Week 6: Obsessive Compulsive and Related Disorders

Introduction to Obsessive-Compulsive and Related Disorders

• Overview of disorders in the DSM-5 section.

• Understanding the grouping of these disorders.

• Contemporary models, cognitive-behavioral perspective.

• Relationship to treatment approaches.

• Discussion of controversial issues.

List of Disorders in DSM-5

• OCD (Obsessive-Compulsive Disorder).

• Body Dysmorphic Disorder.

• Hoarding Disorder.

• Trichotillomania (Hair-Pulling Disorder).

• Excoriation (Skin-Picking) Disorder.

• Substance/Medication-Induced Obsessive-Compulsive and Related Disorder.

• Obsessive-Compulsive and Related Disorder Due to Another Medical Condition.

• Other Specified Obsessive-Compulsive and Related Disorder.

• Unspecified Obsessive-Compulsive and Related Disorder.

• The lecture will focus on the first five disorders.

• The DSM has avenues to cover human experiences that don't quite meet diagnostic criteria such as unspecified obsessive-compulsive and related disorder.

Obsessive-Compulsive Disorder (OCD)

• Most familiar disorder in this section.

• More exposure in media (films, television, etc.).

DSM-5 Diagnostic Criteria (Distilled)

• Experience of obsessions and/or compulsions.

• Experiences cause marked distress.

• Experiences are time-consuming (over an hour a day) or significantly interfere with functioning and relationships.

• Specify level of insight into these experiences (good to absent insight or delusional beliefs).

• Question: Why isn't it a psychotic disorder if delusional beliefs are present?

Obsessions

• Persistent thoughts, ideas, impulses, or images.

• Experienced as intrusive.

• Inappropriate to the circumstances.

• Cause marked anxiety or distress.

• Intrusive thoughts are common, but not always indicative of OCD.

• Recognizing these as products of one's own mind is important.

  

Categories/Types of Obsessions

• Fears of contamination (e.g., viruses).

• Doubts (e.g., "Did I turn the iron off?").

• Order/arrangement obsessions.

• Sexual, horrific, violent, or blasphemous imagery.

• Aggressive or inappropriate impulses.

• Nonsensical thoughts or images.

Compulsions

• Repetitive behaviors or mental/cognitive acts.

• Examples: hand washing, checking, praying, counting, repeating words.

• Goal: to prevent or reduce anxiety.

Examples of Obsession/Compulsion Pairing

• Intrusive thought of contamination → compulsive hand washing.

• Doubt about shutting the front door → repeated checking.

• Pairing of obsession and compulsion may seem logical but can be excessive.

• Muscle tensing routine example: intrusive thoughts of family being harmed paired with a muscle tensing routine.

• Even with awareness of no logical link, compulsions may still occur due to perceived anxiety reduction.

• The goal of treatment is to help the individual stop the routine and hold that anxiety knowing nothing bad will happen.

Common Types of Compulsions

• Washing/cleaning.

• Checking.

• Repeating things.

• Ordering.

• Mental rituals like counting.

• Reassurance seeking.

• Compulsive shopping (mentioned but questioned if relevant).

Prevalence of Intrusive Thoughts and Ritualized Behavior

• Most people experience intrusive, unwanted thoughts.

• Dinner plans during a lecture are an example.

• Sometimes thoughts can be pleasant.

• More than 50% of the population engages in some level of ritualized behavior (e.g., checking keys before leaving the house).

• Not all meet criteria for OCD (distress, time-consuming nature, impact on functioning).

General Population Study

• Checking was the most commonly experienced OCD-like symptom.

• 12-month prevalence rates of OCD are about 1% to 2% (US data, similar in Australia).

• No difference in prevalence rates between male and female adults.

• Late adolescence, early adulthood is the average age of onset, but childhood onset and later adulthood onset are not unknown.

• OCD often follows a fluctuating course, depending on external stressors.

• In about 50% of cases, it's chronic.

Childhood Onset

• Not everyone with adult OCD reports symptoms in childhood (1/3 to 1/2 do).

• Childhood onset OCD is more common in boys than in girls.

Obsessions vs Compulsions

• Around 90% experience both obsessions and compulsions.

• Some have obsessions with more cognitive or behavioral compulsions.

• Some describe compulsions without obsessions.

Terminology

• OCD is part of public discourse and diminishes the experience.

• Concept creep (clinical language drifts into non-clinical space).

Symptom Types

• Aggressive and violent-related symptoms: More likely in women.

• Sexual or religious-type symptoms: More likely in men.

• Checking is the most commonly experienced type of symptom.

Comorbidity

• Comorbidity = experiencing OCD and at least one other diagnosable mental disorder.

• Most commonly diagnosed comorbid disorder = major depressive disorder.

• Suicidal ideation and history of suicide attempt is not unknown, ten percent concerning rates.

• Intrusive thoughts, especially violent imagery can be highly distressing.

  

Causes of OCD

• Multifaceted - Combination of factors.

• Learned responses.

• Early childhood experiences.

• Critical learning incidents > Maladaptive beliefs about responsibility, control.

• Family history of OCD is there. some are linked to genes.

  • Mutations in hSERT gene linked to OCD

• Brain structure and function impacted but can't diagnose with MRI.

• Serotonin can have involvement, SSRIs can reduce symptoms in short term.

• Neurocognitive/neuropsychological functioning deficits (executive functioning, memory), but not diagnostic, standard deviations overlap.

  

Cognitive behavioral Model for OCD

• Developed by Paul Salkoskis. 1985

• Premise: INTRUSIVE thoughts are NORMAL.

• Place MEANING on these thoughts and ADD additional ATTENTION.

• RESPOND and REDUCE intensity -> hyper-vigilant.

• Triggering events increase anxiety and compulsions can be a response.

• Compulsions WORK in short term, but lead to be hyper-vigilant to intrusive thought again.

• Self-perpetuating cycle.

  

• Response to anxiety is avoidance.

• Avoid situations that trigger thoughts.

• Super effective in short term -> safety behavior.

Cognitive behavioral Model Example

• LETTER in the Mail

• Worried touched by someone with HIV -> Infection pass to family, hold responsible

• Results in anxiety, can't tolerate these thoughts.

• So avoid touching things and washing is employed, super effective in the moment.

• Over time triggers are not required and hand washing and avoidance occurs left, right and center.

• Evaluation of Intrusive Thoughts:

• Evaluate if overly important must address.

• The thoughts are highly threatening, or something bad will follow.

• The person needs to be able to control their thoughts > intolerable.

• The thoughts are associated with certain perfection, and it must be certain the bad event will not happen so if not, one must act responsibly.

• Must do these actions perfectly, or it could come True, perfection, control are common amongst those with OCD.

COVID-19 Impact

• Restrictions > impacts from sanitizer and masks.

• Symptom Worsening.

• Some cases became the central focus of those with OCD.

• Specialty care was effective for those with OCD.

Body Dysmorphic Disorder (BDD)

Diagnostic Criteria

• Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.

• At some point, the individual has performed repetitive behaviors (e.g., mirror checking) or mental acts in response to the appearance concerns.

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

• Previously dysmorphophobia

Features

• Preoccupied with perceived defects in physical appearance.

• Describing themselves looking like monsters and being hideously ugly.

• Focus one area or all of the body on a shift basis.

• Intrusive unwanted difficult to control.

• Compulsive mirror checking, grooming, reassurance etc.

• Muscle dysmorphia, concern body is too small

How common is BDD

• Under diagnosed, go to dermatologists and plastic surgeons first.

• Often seen amongst patients with cosmetic surgeons, maxillofacial surgeons.

• Waxes and Wanes, also impacted by functional status of that individual.

• No overall differences from main and female prevalence rates.

• Medical assistance to rectify

• Males - Genitalia more likely, females comorbid with eating disorders more likely

• Impact ranges from moderate to servere>incapacitating, can lead to job and university limitations

• BDD can be distressing to others, especially when asked to provider reassurance >shared responsibility

• What makes some people so focus and others not, cognitive differences?

• There are specific cognitions endorsed by BDD over no BDD?

• If the appearance defective then I am worthless is more BDD than normal

• Mirrors generate more anxiety compared to someone without BDD.

• People are more likely to return or be unhappy with procedures after treatment.

• It is important to screen people at Cosmetic surgeons

• Culture > Societal influences, eating and muscle dysmorphia can be viewed with different lenses

• Social media > increasing focus with increased prevalence to BDD

Hoarding Disorder

• Persistant difficulty discarding or parting with possessions regardless of actual value.

• Distress linked to discarding them and need to save > accumulate.

• Accumulate possessions and this clutter can take over the house or rooms.

• Can be unlivable or the person is resistant to discarding objects.

• Hoarding can cause distress, sometimes with impact on the family, and they recognize it as problematic.

• Hoarding the impairment on the functioning of the individual.

• It became a standalone disorder with DSM 5, previously OCD.

• Estimates 2-6 %, more common older adults. Some have varying levels of insight.

• Affects more males

• Females show up more often.

• Adults are older than young adults.

• Linked to needing control over possessions, concern over memory.

• Possessions have human qualities can generate meaning (bread bag clip).

• Bottle tops, newspapers, electronic information can hoard, all trigger people.

• Is the hoarding behaviour something learned from child, genetics or the environment. It can be familial

• Creates lots of fire danger and the possibility of people not being able to evacuate or get to safety.

• Can be very disruptive and ruptures in functioning and relationships.

• A variant that keeps animals, sometimes the people want non-conditional animals so there are positives. Everyone suffers with animal hoarding.

Trichotillomania and Excoriation

• Trichotillomania means hair pulling.

• Pull their hair out and create lots of bald spots.

• They feel that they can't stop the hair pulling.

• Causes distress and limitations on their functions.

• Hair on the head is most common, but can apply to eyelashes or eyebrows.

• They will also camouflage and hide what happened> hats or sleeves.

• It is not a good thing as they will inflame this, and it hurts the person pulling them.

• Skin picking excoriation, picking the skin and not being able to stop to their skin.

• Trying to camouflage it as the hair pulling above.

• Very similar behavior.

• Research into these is light.

• Wax and Wane is not super studied, however impacts the world.

• People participate because they can participate easily.

• It can: Alleviate pain, it can relieve or generate boredom or trigger + feelings> translate state.

• Can be a tension release strategy is useful to highlight.

• 

Conclusion

• All disorders have the intrusive thoughts as a central theme.

• DSM brought them together as they are all linked through intrusive nature, compulsions.

• Treatments come from the same psychological perspective.

• EXPOSURE therapy + prevent compulsion is the key>
  Involves learning new associations

  • Feared stimulus = dangerous and intolerable

  • Feared stimuli = safe and tolerable

    

• That anxiety is associated prevent actions and change.

• Someone with OCD is afraid of x, clean, fear a stimulus is INtolerable or dangerous create new associations in this scenario.

• IN VIVO exposure works here, and the new associations are not helpful actions.

• Patient needs to learn and not make the same decisions again as they did again