7- OCD Flashcards

1
Q

DSM-5: OCD Dx

A

Previously grouped with anxiety disorders (up until DSM-IV) => Removed and put into its own category in DSM-5

  • Anxiety not as stable a feature?
  • Different, specific treatments?

Now grouped with other more similar diagnoses => Lack of agreement regarding this decision

DSM-5:

  • Presence of obsessions, compulsions, or both
  • Time consuming (more than 1 hour per day) and cause distress and/or impairment

Specify insight: Good or fair insight vs Poor insight vs Absent insight / delusional beliefs

Epidemio

  • 2-3% lifetime prevalence
  • Less clear gender differences
  • Onset typically in adolescence or early adulthood
  • Chronic course => But early detection and intervention improves recovery rates
  • Often co-occurs with anxiety and mood disorders
  • Comorbid MDD predicts increased risk of suicidality

=> Functional Impairment

World Health Organization (2008) ranked OCD as a leading cause of disability worldwide

Psychosocial impairments:

  • Basic self care
  • Work/school
  • Family and social functioning

Comparable to impairments found in physical illnesses and schizophrenia

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2
Q

Obsessions

A

Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and cause marked anxiety and distress

  • Ego-dystonic (because intrusive and “inappropriate”) => vs. eating disorders are ego-syntonic
  • Sense of lack of control

Types of obsessions:

  • Contamination (most common) *
  • Uncertainty *
  • Aggressive
  • Symmetry/Exactness
  • Sexual
  • Religious
  • Somatic (physical/mental)

=> OCD vs Schizo

  • Person recognizes that his-her thoughts are irrational
  • Continuum of insight
  • Distinguishes OCD from schizo (don’t realize it’s irrational) or psychosis => no delusional thought system

=> OCD vs GAD

  • Obsessions and worry share similarities: Intrusiveness and uncontrollability of thoughts
  • How to differentiate? => Obsessions tend to be more bizarre, Involve more imagery
  • Not just worries about everyday real-life problems (like in GAD)
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3
Q

Intrusive Thoughts and Acting on Them

A

Obsessions and compulsive beh exist on a continuum

OCD is differentiated based on:

  • Frequency
  • Intensity
  • Degree of distress/impairment

Many OCD patients feel shame about content of thoughts => Therapy involves normalizing

=> Likelihood of acting on obsession

  • People with OCD almost never act on their urges and impulses regarding their obsession ex: harm and sexual obsessions
  • Unlike other kinds of intrusive thoughts because these are ego-dystonic => Urges with OCD are not pleasurable
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4
Q

Compulsions

A

Repetitive beh or mental acts that attempt to neutralize or suppress obsession => Person must perform the beh

=> Designed to reduce anxiety from the obsession NOT designed to bring pleasure or gratification

Common compulsions => Sometimes simple actions, sometimes very bizarre and complex *Frequently represent a neutralization (Prevent, cancel, or “undo” the feared consequence and distress caused by the obsession)

  • Washing / Cleaning *
  • Checking *
  • Repeating
  • Mental (ex: scenario where sme survives)
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5
Q

Biological Factors

A

Genetic Factors

  • Mild to moderate heritability estimates =>Twin and family studies
  • Earlier onset shows greater genetic influence
  • Over 30 potential genes have been investigated => Nothing conclusive yet in terms of specific genes
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6
Q

Brain Abnormalities

A

Overactivity:

  • Basal ganglia (emotion)
  • Orbital frontal cortex (primitive urges; “the stuff of obsessions”)

Underactivity:

  • Frontal cortex (higher level planning and inhibition)
  • Structural (volume) and/or functional (connectivity) abnormalities

Serotonin Hypothesis

  • Clomipramine was the first effective drug treatment reported for OCD => Backwards logic (just like depression)
  • Led researchers to conclude that abnormalities in serotonin neurotransmission plays in a role in the etiology of OCD (But evidence for its causal role is inconclusive)
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7
Q

Psychological Factors

A

Learning Theory => Anxiety and fear are acquired through learning history (develops with classical cond and maintained with operant cond)

*Neg reinforcement when wash hands to reduce distress

Consequences of neutralization => Negatively reinforces beh and maintains the obsession, Believes that neutralization prevented feared outcome (and therefore necessary to keep doing it)

=> If prevent neutralization:

  • Learning that feared event X did not occur
  • Leaning that anxiety produced from obsession diminishes on its own (even in the absence of neutralization)

Neutralization Study: Neutralize rn or 20min later => neutralization reduces anxiety but urge to neutralize and anxiety goes down when neutralization is delayed or prevented

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8
Q

Cognitive Model (4)

A

1- Obsessive thoughts are very common – but not everyone develops OCD => Why?

  • Intrusive thoughts = stimuli
  • Cognitive responses (negative automatic thoughts) to stimuli (i.e., intrusive thoughts) is what creates distress *Personally significant appraisals

2- Value systems

Content of obsessions often reflect themes that are most important to the person’s system of values ex: A person with very high religious standards will be upset by intrusion of sinful thoughts

3- Catastrophic misinterpretations => Of one’s intrusive thoughts, images, and impulses

  • Obsessions persist as long as misinterpretations continue
  • Turns neutral stimuli into threatening stimuli
  • Frequency of obsessions will decrease when misinterpretations are changed

4- Personal Responsibility

  • OCD have inflated sense of personal responsibility and self- blame
  • Attach undue significance to presence of intrusive thought ex: think that it means something negative about their character
  • This attached meaning is what causes the distress

Study: With OCD, SAD, non-anxious and low/oc-relevant/high risk risk

Ratings of personal responsability:

  • OCD score higher than non-anxious AND socially anxious in low-risk and OC-relevant situations
  • But socially anxious also score higher than non- anxious controls in OC- relevant situations
  • No difference between group in high-risk situation
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9
Q

Cognitive Model - Thought-Action Fusion

A

Moral TAF:

Unwanted thoughts about disturbing actions are equivalent to the actions themselves

Likelihood TAF:

Thinking about a disturbing event makes the event more probable => Self, Other

“Magical Thinking”

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10
Q

Memory Deficits

A

When OCD patients are asked why they perform checking rituals, they often express dissatisfaction with their memory => Early theories that OCD (especially checkers) have objective memory impairments

Study: Memory Deficit or Poor Memory Confidence?

Participants who repeatedly checked the stove (vs. sink) showed:

  • Decrease in metamemory variables (confidence, vividness, detail)
  • Decrease in memory accuracy
  • Same effect for clinical OCD and non-clinical controls
  • No memory differences between OCD and controls at baseline
    *Self-perpetuation/doubting mechanism
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11
Q

Intolerance to Uncertainty (2) and Disgust

A

Intolerance of Uncertainty => Experience uncertainty as negative, dangerous, or unfair and OCD engage in compulsive rituals (ex: checking) to restore certainty

Types of IU

Prospective IU

  • Desire for predictability
  • Negative cognitive responses to future uncertainties
  • Related to all types, but especially checking

Inhibitory IU

  • Behavioral inaction related to uncertainty (belief that uncertainty compromises functioning)
  • Especially related to contamination and “unacceptable” thoughts types => Lacking coping or problem solving skills to manage themselves

*Not specific to OCD – present in many disorders (ex: GAD)

Role of Disgust => Many OCD patients report feeling “disgusted” (not “frightened”) in response to relevant stimuli

  • Disgust = basic emotion =>Disease avoidance function (evolutionarily)

Disgust Proneness => Personality trait that reflects the tendency to experience disgust frequently and intensely

  • DP has strong link with OCD *Especially with contamination subtype => But also other subtypes (ex: ordering, hoarding)
  • Also plays role in other dx ex: spider phobia => “Once in contact always contaminated”
  • Very hard to counter-condition => Can explain some of the challenges in treatment-resistant OCD
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12
Q

Treatments (3)

A

1- Exposure and Response Prevention

  • Exposure to stimuli that provoke obsessions
  • Refrain from engaging in their usual rituals
  • Usually do this gradually (re: fear hierarchy)

Outcomes?

  • At least half show reduction in sx
  • Majority maintain gains at follow-ups
  • Superior effects to medication

How does it work?

Fear conditioning: Association between CS (doorknob) and US (“scary”) => Reduce this through extinction: Present CS without US

=> Historically, thought to be beh habituation-based mechanism

  • “Unlearn” or “erase” obsessional fears
  • Emphasis is on reduction of fear during exposure (i.e., habituation)
    *Not consistently supported by research

2- Inhibitory Learning Model

Assumes that original CS-US association is not erased => Instead, new, secondary inhibitory learning about the CS-US develops

  • Specifically, learn new safety information (ex: “doorknobs are generally safe”) that inhibits existing obsessional fear (ex: “doorknobs are dangerous”)

3- Cognitive Therapy

Psychoeducational component

  • Normalizing obsessions
  • Model of obsessive thoughts and compulsive beh

Reappraisal strategies:

  • Replace catastrophic misinterpretations with more realistic and benign interpretations

Distancing strategies:

  • Targets thought-action fusion
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