CHAPTER 5B

Lecture 05: Anxiety II: Obsession and Preoccupation

Obsessive-Compulsive Disorder (OCD)

Key Features

  • Fear of Unwanted and Intrusive Thoughts (Obsessions)

    • Individuals experience recurrent and persistent thoughts or urges that are intrusive and inappropriate.

    • These obsessions often cause marked anxiety or distress.

  • Repeated Ritualistic Actions or Thoughts (Compulsions)

    • Actions or mental processes designed to neutralize unwanted thoughts.

    • Examples of compulsions could include repetitive handwashing or checking behaviors.

  • Prevalence

    • The lifetime prevalence rate of OCD is between 1.6% and 2.3% in the Canadian population (Calamari et al., 2012; Kessler et al., 2005).

  • Continuum of Severity

    • Obsessions and compulsions can occur on a continuum, where individuals can experience varying degrees of severity.

  • Normal Samples

    • It is noted that even “normal” populations can experience obsessions and compulsions without meeting clinical diagnostic criteria.

OCD DSM-5 Criteria

Criteria A: Presence of Obsessions, Compulsions, or Both

  • Obsessions are defined by the following:

    1. Recurrent and persistent thoughts, urges, or images experienced as intrusive and inappropriate that cause marked anxiety or distress.

    2. The individual attempts to ignore or suppress such thoughts or to neutralize them with some other thought or action (performing a compulsion).

Criteria B: Time Consumption and Distress

  • Obsessions or compulsions are time-consuming, taking more than 1 hour per day, or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criteria C: Substance and Medical Condition Exclusion

  • The obsessive-compulsive symptoms cannot be attributed to the physiological effects of a substance (e.g., drug of abuse, medication) or another medical condition.

Criteria D: Disturbance Not Better Explained by Another Disorder

  • Symptoms should not be better explained by another mental disorder.

Comorbidity with OCD

  • Individuals with OCD may also experience:

    • Severe generalized anxiety

    • Recurrent panic attacks

    • Debilitating avoidance

    • Major depression

Types of Obsessions and Associated Compulsions

Symptom Subtype

Obsession Description

Compulsion Description

Symmetry / exactness / "just right"

Needing things to be symmetrical or aligned just so

Putting things in a certain order

Forbidden thoughts or actions

Urges to do things over and over until they feel "just right"

Repeating rituals and checking

Cleaning / contamination

Fears of germs or contaminants

Repetitive or excessive washing, using gloves, and masks

Hoarding

Fears of throwing anything away

Collecting/saving objects with little or no actual or sentimental value

In-Class Activity: Compulsion Sort

  • Activity Objective

    • Students are to differentiate between compulsions and non-compulsive behaviors.

  • Compulsions are defined as repetitive behaviors or mental acts performed to reduce distress or prevent feared events, such as checking the door multiple times because of fear of burglary.

  • Students will match behaviors into two categories:

    • A) Compulsions

    • B) Not Compulsions

  • Submission Requirement

    • Students must submit their sorted behaviors for credit.

Obsessions and Preoccupations in Nonclinical Samples

Example Obsessions

  • Harming

    • Impulses to jump from high places, wishing harm to others, inappropriate aggressive thoughts.

  • Contamination/Disease

    • Fears catching diseases from public spaces like pools or restrooms.

  • Inappropriate Behavior

    • Thoughts of yelling at authoritative figures or having unnatural sexual urges.

  • Doubts About Safety/Memory

    • Concerns about locking doors, unplugging devices, or ensuring objects are perfectly arranged.

Epidemiology and Statistics of OCD

  • The lifetime prevalence of OCD is between 1.6% - 2.3%.

  • Symptoms can be understood on a continuum regarding their severity.

  • The male-to-female ratio for OCD is 1:1.

  • Onset typically occurs in early adolescence to mid-20s.

  • The condition is chronic when developed.

Etiological Factors of OCD

  • The regulation of thoughts is associated with specific brain circuits.

  • Early experiences may influence the development of OCD.

  • Thought-Action Fusion is a concept where having a thought is equated with the action of carrying out that thought, leading to compulsive behaviors.

  • Suppressing thoughts often results in increased compulsions as individuals struggle against their intrusive thoughts.

Biological Treatments for OCD

  • Psychosurgery

    • Considered a last resort for severe cases of OCD.

    1. Cingulotomy - Involves inserting thin probes to selectively burn targeted brain tissue.

    2. Capsulotomy - A form of radiation treatment that creates controlled lesions in the brain.

  • Careful Screening

    • Screening is essential in determining the appropriateness of these surgical interventions.

  • Side Effects

    • Patients may experience various side effects post-surgery, highlighting the need for careful decision-making.

Psychological Treatments for OCD

  • Exposure and Ritual Prevention (ERP)

    • Patients are actively prevented from performing their rituals while being exposed to feared thoughts or situations.

    • This therapy also includes methods like “reality testing” to help patients distinguish between thoughts and actual occurrences.

    • It specifically addresses and helps mitigate the impacts of thought-action fusion, providing patients tools to manage their obsessive thoughts without resorting to compulsive action.

Obsession- and Preoccupation-Related Disorders

Body Dysmorphic Disorder

  • Definition

    • Preoccupation with an imagined defect in appearance, even if the individual appears reasonably normal.

    • Patients exhibit behaviors like excessive mirror checking and grooming.

  • Co-occurrence with OCD

    • Body Dysmorphic Disorder often co-occurs with OCD, which exacerbates the condition.

  • Prevalence

    • The overall prevalence is about 2.2%, with onset generally occurring in early adolescence.

  • Impact on Quality of Life

    • Individuals experience a high degree of stress and often report reduced quality of life along with functional impairments.

Causes and Treatment of Body Dysmorphic Disorder

  • There is insufficient information regarding psychological or biological predisposition to Body Dysmorphic Disorder, which limits understanding.

  • Evidence-Based Treatments

    • The two treatments that have shown effectiveness include:

    1. SSRIs, for example, fluvoxamine (Luvox) and clomipramine (Anafranil), a tricyclic antidepressant.

    2. Cognitive Behavioral Therapy (CBT), particularly utilizing exposure and response prevention techniques.

Plastic Surgery and Other Medical Treatments for Body Dysmorphic Disorder

  • Patients frequently seek skin treatments and engage with plastic surgery.

  • Statistics indicate that 8% - 25% of individuals requesting plastic surgery may have Body Dysmorphic Disorder, necessitating screening by plastic surgeons before proceeding with operations.

Hoarding Disorder

  • Definition

    • Characterized by excessive acquisition of items, difficulty discarding possessions, and living with excessive clutter.

  • Evolution of Disorder

    • Appears as a separate entity in DSM-5 and commences early in life, worsening over time.

  • Hazards of Hoarding

    • Can create hazardous living conditions; however, individuals typically seek treatment later in life, often post age 50.

  • Treatment

    • Cognitive-behavioral therapy is often employed as a method to treat hoarding disorder, targeting the underlying behaviors and thought patterns associated with the disorder.