Obsessive Compulsive and Related Disorders

Question 1

Williams et al. (2011)

Answer 1

• Previous factor analyses of the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC) have found “pure obsessional” subtype of OCD composed of aggressive, sexual, and religious obsessions but no compulsions
• Hypothesize that “pure obsessional” patients engage in mental rituals and demands for reassurance
• Method: YBOCS-SC used to assess OCD symptoms; factor analysis conducted, where mental compulsions and reassurance-seeking considered separate categories
• Results: Found five-factor solution that explained 67% of the total variance: Contamination-Cleaning, Symmetry-Ordering, Hoarding, Doubt-Checking, and Unacceptable Taboo Thoughts-Mental Rituals
• Mental compulsions, reassurance-seeking, impulsive aggression, sexual obsessions, religious obsessions, and somatic obsessions loaded onto unacceptable taboo thoughts-mental rituals
• Study suggests that the concept of “pure obsessional” may be a misnomer, as these obsessions were associated with mental compulsions and reassurance-seeking

Question 2

Obsessive Compulsive and Related Disorders in DSM-5

Answer 2

New category in DSM-5

Question 3

OCD

Answer 3

• Presence of obsessions, compulsions, or both
• Time consuming or distressing
• Not attributable to substance or medical condition
• Not better explained by another MD

Question 4

Obsessions

Answer 4

• Unwanted thoughts, urges, images
• Individual attempts to ignore or suppress them
• Ex: contamination concerns, fear of harming self/others, desire for symmetry, pathological/pervasive doubt, taboo thoughts/images

Question 5

Compulsions

Answer 5

• Repetitive behaviors or mental acts that the individual feels driven to perform
• Voluntary; often recognize irrational nature
• Behaviors/acts are meant to reduce anxiety/distress
• Ex: cleaning, checking, repeating, stereotyped motor movements, ordering/symmetry, counting, praying

Question 6

OCD specifiers

Answer 6

• With good or fair insight/poor insight/absent insight or delusional beliefs
• Tic-related

Question 7

OCD cycle

Answer 7

Obsessions –> Anxiety –> Compulsions –> Relief –> Obsessions

Question 8

OCD Epidemiology

Answer 8

• About equal male/female (washing/cleaning more common in females, sexual more common in males)
• Average age of onset 19.5
• Typically begins in late adolescence often followed by a stressful event (Earlier onset more common in males)

Question 9

OCD Comorbidity

Answer 9

• Anxiety/depressive disorders
• OC spectrum?
• Similarities with somatic disorders, eating disorders, impulse control disorders, trichotillomania, excoriation
• But the strong similarities of OCD with body dysmorphic disorder, illness anxiety, and eating disorders show differences too (specific obsessions/compulsions and differing levels of insight)

Question 10

OCD: Biological Perspective

Answer 10

• Genetic influences: 53% in MZ twins
• Abnormalities in brain structure/function (prefrontal cortex, cognitive and motor inhibition deficiencies?)
• Biochemical influences (SSRIs effective; Hypersensitivity of postsynaptic serotonergic receptors)

Question 11

OCD: Behavioral Perspective

Answer 11

• Belief that some thoughts are dangerous/unacceptable and need to be reduced reinforces learned behavior
• Classical conditioning: neutral stimulus paired with aversive stimulus evokes fear
• Operant conditioning: negative reinforcement; compulsions reduce anxiety
• This perspective: treat compulsions rather than obsessions

Question 12

OCD: Cognitive-Behavioral Perspective

Answer 12

• Beck’s appraisal model: everyone has repetitive, unwanted, intrusive thoughts but they are problematic when appraised as harmful/significant
• Compulsions are efforts to remove unwanted thoughts: they are negatively reinforced because they reduce distress
• —– Person never learns that thought was exaggerated/unrealistic

Question 13

Body Dysmorphic Disorder

Answer 13

A) Preoccupation with a perceived physical defect or flaw (not observable or appear slight to others)
B) At some point, engaged in repetitive behaviors or mental acts related to flaw
C) distress or impairment
D) not better explained by eating disorder

Question 14

Body Dysmorphic Disorder specifiers

Answer 14

• With muscle dysmorphia: preoccupied with thought that build is too small
• With good or fair insight/ poor insight/ absent insight or delusional beliefs

Question 15

Body Dysmorphic Disorder Associated Features

Answer 15

• Often poor insight
• High risk for suicidality (25%) and comorbid substance use problems
• Removed term “imagined” when describing perceived flaws; BDD not due to psychosis
• Repetitive behaviors look like compulsions

Question 16

Thought-action fusion

Answer 16

When a person thinks that if they think something, it will happen.

Question 17

BDD Epidemiology

Answer 17

• Usually begins in adolescence but not diagnosed until later
• Onset can be abrupt (spontaneous or after remark about appearance) or gradual
• Chronic course
• Body part of focus may change or stay the same
• Family history of GAD or OCD common
• More likely in high SES
• Affects males and females equally
• Not much research

Question 18

Hoarding Disorder

Answer 18

• Difficulty discarding possessions
• Feel a need to save items
• Accumulation of things (compromises living areas)
• Distress or impairment
• —but ego-syntonic: hoarder is usually not distressed by their situation
• Not attributable to medical condition or another MD (ex- OCD or decreased energy to clean in MDD, etc.)

Question 19

Hoarding Disorder specifiers

Answer 19

• With excessive acquisition

- With good or fair insight/poor insight/absent insight or delusional beliefs

Question 20

Hoarding Disorder associated features

Answer 20

• 2-6% of general population
• Seems driven by fear of losing important things, releasing possession
• Distress usually due to secondary consequences (e.g., family conflict)
• Behavior common among those with Prader-Willi, lesions in the anterior ventromedial prefrontal and cingulate cortices
• May be secondary to anxiety or mood disorders or dementia
• Poor insight versus overvalued ideation (may not realize they’re hoarding or may realize it but think their things are more valuable than they are)

Question 21

Trichotillomania

Answer 21

• Repeated pulling of one’s hair (resulting in hair loss)
• Attempts to stop or decrease pulling
• Distress/impairment

Question 22

Trichotillomania Epidemiology

Answer 22

• 1-2% of general pop
• Most commonly pulled from head/face region
• Hair loss need not be noticeable
• Removed “sense of tension before pulling” and “pleasure, gratification after pulling”
• May try to camouflage hair loss (make-up, scarfs)
• Hair is sometimes bitten/swallowed
• Hair pulling behavior can occur secondary to a number of other disorders (OCD, stereotyped behavior, psychosis, stimulant use)
  EX: person with schizophrenia may pull hair if it’s part of their delusion – this wouldn’t be trichotillomania

Question 23

Excoriation Disorder

Answer 23

• Repeated skin picking
• Repeated attempts to stop/decrease skin picking
• Distress/impairment
• Not attributable to substance (e.g., common with “uppers”) or other medical condition
• Not better explained by other MD

Question 24

Excoriation Disorder associated features

Answer 24

• 1.4 to 5.4% of general pop
• Face most common location
• Can use a multitude of tools
• Neurocog data suggests difficulty inhibiting motor behavior
• Picking can last for hours each day
• Use of stimulants and dermatological conditions can increase skin picking
• Less likely to report obsessive thoughts about skin; some don’t realize they’re doing it
• Skin picking during BDD is to improve appearance