Lecture 6 - OCD Flashcards
What is OCD
This condition is illustrated by someone who has recurrent and persistent thoughts/ impules/ images 9obbsessions).
thoughts may focus on cleanliness, puctuality, order or corectiveness
cause patient distress so much so that they will do anything to rid themselves of stress (often bizarre and dangerous)
what is an obbsession
recurrent / persistent thoughts urges and images
intrusive and unwanted
cause anx / distress
thoughts suppressed with the compulsion
What is a complusion
- repetitive behaviours mental acts in response to a obbsession aimed to reduce anx or prevent a 'dreaded event' not realistic and usually excessive
explain the DSM for ocd
Obsessions or compulsions are time consuming
- Take more than 1 hour a day
- Cause clinically significant distress or impairment
- Social, occupational, or other important areas of functioning
- Obsessions and compulsions usually occur together
- Prevalence around 2-3% of population
- Examples (Abramowitz, 2006)
o O: Contamination
- C: Inappropriate washing and cleaning
o O: Responsibility for harm/catastrophe
- C: Compulsive checking
o O: Repugnant, aggressive, sexual, or blasphemous thoughts
- C: Mental rituals, praying
Most OCD sufferers realise that obsessions/compulsions excessive - But DSM5 no longer sets this as one of the criteria
o But some strongly believe rituals prevent bad things happening
o Sometimes fine line between obsession and psychosis
o Important to determine level of insight and delusional thought
- Untreated, OCD is chronic and deteriorating
- OCD symptoms and consequences impair many areas of life
o Job/academic performance
o Social functioning
o Relationship
name some typical obbsessions
Typical obsessions
o Fear of dirt and contamination
- e.g. from shaking hands with someone
o Repeated doubts
- e.g. have not locked a door
o A need to have things in a certain order
o Aggressive impulses
- Possibly (thinking about) hurting own child
o Although these impulses are not (usually) carried out
- Person is bothered that they had the thought at all
name some typical compulsions
Typical compulsions
o Pursuing cleanliness or order
- Often elaborate and time-consuming ceremonies
o Avoiding objects
- Don’t step on the cracks!
o Performing ‘magical’ repetitive (protective) actions
- Counting
- Touching lucky charm, or part of body
o Repeatedly checking
- Going back to check several times that oven is off
- Or that the door is locked
what impact does OCD have on daily functioning
Relationships (Friends, family… Huppert, et al. 2009)
o OCD very time-consuming
o Oddness of compulsions
o Both cause family/social strain
- Quality of life
- Unemployment and other work-related impact (Rodriguez Salgado, et al. 2006)
- Physical injury – e.g. chafing from repeated washing (Kestenbaum, 2013)
- Substance abuse (Brady, et al. 2013)
- Suicidal behaviour (Torres, et al. 2011)
- WATCH SHORT FILM ON SLIDES
Can you be ‘a little bit OCD’
Can you be ‘a little bit OCD’
- All too common to hear someone say ‘I am a little bit OCD about that”
o Preferring to have certain things ‘in order’ might be quirky
- But it’s not OCD
o Trivial programmes like ‘Obsessive Compulsive Cleaners’ don’t help
- Flippant use of the term just adds to stigma
o Prevents those genuinely in need to seek help
o Afraid to talk to friends or family
o Feeling of isolation
- OCD, by definition, is a disorder…
o … ‘a psychological pattern associated with distress or disability’
o It’s not a lifestyle choice
name some co morbid illnesses with OCD
Comorbidity of OCD with psychotic disorders (including schizophrenia)
o OCD symptoms may occur in 8% to 26% of patients with schizophrenia (Pallanti, et al. 2011)
o May show repetitive behaviour in response to delusions and hallucinations
- Other psychiatric disorders that can occur with OCD
o Post-traumatic stress disorder
o Generalized anxiety disorder
o Panic disorder
o Social anxiety disorder
WHAT IS THE DIFFERENCE BETWEEN ocd and ocpd
bsessive-Compulsive Personality Disorder (OCPD)
o Often confused with OCD – but they are not the same
- OCD is a mental disorder
o Develops later in life
- Early adulthood or later
o Obsessions - can’t get rid of intrusive, repetitive thoughts
o Engage in compulsions to reduce anxiety activated by obsessions
- OCPD is a personality type
o Onset often much earlier in life
o Formative years
- Preoccupation with correctness
- Order
- Perfection
- Control
o Lack of flexibility, openness and efficiency
- OCD/OCPD can occur separately
o Or can be comorbid
- Those with OCD are not always perfectionist
o Although some are
explain the psychoanalytic model for OCD
Freud: OCD due to instinctual forces
o Not under control because of harsh toilet training
- Person is fixated at anal stage
- Or may be sexual repression
o Struggle between id and defence mechanisms
- Adler: OCD due to (perceived) incompetence
o Children prevented from developing sense of competence
- Doting or excessively dominating parents
- Child develops inferiority complex
- Unconsciously adopt rituals to maintain control
- Allows at least some mastery in something
EXPLAIN THE COGNITIVE model for ocd
Cognitive model OCD
o Obsessions vs. intrusive thoughts
- Intrusive thoughts can be ‘normal’
- When appraisal becomes pathological à OCD (Salkovskis, 1999)
o But intrusive thoughts and obsessions differ
o Intrusive thoughts…
- Less intense, do not last as long, cause less distress, easier to get out of the mind… (Rachman & de Silva, 1978)
- Less frequent… than obsessions (Purdon & Clark, 1994)
o Obsessions
- Thoughts in conflict with ideal self-image
- Harder to control thoughts with OCD
- Bouvard et al. (2016)
o Used International Intrusive Thought Interview Schedule (IITIS; Research Consortium on Intrusive Fear, 2007)
- Assessed unwanted intrusive thoughts (UITs)
- Compared 28 OCD patients with 28 non-clinical controls
o All participants reported at least one type of UIT
- But OCD group sig. more intrusive thoughts than controls
o In the OCD group, UITs …
- More frequent
- Interfered more with daily life
- Considered to be more important to get out of the mind,
- More difficult to stop
- … than for controls
explain Mowrer’s two-process theory - a cognitive explanation of OCD
Mowrer’s two-process theory
o Neutral stimuli associated with frightening thoughts
o Such as shaking hands and prospect of contamination
o Washing hands extensively reduces anxiety
o Washing response reinforces obsession
- OCD patients have trouble ‘switching off’ for several reasons
o May be depressed or anxious for most of time
- Events more likely to invoke intrusive thoughts
o Unable to suppress thoughts (Szechtman & Woody, 2004)
- OCD patients tend to have rigid moralistic thoughts
o Judge many thoughts more unacceptable than most people
o More anxious about having them
- OCD patients feel they should be able to control all thoughts
o And often believe thoughts to have grounding in reality
- Makes them more anxious
o If anxiety is reduced, behaviour is reinforced
EXPALAIn the genetic influence of OCD
Genetics (Hettema, et al. 2001)
o Twin studies show high heritability
- Concordance in identical twins 68%
- Fraternal twins 31%
o Family studies confirm this
- Significantly higher rates in 1st degree relatives of OCD patients
- Serotonin and neurotransmission (Math & Janardhan Reddy, 2007)
o OCD may be associated with levels of serotonin
- Some antidepressants effective in treating OCD
o Several neurotransmitters may be implicated
- Serotonin, dopamine, acetylcholine
explain some biological treatments for OCD
- Benzodiazepines
o Not very for effective OCD
- Tricyclic antidepressants (TCA)
o Clomipramine is approved for treatment of OCD in USA
- Probably most effective drug for OCD
o But side effects may preclude it as 1st line treatment
- Selective serotonin reuptake inhibitors (SSRI)
o Several SSRIs approved for OCD treatment in USA
- Ideal for 1st line treatment
o Effective, but response is slow
Tcas
- Clomipramine
o First drug to be approved for treating OCD in USA
o Some evidence that clomipramine more effective than SSRIs (e.g. Ackerman, et al., 1995)
- But these studies pre-date SSRIs, so barley comparable
- Head-to-head studies show SSRIs and clomipramine similar efficacy (Mundo, et al. 2001)
o Also, side effects with clomipramine
- Heart problems, dry mouth, constipation, urinary retention, tachycardia, weight gain (Kristensen, et al. 1989)
- Can induce manic episodes for patients with bipolar disorder (Sathyanarayana, et al. 1991)
SSRIS
- Evidence suggests little difference between SSRIs (Soomro, et al. 2008)
o Typically, SSRIs used to treat depression
o And yet SSRI dose often higher for OCD than depression (Kellner 2010)
o SSRI response rates slower for OCD than depression (Pittenger, 2005)
o Up to 12 weeks before effect is seen
- SSRIs argued to be best choice for children and adolescents (Williams, et al., 2003)
