Week Five - Obsessive-Compulsive Disorders

Question 1

Obsessions?

Answer 1

Recurrent and unwanted thoughts, images, urges or doubts that are distressing to the individual - increase anxiety

Question 2

Compulsions?

Answer 2

Repetitive and time consuming mental or overt behaviours that serve to reduce the anxiety/distress caused by the obsessions - decrease anxiety

Question 3

Diagnostic criteria for OCD (A)

Answer 3

presence of obsessions, compulsions or both

Question 4

Diagnostic criteria for OCD (B)

Answer 4

The obsessions/compulsions must be time consuming (>1hr

per day) or cause clinically significant distress or impairment in functioning

Question 5

Diagnostic criteria for OCD (C)

Answer 5

The obsessions/compulsions are not due to a substance or

medical condition

Question 6

Diagnostic criteria for OCD (D)

Answer 6

The symptoms are not better explained by symptoms of

another mental disorder

Question 7

Clinical features of OCD (prev, onset, gender, other)

Answer 7

Prevalence: ~2% in Australia

Onset:
– Early adolescence – Early adulthood
– Most develop symptoms by the age of 20 Childhood
onset more likely in males

Gender differences:
– No gender differences

Other:
– Clinical presentation extremely heterogeneous
• Makes research in this area difficult
– Highly comorbid with other disorders (especially
depressive disorders and anxiety disorders)

Question 8

Types of Obsessions and Associated Compulsions. 3

Answer 8

1. Cleaning and Contamination
   - germs, dirt etc
   - may use safety behaviours eg gloves
   - a lot of avoidance
2. Forbidden thoughts or actions (aka aggressive obsessions)
   - socially inappropriate, often violent, religious, or sexual in nature.
   - mental rituals, reassuring, repeating/checking behaviours
3. Symmetry: A persistent desire to have objects aligned or actions performed perfectly

Question 9

Neurobiological model of OCD?

Answer 9

– Individuals with OCD tend to have dysfunction in
• Orbitofrontal cortex
• Caudate nucleus
• Anterior cingulate cortex

– Neurotransmitter dysfunction in:
• Serotonin
• Dopamine

Question 10

Cognitive Model of OCD?

Answer 10

Model considers that there are 6 main cognitive biases in OCD that maintain symptoms:

1. Inflated responsibility
2. Over importance of thoughts
3. Over importance of controlling ones thoughts
4. Over-estimation of threat
5. Intolerance of uncertainty
6. Perfectionism

Question 11

Controversies in OCD Diagnosis

Answer 11

Can be diagnosed with either obsessions or compulsions
but the link between them is important and often
differentiates between disorders:
– Repetitive behaviors in Autistic Disorders
– ‘Compulsive’ behaviors in Impulse Control Disorders

Question 12

Body Dysmorphic Disorder?

Answer 12

Characterized by a preoccupation with a perceived defect in physical appearance. Areas of concern often include:
– Face (nose, lips, jaw)
– Arms
– Skin tone/imperfection
– Body hair
– Breasts
– Muscles/size

Question 13

How long thinking about concerns in BDD for diagnosis?

Answer 13

> 1 hour spent thinking about appearance concerns

Question 14

Examples of compulsive behaviours in BDD?

Answer 14

– Mirror checking/mirror avoidance
– Measuring body part
– Seeking reassurance from others about the body part
– Camouflaging the area of concern in some way (excessive make up, tanning, baggy clothing, hat etc)
– Skin picking
– Comparing appearance with others

Question 15

Diagnostic criteria for BDD (A)

Answer 15

A. Preoccupation with one or more physical defects or flaws
in physical appearance that are not observable or appear
slight to others

Question 16

Diagnostic criteria for BDD (B)

Answer 16

B. At some point during the course of the disorder, the
individual has performed repetitive behaviours or mental
acts in response to the appearance concerns

Question 17

Diagnostic criteria for BDD (C)

Answer 17

C. The preoccupation causes clinically significant distress or
impairment in social, occupational or other important areas of functioning

Question 18

Diagnostic criteria for BDD (D)

Answer 18

D. The appearance preoccupation is not better explained by body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Question 19

BDD clinical features? (prev, onset, gender, other)

Answer 19

Prevalence: Approximately 2%

Onset: Late adolescence

Gender differences:
– More common in women than men

Other:
• Comorbidity with other disorders is common (eg anxiety,
mood disorders)
• Clients often present for plastic surgery to “fix” their
concern, and are often dissatisfied with the result
• Was classified as a somatoform disorder in DSM-IV

Question 20

Differential diagnosis in BDD (OCD)?

Answer 20

If “obsessions” only concern the perceived defect and
“compulsions” are those commonly seen in BDD then
BDD is the more appropriate disorder

Question 21

Differential diagnosis in BDD (SAD)?

Answer 21

Concerns in SAD are related to social evaluation more
generally. Individuals with BDD are only concerned
about social evaluation specific to their perceived flaw in appearance.

Question 22

Differential diagnosis in BDD (ED)?

Answer 22

If weight or shape is the only concern then an eating

disorder may be the more appropriate diagnosis

Question 23

Hoarding Disorder (HD)

Answer 23

Characterized by the presence of excessive clutter that makes using the home in a normal, reasonable way impossible

Question 24

Diagnostic criteria for HD (all in here)

Answer 24

A. Persistent difficulty discarding or parting with possessions,
regardless of their actual value
B. This difficulty is due to the perceived need to save the items
and to distress associated with discarding them
C. The difficulty discarding possessions results in the
accumulation of possessions that congest and clutter active
living areas and substantially compromises their intended
use
D. The hoarding causes clinically significant distress or
impairment in functioning
E. The hoarding is not attributable to another medical
condition
F. The hoarding is not better explained by the symptoms of
another disorder

Question 25

Clinical features of HD? (onset, gender, other)

Answer 25

Onset:
– Usually begins in childhood/adolescence
– Severe hoarding is seen later in life

Gender differences:
– More common among men than women
– Men seek treatment less often than women

Other:
– Individuals with hoarding disorder often have strained
relationships
- High risk of fire in cluttered homes
- Most clients with HD (>90%) will meet criteria for another
disorder (MDD, GAD, SAD, Impulse control, ADHD (Inattention))

Question 26

Differential diagnosis for HD (depression)

Answer 26

When people are depressed their homes may become
cluttered due to amotivation etc. However depressed
people want to actually throw the items away, they
are just too depressed to do so.

Question 27

Differential diagnosis for HD (adhd)

Answer 27

People with ADHD can potentially have homes that are
cluttered due to disorganization.
– Similar to depression, people with ADHD do not
experience distress when discarding, they just have
trouble organizing themselves to do so.

Question 28

Trichotillomania (TTM)

Answer 28

Characterized by repetitive and uncontrollable hair pulling resulting in noticeable hair loss.
• May pull at hair on head, pubic region, arms, legs, eyelashes or eyebrows.
• May also ingest hair causing medical complications

Question 29

Focused vs. unfocussed hair pulling

Answer 29

– Focused = aware of behaviour when doing it
– Unfocussed = not aware
• More common (75%)

Question 30

Excoriation

Answer 30

Repeated and compulsive picking of skin leading to tissue damage.
For excoriation to be diagnosed the skin picking must result in tissue damage and cause the person significant distress and/or functional impairment

Question 31

Differential diagnosis for Excoriation

Answer 31

BDD may also be associated with skin picking, but in BBD this is motivated by an effort to improve appearance

Question 32

Diagnostic criteria for TTM (all in here)

Answer 32

A. Recurrent pulling out of one’s hair, resulting in hair loss
B. Repeated attempts to decrease or stop pulling hair
C. The hair pulling causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning
D. The hair pulling or hair loss is not attributable to another
medical condition
E. The hair pulling is not better explained by the symptoms
of another mental disorder

Question 33

Clinical features of TTM and Excoriation (prev, onset, gender, other)

Answer 33

Prevalence: Approximately 1-5%

Onset:
– After onset of puberty

Gender:
– Females report more frequently than males

Other:
- An understudied disorder
- Most clients (82%) will meet criteria for an additional disorder:
• Another OCRD
• Mood disorders
• Anxiety disorders
• Substance use disorders
• Eating disorders
• Personality disorders

Question 34

Treatments for OCD (medication)

Answer 34

SSRIs have been shown to be efficacious

Question 35

Treatments for BDD (medication)

Answer 35

SSRIs have been shown to be efficacious

Question 36

Treatments for HD (medication)

Answer 36

No Randomized Controlled trials at this stage

Question 37

Treatments for TTM/Excoriation (medication)

Answer 37

Medication not effective

Question 38

Treatments for OCD (cognitive-behavioural)

Answer 38

Exposure and response prevention
- gradual exposure to feared stimuli whilst preventing the compulsive behavior until habituation occurs, using exposure hierarchy (touch dirty floor without washing hands)

Question 39

Treatments for BDD (cognitive-behavioural)

Answer 39

Exposure and response prevention

- walk around in a public area without being able to check their appearance

Question 40

Treatments for HD (cognitive-behavioural)

Answer 40

Cognitive challenging, skills training, stimulus control

Question 41

Treatments for TTM/Excoriation (cognitive-behavioural)

Answer 41

Stimulus control and competing response techniques

Question 42

Treatments for all OCRD’s (psychosurgery)

Answer 42

Deep Brain Stimulation (DBS): probes send electrical current to the anterior limb of the internal capsule

Ablation: surgical destruction of small regions in one of four areas; Anterior cingulate, Internal capsule, Limbic, Subcaudate

Capsulotomy: Specific lesions to reduce the symptoms of severe medication-resistant OCD

• 50% had very good recover
• some side effects