Anxiety Disorders Flashcards
Concise description of OCD (ICD 9)
The outstanding symptom is a feeling of subjective
compulsion— which must be resisted— to carry out some
action, to dwell on an idea, to recall an experience, or ruminate
on an abstract topic. Unwanted thoughts, which include
the insistency of words or ideas, ruminations or trains of thought, are perceived by the patient to be inappropriate
or nonsensical. The obsessional urge or idea is recognized
as alien to the personality but as coming from within the
self. Obsessional actions may be quasi ritual performances
designed to relieve anxiety, e.g. washing the hands to deal
with contamination. Attempts to dispel the unwelcome
thoughts or urges may lead to a severe inner struggle, with
intense anxiety.
It is the combination of an inner sense of compulsion
and of efforts at resistance that characterizes obsessional
symptoms, but the effort at resistance is the more variable
of the two.
Obsessional ruminations
Obsessional ruminations are internal debates in which
arguments for and against even the simplest everyday
actions are reviewed endlessly. Some obsessional
doubts concern actions that may not have been completed
adequately (e.g. turning off a gas tap or securing
a door), while other doubts concern actions that might
have harmed other people (e.g. that driving a car past
a cyclist might have caused him to fall off his bicycle).
Sometimes doubts are related to religious convictions or
observances (‘scruples’)— a phenomenon well known to
those who hear confession.
Obsessional impulses
Obsessional impulses are urges to perform acts, usually
of a violent or embarrassing kind (e.g. leaping in front
of a car, injuring a child, or shouting blasphemies at a
religious ceremony).
Obsessional rituals
Obsessional rituals include both mental activities
(e.g. counting repeatedly in a special way, or repeating
a certain form of words) and repeated but senseless
behaviours (e.g. washing the hands 20 or more times a
day). Some rituals have an understandable connection
with the obsessional thoughts that precede them (e.g.
repeated hand washing following thoughts about contamination).
Other rituals have no such connection (e.g.
arranging objects in a particular way). The person may
feel compelled to repeat such actions a certain number
of times, and if this sequence is interrupted it has to be
repeated from the beginning. People who use rituals are
usually aware that these are illogical, and usually try to
hide them
Obsessional slowness
Obsessional slowness. Although obsessional thoughts
and rituals lead to slow performance, a few obsessional
patients are afflicted by extreme slowness that is out of
proportion to other symptoms
Obsessional phobias
Obsessional phobias. Obsessional thoughts and compulsive
rituals may worsen in certain situations— for
example, obsessional thoughts about harming other
people may increase in a kitchen or other place where
knives are kept. The person may avoid such situations
because they cause distress, just as people with phobic
disorders avoid specific situations. Because of this resemblance,
the condition is called an obsessional phobia.
Relationship of OCD to OCPD
Relationship to obsessional personality. Obsessional
personality (obsessive compulsive personality disorder
in DSM- 5) is described in Chapter 15. There is no simple,
one- to- one relationship between OCD and this kind
of personality. Although obsessional personality is overrepresented
among people who develop OCD, about
one- third of obsessional patients have other types of
personality (as noted in a classic paper by Lewis, 1936).
Furthermore, people with obsessional personality are
more likely to develop depressive disorders than OCDs.
Aetiology of OCD
- Genetics- Familial studies
have reached a similar conclusion, and indicate that the
risk of OCD in first- degree relatives is increased approximately
fourfold compared with control rates
Glutamate, serotonin transporters, 5HT2A, BDNF
SLC1A1 - Associated with other brain disorders- encephalitis, Tourette, Sydenham’s chorea, PANDAS
- Brain imaging- increase in grey matter volume in
the striatum and decrease in orbitofrontal, dorsomedial,
and anterior cingulate cortex
patients demonstrate increased activity in
orbitofrontal cortex, caudate, anterior cingulate cortex,
and thalamus - Abnormal serotonergic function.
- Psychoanalytical theories
Freud originally suggested that obsessional symptoms
result from unconscious impulses of an aggressive or
sexual nature. These impulses could potentially cause
extreme anxiety, but anxiety is reduced by the action of
the defence mechanisms of repression and reaction formation. - Neuropsychological function- perform less well on tasks of set shifting, reversal learning, relative preponderance, habit learning over goal directed learning. It is also worth noting that although compulsivity
and impulsivity are often regarded as opposite behaviours,
they can coexist. An anatomical basis for this is
that, like compulsivity, impulsivity is thought to arise
from dysfunction in cortico- striatal- thalamic loops, in the
case of impulsivity in pathways involving the ventral
striatum, anterior cingulate cortex, and ventrolateral
prefrontal cortex. - Cognitive theory
Respond to obsessional thoughts as if they were personally responsible. Leads to excessive attempts to ward off thoughts/consequences of thoughts/obsessions. Current theory is unproven.
Key cognitive processes in OCD
- Thought– action fusion. Magical thinking— for
example, the belief that if one thinks of harming
others one is likely to act on the thought or might
have done so in the past. - Responsibility. An inflated sense of responsibility
for preventing harm to others; the belief that one
has power that is pivotal to bringing about or preventing
crucial negative outcomes. - Compulsions and safety- seeking behaviours.
Compulsions— whether behavioural or mental—
are reinforcing because they reduce anxiety temporarily.
They strengthen the belief that, had the
compulsion not been carried out, discomfort would
have increased and harm might have occurred. - Overestimation of the likelihood that harm
will occur. - Intolerance of uncertainty and ambiguity.
- The need for control
Which psychoanalytic personality is hoarding disorder associated with
Anal personality
