A2 Psychology 9990 (Obsessive compulsive and related disorders)

Characteristics of obsessive compulsive and related disorders

• Obsessions: intrusive, recurrent thoughts and unwanted urges.

• Compulsions: repetitive actions that impair normal functioning.

• Patients with OCD will often be compelled to suppress obsessions to reduce anxiety and gain temporary relief. However, these compulsions are excessive and unrealistic - e.g., a person having a fearful obsession of accidentally hitting someone may be compelled to engage in continuous counting.

Types of obsessive compulsive and related disorders

• Hoarding: experiencing great difficulty and distress getting rid of possessions negatively affecting their social life. Their homes may be unsafe due to hygiene or access issues.

• Body dysmorphic disorder (BDD): obsessive thoughts regarding perceived faults in one's physical appearance.

o These faults are slight or not obvious to others.

o The obsessions are often focused on imagined flaws/defects on the face.

o The anxiety caused by obsession leads to compulsive, repetitive behaviour e.g. frequent mirror-checking, excessive grooming (hair-washing, shaving etc) and comparing one's self to others.

Case study: 'Charles' (Rappaport, 1989)

• 14-year-old boy with OCD who spent >3 hours showering, and 2 hours getting dressed.

• He had repetitive routines for holding soap in one hand, putting it under water, switching hands and so on.

• His mother contacted Rappaport after the child exhibited this behaviour for around 2 years.

• He was utterly obsessed with the thought that he had something sticky on his skin that had to be washed off, causing him to leave school.

• He had also had trips to the hospital, where he received standard treatments of medication, behavioural therapy and psychotherapy.

• He was socially isolated as his rituals left him little time outside the house.

• He underwent a drug trial for clomipramine

(antidepressant) giving him effective relief of his

symptoms; however, he developed tolerance to it and relapsed.

Measures for OCD (Maudsley Obsessive-Compulsive Inventory [MOCI],

• MOCI: quick assessment tool (takes around 5 minutes to complete) and is scored between 0-30.

o Consists of 30 items that are scored either 'true' or 'false', which assesses symptoms related to checking, washing, slowness and doubting e.g.

▪ I frequently have to check things (Checking).

▪ I am excessively concerned about germs and diseases (Washing)

▪ I don't take a long time to dress (Slowness)

▪ Despite doing something carefully, I often feel it is not quite right (Doubting)

Evaluation of MOCI and Y-BOCS: (Yale-Brown Obsessive-Compulsive Scale [Y-BOCS])

• Y-BOCS (Goodman et al., 1989): consists of a 30-min semi-structured interview and a checklist of different obsessions and compulsions.

o Checklist includes a 10-item severity scale allowing individuals to rate (between 0-4) time spent on obsessions and compulsions, how hard they resist, and how much distress they cause.

o Total scores range from 0-40, where >16 is in the range for OCD.

Evaluation of MOCI and Y-BOCS:

o High concurrent validity: individuals will score

similarly on different tests for OCD.

o High test-retest reliability: individuals who repeat the measures at different times are likely to get the same results.

o Response bias: self-report measures are subjective

and patients may downplay the severity of their

symptoms, reducing validity.

• Issues and debates:

o Reductionist: symptoms of OCD can be very specific and unique to individuals; therefore, it is difficult to design generic tests. Y-BOCS and MOCI tend to be very lengthy and have specific symptoms to diagnose OCD, making it reductionist.

▪ They are also 'one dimensional' - rating situations

merely as 'not at all distressing' up to 'severely

distressing' without considering the complex

impact/qualitative data OCD may have.

▪ The term 'distress' and can be used to indicate

depression, anxiety and functional impairment, not

just OCD.

o Applications to everyday life: case study (Rapoport) is useful in understanding OCD and its impact on normal functioning.

Biomedical explanation (Genetic, biochemical, neurological)

• Genetic: suggests that patients with OCD inherit specific genes that cause OCD.

o A large-scale study by Mattheisen et al., 2015 involving 1406 people both with and without OCD were analysed.

o 2 genes (PTPRD and SLITRK3) interact to regulate particular synapses in the brain (the irregularity of these synapses lead to neurological disorders like OCD)

o DRD4 (dopamine receptor D4) is related to uptake of dopamine (its abnormal levels are implicated in OCD, e.g. high levels of dopamine associated with compulsive behaviour)

o SERT (onin transporter) gene can cause low levels of serotonin which is associated with OCD (and depression).

• Biochemical: 'oxytocin' or love hormone, is known to enhance trust and attachment, but can also increase distrust and fear of certain stimuli, especially those that pose a threat to survival.

o By analysing cerebral spinal fluid and patient

behaviour, Leckman et. al, 1994 found that oxytocin

levels are higher in patients with OCD and found a

positive correlation with a higher frequency of

repetitive behaviour.

o OCD behaviours could be at the extreme end of a

normal range of behaviours moderated by oxytocin.

• Neurological: abnormalities in brain structure and

function.

o The basal ganglia and two associated regions

(orbitofrontal cortex and cingulate gyrus) work

together to send and check warning messages about

threatening stimuli.

o In brain-damaged (case study) patients, the checking 'loop' doesn't work as it should, so the basal ganglia continues receiving worrying messages, relating to the obsessive thinking symptom of OCD.

Cognitive and behavioural explanation

• OCD consists of cognitive obsessions and behavioural compulsions.

• Obsessive thinking is based on faulty reasoning e.g.

belief that hands covered in germs could kill.

• Compulsive behaviours are outcomes of erroneous

thinking, attempts to alleviate obsessions and the

associated anxiety.

• Such behaviours are learnt can be explained via operant conditioning:

o Hand washing is the negative reinforcement as it has relieved something unpleasant (obsessive thoughts)

o It is also a positive reinforcement as the person is

rewarded by knowing they have cleaner hands.

Psychodynamic explanation

• Freud emphasises the unconscious beliefs and desires to explain OCD, and how childhood experiences shape personality.

• OCD symptoms result as an internal conflict between the id and the ego.

• Freud suggests that conflicts arise in the anal stage of psychosexual development, around the time most

children begin toilet training.

• There's a tension between parents and children, as the parent may want to control when the child

defecates/urinates against the child's wishes.

• Child may soil themselves to regain control, upsetting their parents (leads to anally expulsive behaviour: being messy and careless)

• Alternatively, they may fear harsh responses from

parents and retain faeces/urine to regain control (leads to anally retentive behaviour: compulsive need for order and tidiness)

• Anally retentive/expulsive behaviours can lead to

behavioural disturbances as the individual has become 'fixated' in this stage.

o Fixation: when conflict at psychosexual stage remains unresolved and the person is unable to move onto the next stage.

• Obsessive thoughts coming from id disturb the rational part of self, ego, to the extent that it leads to compulsive cleaning and tidying rituals later in life, to deal with childhood trauma.

Explanation evaluation

o Genetic: objective and usually controlled under lab

conditions, making it highly replicable.

▪ However, it doesn't explain why some individuals

may carry genes that are implicated in OCD but never

develop symptoms.

o Biochemical: oxytocin hypothesis is supported by lab-based studies; however, it is difficult to establish a

causal relationship between hormone and OCD

symptoms.

o Neurological: supported by case studies on brain

damaged individuals, but this lacks generalisability to

other OCD patients.

o Psychodynamic: not supported by research as you

can't mention or control variables involved, so no

causal relationship found e.g. between harsh toilet

training and later compulsive washing.

• Issues and debates:

o Biomedical explanations are potential areas for

research into treatment and management of OCD.

o Individual explanation: biomedical, cognitive and

behavioural explanations focus on the individual e.g.

hormonal abnormalities and faulty thought processes,

making it reductionist.

o Situational explanation: psychodynamic explanation

emphasises the effect of early social relationship on an individual's development.

o Nature: biomedical explanation (genes, hormones,

brain structure)

o Nurture: behavioural (learnt behaviours)

o Both nature and nurture: psychodynamic (natural

urges we are born with vs childhood experiences)

o Deterministic: no free will to influence genetic

makeup or automatic learning process leading to OCD.

Biomedical treatment (SSRIs)

• SSRI acts on serotonin transporter, increasing its level

and acting as a treatment.

• Soomro et al (2008) reviewed the results of 17 studies

comparing effectiveness of SSRIs with placebo.

• In all studies, totalling 3097 participants, SSRIs group was more effective at reducing OCD symptoms shown using Y-BOCS 6-13 weeks after treatment.

• SSRIs reduce severity of OCD as they seem to lessen the anxiety associated with it.

Exposure and response prevention [Lehmkuhl et al., 2008])

Exposure and response prevention (ERP):

o Lehmkuhl researched the application of this form of CBT with a 12-year-old boy Jason who had both OCD and autism spectrum disorder (ASD).

o Jason experienced contamination fear, excessive

hand-washing, counting and checking.

o He spent several hours daily in compulsive behaviour,

having anxiety when prevented from his rituals.

o ERP consists of gathering information about existing

symptoms, therapist-initiated ERP and generalisation

and relapse training.

o Results: Jason's score on Y-BOCS dropped from

severely high pre-therapy score of 18 to just 3

(normal).

▪ At a 3 month follow up, his score remained low, and

he showed improvement in both OCD symptoms and

participation in social activities.

Cognitive Treatment (Lovell et al., 2006)

o Aim: to compare effectiveness of CBT delivered by

telephone vs same therapy offered face-to-face.

o Sample: 72 patients from 2 different hospitals

o Procedure: Lovell et al used RCT wherein participants

underwent 10 weekly sessions of therapy either by

telephone or face-to-face.

o Changes in well-being were measured via Y-BOCS, BDI, and a client satisfaction questionnaire.

o Result: 6 months after treatment, Y-BOCS scores

significantly improved in both groups, along with high

participant satisfaction, suggesting patients may

benefit equally from both forms of CBT.

Treatment evaluation

• Evaluation:

o Cognitive therapy (Lovell et al): used independent

measures design where participants were randomly

allocated to two conditions, removing researcher bias.

o Face-to-face CBT group acted as control group, so

researchers could compare the results and

effectiveness of ERP to the control group.

▪ Validity and reliability: duration of therapy in both

groups was the same, and outcomes were measured

using the same validated scales.

▪ Limited generalisability: case study was used and

participant had ASD too, thus unrepresentative of the

general OCD population.

▪ Ethical issues: Jason was a child with additional

needs, and issues regarding briefing, consent and risk

of psychological harm.

▪ Qualitative and quantitative: in-depth qualitative

data through ERP and interviews, along with

quantitative data via Y-BOCS scores.

• Issues and debates:

o Use of children in psychology:

▪ SSRIs are generally considered safe, but sometimes

restricted in case of children with OCD due to risks of

harmful side effects.

▪ Ethics: Jason's parents would have had to give

consent on his behalf; some procedures of ERP were

altered to accommodate his age and ASD needs.

o Application to everyday life: CBT and SSRIs are

frequently used OCD treatments.

o Individual explanation: SSRIs only treat one aspect:

the individual's serotonin uptake, ignoring what may

have caused the OCD symptoms to emerge, thus also

being a reductionist approach for treatment.

o Situational explanation: CBT considers the

environment in which the compulsive behaviour takes

place e.g. Jason's therapy addressed triggers in home

and school environment in order to help prevent

relapse.