Obsessive-Compulsive Disorder ! Flashcards
DSMV: presence of obsession, compulsions or both
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.
Examples (Abramowitz, 2006).
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.
Typical obsessions
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.
Typical compulsions
Pursuing cleanliness or order.
Avoiding objects.
Performing ‘magical’ repetitive (protective) actions.
Repeatedly checking.
OCD DSMV
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.
Impact
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).
OCD related conditions
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).
Comorbidity with psychotic disorders
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
OCD vs OCPD
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.
OCD aetiology: psychoanalytic
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.
Cognitive appraisal- intrusive thoughts
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.
OCD: cognitive-behavioural theories
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.
OCD: biological factors
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.
OCD treatment- medication
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.
TCAs
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.
