Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder

Prevalence, age of onset, and co-morbidity with other disorders.
Dynamics of Obsessive-Compulsive Disorder.

Introduction to Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive and related disorders are a group of mental disorders characterized by:
- Intrusive, unwanted, persistent thoughts and impulses (Obsessions).
- Repetitive behavior or mental acts that a person feels driven to perform (Compulsions).
These disorders often cause significant distress, impair functioning, and interfere with daily activities.
Prior to DSM-5, OCD was categorized as an anxiety disorder.
DSM-5 recognizes it as a distinct diagnostic category.
Obsessive-Compulsive and related disorders include:
- Hoarding disorder.
- Body dysmorphic disorder (previously grouped with somatoform disorders).
- Trichotillomania—compulsive hair pulling—previously grouped with impulse control disorders.
- Excoriation—skin-picking disorder.

Body Dysmorphic Disorder:

Preoccupation with the “perception” of imperfections in their appearance.
Apparent physical faults may not be noticeable or seem minor to others.
Obsessed with perceived or imagined flaws to the point that they firmly believe they are ugly.
Differs from common concerns that many individuals have about their appearance.
Entails intrusive and undesired repetitive activities (like checking a mirror or looking for reassurance) or repetitive thinking (like comparing one’s attractiveness with others).

Trichotillomania (hair-pulling disorder):

Characterized by recurrent hair pulling, most frequently from the scalp, brows, and eyelids.
Trichotillomania is not the same as these activities.
Trichotillomania brings with it significant anguish and functioning issues.

Dermatillomania:

The skin-picking disorder known as dermatillomania, or excoriation disorder, is characterized by excessively frequent picking at one’s own skin that results in lesions.
The skin-picking activity is very disturbing.

Hoarding Disorder:

Accumulate an excessive quantity of things and keep them in an unorganized way, which typically leads to uncontrollable clutter.
The objects may be worth nothing or very little money.
Obsessive-Compulsive disorder includes both obsessive thoughts and compulsive behaviours created in an effort to balance out these thoughts.

Obsessions

Obsession is a recurrent and persistent thought, urge, or image that an individual experiences as intrusive and unwanted.
Individuals try to suppress or ignore the thought by engaging in other thoughts or images.
For those who experience them, obsessive ideas are both intrusive and alien.
Obsessions frequently manifest as wishes (for example, repeatedly wishing for one’s spouse to pass away), urges (repeatedly wanting to yell at coworkers or in church), images (for instance, fleeting visions of inappropriate sexual scenes), or ideas (the belief that germs are present everywhere) that the person tries to eliminate or repress.

Types of Obsessions

Statistically associated groupings have given four major types of obsessions:
1. Symmetry Obsessions:
  - Obsessions with symmetry usually involve maintaining order and following certain procedures.
  - For example, Placing magazines on a table in “just the correct” arrangement.
2. Prohibited Thoughts:
  - When an OCD sufferer has improper thoughts, such as violent intrusive thoughts or visions of themselves acting violently or abusively, it can make them feel dangerous.
3. Cleanliness or Contamination Anxieties:
  - The majority of obsessive thoughts center around cleanliness or contamination anxieties.
  - Individuals who have this discomfort frequently believe that there are germs nearby.
4. Hoarding:
  - Hoarding is defined as compulsive behavior and persistent intrusive thoughts regarding the acquisition of objects and a difficulty in getting rid of them.
These common fundamental motives can differ from culture to culture, but they are present in the minds of the majority of people who struggle with obsessive thinking.
As an illustration, regions with strong moral standards tend to have higher rates of religious preoccupation.

Compulsions

Compulsion is a behavior or ideas used to control obsessions and bring comfort.
Contrary to recurring thoughts or upsetting images connected with obsessions, compulsions involve repetitive activities.
If the behavior is not carried out or if it is not carried out “correctly” it produces distress or anxiety.
People who have compulsions frequently experience an overwhelming urge to participate in the compulsive behavior.
People who have these disorders participate in compulsive behavior not out of choice but rather because they feel compelled to.
Compulsions might not be severe enough to be considered a sign of mental disease.
Many people have mild compulsions like the need to measure their steps, exercise frequently, or do a certain amount of work.
Compulsions only factor into a mental health diagnosis when they cause distress, get in the way of daily living, or put someone’s health in danger.
OCD is one of the most incapacitating mental illnesses due to the poorer quality of life and significant functional impairment it causes.
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).
But there is a spectrum of “insight” among OCD sufferers regarding how absurd and excessive their thoughts and compulsions are.
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 behavior 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 behavior, and this continuum must be understood.

Prevalence, Age of Onset, Gender Differences and Co-Morbidity with Other Disorders

According to an Indian epidemiological survey, the life time prevalence was 0.6%.
A systematic review and meta-analysis published in the journal of Psychiatry in 2017 analyzed 28 studies on the prevalence of OCD in India.
The review found a pooled prevalence of 1.6% with a range of 0.47% to 2.76% in various studies.
Males begin significantly sooner than females do.
The prevalence of sexual obsessions, hoarding repeating routines, and touch compulsions was linked to early onset.
Nearly equal numbers of men and women were obsessive checkers.
Compulsive cleaning (66%) and avoidance (26%) are more common in women.
In comparison to matched controls, OCD patients have been reported to have a higher proportion of bachelorhood.
Research study conducted in psychiatric outpatients in India reported that females with OCD were more likely to report contamination/cleaning compulsions, while men were more likely to report aggressive and checking compulsions.
OCD typically first manifests around the age of 20, but it can happen at any age, even as early as two years old in infants.
A study conducted in Delhi in 2013 found that the mean age of onset of OCD was 23.3 years.
Another study conducted in Chennai in 2014 found the mean age of OCD was 23.2 years.
OCD frequently co-occurs with illnesses like Tourette’s syndrome, depression, and social phobia.
Numerous studies on co-morbidity have looked at a wide variety of issues, such as spectrum disorders, co-occurring bipolar disorder and schizophrenia, and even the prevalence of OCD in Parkinson’s disease.

Psychosis and OCD:

Researches - Ganesan V., Kumar R, Khanna S. (2001), Obsessive doubts, washing, and checking compulsive behaviors were found to be the most prevalent OC symptoms in a retrospective chart study of 15 instances of OCD with psychosis.
Three instances 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 evaluated 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 attentive 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 of OCD

Sita, a 30-year-old, is married and mother of four.
Despite the fact that she had been experiencing issues with anxiety for a while, she had never before sought expert assistance.
She had been depressed for the previous three months, and her family doctor eventually recommended that she must get counseling.
Sita had been plagued by intrusive, repeated thoughts about the security of her kids for the past few months.
She often found herself imagining that there had been a serious accident, and she could not get these ideas out of her head.
Sometimes, she would think that her son Ram had hurt his knee while playing football at school.
There was no cause to think that there had been an accident.
However, Sita ruminated on the possibility before eventually calling the school to check on Ram.
She was a little surprised when he later came home unharmed even after being assured that he had not been hurt.
Sita added that the extensive number of counting rituals she engaged in throughout each day severely interfered with her ability to go about her daily business.
Sita discovered that certain numerals had come to hold a special significance for her and that her fixation on them was preventing her from carrying out daily tasks.
One instance when she went to buy groceries.
Sita was convinced that if she chose the first item on the shelf, such as a box of cereal, her eldest child would suffer a terrible fate.
If she chose the second one, an unknown disaster would fall on her second child, and so on for the four children.
The children’s ages were also important.
The sixth item in a row, for example, was associated with her youngest child, who was 6 years old.
Thus, specific items had to be avoided to ensure the safety of her children.
Obviously, the rituals required continuing attention because the children’s age changed.
Sita’s preoccupation with numbers extended to other activities like smoking cigarettes.
Sita acknowledged the irrationality of these rituals but, nevertheless, maintained that she felt much more comfortable when she observed them conscientiously.
She often felt anxiety in the form of a subjective sense of dread and apprehension when she was in a great rush to complete the rituals.
Along with her compulsive behaviour and obsessive thoughts, Sita also noted issues with her marriage and parenting.
Prior to her initial visit to the mental health facility, her spouse had been placed on complete physical disability for 11 months.
Ram was only 32, but even the most routine physical activity could be hazardous for him because of a serious heart condition.
He had spent the majority of his time since quit- ting his position as a clerk at a plumbing supply store at home.
He spent the majority of his waking hours relaxing on the couch while watching television.
He had persuaded Sita that she should be in charge of all the household duties and outings for the family.
Cleaning, washing, shopping, and retrieving potato chips and other snacks whenever he required a snack took up most of her days in addition to getting the kids ready for school, fed, and transported there.
Sita could see the unfairness of the situation, which was very upsetting, but 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

There is not a single factor which contributes to OCD.
But there are biological, psychological and social factors that are implicated in Obsessive-Compulsive Disorder.

Psychological Causal Factors

According to some psychologists, Obsessive-Compulsive behavior arises because it helps people feel less anxious.
This connection is explained by classical conditioning theory.
Although these activities are unpleasant, people may acquire ideas or behavior that assists them to avoid the initial unpleasant occurrence if particular thoughts or behavior get associated with an unpleasant event and become conditioned stimuli.
Cognitive elements that contribute to the intense doubts associated with OCD have been explored by psychologists.
Those who have OCD exhibit specific cognitive traits, such as flawed thinking in the following areas:
- Individuals with OCD show Thought Confusion in which the stressful thought about an action, event, object, combine with the event.
- In other words, having these ideas results in the same feelings as if the event had actually happened.

OCD as Learned Behavior

The two-process hypothesis of avoidance learning developed by Mowrer is the basis for the prevalent behavioral or learning perspective on obsessive-compulsive disorder (1947).
According to this view, anxiety is a result of neutral stimuli developing a classical conditioning relationship with terrifying ideas or events.
For instance, shaking hands or touching a doorknob may come to represent the “frightening” thought of contamination.
Once they’ve established the connection, they might find that washing their hands can help them feel less anxious when they shake their hands or touch a doorknob.
As thorough hand washing reinforces the washing reaction after the anxiety is reduced, it is more likely to happen again in the future when other events cause concern about contamination (Rachman & Shafran, 1998).

OCD and Preparedness

By considering obsessive-compulsive disorder in the context of evolution, we have also improved our knowledge of the condition e.g., De Silva, Rachman, & Seligman, (1977); Rappoport, (1989).
For instance, compulsive washing-related concerns about dirt and contamination are so frequent as to make their occurrence seem non-random.
According to the general view, human obsessions with filth, pollution, and other potentially dangerous situations did not develop in a vacuum but rather have a long evolutionary history (Mineka & Zinbarg, 1996, 2006).
Also, some theorists have contended that the displacement behaviors that many species of animals participate in during conflict or times of high arousal are similar to the compulsive rituals associated with obsessive-compulsive disorder.

Cognitive Causal Factors

The Effects of Attempting to Suppress Obsessive Thoughts
- Normal people may experience a paradoxical rise in undesired thoughts after trying to suppress them (for example, “Don’t think about white bears”) (Abramowitz et al., 2001; Wegner, 1994).
- Therefore, these efforts to suppress them may be a factor in the frequency of obsessive thoughts and the depressive moods with which they are frequently associated.
- For instance, when people with OCD were asked to record intrusive thoughts in a diary, both on days when they were instructed to try to suppress those thoughts and on days without instructions to suppress, they 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
- Cognitive theorists have made a distinction between intrusive or compulsive thoughts as such and the catastrophic assessments that people have about having such ideas.
- For instance, OCD sufferers frequently exhibit an exaggerated feeling of duty.
- Consequently, in some weaker individuals, this exaggerated sense of accountability may be linked to ideas that merely considering doing something—like attacking a patient—is morally equivalent to actually doing it or that considering committing a sin increases the likelihood that one will actually do it.
- The term “thought-action fusion” describes this.
- The “perceived awfulness of any adverse repercussions” is increased by this increased sense of responsibility for potential harm, which may also serve as motivation (Salkovskis et al., 2000, p. 348).
Cognitive Biases and Distortions
- Obsessive-compulsive disorder has also been linked to cognitive issues.
- According to research on OCD patients, just like with the other anxiety disorders, they are drawn to disturbing material that relates to their obsessive worries.
- Individuals with OCD may try to repress negative thoughts sparked by this knowledge since they appear to have trouble blocking out negative, irrelevant, or distracting data.
- These persons frequently repeat their ritualistic behaviors because they also lack faith in their recall (particularly for events for which they feel responsible).

Biological Causal Factors

Genetic Factors
- In a review of 14 papers, 80 monozygotic twin pairs and 29 dizygotic twin pairs were examined.
- Among the 80 monozygotic twin pairs, 54 were concordant for the diagnosis of OCD, and 9 were concordant.
- Most family studies have reported 3 to 12 times higher rates of OCD in first-degree relatives of OCD clients than would be anticipated from current estimates of the incidence of OCD, which is consistent with twin studies (Grabe et al., 2006; Hettema et al., 2001a).
- Last but not least, research demonstrates that early-onset OCD has a higher genetic loading than later-onset OCD (Grisham et al., 2008; Mundo et al., 2006).
OCD and the Brain:
- In the past 30 years, as brain-imaging tools have advanced, there has been a significant increase in the hunt for OCD-related abnormalities in the brain.
- According to research, anomalies mostly affect the basal ganglia, a group of subcortical systems, as well as some specific cortical regions.
- At the amygdala, the basal ganglia are connected to the limbic system, which governs emotional behavior.
- The orbital frontal cortex and the cingulate cortex/gyrus, which are both connected to the limbic region, have unusually high levels of activity in OCD sufferers, according to the results of numerous research employing PET scans.
- Moreover, the subcortical caudate activity in OCD patients is excessively high.
Neurotransmitter Abnormalities
- According to recent research, OCD symptoms may be caused by increased serotonin activity and enhanced sensitivity of particular brain regions to serotonin.
- In fact, serotonergic system stimulation medicines make symptoms worse.
- According to this theory, 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.
- That is, even while clomipramine or fluoxetine may temporarily raise serotonin levels (and maybe enhance OCD symptoms as well), their long- term consequences are very different.
- This is in line with the discovery that these medications need to be used for at least 6 to 12 weeks in order to significantly relieve OCD symptoms.
- It is increasingly becoming obvious that serotonergic system failure cannot fully explain this complicated illness on its own.
- Although their function is still unclear, other neurotransmitter systems (including the dopaminergic, GABA, and glutamate systems) also appear to be involved (Dougherty et al., 2007; Stewart et al., 2009).

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 (Challacombe & Salkovskis, 2009).
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 (Briggs & Price, 2009).
Those with OCD tend to experience more severe symptoms when they believe their relatives are critical or unfriendly (Van Noppen & Steketee, 2009).
Although we frequently think of OCD as a personal issue, it frequently arises in a social setting.
OCD symptoms can affect friends, roommates, and family members as well, as demonstrated in the example below.

Summary

The DSM-5 now recognizes them as a distinct diagnostic category, which includes OCD as well as hoarding disorder, body dysmorphic disorder (previously grouped with somatoform disorders), trichotillomania—compulsive hair pulling—previously grouped with impulse control disorders and excoriation—skin-picking disorder.
For those who experience them, obsessive ideas are both intrusive and alien.
Obsessions frequently manifest as wishes (for example, repeatedly wishing for one’s spouse to pass away), urges (repeatedly wanting to yell at coworkers or in church), images (for instance, fleeting visions of inappropriate sexual scenes), or ideas (the belief that germs are present everywhere) that the person tries to eliminate or repress.
Compulsions are behaviors or ideas used to control obsessions and bring comfort.
Contrary to recurring thoughts or upsetting images connected with obsessions, compulsions involve repetitive activities.
If the behavior is not carried out or if it is not carried out “correctly,” distress or anxiety results.
People who have compulsions frequently experience an overwhelming urge to participate