Obsessive Compulsive And Related Disorders

Question 1

Characteristics of OCD

Answer 1

1. These disorders are unified by the presence of obsessive thinking.
   > This means the person with the disorder will experience intrusive, recurrent thoughts and urges that are unwanted.
2. They also involve compulsive behaviour.
   > The person is driven towards repetitive rituals which significantly impair their normal functioning.
3. This type of disorders are relatively common, affecting between 1% and 5% of the population, with obsessive compulsive disorder (OCD) being one of the leading causes of disability worldwide (Black and Grant).
4. Criteria for diagnosis of OCD in the DSM-5 include the presence of obsessions and/or compulsions.
5. Often individuals will attempt to suppress unwanted obsessive thoughts by performing behaviours to stop them.
   > Such behaviours are intended to reduce anxiety and may give temporary relief.
   > However, these behaviours are clearly excessive and not realistically a way to relieve the source of worry.
   > For example, a person who has the obsessive worry that they might accidentally hit someone with their car might be compelled to engage in continuous counting (something which would not actually help prevent an accident).
   > These thoughts and behaviours can be extremely time-consuming, for example, taking more than one hour a day and have a negative effect on the individual’s ability to work and socialise.

Question 2

Types of OCD

Answer 2

1. Hoarding
   > An obsessive compulsive disorder in which individuals experience great difficulty getting rid of possessions.
   > For many hoarders, they collect so many possessions that their homes may be unsafe, due to access or hygiene issues.
   > The home of hoarders may be difficult to clean, leading to infestations.
   > Frequently hoarded items include clothes and newspapers.
   > Those with hoarding disorder find it difficult to part with these items, regardless of their actual value.
   > Individuals experience distress associated with discarding possessions, which can impact their ability to live with their families, have visitor and so on.
2. Body dysmorphic disorder (BDD)
   > Involves obsessive thoughts regarding perceived faults in one’s physical appearance.
   > These faults are slight or not obvious to others.
   > These obsessions are often focused on imagined flaws or defects on the skin around the face and head.
   > The anxiety caused by these intrusive thoughts leads to compulsive, repetitive behaviours such as frequent mirror-checking or excessive grooming (hair-washing, shaving, tooth-brushing) and constantly comparing one’a appearance with others.
   > These behaviours are intensely time-consuming, individuals with body dysmorphic disorder spending several hours a day performing rituals to hide their defect, for example.
3. Case study: ‘Charles’ by Rapoport
   > Charles was a 14-year-old boy with OCD who spent three hours or more each day showering, plus at least another two hours getting dressed.
   > He had elaborate, repetitive routines for holding soap in one hand, putting it under water, switching hands and so on.
   > His mother contacted Rapoport after this behaviour had been going on for around two years.
   > Prior to this time, Charles had been a good student with a particular interest in the sciences.
   > He had to leave school because his washing rituals were making it impossible for him to attend on time.
   > He had also been in and out of hospital for his condition, and had already received standard treatments of medication, behavioural therapy and psychotherapy.
   > Charles was however still utterly obsessed with the thought that he had something sticky on his skin that had to be washed off.
   > In an attempt to help her son overcome this worrying thought, his mother had helped him clean his room and kept things he touched clean with rubbing alcohol.
   > He had only one friend because his rituals left him little time to leave the house.
   > He underwent a drug trial for clomipramine (a type of antidepressant), which gave effective relief of his symptoms. He was able to pour honey, for instance.
   > Yet after a year, he had developed a tolerance for his medication.
   > Charles relapsed and returned to ritualistic washing and dressing.

Question 3

First measure for OCD

Answer 3

Maudsley Obsessive-Compulsive Inventori (MOCI)

1. Short and quick assessment tool which takes around 5 minutes to complete.
2. Consists of 30 items that are scored either ‘true’ or ‘false’.
3. Assess symptoms related to checking, washing, slowness and doubting.
   > Checking: I frequently have to check things (gas or water taps, doors, etc) several times.
   > Washing: I am not unduly concerned about germs and diseases.
   > Slowness: I do not take a long time to dress in the morning.
   > Doubting: Even when I do something very carefully I often feel that it is not quite right.
4. Produce a score between 0 to 30.
5. For clinicians and researchers, rather than a formal diagnostic tool.

Question 4

Second measure for OCD

Answer 4

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)(Goodman et al., 1989)

1. Widely used test designed to measure the nature and severity of an individual’s symptoms.
2. Involve a semi-structured interview that takes around 30 minutes to conduct.
3. Involve a checklist of different obsessions and compulsions, with a 10-items severity scale.
   > The severity scale allows individuals to rate the time they spend on obsessions, how hard they are to resist and how much distress they cause.
   > Scores range from 0 (no symptoms) to 40 (severe symptoms).
   > Those above 16 are considered in the clinical range for OCD.
   > The checklist is administered on its own, as a way of helping plan treatment, or assessing how treatment is progressing.

Question 5

Evaluation for measures of OCD

Answer 5

1. Reliability and validity
   > MOCI and Y-BOCS have good levels of concurrent validity.
   » Meaning that individuals will score similarly on different tests for obsessive compulsive disorder (Esfahani et al.)
   > They also both offer good tests-retest reliability.
   » Meaning that individuals who repeat the measures at different times are likely to get the same results.
   » This is important for researchers wanting to use the tools in trialling psychological interventions.
2. Self-report
   > Both tests use a self-report measure.
   > Which means that they rely on the individual to give accurate and honest answers to each item.
   > This can be quite a subjective process for several reasons.
   > For example, those who are resistant to treatment or fear being thought of badly might downplay the severity of their symptoms.
   > It can therefore be difficult for researchers or clinicians to obtain a true picture of the nature of someone’s condition.

Question 6

Issues and debates for measures of OCD

Answer 6

1. Reductionist
   > The symptoms of obsessive compulsive disorders can be very specific and unique to individuals, which makes designing generic tests difficult.
   > Often they may end up being very lengthy, in order to identify a person’s main obsessions.
   > They may also end up being too ‘one-dimensional’, looking at the impact of situations as being ‘not at all distressing’ up to ‘severely distressing’.
   > However, some argue that this fails to capture the complex impact obsessive thoughts and compulsive behaviours have.
   > ‘Distress’ might also include different feelings and experiences such as depression, anxiety and functional impairment (Abramowitz et al.).
2. Application to everyday life
   > Case study (Rapport) is useful in helping us understand the experience of OCD in everyday life.
   > The experience of Charles and his mother demonstrates the impact of compulsive behaviours on normal functioning, such as the extremely lengthy washing rituals which prevented the young man from attending mainstream schooling.
   > It can also highlight the unique obsessive thoughts (eg: Charles’ ‘stickiness’) that are symptomatic of these disorders.

Question 7

First possible cause of OCD

Answer 7

Biomedical (genetic, biochemical, neurological)

1. Several explanations for obsessive compulsive and related disorders use physiological processes to explain symptoms.
2. Genetic (Mattheisen et al.)
   A. Background
   > The OCD Collaborative Genetics Association Study (OCGAS) is composed of comprehensively assessed OCD patients, with an early age of OCD onset.
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   B. Aim
   > To analyse and identify genes that may be linked to OCD symptoms.
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   C. Sample
   > Total 1065 families were included in this study.
   > Comprising 1406 patients with OCD and 2895 individuals in total.
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   D. Results
   > 2 genes (PTPRD and SLITRK3) interact to regulate particular synapses in the brain (the irregularity of these synapses lead to neurological disorders like OCD).
   > DRD4 (dopamine receptor D4) is related to uptake of dopamine (its abnormal levels are implicated in OCD, for example, high levels of dopamine associated with compulsive behaviour).
   > Serotonin trasporter genes can cause low levels of serotonin which is associated with OCD and depression.
3. Biomedical
   > Oxytocin or love hormone is known to enhance trust and attachment, but can also increase distrust and fear of certain stimuli, particularly those which might pose a thtreat to survival.
   > By analysing cerabral spinal fluid and patient accounts of behaviour, Leckman et al. found that some forms of OCD were related to oxytocin dysfunction.
   » Oxytocin levels are higher in patients with OCD and found a positive correlation with a higher frequency of repetitive behaviour.
   > The role of central oxytocin in OCD and related normal behaviour
   » Oxytocin (OT) is a neurosecretory nonapeptide synthesised in hypothalamic cells, which project to widely distributed sites in the central nervous system as well as the neurohypophysis.
   » Central OT affects a variety of cognitive, grooming, affiliate, sexual and reproductive behaviours in animals.
   » OCD includes a range of cognitive and behavioural symptoms that bear some relationship to dimensions of behaviour associated with OT.
   > Anecdotal data and a recently completed cerebrospinal fluid (CSF) study provide evidence that some forms of OCD are related to OT dysfunction. Based in these findings, it was hypothesise:
   » That some forms of OCD are at the extreme end of a range of normal behaviours that are mediated by OT and related systems.
   » Some normal cognitive, affiliate, and sexual behaviours contain elements that are similar to features of OCD.
4. Neurological
   > Abnormalities of brain structure and function.
   > The area of the brain known as the basal ganglia has been implicated by studies of brain-damaged patients as related to the obsessive thinking symptomatic of OCD.
   » The basal ganglia and two associated regions (orbitofrontal cortex and the anterior cingulate gyrus) usually work together to send and check warning messages about threatening stimuli.
   » In individuals with impaired function in these areas, this checking ‘loop’ does not work as it should, meaning the basal ganglia continues to receive worrying messages that ‘something is wrong’.
   > Heightened activity in the orbitofrontal cortex increases conversion of sensory information into thoughts (obsessions) and actions (behaviours), leading to compulsions.
   » PET scans have found higher activity in the orbitofrontal cortex in patients with OCD.

Question 8

Second possible cause of OCD

Answer 8

Cognitive and behavioural

1. OCD is composed of two aspects:
   > Cognitive obsessions
   > Behavioural compulsions
2. Cognitive explanation considers that obsessive thinking is based on faulty reasoning (Rachman, 1977).
   > For example, the belief that hands are covered in harmful germs that could kill is due to errors in thinking.
3. These mistakes in cognition can worsen under stressful conditions.
   > Compulsive behaviours are the outcome of such erraneous thinking, attempts to alleviate the unwanted thoughts and the anxiety they create.
4. Compulsive behaviour can be explained through the principles of classical conditioning.
   > Engaging in behaviour such as hand-washing may alleviate the obsession over germs, albeit temporarily.
   > The hand-washing has become a negative reinforcer because it has relieved something unpleasant (the worrying obsessive thoughts). It is also a posituve reinforcer, because the person is ‘rewarded’ by knowing that they have clean hands.
   > The influence of negative and positive reinforcement can shape obsessive-compulsive behaviours, meaning they are learned behaviours.

Question 9

Third possible cause of OCD

Answer 9

Psychodynamic (Freud)

1. Freud looks to unconscious beliefs and desires to explain the occurrence of OCD, and how childhood experiences shape personality.
2. Claim that symptoms of these disorders appear as a result of an internal conflict between the id and the ego.
   > Suggest that such conflict arises in the anal stage of psychosexual development, around the time most children begin toilet training.
   > This process may involve tension between children and their parents, who may wish to control how and when the child defecates or urinates, against the child’s wishes.
   > In order to regain control, the child may soil themselves, which causes upset and arguments. Alternatively, the child may fear harsh responses from their parents and retain faeces or urine in order to regain control.
   > Both these behaviours (anally expulsive and anally retentive) can lead to later behavioural disturbances, as the individual has become ‘fixated’ in this stage.
   » Fixation is when conflict at the psychosexual stage remains unresolved and the person is unable to move on to the next stage.
3. Essentially, the obsessive thought coming from id disturb the rational part of self, ego, to the extent that it leads to compulsive cleaning and tidying rituals later in life, to deal with childhood trauma.

Question 10

Evaluation for possible causes of OCD

Answer 10

1. Replicability
   > The scientific analysis used in identifying genes relating to OCD is objective and usually conducted under well-controlled laboratory conditions.
   » This makes it highly replicable.
   » However, it does not offer a complete picture in that it cannot explain why some individuals may carry genes that are implicated in OCD, yet never develop symptoms.
   > Biochemical explanations such as the oxytocin hypothesis are also supported by laboratory-based studies.
   » However, it is difficult to establish a cause-and-effect relationship between the hormone and OCD symptoms.
2. Evidence supported by case study
   > Third biomedical account considers brain structure and function.
   > Evidence suggesting a role for the basal ganglia in OCD is supported by case studies of brain-damaged individuals.
   > This method lack generalisability as these individuals may not be representative of a wider population.
   > More research is needed into examining the structure and function of this and related areas of the brain.
3. Self-report
   > Cognitive and behavioural accounts fit well with the experience of OCD symptoms reported by individuals with the disorder.
   > However, much research in this area relies on self-report, including measures such as the Y-BOCS and MOCI.
   » This introduces bias as individuals may deliberately or inadvertently mislead researchers.
   > The psychoynamic explanation is not supported by empirical research.
   » This is because you cannot accurately measure or control the variables involved.
   » It means it would be difficult to demonstrate a cause-and-effect relationship between harsh parenting during toilet training and a child’s later compulsive washing, for example.

Question 11

Issues and debates for possible causes of OCD

Answer 11

1. Applicable to everyday life
   > Biomedical explanations for OCD can indicate potential areas for research on treating and management of the disorder.
   » For example, understanding the role of the basal ganglia, orbitofrontal cortex and the anterior cingulate gyrus has led to innovations in neurosurgey which may offer symptom relief.
   > Similarly, cognitive-behavioural and psychodynamic accounts have also led to treatment options for OCD, including psychoanalysis and CBT.
2. Individual explanations and reductionist
   > Biomedical, cognitive and behavioural explanations focus on the individual, their hormonal abnormalities or faulty thought processes (Rachman).
   > This ignores the role of situational factors and can also be considered reductionist.
3. Situational explanations
   > The psychodynamic explanation emphasis early social relationships and considers the effect these can have on individual’s development.
4. Nature explanations
   > Biomedical accounts all rely on physiological factors (genes, hormones, brain function).
5. Nurture explanations
   > Behavioural explanation of compulsions suggests that they are learned behaviours, making individuals with OCD a product of their environment.
6. Nature and nurture explanations
   > Psychodynamic (natural urges we are born with vs childhood experience).
7. Deterministic
   > Although these accounts sit on either side of the nature vs nurture debate, they can also be considered to be deterministic.
   > We have no free will to influence our genetic make-up or the automatic learning processes that may lead to developing OCD.

Question 12

First treatment of OCD

Answer 12

Biomedical

1. Selective serotonin reuotake inhibitors (SSRIs)
   > Treat depression, OCD and related disorders
   > These medications are selective in the sense that they work on the neurotransmitter serotonin alone to increase its level by stopping it being reabsorbed and broken down.
2. Soomro et al. (2008)
   > Reviewed the results of 17 studies comparing the effectiveness of SSRIs with placebos.
   > In all studies, totalling 3097 participants, SSRIs as a group were more effective at reducing OCD symptoms 6 to 13 weeks after treatment using the Y-BOCS.
   > SSRIs reduce the severity of obsessive compulsive symptoms as they seem to lessen the anxiety associated with the disorder.
   > They have been shown to work in individuals with and without depression, though generally a higher dosage of medication is given as it has been shown to be more effective (Pampaloni et al.).
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   A. Background
   > Obsessive compulsive disorder is a common and disabling disorder.
   > A significant proportion of patients manifest a chronic course.
   > Individual randomised controlled trials (RCTs) have shown that SSRIs are effective in this condition.
   > Previous systematic reviews or meta-analyses summarising the evidence are methodologically problematic or limited in the scope of their analysis.
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   B. Aim
   > To examine the efficacy and adverse effects of SSRIs versus placebo for obsessive compulsive disorder (OCD) in adults.
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   C. Selection criteria
   > All RCTs and quasi-RCTs examining the efficacy of SSRIs compared with placebo for OCD in adults were eligible for inclusion.
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   D. Data collection and analysis
   > Selection of studies and data extraction (meta-analysis) were carried out by two review authors independently, and quality assessment of studies was undertaken.
   > Data analysis was conducted using Review Manager software.
   > Summary measures were produced using the weighted mean difference (WMD) for continuous data, and relative risk (RR) for dichotomous data, with 95% confidence intervals (CI).
   > SSRIs were examined as an overall group of drugs, and as individual drugs.
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   E. Conclusion
   > SSRIs are more effective than placebo for OCD, at least in the short term, although there are differences between the adverse effects of individual SSRIs drugs.
   > The longer term efficacy and tolerability of different SSRIs drugs for OCD has yet to be established.

Question 13

Second treatment of OCD

Answer 13

Psychological therapies: cognitive (Lovell et al., 2006) and exposure and response prevention (Lehmkuhl et al., 2008)

1. Lovell et al. (2006)
   A. Background
   > Used a randomised control trial to compare the effectiveness of cognitive behavioural therapy delivered by telephone with the same therapy offered face-to-face in those with OCD.
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   B. Aim
   > To compare the effectiveness of cognitive behaviour therapy delivered by telephone with the same therapy given face-to-face in the treatment of obsessive compulsive behaviour.
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   C. Participants
   > 72 patients with obsessive compulsive disorder.
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   D. Experimental design
   > Randomised controlled non-inferiority trial
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   E. Locations
   > Two psychology outpatient departments in the United Kingdom
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   F. Intervention
   > 10 weekly sessions of exposure therapy and response prevention delivered by telephone or face-o-face
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   G. Main outcome measures
   > Y-BOCS
   > Beck Depression Inventory
   > Client Satisfaction Questionnaire
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   H. Results
   > At six months post-treatment, the change in Y-BOCS scores prior to therapy and after therapy showed significant improvement in symptoms for both groups.
   > Patient satisfaction was high for both forms of treatment.
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   I. Conclusion
   > The clinical outcome of cognitive behaviour therapy delivered by telephone was equivalent to treatment delivered face-to-face and similar levels of satisfaction were reported.
2. Exposure and response prevention (ERP)
   > A form of cognitive behavioural therapy.
   > Lehmkuhl et al. (2008)
   A. Background
   > Researched the application of this form of treatment in a case study with a 12-year-old boy referred to as Jason who had both OCD and autism (or autistic spectrum disorder, ASD).
   » Approximately 2% of children with ASD are also diagnosed with OCD.
   > It can be difficult to distinguish ASD rituals and behaviour from compulsive behaviour seen in OCD.
   » However, cleaning, checking and counting tend to be common in those with OCD.
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   B. Case study
   > Jason had been diagnosed with high-functioning autism (normal IQ score), and also experienced contamination fear, excessive hand-washing, counting and checking.
   > He would spend several hours each day engaged in compulsive behaviour and reported significant anxiety when prevented from completing his rituals.
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   C. ERP
   > Gathering information about existing symptoms
   > Therapist-initiated ERP
   > Generalisation and relapse training
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   D. Procedure
   > Jason attended 10 50-minutes CBT sessions over 16 weeks.
   > Some of the ERP techniques were modified to meet Jason’s specific ASD needs.
   > He was not asked to do visualisation exercises as he would find it impossible to imagine pretend situations.
   > Jason first identified feelings of distress and with the help of the therapist, learned coping statements for when he felt anxious, for example, ‘I know that nothing bad will happen…’
   > The next step involved exposing Jason to stimuli which he felt were contaminated and produced feelings of anxiety or disgust.
   » These includes common objects such as door handles and elevator buttons.
   > The exposure involved Jason being asked to touch these items, and repeatedly to do so until he became habituated and his anxiety levels dropped.
   » Exposures became increasingly difficult, so Jason was engaging in behaviours that held increasing anxiety for him.
   > In between sessions, he practised this exposure through specific tasks in his normal environment, handing out papers in a classroom or using ‘contaminated’ items at home.
   > After completing his therapy, Jason’s score on the Y-BOCS had dropped from a severely high pre-therapy score of 18 to just 3, well within the normal range.
   > At a 3-month follow-up, his score remained low.
   > Both he and his parents reported a significant improvement in both his OCD symptoms and his participation in school and social activities.

Question 14

Evaluation for treatment of OCD

Answer 14

1. Experimental design
   > The research by Lovell et al. used an independent measures experiemental design in which participants were randomly alllocated to one of two conditions, thus removing the possibility of researcher bias.
   > The face-to-face CBT group acted as the control group for the experiment, meaning researchers could compare the effectiveness of telephone therapy effectively.
2. Standardisation
   > The duration of the therapy was kept the same in both conditions in Lovell et al.’s study, and outcomes were measured using the same validated scales.
3. Case study
   > Lehmukhl et al. used a case study to investigate the effectiveness of ERP as a treatment for OCD.
   > This method offers limited generalisability, particularly so in this vase because the participant also had ASD, meaning he was not representative of the general population of OCD sufferers.
   > Jason had not had OCD for very long compared to adults with the condition. This may mean we cannot generalise that a similar therapy could work with autistic adults but it does highlight if therapy is brought in early on in the condition, significant improvements can be made.
4. Ethical issue
   > As a 12-year-old, Jason was a child with additional needs, which also raises ethical issues around briefing, consent and the risk of psychological harm.
   > However, it does give us an in-depth understanding of the experience of going through ERP and captures both quantitative and qualitative data through interview and Y-BOCS score.
5. Longitudinal and detailed study
   > Lehmukhl et al. has good validity as it is a longitudinal and detailed study.
   > Provides a lot of information about the treatment and recovery of the patient.
6. Adapted to suit the individual needs
   > Exposure and response prevention is a good therapy technique that can adapt to the patient’s needs.
   > Therefore the therapy is valid.
7. Both qualitative and quantitative data
   > Qualitative data gives detailed information, and comparisons can be made before and after treatment to assess the effectiveness of therapy, which increases the validity of the study and shows that it was the treatment that improved Jason’s symptoms and not something else.
8. Use of children
   > There can be communication problems with children which lowers the validity.
   > But this was taken into account with Jason and the therapy was adjusted, this increases validity.
9. Respond to demand characteristics or social desirability
   > Jason might say that he felt better than he really did due to the close relationships he built with the therapist, this lowers the validity.
   > It is possible Jason didn’t think of himself as a ‘participant’ and more as a ‘patient; and responded in a natural way to the therapy which gives good ecological validity.

Question 15

Issues and debates for treatment of OCD

Answer 15

1. Ethical issues
   > SSRIs have a fairly high success rate in reducing symptoms of OCD.
   > They are generally considered safe though their use is sometimes restricted in cases of children or young people with OCD, as the risks of harmful side effects may be higher.
   > Similarly, the case study of Jason also raises ethical issues around the ethics and practicalities of conducting research with children.
   » His parents would have had to give consent on Jason’s behalf, and some of the procedures of his ERP therapy were altered to accommodate his age and ASD needs.
2. Application to evryday life
   > Cognitive-behavioural therapies and SSRIs are the most frequently used treatments for OCD, meaning research in this area is applicable to real life.
3. Individual explanations and reductionist
   > SSRIs treat only one aspect: the individual’s serotonin uptake.
   > This treatment does not alter their environment or take into consideration what might have caused the OCD symptoms to emerge in the first place.
   > Thus it is also a reductionist approach to treating mental health disorders.
4. Situational explanations
   > Cognitive-behavioural therapies such as those used by Lovell et al. and Lehmukhl et al. consider the environment in which the person’s compulsive behaviour takes place.
   > For example, Jason’s therapy addressed triggers in his home and school environment in order to help pre-empt relapse post-treatment.