Obsesive Compulsive & Related Disorders

Obsessions

Recurrent persistent thoughts, urges, or images experienced as intrusive and unwanted that often cause anxiety or distress

• Person attempts to ignore or suppress them, or to neutralize them with some other thought or action

Compulsions

Repetitive behaviors or mental acts person feels driven to perform in response to obsession or according to rigid rules

• Behaviors or mental acts aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however not realistically connected to what they are designed to neutralize/prevent or are clearly excessive

Common compulsions

• Cleaning or washing

• Checking

• Ordering

• Counting

• Praying

• Repeating words silently

OCD in kids

Can be pure O or pure C, pure C common in kids

ODC Criterion A

Presence of obsessions or compulsions or both

ODC Criterion B

Obsessions or compulsions must

• Be time consuming or

• Cause marked distress or

• Greatly interfere with person’s functioning

• No minimum duration specified, if B is occurring, you have it

Who gets OCD?

• Age at onset: 13-15 in males, 20-24 in females, difference could be biological?

• Lifetime prevalence: 1.6%

• Gender differences: 1.2:1 female, more likely to occur for boys in adolescence, ratio flipped

• No ethnic, socioeconomic, or cultural differences

• Religiosity, believing in tenants of organized religion

• Doesn’t matter religion

• Obsessions can be due to moral stress related to religion

Body Dysmorphic Disorder

Like OCD, but slightly different, means bad, distorted, wharfed form

Body Dysmorphic Disorder Criterion A

Preoccupation with perceived defect in appearance not observable (or appear slight to others), related to obsession

Body Dysmorphic Disorder Criterion B

Individual has performed repetitive behaviors or mental acts in response to appearance concerns

• Related to compulsions e.g., excessive exercise, mirror checking, body adaptation (plastic surgery), reassurance seeking

Body Dysmorphic Disorder Criterion C

Preoccupation causes distress or impairment

• Note: includes muscle dysmorphia; belief you aren’t muscular enough

• People with BDD can have multiple areas of concern

• Predominant concerns are related to face/head areas

Who gets BDD?

• Age at onset: 16-17

• Mode age: 12-13

• 2/3 of patients onset before age 18

• Adult point prevalence: 2.5% females, 2.2% males

• Adolescent girls more dissatisfied with bodies than boys, but BDD rates about equal in adulthood

• African Americans of both sexes less dissatisfied with bodies then caucasians, asians, and hispanics

Hoarding Disorder Criterion A

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

• Not related to getting new stuff

• People worry about discarding things they may need

Hoarding Disorder Criterion B

Due to perceived need to save items and distress about discarding them

Hoarding Disorder Criterion C

Results in accumulation of possessions that congest and clutter active living areas, substantially compromising areas used

• If not because of 3rd patients

• Higher functioning hoarders are usually very organized

Hoarding Disorder Criterion D

Causing distress or impairment in social, interpersonal, or occupational functioning

• Includes maintaining safe environment for self and others

Who gets hoarding disorder?

• Age at onset: progressive severity

• Symptoms: age 11-15

• Interference: mid 20’s

• Significant impairment: mid 30’s

• Average study participant: 50

• Point prevalence: 2-6%

• Gender differences, other cultural differences unclear

Biological Theory

• Genetics: 1st degree relatives at roughly 2x risk

• However, specific polymorphisms elusive

• Perhaps general propensity for anxiety again?

• Structures associated with OCD: caudate nucleus, orbitofrontal cortex, thalamus overactive (clear pattern of activation)

• Areas related to filtering out irrelevant information and associated with repetitive behaviors

• Serotonin primary neurotransmitters

Biological Treatments: Medication

• 1st med shown effective: Anafranil (serotonin reuptake inhibitor)

• SSRI’s (Prozac, Paxil, Luvox)

• 5HT1A Agonists (Buspar) - helpful to add in with other meds

• Meds effective in ~60% of patients

• Treatment gains modes, relapse frequent

Biological Treatments: Surgery

• Typically last result

• Lessions in OCD - can lead to other issues

• Cosmetic surgeries for BDD

• Distress tends to continue after surgery

• OCD disorders have high comorbidity with depression, ~60-70% of patients

Psychodynamic Theory

• Obsessive thought defense against even more unacceptable (unconscious) thought

• Displaced from childhood (usually oedipal) conflict

• Content of obsession paramount in understanding unconscious conflict

• Compulsion is defense against underlying thing

Psychodynamic Treatment

Psychoanalysis: very poor outcomes, better than PTSD, but not great

Behavioral Theory

• The more you try not to think of something, the harder it is not to think about it

• Random thought → “danger” → more random thoughts

• Compulsions maintained by avoidance

• Never gather evidence that compulsion doesn’t overt obsession

Behavioral Treatment

• Exposure and Response Prevention: exposure to obsessions, work to prevent compulsions

• Have to provoke obsession and go beyond what normal people would do

• Therapist needs to be there and doing actions with client

• Have to build trust between therapist and client to stop ritual

• Can’t do compulsions and get better

• Have to do this repeatedly in multiple contexts

• 85% of people get better, low response rates