Week Five - Obsessive-Compulsive Disorders Flashcards
Obsessions?
Recurrent and unwanted thoughts, images, urges or doubts that are distressing to the individual - increase anxiety
Compulsions?
Repetitive and time consuming mental or overt behaviours that serve to reduce the anxiety/distress caused by the obsessions - decrease anxiety
Diagnostic criteria for OCD (A)
presence of obsessions, compulsions or both
Diagnostic criteria for OCD (B)
The obsessions/compulsions must be time consuming (>1hr
per day) or cause clinically significant distress or impairment in functioning
Diagnostic criteria for OCD (C)
The obsessions/compulsions are not due to a substance or
medical condition
Diagnostic criteria for OCD (D)
The symptoms are not better explained by symptoms of
another mental disorder
Clinical features of OCD (prev, onset, gender, other)
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)
Types of Obsessions and Associated Compulsions. 3
- Cleaning and Contamination
- germs, dirt etc
- may use safety behaviours eg gloves
- a lot of avoidance - Forbidden thoughts or actions (aka aggressive obsessions)
- socially inappropriate, often violent, religious, or sexual in nature.
- mental rituals, reassuring, repeating/checking behaviours - Symmetry: A persistent desire to have objects aligned or actions performed perfectly
Neurobiological model of OCD?
– Individuals with OCD tend to have dysfunction in
• Orbitofrontal cortex
• Caudate nucleus
• Anterior cingulate cortex
– Neurotransmitter dysfunction in:
• Serotonin
• Dopamine
Cognitive Model of OCD?
Model considers that there are 6 main cognitive biases in OCD that maintain symptoms:
- Inflated responsibility
- Over importance of thoughts
- Over importance of controlling ones thoughts
- Over-estimation of threat
- Intolerance of uncertainty
- Perfectionism
Controversies in OCD Diagnosis
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
Body Dysmorphic Disorder?
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
How long thinking about concerns in BDD for diagnosis?
> 1 hour spent thinking about appearance concerns
Examples of compulsive behaviours in BDD?
– 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
Diagnostic criteria for BDD (A)
A. Preoccupation with one or more physical defects or flaws
in physical appearance that are not observable or appear
slight to others
Diagnostic criteria for BDD (B)
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
Diagnostic criteria for BDD (C)
C. The preoccupation causes clinically significant distress or
impairment in social, occupational or other important areas of functioning
Diagnostic criteria for BDD (D)
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.
BDD clinical features? (prev, onset, gender, other)
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
Differential diagnosis in BDD (OCD)?
If “obsessions” only concern the perceived defect and
“compulsions” are those commonly seen in BDD then
BDD is the more appropriate disorder
Differential diagnosis in BDD (SAD)?
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.
Differential diagnosis in BDD (ED)?
If weight or shape is the only concern then an eating
disorder may be the more appropriate diagnosis
Hoarding Disorder (HD)
Characterized by the presence of excessive clutter that makes using the home in a normal, reasonable way impossible
Diagnostic criteria for HD (all in here)
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
Clinical features of HD? (onset, gender, other)
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))
Differential diagnosis for HD (depression)
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.
Differential diagnosis for HD (adhd)
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.
Trichotillomania (TTM)
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
Focused vs. unfocussed hair pulling
– Focused = aware of behaviour when doing it
– Unfocussed = not aware
• More common (75%)
Excoriation
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
Differential diagnosis for Excoriation
BDD may also be associated with skin picking, but in BBD this is motivated by an effort to improve appearance
Diagnostic criteria for TTM (all in here)
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
Clinical features of TTM and Excoriation (prev, onset, gender, other)
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
Treatments for OCD (medication)
SSRIs have been shown to be efficacious
Treatments for BDD (medication)
SSRIs have been shown to be efficacious
Treatments for HD (medication)
No Randomized Controlled trials at this stage
Treatments for TTM/Excoriation (medication)
Medication not effective
Treatments for OCD (cognitive-behavioural)
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)
Treatments for BDD (cognitive-behavioural)
Exposure and response prevention
- walk around in a public area without being able to check their appearance
Treatments for HD (cognitive-behavioural)
Cognitive challenging, skills training, stimulus control
Treatments for TTM/Excoriation (cognitive-behavioural)
Stimulus control and competing response techniques
Treatments for all OCRD’s (psychosurgery)
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
