OCD 🧼

what is OCD?

a common chronic and long lasting d/o with uncontrollable recurrent thoughts (obsessions) and/or behaviors (complsions) that they feel the urge to repeat over and over

what are obsessions?

unwanted aversive cognitive experiences

usu. associated with feelings of dread, loathing, or sense

something is wrong

do OCD patients know that they have obsessions?

thye have very good insight and undertsand that whats happening is not appropriate, they are very bothered by it

Individuals recognize these

concerns are inappropriate

and generally attempt to ignore or suppress them

what are compulsions?

overt behaviors or covert mental acts performed to reduce intensity of adverse obsessions

May occur as behaviors

governed by *rigid but often

irrelevant* internal

specifications

very out of proportion or irrelevant to obsession but meant to reduce obsession in their minds

when is onset of OCD?

childhood or early adulthood

usually <25 y/o

more in male children but adult females

what are specific obsessions/complusions?

common fears present in many patients?

what are common specific obsessions/compulsuions?

- contamination fears

- unwarranted fears (pathological doubt)

- need for symmetry, fear of harm to self/others, unwanted sexual concerns

- checking and decontamination

most pts have multiple obsessions or compulsions

what are the possible etiologies of OCD?

• Can result from pathologic processes affecting cerebral functioning (e.g., head trauma, epilepsy)

• Post-infectious autoimmune related OCD seen in children after GABHS ± RF symptoms

how are genetics related to etiology of OCD?

• OCD occurs with greater frequency in family members of OCD patients (10%) vs. general population

• Familial rates are higher in patients with childhood OCD than adult OCT

what syndrome has OCD been associated with genetically?

autosomal dominant Tourette syndrome gene

what are s/sxs of OCD?

- hallmarks of obsessions are aversive experiences of dread and uncertainty, or sense that something isn't right

- complusions are SELF INITIATED and willed responses directed at reducing adverse circumstances associated with obsessive thoughts

what are obsessive thoughts

particular ideas associated with obsessive experiences

they can take form of aversive mental images, dread and disgust, feeling that something very bad is going to happen, or that something must urgently be completed

how can obsessions be present without compulsions?

most frequently when person recognizes that no action can alleviate the experience

what are compulsions?

willed responses directed at reducing aversive circumstances associated with obsessive thoughts

how are compulsions carried out?

in concordance with ideation surrounding obsessions

they can be overt or silent mental acts like choking, praying, counting, or some other mental ritual

(usually in repetitive or stereotypes fashion, can be situation specific depending on context)

what is insight of OCD***?

must adults with OCD recognize fears and behaviors are unrealistic or excessive

insight varies from full awareness to lingering doubt to delusional state

some only lose insight during exacerbations of illness

what is a prominent secondary sx of OCD?

avoidance

pts will avoid circumstances that trigger particularly aversive obsessions or lead to time-consuming compulsions

(not a compulsion, but when illness is severe, may be a prominent feature)

how does OCD stand out among other disorder?s

in degree which patients thoughts and concerns diverge from their awareness of reality

pts recognize absurd nature of behavior and are aware of demeaning perceptions

others make have string fear they will be considered crazy and may feel ashamed and embarrassed (making then reluctant to disclose their sxs to others)

what may delay diagnosis of OCD?

pts will often hide their sxs from others in early illness

what will the combination of secrecy, avoidance of contact, and time-consuming nature of compulsions cause?

social isolation and 2º depression also made have a greater sense of internal tension and distress and the unreasonable fear of losing control

what are pathologic relationships OCD pts may have? what are the types?

pts often have parent or life partner who is involves in illness, this takes two forms

either facilitation or antagonistic-defensive dyad

what is facilitation?

Patient induce others to accommodate fears through pleading, nagging, demanding, or threatening

ex: will corner mom into corners of the house because she is not clean enough to sit on the couch that must stay clean

or

if you wanna come in, wash your hands 15 times

person plays along

what is antagonistic-defensive dyad?

adversarial relationship where antagonistic partner acts in a caustic, demeaning way and doesn't understand or accept nature of illness

• OCD sx are viewed as willful antagonism

• Patient reacts in hostile, defensive manner that aggravates the partner

stress of this relationship worsens OCD sxs

should family members give in to patients compulsions?

it is NOT good to give into these compulsions as the person in the relationship because you're allowing disease progression

what psychological testing can be used for diagnosis of OCD?

Psychological testing has little value in diagnosis of OCD or in predicting outcomes or course of illness

what is the Yale-Brown Obsessive Compulsive Scale (YBOCS)?

semi-structured interview with three parts:

- symptom checklist

- symtoms hierarchy list

- YBOCS

• Max score is 40, >31 extreme symptoms, 24-31 severe, 16-23

moderate, and <16 mild to subclinical (often no tx)

why are the ddx of OCD one of the most complex in psychiatry?

bc of confusion over the meaning of "obsessions" and "compulsions"

you have to recognize cognitive and behavioral phenomena that are ofetn confused with true obsessions and compulsions

what are the two types pf differentials for OCD?

cognitive and behavioral

what are the cognitive differentiations of OCD?

anxious ruminations

pathologic guilt

depressive ruminations

aggressive ruminations

fantasies

paranoid fears

flashbacks

pathologic attractions

rigid thinking

pathologic indecision

realistic fear or concern

what are anxious ruminations?

Persistent intrusive concerns about adverse circumstances in the future

how are anxious ruimations different from obsessions?

they are realistic in nature, although may be excessive

obsessions are immediate, aversive sensory experiences

often accompanied by dreadful mental images and specific unrealistic

fears

what is pathological guilt?

heightened experience of responsibility for misfortune or harm

Perceived responsibility usually excessive for circumstance and can be delusional in nature

how does pathological guilt differ from obsessions?

OCD individual believes they are responsible for an adverse

circumstance and experiences excessive remorse

pathologic pts do not have remorse, they dont have as much insight

what are depressive ruminations?

involve persistent cognitive reprocessing of past memories and experiences associated with sadness, loss, and regret

active, continuous mental process drawn out in time

what are aggressive ruminations?

Anger-related mental processes involving past or future ego injuries → perception (rightly or wrongly) that they were or will be offended in some way

who do aggressive ruminations typically occur in?

individuals with personality d/o (paranoid, OC, or narcissistic) and in people with passive aggressive personality types

how do aggressive ruminations differ from aggressive obsession in OCD?

ruminations are ego-driven and the individual is cognitively involved as active participant

what are fantasies?

mental stories that an individual entertains that extend over a period of time

nearly always have an attractive component, although individual knows that are unlikely to occur

when do fantasies become pathological?

when the person feels locked in them and is unable to withdraw mentally

what are paranoid fears?

concerns that somebody else harbors malevolent intent towards affected individual

May be associated with anger → avoidant, preparatory, or violent

preemptive measures to protect self

how are paranoid fears different from OCD pts fear of being harmed?

Patients with OCD sometimes have fears of being harmed (like poisoned) but fear is usually that they are random

victim, not specific targets

what are flashbacks?

Intense, intrusive experiences associated with memories of past traumatic events

usually re-experinces events in association with related trigger

how do flashbacks differ from obessions?

Differ from obsessions since they spring from memories of past experiences not inexplicable horrific images unrelated to previous experience

what are pathological attractions?

occurs as cognitive visceral experiences draw an individual

towards a maladaptive behavior

Feelings of desire, longing, or need for release of tension; usually accompanied by urge to satisfy that desire

how are pathological attractions different from obsession?

obsessions are by nature an aversive experience and triggers behavior based on escape, NOT gratification

what is rigid thinking?

when individual is unable to adopt a new perspective

usually ego-syntonic and may be delusional in nature

they are unable to adopt the perspective of another individual and cannot be dissuaded from their pov

what is pathologic indecision?

Occurs when individual is unable to make choices with potential outcomes of unknown or mixed valence

they become paralyzed because they cannot make any decision

how is pathological indecision different from OCD?

In OCD, sense of dread tends to motivate decisions (incl. decision not to act)

what are realistic fears or concerns?

Individuals with realistic fears or concerns may be confused for OCD

people with a history of violence, pathologic absent-mindedness, or inattention may have realistic concerns that problems wit recurrent

what is the difference between the cognitive and behavioral differentiations of OCD?

In cognitive differentiation, OCD is defined by distorted thinking and intrusive beliefs driving anxiety, whereas in behavioral differentiation, OCD is defined by maladaptive, repetitive behaviors that are reinforced through anxiety reduction.

what are the behavioral differentiation of OCD?

impulsions

perfectionism

pathologic atonement

repetitive replacement behavior

pervasive behavior

stereotypic behavior

self-injurious behavior

pathologic overinvolvement

pathologic persistence

hoarding

complex tics

what are impulsions?

Maladaptive behaviors that an individual is attracted to or feels impelled to perform

drawn to the act itself

what are impulsions associated with?

urge for gratification, satisfactions, or release of tension

Can be *violent or destructive behaviors that release tension

associated with poorly controlled anger

how do impulsions differ from compulsions?

differ from compulsions in that individual is drawn to act and derives inherent (not 2) pleasure from completion

what is perfectionism?

Motivated by a positive sense of accomplishment in completing activities in proper or optimal manner

• Individual often believes others should behave in a similar manner regardless of whether their behavior affects the perfectionist

how does perfectionism differ from obsessions?

it is reinforced with positive consequences

what is pathological atonement?

Motivated by guilt or fear of punishment

• Individuals may regret past actions and seek to reduce their

discomfort by performing penitent behaviors

• Includes religious rituals, self-punitive tasks, or self-injurious acts (e.g., flagellation, self-mutilation)

how does pathological atonement differ from compulsions?

it is not motivated by doubt or incompletion but willfully carried out to reduce guilt

what is repetitive replacement behavior?

perfumed to escape or numb an aversive experience associated with an affective state (ex: depression, extreme anxiety)

how can repetitive replacement behavior MIMIC OCD?

where depressed or anxious individuals engage in repetitive cleaning or straightening to reduce affective experience

• Function of behavior is to numb the psychic distress associated with primary condition

what is pervasive behavior?

repitition of thoughts, speech or brief behavioral sequences

can be carried out without conscious thought or because it reduces awareness of anxiety or other aversive experience

may occur in response to urge without any affective component

what is stereotypic behavior?

form of preservation motor behavior that is rhythmic in nature

simpler than pervasive behavior, may be associated with 1º reward or reduced awareness of anxiety or other aversive experience

why may self-injurious behavior occur?

in psychological settings, frequently as an escape behavior to reduce intensity of highly aversive-affective experience

can occur as a pathological-manipulative process or as a self-punitive process in pathologic atonement when escape behavior describes a release of tension

how can escaping/self-injurious behavior be differentiated from compulsions of OCD?

compulsions of uncomplicated OCD never involve direct self-harm

when does pathological overinvolvement occur?

when individual is preoccupied with a single process or set of processes to the exclusion of other

individual experiences gratification from the process as it occurs or is completed

when does overinvolvement become pathological?

when the individual neglects or is unable to attend to more important tasks or social responsibilities

what is pathologic resistance?

when individual contributes to pursue and endeavor or interaction despite repeated failure or rebuff (rejection)

what is pathological persistence associated with?

rigidity of thought or related to individuals inability to accept unwanted circumstances

in what syndromes can hoarding be observed?

OCD, anorexia, Tourettes, autism, OCPD, stimulant abuse, schizotypal personalty disorder, schizophrenia

what is hoarding/collecting motivated by in OCD?

unreasonable urge to obtain an item without reason (like bird feathers on the street) or with unreasonable concern that item might be needed in the future

when do complex tics occur?

in setting of tic disorder, usually motivated by unwanted urges without rational motivation

can be confined to localized muscle groups

pts with tourettes can have obsessions associated with tics (fear something bad with happen if they do not give into urge)

how are complex tics differentiated from OCD?

they can become undistinguishable from compulsive behavior of OCD, best to classify as both a tic and compulsion (OCD-tic)

these were all behavioral differentials :)

:)

what are the main differential diagnoses of OCD?

anorexia nervosa

body dysmorphic disorder

hypochondriasis

obsessive compulsive personality disorder

pathologic skin-picking

specific phobias

trichotillomania

what is obsessive compulsive personality disorder (OCPD)?

associated with meticulousness, persistence, rigidity, and personal isolation

what differentiates OCD and OCPD?

dont have sense of dread that OCD have

Major difference between OCPD and OCD is the ego-syntonic nature of experiences and behavior in OCPD

OCD can have insight and OCPD dont, also OCD are intrusive thoughts and repetitive behaviors which OCPD is a preoccupation with perfection and control

what are specific phobias?

involves excessive fears of specific situations or circumstances

Often involves fear of situations that others might experience as mildly aversive or anxiety provoking (ex: contact with snakes or spiders)

how do specific phobias differntiate from OCD?

avoidance is prominent and effective in allaying anxiety

if you just avoid the phobia you can function in everything else in life for specific phobias

in OCD that can have association of dread whether that thing is present or not and they just cant avoid the circumstances

how is hypochondriasis a ddx of OCD?

unreasonable, persistent concern that something is wrong with the body

can mimic obsessions of OCD, but concert are limited to the body

what is body dysmorphic disorder (BDD)? how does it differ from OCD?

unreasonable sense that something about the body is malformed, inadequate, or offensive to others

may spend excessive time looking at or seeking medical or surgical tx

duffers from OCD in level of insight (BDD pts truly believe there is something abnormal)

what is trichitollomania?

characterized by urges to pull hairs from body

usually one at a time

associates with an experience of pleasure or release of tension

while oCD may be inclined to do something like this, it is not out of pleasure

what is anorexia nervosa?

excessive concern with body image accompanied by refusal to eat with main goal of maintaining low body weight

delusional perception that they are ways overweight

how does anorexia nervosa differ from OCD?

OCD can avoid eating from fear of sickness, or illness, etc. but they have INSIGHT

anorexia have no insight regarding concern

how can OCD be tx?

range from stress reduction to neurosurgery

mild forms can really respond to stress reduction and supportive measures, but most pts need more definitive tx

what does psychotherapy include for OCD?

behavioral therapy for OCD involves exposure and response prevention

clinician encourages patient to experience aversive condition without performing the compulsion

why may patients decline psychotherapy?

they are just not ready to face their obsessions or compulsions

how may psychotherapy be better tolerated?

if pt has appropriate pharmacologic tx

what is the most effective medications in treating OCD?

PSRI's

Preferential serotonergic reuptake inhibitors

60

joint treatment is most effective

PSRI and psychotherapy together

61

if SSRI and PRSI dont work you can try TCA

what do you do if pt does not achieve adequate response with propter trial of PSRI?

add a second medication

what combo should be used as secondary medicine? what is danger?

Combo of SSRI + clomipramine also neuroleptics

risk of serotonin syndrome!

Low-dose, high-potency neuroleptics (e.g., risperidone, olanzapine,

ziprasidone, aripiprazole, ...) can be used to augment PSRI tx

what should pts whose OCD has significant anxiety component or with h/o seizures?

clonazepam

Clonazepam also considered adjunct to high-dose clomipramine tx to reduce seizure potential

what should be considered for pts that do not respond to PSRI's and adjuncts?

alternative medication trials like an

MAOI for pts wit panic or phobic sxs

clonazepam for seizure hx ~ this can even be monotherapy

what should family therapy involve?

family should be taught NOT to enable behaviors because they will make them worse but also do not be overly critical of patient

what is tx of last resort for OCD?

neurosurgery only indicated is there are 3 failed PSRI trials including one trial of clompramine an trials of neuroleptics and clonazepam

what are experimental tx of OCD?

IV cloparamine

in kids with post-infectious OCD (like post strep infection): immunosuppressive measures like steroids