction of the brain or internal biochemical substances that help individuals prepare for danger. Neurotransmitters (norepinephrine, serotonin, and dopamine) control mood, movement, blood pressure, and neural impulse conduction. Norepinephrine triggers the onset of tremors, anxiety, nervousness, and increased vital signs. Some individuals also may have an overly sensitive response system. Biochemical theory posits that OCD is not caused by lack of willpower or motivation. Serotonergic agents relieve obsessive-compulsive symptoms and are superior to selective norepinephrine reuptake inhibitors. The serotonin reuptake blockade mediates the medication's therapeutic action. Current research (Schwartz, 1996; Soomro, 2001; Steketee, 1998) suggests that serotonin (5-HT) modulates cooperative social behavior and latency or impulsivity. Medications without serotonin reuptake-inhibiting ability are not effective.
Medications to regulate OCD are not just a crutch to reduce symptoms but a treatment for a chemical imbalance (Valente, 1996). Evidence for a biological etiology also emerges from clinical improvement following brain surgery. In patients who had a cingulotomy in the past 25 years, 25% to 30% had substantial benefits with minimal side effects, 25% reported they functioned well, and 31% markedly improved (Steketee, 1998). However, 4 OCD patients committed suicide. Another 28 OCD patients had a subcaudate tractotomy, and 50% reported substantial benefit with few side effects. In England, a limbic leucotomy led to clinical improvement in 84% of patients who had no long-term side effects (Steketee & Frost, 1998). One patient, however, committed suicide. These radical procedures have prompted substantial improvement for many patients with severe OCD (Steketee, 1996).
According to cognitive theorists, anxiety disorders-- including OCD-may stem from negative thinking and irrational ideas as well as genetic and biochemical sources. Automatic negative thoughts and irrational ideas (e.g., "everyone must love me"; "I have to do all this checking to be safe") can lead to anxiety (Banazak, 1997). Genetic researchers suggest that close biological relatives of individuals with OCD are more likely to develop OCD symptoms than are those without a family history given the findings in twin studies. Understanding this etiology helps inform patient teaching.
Signs and Symptoms
Hallmarks of OCD include anxiety-producing intrusive thoughts and repetitive anxiety-reducing rituals. People know they are unable to control their OCD behaviors and they avoid situations that trigger their anxiety. Common examples of OCD include fear of germs and excessive hand-washing rituals, fear of being unsafe and constant checking of locks and security measures, and fear of being late and constant checking of clocks and time. These rituals of checking or counting consume hours a day. A person with OCD who fears germs may use several bars of soap and rolls of paper towels in a week. In one severe case, a woman was so frightened of becoming impregnated with sperm that she could not clean her house or change her husband's or son's beds. She also became housebound for fear of going outside and touching anything that might have been touched by a male. People with this disorder feel upset, distressed, ashamed, and embarrassed by their fears and ritual behaviors, so they often hide them.
From 62% to 92% of people with OCD report that their symptoms have interfered with relationships; 58% report symptoms lowered their academic achievement and work performance (Hollander, Kwon, & Stein, 1996). For 66%, OCD symptoms lowered their career aspirations, interfered with their work efficiency (47%), and 40% were unable to work and had lost an average of two years of work. Approximately 13% of suicide attempts have resulted from OCD symptoms, so counseling needs to address these issues (Hollander et al.).
Case example. Fred was a 24-year-old student and military cadet in a psychiatry course. His obsessions related to fear of being late, and his ritualistic behavior involved setting several alarm clocks to ring at 15-minute intervals before his scheduled appointments or classes. Before treatment, he spent many hours each day performing these rituals. He knew this behavior was strange and embarrassing, and he rarely disclosed it. After he attended a psychiatry class on OCD, he told the instructor about his experiences with OCD. The time required for rituals also interfered with his sleep, activities, selfesteem, and daily life. Fortunately, a relative who was a nurse heard him mention his alarm clocks, and he trusted her enough to respond to her questions about other rituals and behaviors. She recognized the possibility of OCD, explained the disorder, and referred him for treatment. Medications and behavioral group therapy effectively reduced his obsessions and compulsions so they no longer interfered with his life. Fred is like many people who have persistent thoughts they cannot control with willpower: Without medication he feels compelled to check and recheck the clock in response to his persistent ideas. He is able to keep his affliction a secret even though the persistent thoughts occur frequently during his waking hours and awaken him from sleep.
OCD includes both obsessions and compulsions. Obsessions are recurrent, inappropriate, persistent thoughts, impulses, or images that cause marked anxiety or distress. These images are time-consuming and interfere with normal routines at school or work, social and occupational activities. Compulsions include repetitive behaviors or mental acts that one feels driven to perform in response to an obsession and are performed according to rigidly applied rules (Steketee, 1996). For instance, one may have to check and recheck the locks on all windows and doors in a specific order several times a day. The compulsions are intended to reduce anxiety and prevent some dreaded event or situation. They are not realistically connected with the purpose and are clearly excessive. For example, the woman's avoidance of changing her husband's or son's bed linen or avoiding touching areas they had touched is realistically not connected to how people get pregnant.
Assessment. The clinician establishes rapport, reviews past history, and conducts a neurobehavioral mental status exam. Information is gathered on the OCD symptoms (e.g., obsessions, avoidance, compulsions, cognitive and affective responses). Because of the variety of OCD symptoms, several approaches to data collection are useful, including clinical interview, behavioral observations, objective questionnaires, and family members' descriptions of the problem. Asking if the person has repeated behaviors or rituals is a good way to begin an interview. Discussing compulsive actions and rituals first is easy because they are observable. The clinician or staff also may observe some ritual behaviors in the clinic. Currently no laboratory studies and physical examination data are used to diagnose OCD. More than 50% of adults with OCD have multiple obsessions and compulsions (Steketee, 1996). Fear of contamination and germs, pathological doubt, and somatic obsessions are common (Table 1).
Determining onset and triggers for obsessions and compulsions is helpful. Exploring the cues for obsessions and fears, making a list of obsessive situations, and discussing the patient's insight into obsessive beliefs are important. The clinician also identifies avoidance behaviors and mental and physical rituals, and explores social support. Information about the details of a typical day, from awaking in the morning until falling asleep, can help identify feared and avoided cues and details about triggers for avoidance rituals.
Because there may be a genetic predisposition to OCD, a family history is useful. Documenting alcohol, drug, and caffeine intake also helps identify precipitants of anxiety. Over-the-counter preparations such as cold and allergy compounds can induce anxiety. Asking a patient to complete a diary for a couple of weeks or a daily chart indicating obsessions and compulsions helps provide a baseline for measuring therapeutic outcomes.
OCD symptoms are not just excessive worries about real problems. The person needs to recognize that these obsessions originate not from external sources but from the brain. The symptoms are not related to another psychiatric DSM-IV disorder (e.g., dieting or food obsessions related to an eating disorder) (American Psychiatric Association, 1994). The person's avoidance of certain situations may be one indicator of the severity of obsessions. Situations that elicit obsessions may be avoided because they are uncomfortable and anxiety producing. For instance, a person afraid of germs may avoid crowded social situations where touching or brushing another may occur, and may wear clothing and gloves to reduce exposure of body parts. Screening questionnaires help gather objective data about OCD.
Screening. Screening instruments help detect OCD symptoms and can indicate the need for a more extensive psychiatric evaluation or psychological consultation. They identify people at risk, but do not stand alone as diagnostic tools. They also monitor effectiveness of treatment and improve diagnostic accuracy, particularly when people hesitate to disclose their symptoms (Valente, 1996). Screening tools for OCD are convenient and easily completed in the waiting room. The Yale Brown Obsessive Compulsive Scale (YBOCS) Symptom Checklist was developed for research but is useful in clinical practice. The YBOCS Compulsive Scale is a brief questionnaire that documents current and past OCD symptoms and their severity (Goodman, McDougle, & Price, 1992; Goodman et al., 1989). A score above 10 creates suspicion of OCD; scores above 16 indicate moderate severity. People often seek treatment at a score of 10.
Case example. Mrs. R came to the women's clinic for a follow-up appointment for her abdominal pain. Her psychiatric history was negative. While the laboratory was taking her blood for a CBC, the APN in clinic chatted with Mrs. R's husband. He apologized for being late and mentioned it took his wife forever to leave the house because she had to check everything. The APN asked for more information, suggested that people who excessively checked things might benefit from treatment, and subsequently asked Mrs. R to complete a YBOCS. Mrs. R indicated current needs to repeat rituals, order/arrange things, checking and counting compulsions that were severe and interfered with her life. She had little control over these behaviors. The APN explained about OCD and its treatment. When asked, Mrs. R said it was very embarrassing and she would like to have more control and reduce or eliminate these behaviors. The APN also explained they would use the YBOCS to monitor their progress in treatment.
Diagnosis and differential diagnosis. OCD typically does not exist alone but has frequent traveling companions. OCD may coexist with neurobiological disorders (e.g., Tourette's syndrome), attention deficit/hyperactivity disorder, learning disabilities, schizophrenia, depression, and anxiety disorders such as phobias (Table 2). Schizophrenia is easy to differentiate from OCD, because the person with OCD knows reality and understands that obsessions and compulsions are excessive. The person with schizophrenia asserts that his or her fixed, false beliefs and hallucinations are real. A person with a diagnosis of psychosis or schizotypal personality disorder may be unsuitable for behavioral therapy. The symptoms that differentiate OCD from depression are the sad, anhedonic hallmarks of depression. Usually people with OCD do not have a sad, depressed mood but may have fears about the future. People with phobias are most concerned with coming in contact with the thing they fear, while people with OCD are more concerned about the time absorbed by their rituals. While phobics are terrified about encountering their feared situation, people with OCD are more embarrassed or disgusted by their behaviors. To qualify for a diagnosis of OCD, these symptoms must be distressing, time-consuming (e.g., at least 1 hour per day) activities and must interfere with normal routine. Alcohol and substance use in response to anxiety or OCD symptoms requires assessment because it may compromise therapy.
The advanced practice nurse has a role to play in management with diverse therapies. Initially, one uses a permissive approach where rituals and compulsions are allowed but given a limited time. The patient and family need time to adjust to limits and to learn strategies to reduce the anxiety the rituals had previously controlled. If the patient takes an hour to check locks before leaving the house, advise the patient and family to limit this behavior to 5 or 10 minutes-enough time to check but not recheck-and to help the patient use slow, deep breathing and cognitive approaches to reduce anxiety. Patients benefit from combined treatments using medication, cognitive behavioral therapy, and education (e.g., self-management, relaxation, guided imagery). Advanced practice nurses are often skilled in many if not all these interventions and may refer patients to community treatment resources such as group therapy. Cognitive behavioral therapy is a time-limited intervention that is highly effective alone and in combination with medications. Behavioral therapy groups teach skills and reduce obsessions, compulsions, and avoidance behaviors by slowly increasing exposure to anxiety-producing situations. Medications are recommended when OCD compromises social or work activities, when patients self-medicate with alcohol or drugs, or when depression emerges.
One challenging barrier to treating OCD may be to engage the concern of the primary care provider and other colleagues because they may dismiss or overlook the psychiatric diagnosis and symptoms. The best approach is often to supplement your synopsis of the duration and frequency of OCD and type of symptoms with an objective measure from a screening tool. Part of the problem is that everyone has some concern about safety, burglary, lateness, infections, and contamination. So initially, the idea of checking the locks to prevent theft may seem normal, and the excessive and time-consuming nature of the rituals needs to be emphasized. Educating the patient, family, and nonpsychiatric clinician about the nature of the disorder and its treatment is important.
Nonpharmacological management. Education and brief counseling help patients develop the knowledge and skills to cope with OCD. Encouraging the patients and family members to share their concerns is an important therapeutic intervention. Typically, patients who are reluctant to disclose their worries and mental health problems will feel more comfortable talking with the nurse. They often fear the community or their physician will respond negatively to mental problems. Identifying local resources and referrals improves the patient's options for help seeking and self-management.
Cognitive-behavioral strategies. Cognitive therapists believe that anxiety arises from a negative view of the world and from automatic and negative thinking patterns, and that OCD is a disorder of cognitive processing where fears are exaggerated and lead to ritual behaviors. People with OCD misperceive and overestimate the risk of negative consequences for many actions. Cognitive therapy, a directive, time-limited approach, helps change irrational thoughts including obsessions, overvalued ideas, perfectionistic expectations (Beck, 1979), and explains the nature of anxiety and negative thoughts. Limited evidence suggests that cognitive therapy is as effective as behavioral therapy (Soomro, 2001). For instance, a person might change his/her negative thoughts connected with fears or worries, insecurities, self-esteem, excessive guilt, or fear of failure. Expecting to be perfect and always loved illustrates an irrational thought, leading to anxiety. Irrational fears about aging or death, germs, security, being unloved, or survivor guilt may cause unnecessary distress. An irrational fear or obsession can be so strong that it blocks discovery of the facts. When anxiety disorders remain untreated, a patient may view suicide as the only escape from emotional pain (Valente, 1996).
The cognitive-behavioral model includes interventions (Table 3) that help people focus on here-and-now problems, improve problem solving, and develop rational thinking. Cognitive interventions do not focus on an indepth examining of the meaning or psychodynamics of the anxiety, but on changing behaviors. Interventions include encouraging patients to notice when they view events negatively, to differentiate accurate from distorted perceptions by using the technique of cognitive appraisal, and to substitute accurate perceptions for overgeneralizations or catastrophic expectations (Bums, 1990). The nurse teaches thought-stopping strategies to limit persistent negative and worrisome ideas that lead to anxiety, and explains how to reduce panic attacks. Advanced practice nurses can encourage patients to set realistic goals, identify a patient's efforts toward success, and praise each step of a task. Assigned homework such as keeping a log of pleasurable events, skills mastered, or automatic thoughts reduces the depressed patient's tendency to forget or minimize success, satisfaction, or pleasure.
Case example. Jean, a 23-year-old college sophomore, came for treatment for depression, fatigue, indecisiveness, poor concentration, insomnia, and constipation. Jean reported receiving an antidepressant for the past 4 months from her physician at home. However, she was not feeling any better. The advanced practice nurse noticed Jean's raw, red hands and asked about them. Jean said, "Good hand washing prevents deadly infection; I must be allergic to this soap," and looked tearful. During the history, the nurse asked if Jean had to check or do things repeatedly or often had disturbing thoughts that came into her mind that she could not control. She became tearful and wanted to leave but agreed to complete the YBOCS and talk further with the APN. She reported that she washed her hands incessantly to prevent germs and catching anthrax or a deadly and incurable disease (e.g., misperceiving the consequences of germs and negative and catastrophic thinking). She scored high on the YBOCS and agreed to begin brief treatment with education and cognitive behavioral therapy, and to consider medications. The APN taught her to limit her handwashing ritual. She could wash her hands for 2 minutes, or about the time it takes to imagining singing "happy birthday." She learned to practice slow, deep breathing, and to repeat silently that everyone has germs, that these germs do not cause much other than a cold, and to correct other myths about germs and disease.
Cognitive appraisal, another therapeutic strategy, helps the patient identify typical irrational beliefs and automatic thought patterns such as overgeneralizing, personalizing, catastrophizing, and forming negative conclusions (Wright, Thase, Beck, & Ludgate, 1993). After recognizing these automatic thought patterns, people can identify alternate conclusions. Exploring how an event was misinterpreted and led to a negative generalization helps the patient recognize, examine, and change ingrained negative thinking habits. At least two alternative explanations for an event need to be considered. Patients also benefit from examining negative conclusions.
Behavioral treatment. Behavioral strategies involve teaching skills to reduce anxiety, provide systematic desensitization, and introduce graded exposure (Greist & Jefferson, 1995). Exposure is most effective when it is combined with strategies to block rituals and inhibit obsessive responses. Skills may include relaxation, controlled breathing, and management of anxiety-provoking stimuli. Often, treatment with behavior and cognitive therapy effectively reduces OCD symptoms. For some, cognitive and behavioral interventions alone offer sufficient treatment, whereas others also need medications. However, to be effective, behavioral exercises need to be done daily.
Systematic desensitization helps people overcome specific fears (e.g., fear of elevators, flying, heights, open spaces). Some severe fears have led to rituals that keep people at home. People master the smallest anxietyproducing event before proceeding to larger ones. For instance, a person with an obsession about germs or pregnancy would first imagine and then discuss with the therapist contact with a contaminated surface, then look at pictures of germs, then go to an area with contamination (e.g., supermarket), then enter the market with a trusted person, and exit. After each step was repeated as necessary and mastered, the next step would begin. Finally, the person would pick a contaminated shopping cart and go shopping with someone they trust.
At the other end of the spectrum of desensitization is flooding, which begins with more extensive exposure. The individual is continuously presented with images or the feared stimulus until it no longer elicits anxiety. Although this approach is faster than systematic desensitization, it also raises blood pressure, stress, and psychological discomfort, so candidates for this are carefully selected. Behavioral skills are mastered through practice.
Group treatment offers education, a supportive environment for practice, and skill-building. Patients can learn to prevent stresses, set realistic goals, reduce isolation, decrease worry, and experiment with new strategies to reduce anxiety. A support group for the patient's family also is helpful, because family understanding enhances treatment. Behavioral strategies help people change behaviors or habits and learn new effective behaviors.
Combined exposure and response prevention. A combined exposure and response program introduces patients to their feared situations and prevents performance of the compulsions over 11 to 15 sessions using in vivo exposure. More than 25 open trials and controlled studies have examined this intervention and have reported from 75% to 100% improvement, although measures of improvement varied (Steketee, 1996; Steketee, Frost, & Cohen, 1998). Combined exposure and response prevention was more effective than relaxation (Steketee; Steketee et al.). Exposure per se, however, does not correct negative thinking patterns or irrational beliefs that accompany OCD. Several strategies help the patient cope with high anxiety during exposure, including humor, reassessment of the risk of the exposure, relaxation training (which has a weak effect), and paradoxical intention. In paradoxical intention, the discomfort is deliberately exaggerated until the patient says anxiety has reached a plateau.
Pharmacological treatment. Selective serotonin reuptake inhibitors (SSRIs) such as fluvoxamine (Luvox), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) are popular first-line therapy because of their low side effects and benefits (Table 4). They produce a 30% to 60% reduction in obsessive compulsive symptoms that is meaningful to the patient (Greist & Jefferson, 1998). Three systematic reviews have reported that SSRIs improve symptoms more than placebo (Abramowitz, 1997; Kronig, Apter, & Asnis, 1999; Soomro, 2001). One double-blind placebo study (Soomro) found that most participants relapsed within weeks of stopping treatment. Limited evidence from randomized clinical trials suggests that behavioral therapy plus fluvoxamine is more effective than behavioral therapy alone (Soomro). Although one randomized clinical trial reported that sertraline was more effective than clomipramine at reducing symptoms, other studies have yielded equivocal results (Soomro). Patients need to take SSRIs for 8 to 10 weeks before effective therapeutic outcomes occur. Side effects include headache, asthenia, nausea, somnolence, insomnia, and nervousness.
Caution regarding drug interactions and toxicity is important when SSRIs are used with other drugs (tricyclic antidepressants, antiarrhythmics, codeine, carbamazepine, benzodiazepines, and beta- or calciumchannel blockers). A behavioral health consultation helps verify or improve evaluation and treatment plans and to reevaluate treatment-resistant patients. One of the issues in pharmacotherapy is preventing relapse. If SSRIs are discontinued abruptly, 90% of patients relapse within 2 months (Greist & Jefferson, 1998). Typically, the SSRI benefits should be observed before beginning behavioral treatment with exposure and response prevention.
Tricyclic antidepressants (TCAs) are the most studied antidepressant medications. While the side effects of TCAs appear immediately, the therapeutic effects require about 2 to 3 weeks to occur; they can reduce insomnia. Common adverse effects include sedation, anticholinergic symptoms, orthostatic hypotension, and potential for overdose in suicide attempts because of a narrow therapeutic window and cardiotoxicity. Clomipramine (Anafranil) is the common TCA used for OCD. Side effects include somnolence, dry mouth, weight gain, sexual dysfunction, increased resting heart rate, risk of orthostatic hypotension, and decreased seizure threshold. Clomipramine has an affinity for other neurotransmitter receptors, the central dopamine-D2 and Histamine-Hl, and alpha, adrenergic receptors. It also has anticholinergic activity and increased prolactin in depressed patients.
Obsessive-compulsive disorder is a common psychiatric disorder that is typically overlooked and untreated. Assessment is based on a review of history, triggers, symptoms, screening questionnaires, and an understanding of the client's motives, fears, and expectations. Pharmacological, behavioral, and cognitive treatments effectively relieve obsessive and compulsive symptoms in 70% to 80% of people who adhere to these treatments. Cognitive therapy also corrects the irrational and negative thinking patterns of OCD and can help prevent relapse. Nurses can provide education, self-management strategies, cognitive interventions, and various stress-reducing techniques. Nurses have a pivotal role in teaching these self-management techniques and in referring clients with OCD for behavioral evaluation or treatment. All members of the treatment team can use education, interventions, and cognitive strategies to help clients recognize and change negative thinking patterns or irrational beliefs. Clients also need help to set realistic goals that will lead to success and build self-esteem.
Acknowledgment. This material is the result of work supported with the resources and use of the facilities at Department of Veterans Affairs Greater Los Angeles Healthcare System.
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Sharon M. Valente, PhD, RN, CS, FAAN
Sharon M. Valente, PhD, RN, CS, FAAN, is a Nursing Research Fellow, Department of Veteran Affairs, Los Angeles, and Assistant Professor, University of Southern California, Los Angeles.
Author contact: firstname.lastname@example.org or sharon.valente@med. va.gov, with a copy to the Editor: email@example.com
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