Lecture 6: Obsessive Compulsive and Related Disorders: Chapter 7 (186-201) Flashcards
What is the common factor in obsessive-compulsive and related disorders?
Repeated thoughts and behaviors that are so extreme they interfere with daily life
What are 3 obsessive compulsive related disorders? What is common for all 3?
- OCD
- Body dysmorphic disorder (BDD)
- Hoarding disorder
All share repetitive thought and irresistable urges to engage repetitively in some behavior
What is hoarding disorder?
Acquisition of an excessive number of objects and an inability to part with those objects
What are 2 key features of OCD?
- Obsessions: repetitive, intrusive thoughts or urges
- Compulsions: repetitive behaviors or mental acts that a person feels compelled to perform
What is trichotillomania?
Compulsive hair pulling
What is excoriation disorder?
Compulsive skin picking
What are the goals of compulsions?
- Preventing or reducing anxiety or distress
- Preventing event or situation
What are 3 criteria for OCD?
Obsessions and/or compulsions
Time consuming >1hour per day, or distress/impairment
What is the difference between overt and covert compulsions?
Overt: observable (hand washing)
Covert: not observable (compulsive thoughts)
How can cognitive treatment be a compulsion?
Sometimes if you treat someone, they actually take the cognitive strategies you teach them as new compulsions
What did the classic study of Rachman and de Silva demonstrate?
That nobody can say whether intrusions are normal or abnormal. Students did equally well as experienced psychologists in identifying abnormal or normal intrusions
What are 2 similarities of intrusions between OCD patients and control groups?
- Most people have intrusions
- Form and content are quite similar
What are 5 differences for intrusions in OCD patients compared to controls?
- Higher frequency of intrusions
- More intense experience of intrusions
- Longer duration
- More distress
- Stronger urge to neutralize
What are 3 possible causes of OCD concerning cognitive styles? Give an example of each)
General reasoning errors:
1. Emotional reasoning
–> I’m afraid so there is danger
2. Magical thinking/superstition
–> If I step on the cracks of the tiles, my mom will die
3. Dichotomous thinking
–> omission = commission
What does dichotomous thinking in OCD patients mean? Give an example
Omission = commission
So they think forgetting something and something bad happens is equally bad as intentionally doing something and something bad happens
E.g. forget to turn stove off or intentionally not turn stove off
What do behavioral models say about the etiology of OCD?
Compulsions arise from a high sensitivity to operant conditioning. They feel relieved if they’ve done the compulsion
= Neurotic paradox
What does the Thought Action Fusion (TAF) model say about the etiology of OCD? What are its 2 dimensions and give examples for each?
According to this model, the problem with OCD is not the initial intrusive thought, but the response to the thought
Dimensions:
1. Likelihood: thinking about it increases chances it occurs
–> Thinking about wife having a car crash –> suppress thought because otherwise it will happen
- Moral: thinking about it is equivalent to acting
–> Thought of harming child: bad mother!
What is the white bear effect and what does it demonstrate?
If instructed to not think of a white bear in the next minute, you think more about it
So if one suppresses a thought, the thought usually occurs more
What can be a possible consequence of excessive checking?
Memory distrust
What are the prevalences of OCD, BDD and hoarding disorder?
OCD: 1,3%
BDD: 3%
Hoarding: 1,5%
How do prevalences differ in men vs. women for OCD, BDD and hoarding disorder?
OCD: slightly more among women than men
BDD: equal prevalence
Hoarding: more common in men than women (but animal hoarding more common in women)
What are 6 common foci of obsessions in OCD?
- Contamination
- Responsibility for harm
- Sex/morality
- Violence
- Religion
- Symmetry/order
What are 5 foci of compulsions in OCD?
- Decontamination
- Checking
- Repeat routine activities
- Ordering/arranging
- Mental rituals
What are 4 symptoms of BDD?
- Preoccupation with one/more perceived defects in appearance
- Others find the defects slight or unobservable
- Performance of repetitive behaviors/mental acts (mirror checking)
- Preoccupation not restricted to weight or body fat concerns
How much time do people with BDD worry about their appearance?
3-8 hours per day
What part of BDD clients have little insight into their harsh views?
1/3 of clients
What percentage of BDD patients cope with suicidal thought and how many actually attempt suicide?
1/3 suicidal ideation
20% attempted suicide
How is BDD cross-culturally?
The symptoms and outcomes are more or less the same across cultures.
Sometimes different focuses of body parts per culture
What is the heredity for OCD?
30-50%
What are comorbid disorders of OCD, BDD and hoarding disorder?
Anxiety disorders, depression, substance abuse
OCD especially a lot with anxiety
What part of hoarding disorder clients also hoard animals?
1/3 hoards animals as well
What are some physical consequences of hoarding disorder?
Poor hygienic and health conditions leading to poor physical health
Why do many people with hoarding disorder don’t get treatment?
Because they’re often unaware of their problem themselves
What are 4 defining symptoms of hoarding disorder?
- Persistent difficulty discarding or parting with possessions
- Perceived need to save items
- Distress associated with discarding items
- Accumulation of possessions clutters active living spaces to the extent that their intended use is compromised unless others intervene
What are 4 cognitive aspects hoarding disorder can be attributed to?
- Poor organizational skills
- Difficulty making decisions
- Unusual beliefs about possessions, extreme emotional attachment
- Avoidant behavior (can’t make decisions)
Give an example of adaptive hoarding
Our grandparents who grew up after the war: it would be adaptive if they hoarded a bit :)
What do clients with BDD think their self-esteem depends on?
Entirely on their appearance
What is the age of onset in people with OCD/ BDD / hoarding disorder?
OCD/hoarding: childhood/early adolescence
BDD: adolescence
What can you say about the co occurrance of OCD, BDD and hoarding disorder?
They often co occur
1/3 BDD patients and 1/4 hoarding disorder patients meet criteria for OCD during their lifetime
1/3 of OCD patients experience some symptom of hoarding
What is the percentage of people with OCD also experiencing an anxiety disorder during their lifetime?
75%
What 3 brain regions are unusually active in people with OCD? What is the impact of treatment on these regions?
Fronto-striatal circuits regions:
1. Orbitofrontal cortex
2. Caudate nucleus (basal ganglia)
3. Anterior cingulate cortex
With good treatment, activation in OFC and CN is reduced
What brain area is involved in OCD, BDD and hoarding disorder?
Fronto-striatal circuit
What are neurobiological similarities and differences between OCD, BDD and hoarding disorder?
All tied to fronto-striatal circuits
Differences: each disorder is tied to additional brain regions
–> e.g. BDD: tied to connections in visual processing
What is the etiology behind BDD?
Visual perception is the same, but their focus is different. People with BDD focus on separate parts of the body instead of the whole
What are the most commonly used drugs for obsessive compulsive and related disorders?
Anti-depressants (SNRI and SSRI), typically higher dosage then with mood disorders
What are 4 possible treatments for OCD? Place the most effective one on place 1
- Exposure with Response Prevention (ERP)
- Cognitive therapy
- Medication (SSRI)
- Deep brain stimulation (DBS)
Give an example of an obsession and a compulsion in someone with BDD
Obsession: appearance
Compulsion: mirror checking
What is a neurotic paradox in OCD?
Short term relief from compulsions, but it’s a long term pathology
What is the reasoning behind the approach of exposure and response prevention as a therapy for OCD? Describe in 3 steps
- Not performing ritual exposes person to full force of anxiety
- Exposure promotes extinction of conditioned stimulus (anxiety)
- Facing feared stimulus helps person develop new, more positive thoughts in response to the stimulus
Give an example of ERP treatment
Someone has to touch something dirty and not wash their hands afterwards.
The timing of washing hands is extending per exposure –> hierarchical approach
How can someone doing ERP refrain from covert compulsions?
E.g. covertly counting to 10 and therefore not thinking about the compulsive thought
What would ERP therapy look like for a person with BDD?
Therapist might ask client to avoid activities they use to reassure themselves about their appearance (such as looking in mirrors)
How effective is ERP for BDD?
Pretty effective, but many people do continue to experience at least mild symptoms after treatment (no difference if it’s online or in person)
What does ERP look like for people with hoarding disorder?
The exposure element is getting rid of their objects (their biggest fears).
The response-prevention focuses on halting the rituals that people with hoarding disorder engage in to reduce anxiety (e.g. counting/sorting)
Always working hierarchically!
Give an example of rituals people with hoarding disorder do to cope with their anxiety
E.g. counting or sorting their possessions
What is often needed in treatment for hoarding disorder before ERP can start?
Cognitive therapy
How do hoarding symptoms damage family relationships?
Relatives try to help clear the clutter, only to become more and more distressed as those attempts fail. Coercive strategies create mistrust and animosity.
How does cognitive therapy for obsessive compulsive and related disorders work? For which patients is this necessary before going into further treatment?
Try to challenge the belief the patient has over something.
When someone has poor insight and doesn’t accept the idea there is a mental disorder, cognitive therapy is needed before going into ERP
What percentage of OCD patients won’t respond to pharmacological treatments? What are the 2 next options?
10% don’t respond
Either dTMS (deep transcranial magnetic stimulation) or DBS (deep brain stimulation)
What brain region is often stimulated in OCD patients with DBS?
Basal ganglia : implanted electrodes
