New DSM-5 category separate from anxiety disorders
Focus on similarities and differences between OCD and other anxiety disorders
Similarities between OCD and other anxiety disorders
Pattern of comorbidities observed in probands and families
Cognitive and emotional processing shared between disorders
Certain temperamental antecedents present, such as behavioral inhibition
Differences between OCD and other anxiety disorders
Centrality of anxiety symptoms
Anxiety symptoms are common in OCD but also seen in developmental, psychotic, and affective disorders
Anxiety acts as a common denominator among anxiety disorders
Neurobiological pathways
Contemporary models link anxiety disorders to amygdala hyperresponsivity and amygdala-cortical interactions
Models related to OCD focus on frontostriatal abnormalities. These abnormalities involve circuits connecting the frontal cortex (involved in planning and decision-making), the striatum (involved in habit formation and motivation), and the thalamus, suggesting dysregulation in inhibitory control and repetitive behaviors.
Criterion A: Presence of obsessions, compulsions, or both
Obsessions defined as:
Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted, causing significant anxiety or distress.
The individual attempts to ignore or suppress these thoughts, urges, or images, or neutralizes them through compulsions.
Compulsions defined as:
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words) that the individual feels driven to perform in response to an obsession or according to rigid rules.
The behaviors or mental acts are aimed at preventing or reducing anxiety or distress but are not realistically connected to the event or are clearly excessive.
Criterion B: Time Consumption and Distress
Obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Prevalence of OCD
Worldwide prevalence ranges between 1.5\% to 3\%
Considered one of the most prevalent mental disorders
WHO classifies OCD as the 10th most burdensome condition among all medical conditions. Its chronic nature often leads to significant functional impairment across various life domains.
Definition and Characteristics of OCD
Defined by the presence of obsessions and compulsions:
Obsessions: Recurrent intrusive thoughts, images, and impulses.
Compulsions: Repetitive behaviors or mental rituals governed by specific rules, performed to neutralize intrusions/obsessions.
Ego-Dystonic Nature of the Disorder
Majority of patients have good insight regarding their obsessions
Example: Patients may acknowledge their hands are clean after washing multiple times yet feel compelled to wash again. This cognitive dissonance highlights the intense, involuntary nature of the compulsions, even when the individual intellectually understands their unreasonableness.
Reflective of an old DSM-IV criterion stating:
"At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable" (p. 462).
Cognitive-Behavioral Model of OCD
Patients misinterpret normal intrusive thoughts as overly important and dangerous.
This misinterpretation leads to distress
To alleviate distress, patients engage in:
Ritualistic behaviors
Avoidance behaviors
These behaviors result in transient distress reduction but reinforce the likelihood of future engagements in similar behaviors.
Maintaining Maladaptive Beliefs in OCD
Ritualistic and avoidance behaviors help maintain false beliefs about the dangers of intrusive thoughts.
Patients do not receive opportunities to learn that feared outcomes do not occur when certain behaviors are not performed.
This creates a vicious cycle preventing beliefs from being effectively challenged.
Responsibility and Magical Thinking in OCD
Healthy individuals feel responsible for their actions; OCD patients often exhibit inflated responsibility.
Defined as the perception they can cause or prevent highly probable negative outcomes.
This perception is referred to as "magical thinking" but is not framed in a narcissistic or psychotic manner.
Thought-Action Fusion (TAF) in OCD
Cognitive biases seen in individuals with OCD:
Moral TAF: The belief that thoughts hold equal moral weight as actions.
Likelihood TAF: The belief that thoughts increase the probability of real-life events occurring.
These biases are directly targeted in Cognitive Behavioral Therapy (CBT) for OCD.
Symptom Dimensions of OCD
OCD is characterized by heterogeneity.
Different patients exhibit different symptomatic manifestations.
The two most prevalent symptoms are contamination/washing and checking, found in over 50\% of OCD patients.
Meta-analysis identifies four basic symptom categories:
Symmetry: Obsessions with symmetry and compulsions related to repeating, ordering, and counting.
Forbidden thoughts: Aggression, sexual, religious, and somatic obsessions with checking compulsions. These often involve fears of harming oneself or others, engaging in taboo sexual acts, blasphemy, or concerns about health, leading to repetitive checking or mental rituals to neutralize the thought.
Cleaning: Focus on cleaning and contamination themes.
Hoarding: Related obsessions and compulsions around hoarding behaviors.
Course of Illness in OCD
Average age of onset is 19.5 years, possibly bimodal with an earlier peak at age 10 years.
Generally chronic and persistent with the following probabilities for remission:
At 2 years:
Full remission probability: 0.06
Full or partial remission probability: 0.24
At 5 years:
Partial remission probability: 0.53
Marital status and lower global severity score at intake predict partial remission after 5 years.
Treatment of OCD
Pharmacological Treatments
Neurochemical research indicates involvement of dysfunctional serotonergic and dopaminergic systems in OCD.
Most effective treatment is through Serotonin Reuptake Inhibitors (SRIs), which are commonly prescribed at high doses. Specifically, Selective Serotonin Reuptake Inhibitors (SSRIs) like fluoxetine, sertraline, fluvoxamine, and paroxetine are commonly used, often requiring higher doses than for other anxiety or depressive disorders.
Patients may also respond positively to dopamine antagonists (antipsychotics/neuroleptics) when used to augment SRI treatment.
Psychological Treatments
Cognitive-Behavioral Therapy (CBT) is recognized as the most effective psychological treatment, especially with an Exposure and Response Prevention (ERP) component.
ERP has shown equal or better efficacy compared to pharmacological treatments.
Cognitive therapy is also employed to challenge maladaptive processes such as intolerance to uncertainty.
Deep Brain Stimulation (DBS)
Typically utilized for patients who do not respond to pharmacological and psychological interventions.
Proven effective in at least 50\% of cases.
Genetics and Familiality in OCD
Twin studies suggest that about 45\% to 61\% of OCD symptoms may be attributed to genetic factors.
Approximately 50\% of symptomatic variance relates to environmental factors.
Familiality of OCD is notable:
Prevalence in families of non-psychiatric controls: 2.7\%
Prevalence in families with an affected member: 11.7\%
Comorbidity in OCD
Around 90\% of OCD patients are diagnosed with at least one additional psychiatric disorder.
The most common comorbidity is Major Depressive Disorder (MDD), with rates around 10 times higher than in the general population.
Comorbid anxiety disorders are also prevalent.
Comorbidity rates for specific disorders include:
Specific phobia: 42.7\%
Social phobia: 43.5\%
Generalized anxiety disorder: 8.3\%
Panic disorder: 20\%
Body Dysmorphic Disorder (BDD) Diagnostic Criteria
Criterion A
Preoccupation with one or more perceived defects in physical appearance, deemed not observable or appearing slight by others.
Criterion B
Individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing one’s appearance to others) in response to their concerns.
Criterion C
The preoccupation leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Criterion D
Preoccupation is not better explained by concerns with body fat or weight in individuals whose symptoms meet criteria for an eating disorder.
Body Dysmorphic Disorder (BDD) Historical Context
Formerly termed dysmorphophobia, deriving from the Greek word for “facial ugliness.”
Historically viewed as a condition in which patients believe to be physically deformed or ugly despite normal appearance.
Previously categorized as a somatoform disorder linked to early associations with hypochondriasis.
Treatment Outcomes for BDD
Patients often seek dermatological treatments and cosmetic surgery.
Prevalence of BDD in cosmetic surgery settings: 6\% to 15\%
Prevalence in dermatology settings: 12\%
Medical and surgical treatments generally ineffective, with 90\% of patients reporting no symptoms changes.
Comparison Between OCD and BDD
Shared Clinical Features
Both disorders involve obsessions or preoccupations.
Differences in Obsessions and Preoccupations
BDD Characteristics:
Primarily focused on appearance defects perceived as grossly deficient.
Patients think others negatively evaluate them based on their perceived defects.
These features reflect self-defeating and negative self-worth beliefs, more aligned with Major Depressive Disorder (MDD) than OCD.
Insights Level
OCD Patients:
Majority perceive obsession content as irrational.
Intact insight in 66\% - 85\% of patients; "delusional insight" in only 2\% - 3\%
BDD Patients:
High prevalence of "delusional insight" (32\% - 39\%
Repeated attempts to decrease or stop skin-picking behavior.
Criterion C
Skin picking leads to clinically significant distress or impairment in life areas.
Criterion D
Not attributable to physiological effects of substances or other medical conditions.
Criterion E
Distress is not better explained by symptoms of another mental disorder or the intention to harm oneself.
Hair Pulling and Skin Picking Disorder Overview
Both recognized as psychological conditions characterized by repetitive grooming behaviors:
Hair Pulling Disorder: Pulling out hair leading to distress and functional impairment.
Skin Picking Disorder: Picking at skin leading to lesions and distress or functional impairment.
Prevalence Estimates
Hair Pulling Disorder: Estimated occurrence in 3 million U.S. individuals; true prevalence remains unknown due to lack of extensive epidemiological studies.
Skin Picking Disorder: Estimates range from 2\% among dermatology patients to 5\% among clinical samples.