Obsessive-Compulsive Disorder DSM-5

Obsessions

• recurring + persistent thoughts / urges / images

• at some point considered intrusive + unwanted

• cause marked anxiety / distress

• lead to some attempt to ignore / suppress them or neutralise them w/ another thought / action (ie: performing a compulsion)

Compulsions

• repetitive behaviours / mental acts that an individual feels driven to perform in response to an obsession or according to a strict set of rules

• eg: praying, countring, repeating words silently, etc

• meant to prevent or reduce anxiety / distress, or prevent a dreaded event / situation 

• not realistically connect w/ what they’re meant to prevent / reduce, or are excessive

Diagnostic Criteria

A) presence of obsessions, compulsions, or both

B) obsessions / compulsions are time-consuming (take more than one hour a day) or cause clinically significant distress or impairment in important areas of functioning

C) symptoms are not attributable to the physiological effects of a substance or another medical condition

D) symptoms are not better explained by symptoms of another mental disorder

Specifiers

• people w/ OCD have varying degrees of insight about the accuracy of the beliefs underlying their OCD symptoms

  • can also vary for a person throughout their life

• insight qualifiers: good, fair, poor, absent / with delusional beliefs

• many have good/fair insight: aware that beliefs definitely aren’t true, probably aren’t true, or may or may not be true

• some have poor insight: beliefs are probably true

• 4% or less: absent insight or delusional beliefs: convinced that beliefs are true

• worse insight associated w/ worse long-term outcomes

Diagnostic Features

• most ppl have both obsessions + compulsions

• obsessions + compulsions usually thematically related (eg: thoughts of contamination → washing rituals)

• common themes: cleaning (contamination thoughts + cleaning compulsions), symmetry (symmetry obsessions + repeating, ordering, + counting compulsions), forbidden / taboo thoughts (aggressive, sexual, or religious obsessions + related compulsions), harm (fear of harm to self / others + checking compulsions)

• themes occur across different different cultures + tend to be consistent over time in OCD adults

• ppl may have symptoms in more than one theme / dimension

• compulsions aren’t done for pleasure, but may give temporary relief from anxiety / distress

• frequency + severity of obsessions / compulsions vary from person to person

Associated Features

• up to 60% report sensory phenomena: physical experiences that happen before compulsions (eg: physical sensations, just-right sensations, feelings of incompleteness)

• range of emotional responses to situations that trigger obsessions / compulsions (eg: anxiety, disgust, incompleteness)

• avoidance of people / places / things that could trigger obsessions / compulsions is common

• many people have dysfunctional beliefs (eg: overestimating threats, inflated sense of responsibility, perfectionism, need to control their thoughts, overimportance of thoughts, intolerance of uncertainty)

• family + friends accommodating rituals can exacerbate / maintain symptoms

Prevalence

• 12 month prevalence in US: 1.2%

• 12 month international prevalence: 1.1 - 1.8%

• women affected slightly more in adulthood; men more commonly affected in childhood

Development and Course

• mean onset age: 19.5

• 25% of cases start by 14

• men have earlier onset than women — almost 25% have onset before age 10

• onset after 35 is rare

• onset of symptoms is usually gradual, but can be acute

• if untreated, the course is usually chronic w/ waxing + waning symptoms & low remission rates in adults

• some people have episodic courses + a minority have a deteriorating course

• 40% of people w/ childhood / adolescence onset may experience remission by early adulthood

• often course is complicated by comorbidities

• compulsions are more easily diagnosed than obsessions in children bc you can see them, but most have both

• obsession / compulsion content likely varies w/ developmental stage

Etiology: Temperament

• risk factors: greater internalising symptoms, higher negative emotionality, + behavioural inhibition in childhood

Etiology: Environmental 

• increase risk of development: adverse perinatal (immediately before + after birth) events, premature birth, maternal tobacco use during prenancy, physical + sexual childhood abuse, stressful / traumatic events

• sudden onset of obsessive / compulsive symptoms in children has been associated w/ postinfectious autoimmune syndrome + various infectious agents

Etiology: Genetic

• rate of OCD in first-degree relatives of people w/ OCD is 2x the rate of OCD in genpop

• rate of OCD in first-degree relatives whose onset was in childhood / adolescence is 10x higher

• familial transmission is in part due to genetic factors

Functional Consequences

• 14.2% mean rate of lifetime suicide attempts

• 44.1% mean rate of lifetime suicidal ideation

• 25.9% mean rate of current suicidal ideation

• associated w/ lower quality of life & high levels of social + occupational impairment

• avoiding situations that trigger obsessions / compulsions can impair functioning (obsession with harm → relationships w/ friends + family feel hazardous → avoid friends)

• frequent health consequences

• childhood / adolescent onset can lead to developmental difficulties

Differential Diagnoses

• 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 behaviours

• obsessive-compulsive personality disorder

Differential Diagnosis: Anxiety Disorders

both frequently deal w/ recurrent thoughts, repetitive reassurance seeking, + avoidant behaviours

generalised anxiety disorder: recurrent thoughts are usually about real life concerns, whereas obsessions in OCD are usually odd / irrational / magical w/ frequent presence of compulsions

specific phobia: fear response towards specific situations / objects overlaps, but in specific phobia it is usually a more limited object / situation without the presence of rituals

social anxiety: feared object / situation is limited to social interactions / performance + avoidance / reassurance-seeking centers on reducing embarrassment

Differential Diagnosis: Major Depressive Disorder

OCD is different from MDD rumination, where thoughts are usually congruous w/ mood + not necessarily intrusive / distressing. ruminations also aren’t linked to compulsions like obsessions would be

Differential Diagnosis: Other Obsessive-Compulsive and Related Disorders

body dysmorphic disorder: obsessions + compulsions are limited to physical appearance concerns

trichotillomania: compulse behaviour is limited to hair-pulling w/ no obsessions

hoarding disorder: symptoms exclusively focus on difficulty throwing things away / parting w/ things, the distress caused by doing so, + excessive accumulation of objects. however, if person has OCD-typical obsessions (eg: incompleteness, harm) that lead to compulsive accumulations (eg: getting objects to feel complete, not throwing away old newspapwers in case they contain info that could prevent harm), OCD should be diagnosed instead of hoarding disorder

Differential Diagnosis: Eating Disorders

unlike anorexia, OCD obsessions / compulsions aren’t limited to concerns about weight / food

Differential Diagnosis: Tics (in Tic Disorder) and Stereotyped Movements

tics: sudden rapid nonrythmic recurrent movements or vocalisations

stereotyped movements: repetitive, seemingly purposeless motor behaviours that are rhythmic & predictable in their pattern + location on body (eg: head banging, body rocking, self-biting)

tics + stereotyped movements are usually less complex than compulsions + aren’t meant to neutralise obsessions. can be hard to tell the difference w/ more complex tics. tics are usually preceded by premonitory sensory urge (uncomfortable feeling / sensation, either bodily or mental, that will be relieved by motion) whereas compulsions are usually preceded by obsessions. some ppl have symptoms of both + should receive comorbid diagnoses

Differential Diagnosis: Psychotic Disorders

OCD can come w/ poor insight or delusional beliefs, but presence of obsessions / compulsions precludes delusional disorder + ppl w/ OCD alone will lack other aspects of schizophrenia / schizoaffective disorder (eg: hallucinations, disorganised speech). if person w/ OCD has delusions or no insight, they should receive the “w/ absent insight / delusional beliefs” specifier, not a psychotic disorder diagnosis

Differential Diagnosis: Other Compulsive-Like Behaviours

some behaviours are described as compulsive (eg: sexual behaviour in paraphilias, gambling in gambling disorder, substance use in substance use disorders), but that’s not the same as OCD compulsions — people w/ these behaviours usually get pleasure from the activities, + might only want to stop bc of harmful consequences

Differential Diagnosis: Obsessive-Compulsive Personality Disorder

obsessive-compulsive personality disorder doesn’t involve intrusive thoughts / images / urges or repetitive behaviours in response to them, but is characterised by consistent + pervasive maladaptive patten of excessive perfectionism + strict control. if someone has symptoms of both, they can receive both diagnoses

Comorbidity

• people w/ OCD often have other disorders

• 76% of OCD adults in US have lifetime diagnosis of an anxiety disorder, 63% have a depressive or bipolar disorder, 56% have an impulse-control disorder, + 39% have a substance use disorder

  • of the depressive + bipolar disorders, major depressive disorder is the most common at 41%

• OCD onset usually later than most comorbid anxiety disorders (except separation anxiety) + PTSD, but often precedes depressive disorders

• study: of 214 US adults w/ OCD seeking treatment, 23 - 32% were found to have comorbid obsessive-compulsive personality disorder in a longitudinal study

• up to 30% have comorbid lifetime tic disorder

  • most common in men w/ childhood onset of OCD

  • tend to differ from other ppl w/ OCD but no tics: themes of symptoms, comorbidity, course, + pattern of familial transmission

• children sometimes have triad of OCD, ADHD, + tic disorder

• some obsessive-compulsive + related disorders are more common in people w/ OCD than in people without: body dysmorphic disorder, trichotillomania, excoriation (skin-picking)

• people w/ certain disorders have much higher rates of OCD than expected from the genpop prevalence — if diagnosed with one of these disorders, individuals should also be assessed w/ OCD

  • in people w/ schizophrenia / schizoaffective disorder, OCD prevalence is 12%

  • bipolar disorder, eating disorders (anorexia + bulimia esp), body dysmorphic disorder, Tourette’s