Obsessive-compulsive and related disorders

Characteristics of obsessive-compulsive and related disorders

\- types of and common obsessions, common compulsions, hoarding disorder and body dysmorphic disorder

\- examples and case studies ('Charles' by Rappaport, 1989)

\- measures: Maudsley Obsessive-Compulsive Inventory (MOCI). Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

Types of and common obsessions, common compulsions

OCD can affect up to 5% of the population. An individual with OCD is likely to suffer with obsessions and compulsions (although they may not experience both).

Obsessions - are thoughts (cognitive) that are persistent, worrying, intrusive and disturbing. Common examples include:

\- fear of illness or infection

\- fear of accidentally injuring oneself or others

\- strong desire for order and symmetry

Compulsions - are behaviours that are repetitive and give temporary relief to the anxiety/obsessions. Behaviours are excessive and are not a realistic way to relieve the source of anxiety. Common examples include:

\- frequent and excessive hand washing

\- ordering objects in some way

\- checking repeatedly

\- ritualistically sequenced behaviour

Hoarding disorder and body dysmorphic disorder

Hoarding disorder - characterised by difficulty in disposing of possessions. This can result in collecting so many items that their homes are unhygienic and unsafe. Hoarders may collect clothes, magazines, household supplies, photographs and newspapers. Hoarders cannot part with items without this leading to great distress and anxiety regardless of the utility or value of the items concerned. Hoarders may hoard because they think someone will come to harm if something is thrown away or because they fear that they will need an item in the future or because they believe items have an emotional significance.

Body dysmorphic disorder (BDD) - characterised by obsessive thoughts about perceived flaws in physical appearance. These faults may be slight and not noticed by others and are often on the skin of the face. Anxiety about these perceived flaws (obsessions) leads to compulsive repetitive behaviours such as frequent mirror-checking or grooming (hair-washing, shaving, or constant comparisons with others) that may occupy several hours per day.

Examples and case studies ('Charles' by Rappaport, 1989)

Rapoport (1989) conducted a case study on a 14 y.o. boy named Charles. He spent lengthy amounts of time engaged in repetitive washing behaviors and rituals due to to the obsessive belief of experiencing persistent stickiness on his skin.

Before the appearance of his compulsions, Charles was a good student with a passionate interest in academics however his OCD forced him to drop school because of him being unable to attend classes. He also lost of his friendship and only had one friend.

After taking a course of clomipramine (an antidepressant), Charles experienced a decline in his symptoms and was even able to pour honey on his skin. However, he developed a tolerance and relapsed back to his compulsions.

Measures: Maudsley Obsessive-Compulsive Inventory (MOCI). Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

MOCI - a psychometric test designed to assess OCD. It is a quick assessment tool for clinicians, rather than a formal diagnostic tool. MOCI is a self-report questionnaire using a forced choice 'yes' or 'no' format. There are 30 items leading to a total score between 0 and 30. The 30 items are divided into 4 sub-scales

Y-BOCS - used to measure the nature and severity of symptoms. It involves a semi-structured interview, taking about 30 minutes and involves a checklist of different obsessions and compulsions, with a 10-item severity scale. Obsessive categories include religious, contamination and aggressive. Compulsion categories include counting, hoarding and washing.

Individuals can rate the time they spend on obsessions, how hard they are to resist and how much distress they cause. Scores range from 0 (no symptoms) to 40 (severe symptoms).

Explanations of obsessive-compulsive disorder

\- biomedical (genetic, biochemical and neurological)

\- cognitive and behavioural

\- psychodynamic

Biomedical

Genetic - Genes such as PTPRD, SLITRK3 and DRD4 (related to uptake of dopamine) have been found to have a possible role in OCD type symptoms.

Biochemical - Oxytocin dysfunction - increase worries and fear of certain situations/stimuli with the belief that survival could be threatened.

Neurological - abnormalities of brain structure and function that may lead the OCD patient to continue to receive messages to do 'survival' type activities (such as hand-washing) even when this has already been done by the person.

Cognitive and behavioural

Cognitive  -This explanation is linked to obsessive thinking. These thoughts lead to increased levels of stress and anxiety for the person. The reasoning behind the thoughts is faulty, stressful situations can make these thoughts worse.

Behavioural - This leads to compulsive behaviour which reduces the obsessive thoughts for a time and acts as the negative reinforcer of the behaviour.

Psychodynamic

Arise from the anal stage of psychosexual development. There may have been difficulties between the child and parent at this stage when the child defecated or urinated. Children may become either anally expulsive or anally retentive and the individual may become fixated at this stage. Obsessive thoughts come from the id which disturb the ego that lead to compulsive cleaning or other rituals may help to soothe the early childhood trauma. Could also be the id and the superego in conflict with each other. The obsessive cleaning could act as an ego defence mechanism to deal with this conflict.

Treatment and management of obsessive-compulsive and related disorders

\- biomedical (SSRIs)

\- psychological: cognitive (Lovell et al., 2006)

\- exposure response prevention (Lehmkuhl et al., 2008)

Biomedical (SSRIs)

The main medications prescribed are selective serotonin re-uptake inhibitors (SSRIs). These can help improve OCD symptoms by increasing the levels of a chemical called serotonin in the brain. This seems to then cause a lessening of anxiety experienced by the patient and therefore they do not need to engage in the OCD behaviours in order to relieve their anxiety (such as hand washing).

Cognitive (Lovell et al., 2006)

Study - Comparing telephone versus face-to-face treatment of CBT for OCD. 72 out-patients took part. 10 weekly sessions of exposure and response prevention therapy were given. 3 depression inventories given during therapy (Yale-Brown, Beck and client satisfaction). No significant differences found at six months. Concluded both face-to-face and telephone treatment are equally as effective in treating OCD.

Exposure response prevention (Lehmkuhl et al., 2008)

Case study with a 12-year-old boy called Jason who had both autism and OCD. 10 50-minute sessions of CBT over 16 weeks. Used exposure response prevention, for example:

Exposure - getting Jason to touch objects he has difficulties with such as elevator buttons, door handles, etc.

Response prevention - reducing the anxious response to the objects by using coping statements. Jason does have high anxiety responses but he learns as therapy progresses that these reduce quickly within a few minutes.

After therapy score on Y-BOCS dropped from 18 to 3