Abnormal Psychology: Obsessive Compulsive and Related Disorders

Chapter 6: Obsessive Compulsive and Related Disorders

1. Overview of Obsessive Compulsive Disorder (OCD)

  • Definition: Obsessive-Compulsive Disorder (OCD) is characterized by:

    • Persistent and uncontrollable thoughts (referred to as obsessions)

    • Compulsions: the individual feels compelled to perform certain acts repeatedly.

  • Prevalence and Impact:

    • Less common than anxiety disorders, with a lifetime prevalence of about 2%.

    • Occurs as one of the top 10 conditions causing impairment according to the World Health Organization (WHO).

    • High rates of suicidal tendencies among those with OCD.

    • High co-morbidity with anxiety disorders; over __ of people with OCD also meet criteria for an anxiety disorder (Ruscio et al., 2010).

    • Often misdiagnosed (Glazier et al., 2015).

  • Demographics:

    • Affects men and women equally.

    • Typical age of onset is around 20 years, with late-onset OCD (after early 30s) being rare (Ruscio et al., 2010).

2. Diagnostic Features of OCD

  • Obsessions:

    • Defined as intrusive and recurring thoughts, impulses, or images that trigger anxiety.

    • Key characteristics:

    • They are often kept secret for years (Newth & Rachman, 2001).

    • Common themes include:

      • Dirt/contamination

      • Violent thoughts and aggression

      • Orderliness and symmetry

      • Religious and sexual obsessions

  • Common Obsession Examples:

    • Fear of germs from using public toilets.

    • Imagining violent acts like using a knife on someone.

    • Intrusive sexual thoughts.

    • Religious thoughts that involve moral dilemmas.

    • The need for order or symmetry (e.g., items positioned perfectly).

  • Compulsions:

    • Defined as repetitive behaviors or mental acts performed to alleviate anxiety from obsessions or to prevent perceived calamities.

    • Common compulsions include:

    • Checking

    • Cleanliness and orderliness

    • Mental rituals

    • Protective practices

    • Slowness (Primary Obsessional Slowness)

  • Factors that Worsen Compulsions:

    • According to Rachman (2002), several factors increase intensity and frequency of compulsive behaviors:

    • A sense of personal responsibility

    • The perceived probability of harm if rituals are not performed

    • The predicted seriousness of the potential harm.

3. Etiology of OCD

  • Behavioral Theories:

    • Behaviors are learned and reinforced by fear reduction.

  • Cognitive Theory:

    • Compulsive behaviors may result from misinterpretations of intrusive thoughts, possibly related to deficits in prospective memory and non-verbal memory.

    • Research by Radomsky et al. indicates that memory confidence is impacted by relevant versus irrelevant checking behaviors.

  • Rachman's Theory:

    • Proposes that individuals catastrophically misinterpret negative intrusive thoughts.

    • Identifies an inflated sense of personal responsibility and a cognitive bias referred to as thought-action fusion, which entails:

    • The belief that merely thinking of harmful events increases the likelihood of their occurrence.

    • The moral equivalence of thinking about harmful actions and actually executing them.

  • Meta-Cognition in OCD:

    • Beliefs about thought control and the negative consequences associated with uncontrolled thoughts are predictive of obsessions (Clark et al., 2003).

    • Excessive self-reflection on cognitive processes can lead to heightened distress when thoughts conflict with one’s self-concept, leading to ego-dystonic thought.

  • Biological Factors:

    • Genetic studies show higher occurrence in first-degree relatives (10.3% in relatives as compared to 1.9% in controls; Pauls et al., 1995).

    • Concordance rates for monozygotic twins (68%) are significantly higher than for dizygotic twins (31%).

    • Neuroanatomical associations include abnormalities via PET scan indicating abnormal activation in the frontal lobes and basal ganglia which affect motor control.

  • Neuropsychological Testing:

    • Patients with OCD often display impairments in executive functions and attention (Nakao et al., 2009; Snyder et al., 2015).

    • The relationship between OCD and serotonin dysfunction is noted, although SSRIs benefit only 40-60% of patients.

  • Psychoanalytic Perspective:

    • Freudian theory views obsessions and compulsions as manifestations of instinctual forces (sexual or aggressive) that surface due to overly punitive toilet training during early development.

    • Alfred Adler adds the notion that OCD can arise from an inferiority complex, leading individuals to adopt compulsive behaviors to exert control and feel proficient.

4. Psychological and Biological Therapies for OCD

  • Behavioral Treatment:

    • Exposure and Response Prevention (ERP): Exposure involves presenting the client with anxiety-provoking stimuli (e.g., touching a dirty dish) while refraining from performing the compulsive behavior (e.g., hand washing).

    • The ritual acts as a negative reinforcer; preventing it initially induces anxiety which can be treated with ERP over time.

    • Sessions generally require 90 minutes over a series of 15-20 treatments, with practice recommended between sessions.

    • However, refusal of treatment can pose a significant issue (Clark, 2005).

  • Cognitive Approaches:

    • A combination of Cognitive Behavioral Therapy (CBT) is essential, including exposure and response prevention.

    • Specifically, helping clients confront beliefs about the need to perform compulsions is critical in rewriting faulty appraisals (Salkovskis, 1998).

    • The inference-based approach aims at addressing obsessional inferences.

  • Treatment Effectiveness:

    • Meta-analysis indicated that CBT in clinical settings is effective for OCD (Hunsley & Lee, 2007; van Ingen et al., 2009).

    • Group CBT/ERP has been shown to yield significant positive results such as symptom reduction and improvement compared to no treatment.

    • Neither medication nor CBT together doubled efficacy compared to placebo.

  • Challenges in Treatment:

    • About 20% dropout rates reported; online CBT has shown promise comparable to in-person sessions (Mewton et al., 2014).

    • Inclusion of structured exercise programs may improve adherence and outcomes.

  • Biological Treatments:

    • Psychosurgery (e.g., Cingulotomy) is occasionally utilized but is risky and irreversible.

    • Deep Brain Stimulation (DBS) is reserved for severe non-responsive cases and shows a reduction in symptoms averaging 40%.

  • Psychoanalytic Treatments:

    • These approaches aim to explore repressed conflicts but have shown limited effectiveness, highlighting the importance of dealing with decision-making anxiety.

5. Hoarding Disorder

  • Definition: Previously under-recognized, it involves persistent difficulty discarding objects leading to clutter that dominates a person’s life.

  • Recent changes see Hoarding Disorder included in DSM-5, distinguishing it from OCD.

  • Diagnostic Criteria:

    1. Persistent difficulty discarding possessions.

    2. Perceived need to save items, coupled with distress when discarding.

    3. Accumulation resulting in congested living spaces.

    4. Causes significant distress or impairment in social or occupational functioning.

    5. Not attributable to a medical condition or another mental disorder.

  • Physiological and Genetic Aspects: Evidence points towards different neurological and psychological patterns in hoarders as compared to typical OCD presentations.

  • Treatment Approaches:

    • Focus on cognitive restructuring, skills training, and motivation interviewing.

    • CBT protocols have shown effectiveness.

6. Body Dysmorphic Disorder (BDD)

  • Definition: Characterized by preoccupation with perceived defects in physical appearance, predominantly the face.

  • Gender Differences: Women often focus on skin, hips, and breasts, whereas men may worry about height and genital size.

  • Symptoms and Behavior:

    • Patients spend extensive time addressing perceived flaws, often seeking cosmetic procedures and significantly experiencing avoidance strategies.

  • Comorbidities: Chronic condition with linkage to numerous mental health disorders, including depression and substance use.

  • Treatment:

    • ERP, similar to that used in OCD, coupled with CBT for increasing awareness and coping with appearance-related anxiety.

7. Trichotillomania and Excoriation Disorders

  • Trichotillomania: Characterized by recurrent hair pulling, can occur on various body parts, leading to noticeable hair loss and often accompanied by feelings of shame.

    • Treatment focuses on managing triggers with behavioral therapy (e.g., habit reversal training).

  • Excoriation (Skin Picking) Disorder: Involves chronic skin-picking behavior that leads to skin lesions; may overlap with BDD and other impulse-control disorders.

8. Etiology of Body-Focused Repetitive Disorders

  • Genetics: Evidence suggests risk factors and brain structure differences inherent to these behaviors. Impairments often associated with emotional regulation and cognitive processing.

  • Therapeutic Approaches: Emphasizes behavior modification through habit reversal, awareness training, and self-monitoring to replace harmful behaviors with healthier coping strategies.