integ: abpsych (ocd and related disorders)

Obsessive-Compulsive Disorder

• characterized by the presence of obsessions and/or compulsions 

• Culmination of the anxiety disorders

• The dangerous event is a thought, image, or impulse

Obsessions

intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or eliminate that causes anxiety

ex: Fear of contamination (“What if I get sick from touching this?”)

• Doubts (“Did I leave the door unlocked?”)

• Disturbing thoughts (e.g., harming someone accidentally)

compulsions

Behaviors or mental acts you feel driven to do to reduce the anxiety caused by obsessions or to prevent something bad from happening.

ex: Washing hands over and over

• Checking locks repeatedly

• Counting, praying, or repeating phrases silently

Obsessive-Compulsive Disorder

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 perform 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.

Obsessive-Compulsive Disorder

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; preoc- cupation 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 disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

obsessive-compulsive disorder with good or fair insight

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

obsessive-compulsive disorder with poor insight

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

obsessive-compulsive disorder with insight/deiusionai beiiefs:

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

tic disorder

Up to 30% of individuals with OCD have a lifetime

males

lifetime tic disorder is most common in who with onset of OCD in childhood.

19.5

the mean age at onset of OCD is what years?

14

and 25% of OCD cases start by age what years.

35

Onset of OCD after age what years is unusual but does occur.

males

10

who have an earlier age at onset: nearly 25% of who have onset before age

major depressive disorder

in ocd, presence of comorbid what increases the suicide risk

females

ocd in what affected at a slightly higher rate in adulthood

males

ocd in what are more commonly affected in childhood

Symmetry

Needing things to be symmetrical or aligned

Putting things in order

Forbidden Thoughts / Actions

Urges to harm self or others

Repeated checking, avoidance, or need for reassurance

Cleanliness

Fear of germs or contamination

Repetitive or excessive washing

Hoarding

Fear of throwing anything away

Collecting or saving items with little or no sentimental value

Thought-Action Fusion

when patients with OCD equate specific actions represented by thoughts

Bad thoughts = bad person

Clomipramine (aka Anafranil)

ocd psychopharmacology treatment

Exposure and Ritual Prevention (ERP)

• Most effective approach 

• Process in which the rituals are actively prevented

• Patient is systematically and gradually exposed to feared thoughts / situations

Psychosurgery

A misnomer that refers to neurosurgery for a psychological disorder

Body Dysmorphic Disorder

• persistent, intrusive, and horrible thoughts about appearance

• Often co-occurs with OCD

• Engage in such compulsive behaviors as repeatedly looking in mirrors to check their physical features

• Excessive grooming and skin picking are also common

Imagined Ugliness

imagined defect in appearance by someone who actually looks reasonably normal

skin

hair

in BDD, 61% adolescents focused on their what and 55% on their what

Body Dysmorphic Disorder

• Considered a somatoform disorder

• Previously known as dysmorphophobia

• Suicidal ideation, suicide attempts, and suicide itself are typical consequences of this disorder

Body Dysmorphic Disorder

Most common procedures are rhinoplasties (nose jobs), facelifts, eyebrow elevations, liposuction, breast augmentation, and surgery to alter the jawline

body dysmorphic disorder

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.

Body Dysmorphic Disorder 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.

• typically occuring in men

BDD 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.

BDD with poor insight

The individual thinks that the body dysmorphic disorder beliefs are probably true.

BDD With absent insight/delusionai beliefs

The individual is completely convinced that the body dysmorphic disorder beliefs are true.

16-17 years

The mean age at BDD onset is

15

the median age at BDD onset is

12-13 years

most common age at BDD onset is

18

Two-thirds of individuals have BDD onset before age

12-13

Subclinical body dysmorphic disorder symptoms begin, on average, at age

shubo-kyofu

"the phobia of a deformed body” in japan

• Clomipramine (aka Anafranil) 

• Fluvoxamine

ssris common in BDD

Dermatology Treatment

Most often received treatment in BDD

rhinoplasties (nose jobs), facelifts, eyeshadow elevations,  liposuction, breast augmentation, surgery to alter the jawline

Most common procedures in plastic surgeries for BDD

Hoarding disorder

• difficulty discarding or parting with possessions, regardless of their actual value

• Difficulty is due to a perceived need to save the items and to distress associated with discarding them

Hoarding disorder

• Results in the accumulation of possessions that congest and clutter active living areas

• Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

hoarding disorder

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).

hoarding disorder with excessive acquisition

If difficulty discarding possessions is accompanied by ex-

cessive acquisition of items that are not needed or for which there is no available space.

hoarding disorder 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.

hoarding disorder 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.

hoarding disorder with absent insight/deiusionai 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.

newspapers, magazines, old clothing, bags, books, mail, and paperwork

The most commonly saved items in hoarding disorder are

Clutter

large group of usually unrelated or marginally related objects piled together in a disorganized fashion in spaces designed for other purposes

Animal hoarding

accumulation of a large number of animals and a failure to provide minimal standards of nutrition, sanitation, and veterinary care and to act on the deteriorating condition of the animals and the environment

11-15

Hoarding symptoms may first emerge around ages what years

20s

30s

hoarding disorder start interfering with the individual's everyday functioning by the mid-what, and cause clinically significant impairment by the mid-what.

females

tend to display more excessive acquisition, particularly excessive buying

Trichotillomania

• urge to pull out one’s own hair from anywhere on the body 

• Results in noticeable hair loss, distress, and significant social impairments

Trichotillomania

A. Recurrent pulling out of one’s hair, resulting in hair loss.

B. Repeated attempts to decrease or stop hair pulling.

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.g., a dermatological condition).

E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

distress

negative affects that may be experienced by individuals with hair pulling, such as feeling a loss of control, embarrassment, and shame.

eyebrows and eyelashes

pulling these in trichotillomania may be completely absent.

pets, dolls, and other fibrous materials (e.g., sweaters or carpets)

Some individuals may pull hairs from

skin picking, nail biting, and lip chewing.

The majority of individuals with trichotillomania also have one or more other body-focused repetitive behaviors, including

infants

Hair pulling maÿ be seen in who, and this behavior typically resolves during early development.

puberty

Onset of hair pulling in trichotillomania most commonly coincides with, or follows the onset of, what.

Excoriation

repetitive and compulsive picking of the skin, leading to tissue damage

Noticeable damage to skin occurs, sometimes requiring medical attention

Excoriation (Skin-Picking) Disorder

A. Recurrent skin picking resulting in skin lesions.

B. Repeated attempts to decrease or stop skin picking.

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

D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies).

E. The skin picking is not better explained by symptoms of another mental disorder (e.g.. delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).

fingernails

tweezers, pins, or other objects.

Most individuals pick with their what, although many use what

rubbing, squeezing, lancing, and biting.

In addition to skin picking, there may be skin

skin or scabs

Skin picking may be accompanied by a range of behaviors or rihials involving

Pain

not routinely reported to accompany skin picking.

adolescence

the skin picking most often has onset during

puberty

the skin picking commonly coinciding with or following the onset of what.

acne

The excoriation frequently begins with a dermatological condition, such as

obsessive-compulsive disorder (OCD)

Excoriation disorder is more common in individuals with

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder

A. Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of the obsessive-compulsive and related disorders predominate in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings of both

(1)and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.

2. The involved substance/medication is capable of producing the symptoms in Criterion A.

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder

C. The disturbance is not better explained by an obsessive-compulsive and related disorder that is not substance/medication-induced. Such evidence of an independent obsessive-compulsive and related disorder could include the following:

The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non-substance/medication-induced obsessive-compulsive and related disorder (e.g., a history of recurrent non-substance/medication-related episodes).

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder With onset during intoxication

If the criteria are met for intoxication with the substance and the symptoms develop during intoxication.

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder with onset during withdrawai

If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder with onset after medication use:

Symptoms may appear either at initiation of medication or after a modification or change in use.

Obsessive-Compulsive and Related Disorder Due to Another Medical Condition

A. Obsessions, compulsions, preoccupations with appearance, hoarding, sl<in picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of obsessive-compulsive and related disorder predominate in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.

C. The disturbance is not better explained by another mental disorder.

D. The disturbance does not occur exclusively during the course of a delirium.

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

OCD due to another medical condition With obsessive-compulsive disorder-like symptoms:

If obsessive-compulsive disorder-like symptoms predominate in the clinical presentation.

OCD due to another medical condition with appearance preoccupations

If preoccupation with perceived appearance defects or flaws predominates in the clinical presentation.

OCD due to another medical condition with hoarding symptoms

If hoarding predominates in the clinical presentation.

OCD due to another medical condition With hair-pulling symptoms

If hair pulling predominates in the clinical presentation.

OCD due to another medical condition with skin-picking symptoms:

If skin picking predominates in the clinical presentation.

Body dysmorphic-like disorder witli actual flaws

This is similar to body dysmorphic disorder except that the defects or flaws in physical appearance are clearly observable by others (i.e., they are more noticeable than “slight”). In such cases, the preoccupation with these flaws is clearly excessive and causes significant impairment or distress.

Body dysmorphic-like disorder without repetitive behaviors

Presentations that meet body dysmorphic disorder except that the individual has not performed repetitive behaviors or mental acts in response to the appearance concerns.

Body-focused repetitive behavior disorder

This is characterized by recurrent body-focused repetitive behaviors (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning and are not better explained by trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, stereotypic movement disorder, or nonsuicidal self-injury.

Obsessional jealousy

This is characterized by nondelusional preoccupation with a partner’s perceived infidelity. The preoccupations may lead to repetitive behaviors or mental acts in response to the infidelity concerns; they cause clinically significant dis- tress or impairment in social, occupational, or other important areas of functioning; and they are not better explained by another mental disorder such as delusional disorder, jealous type, or paranoid personality disorder.

Habit Reversal Training

patients are carefully taught to be more aware of their repetitive behavior, particularly