4 Obsessive-Compulsive and Related Disorders: OCD

Question 1

What is listed in the DSM-5 under Obsessive-Compulsive and Related Disorders?

Answer 1

• OCD
• Body Dysmorphic Disorder
• Hoarding Disorder
• Excoriation (Skin-Picking)
• Trichotillomania (hair-pulling)

Question 2

What are the commonalities of Obsessive-Compulsive and Related Disorders?

Answer 2

• All hallmarked by repetitive behaviours or mental acts that are difficult to stop or decrease
• Person feels compelled for some sort of thing and that aspect is not part of anxiety disorders

Question 3

Describe Hoarding Disorder.

Answer 3

Hoarding is characterised by difficulty parting with possessions regardless of their value. It stems from a perceived need to save the items and to distress associated with discarding them. As a result, hoarding disorder patients accumulate many items that clutter living areas and compromise their use.

Question 4

Describe Body Dysmorphic Disorder

Answer 4

Body dysmorphic disorder involves a preoccupation with perceived defects in physical appearance - that are not observable to others i.e. the person sees a body feature(s) as exaggerated or worse than they are - this is different to normal appearance concerns.

Question 5

What is the muscle dysmorphia specifier of body dysmorphic disorder?

Answer 5

The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas

• Associated with high levels of anxiety, depression, shame, low self esteem
• Onset in adolescence (most developed by age 18)

Question 6

What are some effects of body dysmorphic disorder?

Answer 6

Different from normal appearance concerns

Impaired psychosocial functioning

• Avoidance of social situations, relationships, intimacy
• About 20% of affected youths report dropping out of school due to associated symptoms
• can become housebound
• poor quality of life
• elevated suicide risk

Question 7

Name and describe the disorder known for the pulling out of one’s hair.

Answer 7

Trichotillomania (Hair-pulling disorder)

Recurrent pulling out of one’s hair, resulting in hair loss. It requires repeated attempts to decrease or stop hair pulling. This hair pulling must cause clinically significant distress or impairment and not be attributable to another medical condition.

Question 8

Name and describe the disorder known for the picking of one’s skin.

Answer 8

Excoriation (Skin-Picking) Disorder

Recurrent skin picking resulting in skin lesions. It requires repeated attempts to decrease or stop skin picking. The skin picking causes clinically significant distress or impairment and not be attributable to the physiological effects of the substance or another medical condition.

Question 9

How does OCD differ from the other disorders listed in the same category in the DSM?

Answer 9

Sometimes when people say they’re triggered by emotional states (anxiety or boredom) and what makes them different to OCD is they’re preceded by mounting tension and after completed there is gratification

Question 10

What are the DSM-5 criteria for OCD?

Answer 10

To qualify for OCD a person must be experiencing obsession, compulsions or both as defined by DSM (A). These behaviours must be time-consuming or cause significant distress or dysfunction (B).

Individuals may vary in their level of insight into the problematic nature of their behaviours, better insight = better treatment outcome. OCD may be tic-related.

Question 11

Define an Obsession

Answer 11

Recurrent and persistent thoughts, urges or images that are unwanted and cause distress

• Are unwanted and perceived as intrusive and senseless = egodystonic
• Result in efforts to resist, ignore or suppress obsessions

Question 12

Define a Compulsion.

Answer 12

Repetitive behaviours or mental acts that are performed in response to an obsession in order to prevent the occurrence of a feared event or to prevent discomfort, distress or anxiety.
- Aimed at neutralising the obsessions
- Any behaviour, overt or covert, has the potential to be a compulsion
○ Washing (contamination
○ Checking (responsibility for harm)
○ Ordering (perfection and fear of harm)

Question 13

What are the specifiers of OCD?

Answer 13

• Insight, which can range from good/fair, to poor, absent, or completely delusional beliefs.
• Symptoms must be in response to intrusive thought
• Some OCD can be tic-related (tends to occur with childhood onset, or otherwise associated with neurological disorders, eg ADHD)

Question 14

What are the 4 dimensions of presenting symptoms in OCD?

Answer 14

• Cleaning (contamination obsessions, cleaning compulsions)
• Harm (fears of harm to oneself or others, checking compulsions)
• Symmetry (obsession with symmetry, repeating, ordering and counting compulsions)
• Forbidden or taboo thoughts (Aggressive, sexual, religious obsessions & related disorders)

Question 15

What is the one possible common underlying theme in the dimensions of symptoms in OCD according to Menzies & Dar nimrod (2018)

Answer 15

Death

Question 16

Are symptoms in OCD only allowed in one dimension?

Answer 16

Symptoms often reside in more than one dimension

Question 17

What are the common compulsions in OCD?

Answer 17

• Washing and cleaning
• Checking (harm, mistakes)
• Repeating
• Mental compulsions
• Ordering and arranging objects

Question 18

Describe the prevalence of OCD.

Answer 18

Mean age of onset is 19.5 years, but can be very early on. Lifetime prevalence of 2-3%, more common in women, but men have earlier onset. OCD is chronic if untreated, it is unlikely the individual will get better by themselves. OCD is often comorbid - high levels of comorbidity with anxiety (76%), depression and bipolar (63%)

Question 19

How does operant reinforcement relate to the causation of OCD?

Answer 19

OCD is maintained by operant reinforcement; compulsions are negatively reinforced through reduction of anxiety forming a self-feeding maintenance cycle.

Avoidance maintains anxiety

Question 20

How would a cognitive model explain the causation and maintenance of OCD?

Answer 20

Obsessions are not qualitatively different from intrusive thoughts in the general population.
OCD is caused by a misinterpretation of the thoughts - thought-action fusions and unrealistic ownership of imagined negative events.

Question 21

What are some cognitive factors associated with OCD?

Answer 21

• Intolerance of uncertainty
• Inflated responsibility
• Thought-action fusion
• Magical Ideation

Question 22

Why would attempts to suppress intrusive thoughts make things worse?

Answer 22

Trying to suppress thoughts results in checking for those thoughts. This hypervigilance results in those thoughts being created.

Question 23

How does Rachman’s (1997) Cognitive Theory of Obsessions explain the causation of OCD?

Answer 23

Whilst obsessions are not uncommon people with OCD respond to obsessive thoughts differently or misinterpret them, sometimes perceiving the thought as an intention (harm compulsion). Attempts to supress thoughts leads to thought checking which actually creates the thoughts making matters worse

Question 24

What is thought-action fusion (Rachman, 1987)?

Answer 24

Thinking a bad thought increases the probability that the feared event will occur, and believing that having a bad thought is equivalent to carrying out the action -> increases the sense of personal responsibility and guilt

Question 25

How does Salkovskis (1985) Cognitive Behavioural Model of OCD explain the causation and maintenance of OCD?

Answer 25

• Unpleasant/unwanted/unacceptable intrusions and obsessions part of normal human experiences (thoughts not pathological)
• Intrusions come to disturb mood when they are interpreted negatively
• Appraisal of harm/danger -> anxiety; loss -> depression
• May activate pre-existing dysfunctional schemata

Question 26

What is the main treatment for OCD?

Answer 26

Cognitive behavioural therapy (CBT)

• Psychoeducation
• Cognitive strategies
• Behavioural experiments
• Exposure and response prevention

Question 27

Explain the psychoeducation treatment in CBT for treating OCD?

Answer 27

Normalise intrusive thoughts, talk about the role of engaging in compulsions

Question 28

Explain the cognitive strategies treatment in CBT for treating OCD?

Answer 28

• Challenge beliefs about intrusive thoughts

- Challenge beliefs about the consequences of not engaging in compulsions

Question 29

Explain the exposure and response prevention treatment in CBT for treating OCD?

Answer 29

• Exposure to obsession but prevent compulsion from being carried out
• An opportunity to learn that there are not negative consequences if the compulsion is not performed

Question 30

List the certain cognitive strategies OSC is associated with

Answer 30

• Overestimation of danger: logical vs subjective probabiltities; talking to an expert
• Inflated responsibility: pie charting; courtroom procedure
• Over importance of thoughts: normalising/surveying others; thought sampling
• Thought-action fusion: demonstrating that having thoughts does not result in action (e.g. buying a lottery ticket)
• Intolerance of uncertainty/need for control/perfectionism: cost/benefit analysis; continuum scaling

Question 31

What is Exposure and response prevention (ERP)?

Answer 31

Client is exposed to the feared situation that triggers the obsessional thought(s), then prevented from engaging in their compulsion until anxiety decreases through the process of habituation

Question 32

What was ERP initially conceived as and eventually adapted to?

Answer 32

Originally conceived as a pure behaviour intervention, now been adapted to a cognitive model in the form of a behavioural experiment in which the client learns that their obsessional thoughts are not justified and they can tolerate distress

Question 33

What is proposed about ERP in terms of exposure to the trigger?

Answer 33

Proposed that exposure works not just through the process of habituation, but because it provides the opportunity for disconformity experiences and the opportunity to change appraisals

Question 34

How does ERP work?

Answer 34

Involves developing a hierarchy of feared situations, from least fear eliciting to most fear eliciting

Question 35

In how ERP works what role does exposure play?

Answer 35

The client is guided through exposure to feared situations that trigger the compulsion

Question 36

In how ERP works what is the role of response prevention?

Answer 36

The client is asked to refrain from completing the compulsions that would otherwise eliminate the anxiety or distress

Question 37

What context do ERP exercises occur and at what point does it continue?

Answer 37

Exposure continues until the highest feared situations on the hierarchy are readily tolerated without the client engaging in the compulsions
ERP exercises occur both in vivo (in real life), and imaginal (in the clients imagination)