Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder (OCD)

  • Overview:

    • Characterized by intrusive, unwanted, persistent thoughts and impulses (obsessions) and repetitive behaviors or mental acts (compulsions).
    • Causes significant distress, impairs functioning, and interferes with daily activities.

  • DSM-5 Classification:

    • Recognized as a distinct diagnostic category, separate from anxiety disorders.
    • Includes: Hoarding disorder, body dysmorphic disorder, trichotillomania (hair-pulling), and excoriation (skin-picking).

Body Dysmorphic Disorder

  • Preoccupation with perceived imperfections in appearance.
  • Perceived flaws may be unnoticeable or minor to others.
  • Obsessive focus leads to the belief that they are ugly.
  • Involves intrusive and undesired repetitive activities:
    • Checking mirrors
    • Seeking reassurance
    • Comparing attractiveness to others

Trichotillomania (Hair-Pulling Disorder)

  • Recurrent pulling of hair, often from the scalp, brows, or eyelids.
  • Distinct from simply playing with or biting hair.
  • Causes significant anguish and functional issues.

Dermatillomania (Skin-Picking Disorder)

  • Excessively frequent picking at one's skin, resulting in lesions.
  • Causes significant distress.

Hoarding Disorder

  • Accumulation of an excessive quantity of items.
  • Items are kept in an unorganized way, leading to clutter.
  • Objects may be worthless or of little monetary value.

Obsessions

  • Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted.
  • Individuals attempt to suppress or ignore these thoughts.
  • Obsessive ideas are intrusive and alien.
  • Manifestations:
    • Wishes (e.g., repeatedly wishing for a spouse to pass away).
    • Urges (e.g., wanting to yell at coworkers or in church).
    • Images (e.g., fleeting visions of inappropriate sexual scenes).
    • Ideas (e.g., belief that germs are everywhere).

Types of Obsessions:

  • Symmetry Obsessions:
    • Maintaining order and following specific procedures.
    • Example: Placing magazines on a table in a precise arrangement.
  • Prohibited Thoughts:
    • Improper thoughts, such as violent intrusive thoughts or visions.
    • Can make the individual feel dangerous.
  • Contamination Anxieties:
    • Obsessive thoughts centered around cleanliness or contamination.
    • Belief that germs are nearby.
  • Hoarding:
    • Compulsive acquisition of objects and difficulty discarding them.

Compulsions

  • Behaviors or ideas used to control obsessions and provide comfort.
  • Involve repetitive activities.
  • Distress or anxiety results if the behavior is not carried out or is not carried out "correctly”.
  • Overwhelming urge to participate in the compulsive behavior.
  • Compulsions are not a matter of choice, but a feeling of being compelled.
  • Mild compulsions (e.g., measuring steps) are common, but compulsions factor into a mental health diagnosis when they cause distress, interfere with daily living, or endanger health.

OCD and OCD Cycle

  • OCD is one of the most incapacitating mental illnesses due to the poorer quality of life and significant functional impairment it causes, Stein et al. (2009).
  • The individual must also understand that the fixation is a creation of their own minds rather than something that was forced upon them (as might occur in schizophrenia).
  • However, there is a spectrum of “insight” among OCD sufferers regarding how absurd and excessive their thoughts and compulsions are [Ruscio et al. (2010)]. This understanding is occasionally present, but not always.
  • Most people have had fleeting obsessive ideas, like worrying about whether they locked the door or turned off the stove.
  • The majority of us also occasionally act in repetitive or stereotyped ways, like verifying the stove or the door’s lock or stepping over cracks in the pavement.
  • However, in OCD, the compulsive behaviour that goes along with the excessive, persistent, and distressing ideas disrupt daily activities.
  • The regularity, intensity, and degree to which obsessions and compulsions are resisted and are distressing vary between normal and abnormal obsessions and compulsive behaviour, and this continuum must be understood [Steketee and Barlow (2002)].

Prevalence, Age of Onset, Gender Differences, and Co-Morbidity

  • Prevalence:
    • Indian epidemiological survey: lifetime prevalence of 0.6%.
    • Meta-analysis (2017): pooled prevalence of 1.6% (range: 0.47% to 2.76%).
  • Age of Onset:
    • Males tend to begin significantly sooner than females.
    • Typically manifests around age 20, but can occur as early as two years old.
    • Studies in Delhi (2013) and Chennai (2014) found a mean age of onset of OCD around 23.3 and 23.2 years, respectively.
  • Gender Differences:
    • Early onset is linked to sexual obsessions, hoarding, repeating routines, and touch compulsions.
    • Equal numbers of men and women were obsessive checkers.
    • Compulsive cleaning (66%) and avoidance (26%) are more common in women.
    • Females with OCD were more likely to report contamination/cleaning compulsions; men were more likely to report aggressive and checking compulsions.
  • Co-Morbidity:
    • Frequently co-occurs with Tourette’s syndrome, depression, and social phobia.

Psychosis and OCD

  • Obsessive doubts, washing, and checking compulsive behaviors were found to be the most prevalent OC symptoms in a retrospective chart study of 15 cases of OCD with psychosis.
  • Three cases had atypical psychosis, while twelve cases had a diagnosis of schizophrenia.
  • First Rank symptoms of schizophrenia were present in about half of the cases.
  • After receiving treatment of antipsychotic and anti-obsession medications, nearly three-fourths of the sample displayed a substantial improvement.

Bipolar Disorder and OCD

  • Studies have looked at the distinctions between non- bipolar and bipolar OCD (Zutshi et al.).
  • Depression, social phobia, and generalized anxiety disorder were all linked to bipolar and OCD.
  • OCD was present in the majority of patients before they developed bipolar illness, and it got worse during depression and got better during mania.
  • The authors came to the conclusion that bipolar illness and OCD may have a path physiological relationship.

Parkinson’s Disease and OCD

  • In 69 Parkinson’s disease patients and paired medically ill controls, Harbishettar et al. thoroughly eval- uated OC symptoms and OCD.
  • Regarding OC symptoms, clinical and subclinical OCD, and tics, there was no variation between the groups.
  • Furthermore, no correlation was found between the intensity of OC symptoms and Parkinson’s disease symptoms.
  • Although basal ganglia’s involvement may be similar in both disorders, authors hypothesized that distinct circuitry may be involved in the pathophysiology of OCD and Parkinson’s disease.

Schizophrenia and ADHD

  • Schizophrenic individuals with and without Co-morbid OCD were compared in terms of their clinical profiles by SCH Rajkumar et al. (50 in each group).
  • Paranoid symptoms and first- rank symptoms of schizophrenia were more prevalent in schizo-obsessive individuals.
  • They scored more severely depressed, had greater levels of comorbid personality disorders, more disability, and lower energy.
  • OCD severity ratings and schizophrenia symptom dimension scores showed a strong association.
  • The researchers came to the conclusion that “schizo-obsessive” schizophrenia might be a separate subtype with distinctive clinical traits.

OCD and ADHD

  • Between 0 and 51% of OCD patients have ADHD, which is a broad range [Geller et al. (2001); Jaisoorya et al., (2003)].
  • About 5% of the population experiences attention deficit hyperactivity disorder, a prevalent neuro-developmental disorder with childhood onset that frequently co-occurs with OCD.
  • Differentiating between primary at- tentive symptoms and attentive symptoms secondary to anxiety disorders is crucial for prognosis and treatment because both of the two conditions may show symptoms of inattention.

Case Study: Sita

  • 30-year-old married woman and mother of four.

  • Experienced anxiety for a while but had never sought expert assistance.

  • Depressed for three months and was recommended for counseling.

  • Obsessions: Intrusive, repeated thoughts about the security of her children, imagining serious accidents.

  • Compulsions: Counting rituals, specific numerals holding a special significance, affecting daily tasks like grocery shopping.

  • Avoidance of items based on her children's ages to ensure their safety.

  • Acknowledged the irrationality of these rituals but felt more comfortable when she observed them conscientiously.

  • Felt anxiety in the form of dread and apprehension when in a rush to complete rituals.

  • Issues with her marriage and parenting.

  • Her spouse had been placed on complete physical disability for 11 months.

  • cleaning, washing, shopping, and retrieving potato chips and other snacks whenever her husband required a snack took up most of her days in addition to getting the kids ready for school, fed, and transported there.

  • the most routine physical activity could be hazardous for him because of a serious heart condition.

  • She was powerless to deal with it.

  • Symptoms Covered in the Case Study (in accordance with DSM-5)

    • Sita’s need to count things, which she feels compelled to do as a result of her fascination with numbers.
    • Sita had been plagued by intrusive, repeated concerns about the security of her kids. She often found herself imagining that there had been a major accident, and she could not get these thoughts out of her head. (Repeated and enduring ideas)
    • Sita’s obsession with numbers and other behaviours, such as smoking cigarettes (Substance abuse).
    • Sita acknowledged the absurd of the routines, but she insisted that she felt much more at ease when she diligently followed them.
    • Sita’s inability to manage her children was making her increasingly upset, and she was receiving little to no assistance from her husband. - Unwarranted anxiety.

Dynamics of Obsessive-Compulsive Disorder

  • No single factor contributes to OCD.
  • Biological, psychological, and social factors are implicated.

Psychological Causal Factors

  • Obsessive-compulsive behavior arises because it helps people feel less anxious.

  • Classical Conditioning Theory: Ideas or behaviors become associated with an unpleasant event and become conditioned stimuli.

  • Cognitive elements contribute to the intense doubts associated with OCD.

  • Individuals with OCD show thought confusion, in which the stressful thought about an action, event, object, combine with the event.

  • Having these ideas results in the same feelings as if the event had actually happened.

  • OCD as Learned Behavior

    • Two-process hypothesis of avoidance learning.
    • Anxiety results from neutral stimuli developing a classical conditioning relationship with terrifying ideas or events.
    • Example: Shaking hands represents the "frightening" thought of contamination.
    • Washing hands reduces anxiety, reinforcing the washing reaction.

  • OCD and Preparedness

    • Compulsive washing-related concerns about dirt and contamination are frequent.
    • Human obsessions with filth, pollution, and potentially dangerous situations have a long evolutionary history.
    • Displacement behaviors in animals during conflict are similar to compulsive rituals.

Cognitive Causal Factors

  • The Effects of Attempting to Suppress Obsessive Thoughts

    • Paradoxical rise in undesired thoughts after trying to suppress them.
    • Efforts to suppress may contribute to the frequency of obsessive thoughts and depressive moods.
    • People with OCD reported roughly twice as many intrusive thoughts on the days when they were attempting to suppress (Kirk & Salkovskis, 1997).

  • Appraisals of Responsibility for Intrusive Thoughts

    • Catastrophic assessments about having such ideas.
    • OCD sufferers frequently exhibit an exaggerated feeling of duty.
    • Thinking about doing something is morally equivalent to actually doing it (thought-action fusion).
    • Increased sense of responsibility for potential harm.

  • Cognitive Biases and Distortions

    • OCD patients are drawn to disturbing material that relates to their obsessive worries.
    • They may try to repress negative thoughts sparked by this knowledge.
    • Trouble blocking out negative, irrelevant, or distracting data.
    • Lack faith in their recall (particularly for events for which they feel responsible).

Biological Causal Factors

  • Genetic Factors

    • Twin studies show higher rates of OCD in monozygotic twins.
    • Family studies report 3 to 12 times higher rates of OCD in first-degree relatives.
    • Early-onset OCD has a higher genetic loading than later-onset OCD.

  • OCD and the Brain

    • Anomalies mostly affect the basal ganglia and specific cortical regions.
    • High activity in the orbital frontal cortex and the cingulate cortex/gyrus.
    • Excessively high subcortical caudate activity.

  • Neurotransmitter Abnormalities

    • OCD symptoms may be caused by increased serotonin activity and enhanced sensitivity of brain regions to serotonin.
    • Stimulation medicines make symptoms worse.
    • Long-term use of clomipramine (or fluoxetine) results in a down-regulation of some serotonin receptors, which further results in a functional drop in serotonin availability.
    • Other neurotransmitter systems (dopaminergic, GABA, and glutamate systems) also appear to be involved

Social and Sociocultural Dimensions

  • Family factors like a controlling, overly critical parenting style, little parental affection, and a disapproval of autonomy are linked to the emergence of OCD symptoms
  • Those who grow up in unfavorable situations may adopt unhelpful views on personal responsibility; they could think it is their duty to protect others and themselves and exaggerate their sense of obligation and threat
  • Those with OCD tend to experience more severe symptoms when they believe their relatives are critical or unfriendly
  • OCD symptoms can affect friends, roommates, and family members as well