OCD

ANDAMI YUDIP

Obsessive- complusive and related disorder

INCLUDE:

• Obsessive-compulsive disorder (OCD)

• Body dysmorphic disorder

• Hoarding disorder

• Trichotillomania (hair- pulling disorder)

• Excoriation (skin-picking) disorder,

• substance/medication-induced obsessive-compulsive and related disorder

• Obsessive-compulsive and related disorder due to another medical condition, and other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder (e.g., body-focused repetitive behavior disorder, obsessional jealousy).

Obsessions

are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted,

compulsions

are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

Obsessive-Compulsive Disorder

Diagnostic Criteria

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to per- form in response to an obsession or according to rules that must be applied rigidly.

2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder

• (e.g., excessive worries, as in generalized anxiety disorder

• preoccupation with appearance, as in body dysmorphic disorder

• difficulty discarding or parting with possessions, as in hoarding disorder

• hair pulling, as in trichotillomania [hair-pulling disorder]

• skin picking, as in excoriation [skin-picking] disorder

• stereotypies, as in stereotypic movement disorder;

• ritualized eating behavior, as in eating disorders;

• preoccupation with substances or gambling, as in substance-related and addictive disorders;

• preoccupation with having an illness, as in illness anxiety disorder sexual urges or fantasies, as in paraphilic disorders impulses, as in disruptive,

• impulse-control, and conduct dis- orders; guilty ruminations, as in major depressive disorder

• thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders

• repetitive patterns of behavior, as in autism spectrum disorder).

Specify if:

With good or fair insiglit:

The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.

With poor insight:

The individual thinks obsessive-compulsive disorder beliefs are probably true.

With absent insight/deiusionai beiiefs:

The individual is completely convinced that obsessive-compulsive disorder beliefs are true.

Specify if:

Tic-reiated: The individual has a current or past history of a tic disorder.

• Specifiers

Many individuals with obsessive-compulsive disorder (OCD) have dysfunctional beliefs.

These beliefs can include an inflated sense of responsibility and the tendency to overestimate threat; perfectionism and intolerance of uncertainty; and over-importance of thoughts (e.g., believing that having a forbidden thought is as bad as acting on it) and the need to control thoughts.

Individuals with OCD vary in the degree of insight they have about the accuracy of the beliefs that underlie their obsessive-compulsive symptoms.

Many individuals have good or fair insight

• (e.g., the individual believes that the house definitely will not, probably will not, or may or may not bum down if the stove is not checked 30 times).

Some have poor insight

• (e.g., the individual believes that the house will probably burn down if the stove is not checked 30 times), and a few (4% or less) have absent insight/delusional beliefs (e.g., the in dividual is convinced that the house will bum down if the stove is not checked 30 times).

Insight can vary within an individual over the course of the illness.

• The characteristic symptoms of OCD are the presence of obsessions and compulsions (Criterion A).

Importantly, obsessions are not pleasurable or experienced as voluntary: they are intrusive and unwanted and cause marked distress or anxiety in most individuals.

Compulsions (or rituals) are repetitive behaviors (e.g., washing, checking) or mental acts (e.g., counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

• Most individuals with OCD have both obsessions and compulsions.

• Criterion B emphasizes that obsessions and compulsions must be time-consuming (e.g., more than 1 hour per day) or cause clinically significant distress or impairment to warrant a diagnosis of OCD.

• This criterion helps to distinguish the disorder from the occasional intrusive thoughts or repetitive behaviors that are common in the general population (e.g., double-checking that a door is locked).

Associated Features Supporting Diagnosis OCD

The specific content of obsessions and compulsions varies between individuals. However, certain themes, or dimensions, are common, including those of cleaning (contamination obsessions and cleaning compulsions); symmetry (symmetry obsessions and repeating. ordering, and counting compulsions); forbidden or taboo thoughts (e.g., aggressive, sexual, or religious obsessions and related compulsions); and harm (e.g., fears of harm to oneself or others and checking compulsions).

Prevalence OCD

• The 12-month prevalence of OCD in the United States is 1.2%, with a similar prevalence internationally (1.1%-1.8%).

• Females are affected at a shghtly higher rate than males in adulthood, although males are more commonly affected in childhood.

Development and Course

• If OCD is untreated, the course is usually chronic, often with waxing and waning symptoms. Some individuals have an episodic course, and a minority have a deteriorating course.

• Compulsions are more easily diagnosed in children than obsessions are because compulsions are observable. However, most children have both obsessions and compulsions (as do most adults). The pattern of symptoms in adults can be stable over time, but it is more variable in children.

Risk and Prognostic Factors OCD

Temperamental.

• Greater internalizing symptoms, higher negative emotionality, and behavioral inhibition in childhood are possible temperamental risk factors.

Environmental.

• Physical and sexual abuse in childhood and other stressful or traumatic events have been associated with an increased risk for developing OCD. Some children may develop the sudden onset of obsessive-compulsive symptoms, which has been associated with different environmental factors, including various infectious agents and a post-infectious autoimmune syndrome.

Genetic and physiological.

• The rate of OCD among first-degree relatives of adults with OCD is approximately two times that among first-degree relatives of those without the disorder; however, among first-degree relatives of individuals with onset of OCD in child- hood or adolescence, the rate is increased 10-fold.

Culture-Related Diagnostic issue OCD

• OCD occurs across the world. There is substantial similarity across cultures in the gender distribution, age at onset, and comorbidity of OCD.

• Moreover, around the globe, there is a similar symptom structure involving cleaning, symmetry, hoarding, taboo thoughts, or fear of harm.

Gender-Related Diagnostic issues OCD

• Males have an earlier age at onset of OCD than females and are more likely to have comorbid tic disorders.

• Gender differences in the pattern of symptom dimensions have been reported, with, for example, females more likely to have symptoms in the cleaning dimension and males more likely to have symptoms in the forbidden thoughts and symmetry dimensions.

Suicide Risk OCD

Suicidal thoughts occur at some point in as many as about half of individuals with OCD.

Functional Consequences of Obsessive-Compulsive Disorder

OCD is associated with reduced quality of life as well as high levels of social and occupational impairment.

• Impairment can be caused by the time spent obsessing and doing compulsions. Avoidance of situations that can trigger obsessions or compulsions can also severely restrict functioning. In addition, specific symptoms can create specific obstacles. For example, obsessions about harm can make relationships with family and friends feel hazardous; the result can be avoidance of these relationships.

• Obsessions about symmetry can derail the timely completion of school or work projects because the project never feels "just right," potentially resulting in school failure or job loss.

Differential Diagnosis

• Anxiety disorders.

• Major depressive disorder.

• Other obsessive-compulsive and related disorders.

• Eating disorders.

• Tics (in tic disorder) and stereotyped movements.

• Psychotic disorders.

• Other compulsive-like behaviors.

Comorbidity OCD

• Individuals with OCD often have other psychopathology. Many adults with the disorder have a lifetime diagnosis of an anxiety disorder (76%; e.g., panic disorder, social anxiety disorder, generalized anxiety disorder, specific phobia) or a depressive or bipolar disorder

• (63% for any depressive or bipolar disorder, with the most common being major depressive disorder [41%]).

• Onset of OCD is usually later than for most comorbid anxiety disorders (with the exception of separation anxiety disorder) and PTSD but often precedes that of depressive disorders.

• Up to 30% of individuals with OCD also have a lifetime tic disorder. A comorbid tic

  disorder is most common in males with onset of OCD in childhood.

Body Dysmorphic Disorder

Diagnostic Criteria

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

B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.

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

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

Specify if:

With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.

Specify if:

Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or “I lool< deformed”).

With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true.

With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true.

With absent insight/delusionai beliefs: The individual is completely convinced that

the body dysmorphic disorder beliefs are true.

Diagnostic Features BDD

Individuals with body dysmorphic disorder (formerly known as dysmorphophobia) are preoccupied with one or more perceived defects or flaws in their physical appearance, which they believe look ugly, unattractive, abnormal, or deformed (Criterion A).

Excessive repetitive behaviors or mental acts (e.g., comparing) are performed in response to the preoccupation (Criterion B).

The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C);

• usually both are present. Body dysmoφhic disorder must be differentiated from an eating disorder.

• Muscle dysmorphia, a form of body dysmoφhic disorder occurring almost exclusively in males, consists of preoccupation with the idea that one's body is too small or insufficiently lean or muscular.

Associated Features Supporting Diagnosis BDD

• Many individuals with body dysmorphic disorder have ideas or delusions of reference, believing that other people take special notice of them or mock them because of how they look.

• Body dysmorphic disorder is associated with high levels of anxiety, social anxiety, social avoidance, depressed mood, neuroticism, and perfectionism as well as low extroversion and low self-esteem.

Prevalence BDD

• The point prevalence among U.S. adults is 2.4% (2.5% in females and 2.2% in males).

• Outside the United States (i.e., Germany), current prevalence is approximately 1.7%-1,8%, with a gender distribution similar to that in the United States. The current prevalence is 9%-15% among dermatology patients, 7%-8% among U.S. cosmetic surgery patients, 3%- 16% among international cosmetic surgery patients (most studies), 8% among adult orthodontia patients, and 10% among patients presenting for oral or maxillofacial surgery.

Deveiopment and Course BDD

• The mean age at disorder onset is 16-17 years, the median age at onset is 15 years, and the most common age at onset is 12-13 years.

• Two-thirds of individuals have disorder onset before age 18.

• Subclinical body dysmorphic disorder symptoms begin, on average, at age 12 or 13 years. Subclinical concerns usually evolve gradually to the full disorder, although some individuals experience abrupt onset of body dysmorphic disorder.

Risk and Prognostic Factors BDD

Environmental.

• " Body dysmorphic disorder has been associated with high rates of childhood neglect and abuse.

Genetic and physiological.

• The prevalence of body dysmorphic disorder is elevated in first-degree relatives of individuals with obsessive-compulsive disorder (OCD).

Culture-Reiated Diagnostic issues BDD

Taijin kyofusho, included in the traditional Japanese diagnostic system, has a subtype similar to body dysmorphic disorder: shubo-kyofu ("the phobia of a deformed body").

Gender-Reiated Diagnostic issues BDD

Females and males appear to have more similarities than differences in terms of most clinical features— for example, disliked body areas, types of repetitive behaviors, symptom severity, suicidality, comorbidity, illness course, and receipt of cosmetic procedures for body dysmorphic disorder.

However, males are more likely to have genital preoccupations, and females are more likely to have a comorbid eating disorder. Muscle dysmorphia occurs almost exclusively in males.

Suicide Risk BDD

Rates of suicidal ideation and suicide attempts are high in both adults and children/adolescents with body dysmorphic disorder.

Functional Consequences of Body Dysmorphic Disorder

Nearly all individuals with body dysmorphic disorder experience impaired psychosocial functioning because of their appearance concerns. Impairment can range from moderate (e.g., avoidance of some social situations) to extreme and incapacitating (e.g., being completely housebound).

Differential Diagnosis BDD

• Normal appearance concerns and clearly noticeable physical defects.

• Eating disorders.

• Other obsessive-compulsive and related disorders.

• Illness anxiety disorder.

• Major depressive disorder.

• Anxiety disorders.

• Psychotic disorders.

• Other disorders and symptoms.

Comorbidity BDD

Major depressive disorder is the most common comorbid disorder, with onset usually after that of body dysmorphic disorder. Comorbid social anxiety disorder (social phobia), OCD, and substance-related disorders are also common.

Hoarding Disorder

Diagnostic Criteria

A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.

B. This difficulty is due to a 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. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).

D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).

F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

Specify if:

With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.

Specify if:

With good or fair insight:

• The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

With poor insight:

• The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

With absent insight/delusional beliefs:

• The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Specifiers HD

With excessive acquisition. Approximately 80%-90% of individuals with hoarding disorder display excessive acquisition.