Obsessive-Compulsive Disorder ! Flashcards

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1
Q

DSMV: presence of obsession, compulsions or both

A

Obsessions:

  • Recurrent and persistent thoughts, urges, or images.
  • Intrusive and unwanted.
  • Caused marked anxiety or distress.
  • Thoughts suppressed with some other thought/action (compulsion).

Compulsions:

  • Repetitive behaviours.
  • Or mental acts (eg. praying, counting).
  • Aimed at preventing or reducing anxiety.

Time consuming, cause clinically significant distress, usually occur together.
Prevalence: 2-3% of pop.

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2
Q

Examples (Abramowitz, 2006).

A

Contamination = inappropriate washing and cleaning.
Responsibility for harm = compulsive checking.
Unwanted, agressive-violent, sexual, blasphemous thoughts = mental rituals, praying etc.
Excessive concerns about lucky or unlucky numbers.
Worries about orderliness and symmetry.

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3
Q

Typical obsessions

A

Fear of dirt and contamination.
Repeated doubts.
A need to have things in a certain order.
Agressive impulses.
Sexual or pornographic thought.
Impulses to do something against a moral code.
Although these impulses are not (usually) carried out- patient is bothered they had the thought.

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4
Q

Typical compulsions

A

Pursuing cleanliness or order.
Avoiding objects.
Performing ‘magical’ repetitive (protective) actions.
Repeatedly checking.

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5
Q

OCD DSMV

A

Most OCD sufferers realise that obsessions/compulsions excessive.
DSM5 no longer sets this as one of the criteria:
- some strongly believe rituals prevent bad things.
- sometimes fine line between obsession and psychosis.
- important to determine level of insight and delusional thought.
Untreated, OCD is chronic and deteriorating.
OCD symptoms and consequences impair many areas of life.
Comorbid with other mental health problems- mood, anxiety etc.

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6
Q

Impact

A

Relationships (Huppert et al, 2009): OCD very time consuming, oddness of compulsions causes family/social strain.
QoL.
Unemployment and other work related impact (Rodriguez Salgado et al, 2006).
Physical injury- eg. chafing from repeated washing.
Substance abuse (Brady et al, 2013).
Suicidal behaviour (Torres et al, 2011).

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7
Q

OCD related conditions

A

OCD related conditions:

  • body dysmorphic disorder.
  • hoarding disorder.
  • trichotillomania (hair pulling) disorder.
  • excoriation (skin-picking) disorder.
  • tic disorders: sudden brief involuntary movements or vocal sounds.
  • tourette’s disorder: multiple motor tics and at least one vocal tic. (around 50% or patients have OCD symptoms; around 30% will have OCD diagnosis).
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8
Q

Comorbidity with psychotic disorders

A

OCD symptoms may occur in 8% to 26% os patients with schizophrenia (Pallanti et al, 2011).
Some schiz pts may show repetitive behaviour in response to delusions and hallucinations.

Other disorders that can co-occur:

  • PTSD
  • GAD
  • Panic disorder
  • SAD
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9
Q

OCD vs OCPD

A

Obsessive compulsive personality disorder: often confused with OCD but not the same.
OCD = mental disorder: developed in early adulthood or later.
OCPD = personality type: onset earlier in life, preoccupation with correctness (order, perfection, control), lack of flexibility, openness and efficiency.

OCD/OCPD can occur separately or be comorbid.
Those with OCD are not always perfectionist.

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10
Q

OCD aetiology: psychoanalytic

A

Freud: OCD due to instinctual forces.
Not under control because of harsh toilet training- person fixated in anal stage; or may be sexual repression.
Struggle between id and defence mechanisms- aggressive id dominates unpleasant thought arise; defence mechanisms reflect counter measures.

Adler: OCD due to (perceived) incompetence.
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.

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11
Q

Cognitive appraisal- intrusive thoughts

A

Bouvard et al (2016):

  • used international intrusive thought interview schedule (IITIS)- assessed unwanted intrusive thoughts (UITs); compared 28 OCD patients with 28 non-clinical controls.
  • all participants reported at least one type of UIT- but ocd group sig. more thoughts than controls.
  • in OCD group UITs are more frequent, interfered more with daily life, considered to be more important to get out of the mind, more difficult to stop.
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12
Q

OCD: cognitive-behavioural theories

A

Mowrer’s two-process theory:

  • neutral stimuli associated with frightening thoughts (eg. shaking hands and prospect of contamination).
  • washing hands extensively reduces anxiety (washing response reinforces obsession.

Distraction:

  • compulsions reduce anxiety and maintain obsessions (eg. distraction might include tidying room to avoid thinking about revising).
  • distraction occurs more often if it reduced anxiety.

OCD patients have trouble ‘switching off’ for several reasons:
- may be depressed or anxious for most of time- events more likely to invoke intrusive thoughts.
- unable to suppress thoughts (Szechtman & Woody, 04).
OCD patients tend to have rigid moralistic thoughts- judge any thoughts more unacceptable than most people, more anxious about having them.
Feel they should be able to control all thoughts- often believe thoughts to have grounding in reality; if anxiety is reduced, behaviour is reinforced.

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13
Q

OCD: biological factors

A

Genetics (Hettema et al, 01):

  • twin studies show high heritability- concordance in identical twins = 68%; fraternal twins = 31%.
  • family studies confirm this- significantly higher rates in first degree relatives.

Serotonin & neurotransmission (Math & Janardhan Reddy, 07):

  • OCD may be associated with serotonin- some antidepressants effective in treatment.
  • several neurotransmitters may be implicated- serotonin, dopamine, acetycholine.
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14
Q

OCD treatment- medication

A

BZs- not very effective.
TCA- Clomipramine approved for treatment of OCD in USA; probably most effective drug but side effects preclude it as first line treatment.
SSRI- several approved for OCD in USA; ideal for first line; effective but response is slow.
SNRI- no particular advantage over SSRI or TCA; better side effect profile than clomipramine.

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15
Q

TCAs

A

Clomipramine: first drug approved for treating.
Some evidence that it’s more effective than SSRIs (eg. Ackerman et al, 95)- but these studies pre-date SSRIs so barely comparable; head to head studies show similar efficacy (Mundo et al, 01).
Side effects with C: heart problems, dry mouth, constipation, weight gain (Kristensen et al, 89)
- can induce manic episodes for patients with bipolar.

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16
Q

SSRIs

A

Evidence suggests little difference between SSRIs (Soomro et al, 08).
Typically used to treat depression- and yet SSRI dose often higher for OCD (Kellner, 2010); response rates slower for OCD (Pittenger, 05), up to 12 weeks before effect seen.
SSRIs argued to be best choice for children and adolescents (Williams et al, 03).

17
Q

SNRIs

A

Most frequent evidence related to venlafaxine.
- response rates compared in one study (Albert et al, 02).
Venflafaxine 36% vs clomipramine 50%; but small sample size so not generalisable.
- withdrawal syndrome greater for venlafaxine than SSRIs.

18
Q

Treatment-resistant OCD

A

Treatment resistance = failing single ‘trial’ or SSRI.
Treatment refractory = failing 2 trials.
Options for treatment-resistant OCD include adding SSRi to: clomipramine, mirtazapine, lithium, buspirone, or even an antipsychotic (Linder, 2013).
Treatment-refractory patients may benefit from haloperidol (antipsychotic; McDougle et al, 90):
- pts treated with fluvoxamine.
- if Y-BOCS improvement < 35% pts given haloperifol or placebo.
- pts sig. improved with haloperidol after 4 weeks.

19
Q

OCD treatment - psychological: exposure and response prevention

A

Exposure and response prevention (ERP):

  • exposure to fear provoking events.
  • prevention from engaging in compulsive behaviour - educate about OCD; expose to fear until anxiety subsides; coach patient to refrain from compulsive behaviours.
  • good efficacy profile if patient can adhere to treatment- at least 50% ‘much improved’; another 25% ‘moderately improved’.
20
Q

Evaluation of ERP

A

Treatment effects can last several years.
Fewer sessions needed than with systematic desensitisation- but additional methods may be needed during follow up.
Behavioural therapies not entirely successful- some obsessions and compulsions remain.

21
Q

OCD psychological treatments

A

Cognitive therapy (including CBT):

  • identify and modify irrational thoughts- effective as exposure alone.
  • some therapies combine ERP and CBT- during ERP sessions are recorded (client monitors faulty thinking, lists illogical thought, identifies examples of ‘over reaction’, produce more realistic thought).

Group ERP/CBT also receiving attention- some evidence of benefits (Jonsson & Hougaard, 09).

CBT: considered first line treatment in mild to moderate OCD- recommended ahead of medication.

  • as effective as SSRIs- although combination may be more effective.
  • CBT found to be more effective than ERP- Y-BOCS reductions 53% and 43% respectively but both led to symptom improvement.
  • current evidence suggests combing CBT/ERP most effective.