Obsessive-Compulsive and Related Disorders Flashcards
Obsessive Compulsive Disorder: DSM IV
Characterized by:
(1) Obsessions: recurrent and persistent thoughts, impulses that are experienced as being intrusive and inappropriate and cause marked anxiety and distress
and/or
(2) Compulsions: repetitive behaviors or mental acts that are time consuming, and are either distressing or disabling, which the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly; aimed at reducing or preventing distress or preventing a dreadful situation or event, however not connected in any realistic way to what they are intended to prevent or neutralize (i.e, magical thinking)
There is INSIGHT associated with the obsessions and compulsions at some point in the course of the disorder
Obsessive Compulsive Disorder: DSM 5 Changes
The “with poor insight” specifier of the DSM IV has been refined to: (1) good or fair insight, (2) poor insight, (3) absent insight/delusional
Includes a “tic-related” specifier
Obsessive Compulsive Disorder: Facts
- Prevalence = 2.5%; equal sex ratio
- Usually begins in adolescent
- Earlier onset for males
- High comorbidity with Major Depressive Episodes
- High incidents of OCD in individuals with Tourettes Disorder (35-50%)
- 30-30% of OCD individuals have current or past tics
- Most OCD individuals do NOT have premorbid OC personality disorder
- No strong evidence of a genetic link between OCD and OC PD
Obsessive Compulsive Disorder:
Etiology/Causal Explanations
(1) Biological: genetic heritability based on twin studies and familiy studies; serotonin dysregulation, probably in basal ganglia and limbic system or ACC
(2) Psychoanalytic: fixation with anal stage; over-reliance on defenses of isolation of affect; undoing, magical thinking and intellectualization to solve intrapsychic conflict
(3) Behavioral/Cog Behavioral: compulsions become to associate with provoking stimuli through chance classical conditioning. they are maintained through operant conditioning (on an intermittent schedule of reinforcement)
OCD vs. OCPD
Three main differences between OCD and OCPD:
(1) OCPD is usually ego syntonic, OCD is not
(2) No prominent obsessions or compulsive behaviors in OCPD (rather, characterized with a preoccupation with orderliness, perfectionism, and control)
(3) OCPD is not associated with Tic Disorders
Most OCD patients do not have a premorbid OCPD personality
No unequivocal evidence of a genetic link between the two disorders
Obsession/Compulsion Themes
Obsession- contamination; doubt; derogatory, aggressive, or sexual thoughts; symmetry, neatness, precision
Compulsion- cleaning; checking; usually without compulsions, may involve mental acts; perfectionism, leading to slowness
Obsessive Compulsive Disorder: Treatments
(1) Biological- antidepressants; neuroleptics (antipsychotic medications)
- serotonin dysregulation, probably in basal ganglia and limbic system
(2) Intractable OCD treated surgically (lesioning the cingulum)
- hyperactivity in the Anterior Cingulate cortex (action monitoring and error prevention system) generates feelings of excessive doubt and the need to repeat actions
(3) Behavioral/Cog Behavioral- implosion therapy with response prevention; systematic desensitization therapy
The Anterior Cingulate Cortex
(1) Dorsal: cognitive
- connected to the prefrontal and parietal cortexes, motor system, and frontal eye fields; responsible for assigning control to other areas in the brain; utilized in effort-demanding problem solving (secondary appraisal)
(2) Central: emotional
- connected to the limbic system, including the amygdala,, anterior insula, hypothalamus, nucleus accubens; helps to assess the significance of emotional information (primary appraisal)
The ACC has an unusual abundance of spindle cells, which are found only in humans, other great apes, elephants, and whales
In his book, the Astonishing Hypothesis, Sir Francis Crick argues that the anterior cingulate is probably the center of free will, making this claim o the basis or neuroimaging data that suggests that patients with ACC lesions often manifest syndromes that involve interference with their sense of independent will (e.g., Alien Hand Syndrome)
Body Dysmorphic Disorder
Preoccupation with an imagined or exaggerated defect in physical appearance
At some point the individual has performed repetitive acts, mental or behavioral, in response to the appearance concerns (e.g., mirror checking; excessive grooming; seeking reassurance) (like OCD and Hypochondriasis, symptoms can range from obsession to delusional)
Specifiers- with muscle dysmorphia; insight: (1) with good or fair insight, (2) with poor insight, (3) with absent insight/delusional
Body Dysmorphic Disorder: Prevalence
Prevalence = 0.7% by some estimates but probably more common than previously thought. DSM 5 reports point prevalence in US of 2.4%; lower outside of US
Higher rates among dermatology and cosmetic surgery patients
Gender: M=F; males have more genital preoccupations; females more likely to have comorbid eating disorders
Body Dysmorphic Disorder: Comorbidities
Most have a current or lifetime history of one of more of the following:
Major Depressive Disorder, Delusional Disorder, Social Phobia, Obsessive Compulsive Disorder, Psychotic symptoms in the context of or outside of a mood disorder, Eating Disorders, possibly Agoraphobia
Body Dysmorphic Disorder: Course
- Onset usually in adolescence
- May be hidden for many years
- Onset may be insidious or acute but both tend to result in the same chronic course
- The part of the body on which concern is focused may remain the same or change
Body Dysmorphic Disorder: Associated Features
- Like some EDs, frequent mirror checking is common as is mirror avoidance
- Excessive grooming (usually accompanies the frequent mirror checking)
- May alternate between checking and avoidance
- May engage in frequent social comparisons
- May seek constant reassurance
- May try to camouflage the imagined defect
- Ideas of reference possible (spotlight effect)
- May avoid usual activities (some individuals may only leave home at night)
- Suicidal thoughts and attempts possible
- Frequent attempts to correct the defect through medical procedures, but seldom satisfied, leading to a viscous cycle
Body Dysmorphic Disorder:
Differential Diagnostic Considerations
- Normal concerns about appearance
- Anorexia Nervosa
- Gender Identity Disorder
- Major Depressive Episode (mood congruent ruminations about appearance that are limited to depressive episode)
- OCD (separate dx given only when obsessions and compulsions are not limited to appearance)
- Delusional Disorder, somatic type (cannot be given in addition to BDM. if the preoccupation reaches delusional intensity the diagnosis of BDM with absent insight/delusional beliefs specifier is given)
- Koro (usually of short duration, responds to reassurance and often part of an epidemic)
Hoarding Disorder
Persistent difficulty discarding possessions regardless of value
Due to perceived need to save and distress associated with discarding items
Results in clutter and congestion (unless there is an intervention of a third party)
Distress or impairment
Specifiers: (1) with excessive acquisition (2) insight- good or fair; poor; absent/delusional beliefs
