Obsessions and Compulsions Flashcards
Definition of obsessions
RECURRENT, PERSISTENT, INVOLUNTARY
- thoughts e.g. single words, phrases
- images e.g. vivid scenes of violence, abnormal sexual acts
- impulses e.g. to perform violent or embarrassing acts
- ruminations e.g. internal debates, continuous arguments
- doubts e.g. actions not completed adequately or may have harmed someone
- rituals e.g. repeated senseless mental activities or behaviours such as hand washing
which are INTRUSIVE and experienced as unpleasant and distressing
enter the mind against CONSCIOUS RESISTANT
recognised by patients as a product of their own mind (not thought insertion)
often HAVE INSIGHT that they are irrational –> EGODYSTONIC
Definition of compulsions
aka. Obsessional rituals
Repetitive mental operations or physical acts
- feel COMPELLED TO PERFORM in response to obsession or irrationally defined “rules”
- REDUCES ANXIETY and WILL PREVENT A DREADED EVENT from occurring even though not realistically connect or clearly excessive
- UNPLEASANT and SERVES NO REALISTIC PURPOSE
- may be resisted but will increase anxiety
Usually followed by temporary release of distress but then doubts will build up again about adequacy of actions and individual repeats sequence
Common obsession-compulsion associations and additional symptoms (must ask in Hx taking)
Most common: Fear of contamination - Excessive washing and cleaning, avoid contaminated object
Pathological doubt - exhaustive checking for omission
Violent, blasphemous or sexual thoughts/impulses/images - act of “redemption” or seeking reassurance
Need for symmetry and precision - arranging objects to obtain perfect symmetry
Other common symptoms:
- anxiety, depression
- depersonalisation may occur (more disabling)
Differential diagnosis for obsessions and compulsions
Obsessions and compulsions
- OCD
- Eating disorder
- Obsessive-compulsive personality disorder
- Delusional disorder? (from pp)
Mainly obsessions
- depressive disorder (depressive symptoms first)
- other anxiety disorders (anxiety symptoms more prominent; phobia concern harm to self and more specific vs OCD concern harm to others)
- hypochondriacal disorder
- schizophrenia (MSE)
Mainly compulsions
- habit and impulse control disorders e.g. kleptomania, gambling, trichotillomania
- tourette’s syndrome
Diagnostic criteria of obsessive-compulsive disorder 強迫症
- Presence of obsessions, compulsions or both:
- obsession - recurrent, intrusive, persistent, unwanted thoughts that cause marked anxiety and distress; tries to ignore or suppress them with some other thought or action
- compulsion - repetitive behaviours or mental acts compelled to perform in response to obsession; aimed to reduce anxiety or distress or prevent a dreaded event from occurring – but are not connected and clearly excessive
2. obsessions are TIME CONSUMING or cause CLINICALLY SIGNIFICANT IMPAIRMENT
3. Not due to SA or medical condition
4. Not better explained by GAD, dysmorphic disorder, eating disorders, MDD, schizophrenia spectrum
OCD epidemiology
2-3% lifetime prevalence
0.8-1% 1 yr prevalence
M=F
Mean age of onset 20 yrs old (but many start having symptoms in early teens)
OCD comorbidities
- *MDD
- lifetime risk 60-70%
Others
- *alcohol use disorder, eating disorder, phobias, PTSD
OCD aetiology
Predisposing:
- GENETICS - 10x lifetime risk in 1st degree relatives
- neurobiological mechanisms
- –> increased activity in frontal lobe, caudate nu and cingulum
- –> 5HT pathways (disorder of pathways in basal ganglia a/w high level of obsessional symptoms e.g. Tourette’s)
- –> damage to caudate nucleus e.g. AI disease Sydenham’s chorea which is a/w OCD in 2/3 cases
- early experiences
- OC personality
Precipitating:
- stressful events
Perpetuating:;
- conditioned response to anxiety provoking events
- MDD
- cycle of anxiety
- continuing stress
OCD prognosis
1/3 chronic and fluctuating course
2/3 improve within a year
50% patients improve substantially with medication
Management of OCD
Detect comorbidities esp MDD (and treat)
Inpatient rare
- severe risk, severe MDD, AN, schizophrenia
General:
- psychoeducation (understand thoughts and actions, reduce fear about progressing to act on impulses)
- problem solving techniques, relaxation
- self-help books to start resisting rituals
Mild-mod:
- CBT (EXPOSURE WITH RESPONSE PREVENTION – exposure = facing and confronting one’s fears repeatedly until fear subsides; response prevention = refraining from compulsion or avoidance behaviours)
- –> brief individual (up to 10 hrs), telephone or group
Mod-severe:
- individual CBT
+/-
- 1st line: SSRI
- Alternative: clomipramine (also effective but need high dose which produces undesirable S/E)
—> meds take 6 wks to reach full effect (can use BZD in short term)
—> continuation for >12 months after symptoms recede
Obsessive Compulsive personality disorder - characteristics, risk of OCD and MDD
Enduring behaviour pattern of rigidity, doubt, perfectionism, pedantry
Egosyntonic
No true obsessions or compulsions
2/3 of OCD patients have this
But more likely to develop MDD than OCD
