Comprehensive Notes on OCD and Related Disorders (Lecture Transcript)

Brief History of OCD

• Pierre Janet (1903): observed that obsessions are secretive, often involve forbidden thoughts/acts (sacrilegious, violent, or sexual in nature); obsessions are intrusive and egodystonic; obsessions are worries about things within the imagined control. (Pitman, 1984 p. 293)
• Sigmund Freud: OCD described as highly interesting for analysis; first to distinguish OCD as a separate disorder; OCD viewed as a neurotic disorder involving regression to anal-sadistic stage, erotic/aggressive impulses defended against by the superego and sometimes breaking through as intrusive thoughts; compulsions serve as a defense against anxiety.
• The DSMs: OCD terminology evolved across editions:
  • Obsessive Compulsive Reaction (I)
  • Obsessive Compulsive Neurosis (II)
  • Obsessive Compulsive Disorder (III, III-R, IV, 5, 5-TR)
  • Little substantive change beyond clarification.

DSM-5-TR Definition

• The presence of obsessions, compulsions or both.
  • Obsessions: Recurrent & persistent thoughts, urges or images experienced as intrusive & inappropriate and that cause marked impairment or distress; person attempts to ignore/suppress/neutralise.
  • Compulsions: Repetitive behaviours driven by obsessions or according to rigid rules; aimed at reducing distress, preventing dreaded event/situation in an inelastic/excessive way.
• Marked distress & impairment: over $1\,\text{hr/day}$

Obsessions

• Intrusive thoughts: automatic, unwanted, distressing
• Can come in the form of images, words, sounds
• Often these thoughts are ignored, suppressed and neutralised by another thought or action (compulsion)
• "Pure O": there is often some form of neutralising behaviour

Types of Obsessions

• Contamination
• Aggression, Violence, Harm to self/others
• Personally unacceptable sexual thoughts
• Scrupulosity: religious, moral
• Order & symmetry
• Superstition
• Existential
• Any other intolerable thoughts

Types of Compulsions

• Physical compulsions
  • Washing, cleaning (36%)
  • Checking (63%)
  • Avoidance
  • Reassurance seeking
  • Need to confess (28%)
  • Ordering/keeping things symmetrical (18%)
  • Repeating actions e.g., touching, tapping, blinking
• Mental compulsions
  • Rumination
  • Self reassurance
  • Counting (31%)
• Prevalence rates in brackets according to Rasmussen & Eisen (1988)

Other Presentations of OCD

• Obsessions with no overt compulsions (ICD-10)
• Compulsions without obsessions
• OCPD
• Childhood onset OCD
• PANDAS

Obsessions vs Worries

• Worry is common to most anxiety disorders & a hallmark of GAD
  • Chain of thought/images that are associated with negative emotions and are experienced as uncontrollable
• Form & content of worries and obsessions differ
• Worries appraised differently

Cultural Factors

• Generally, prevalence rates are stable in different countries
• Phenomenology may vary (e.g., religious obsessions)
• Role of beliefs may also vary

Some Stats

• OCD’s mean age of onset = $19.5\,\text{years}$ (Kessier et al., 2005)
• ¼ of the time, most cases start by 14yo (Ruscio et al., 2010): $P(\text{onset by age 14}) = 0.25$
• Males tend to have an earlier age of onset; nearly $0.25$ (25%) of males have an onset before 10yo (Ruscio et al., 2010)
• $40\%$ of individuals with onset in childhood may experience remission by early adulthood (Stewart et al., 2004)
• OCD can appear “full blown” from before puberty (Grados & Riddle, 2008)
• Lifetime prevalence: $P(\text{lifetime prevalence}) \approx 0.01 \text{ to } 0.02$
• Course: most chronic (44%) or intermittent (31%); few full recoveries
• Quality of life: impairment in social functioning, role limitations due to emotional problems; higher unemployment and relationship difficulties

Comorbidities (Selected)

• Richter et al. 2003 (N=98) and Bienvenue et al. 2001 (N=80)
  • Major Depressive Disorder (MDD): 54% (recurrent) [Richter]; 61% [Bienvenue]
  • Dysthymia: 8% / 12%
  • Social Anxiety Disorder: 36% / 27%
  • Specific Phobia: 31% / 13%
  • Separation Anxiety: 18% / NA
  • Panic Disorder: 21% / 12%
  • Agoraphobia: 17% / 10%
  • Generalized Anxiety Disorder (GAD): 13% / 12%
  • Alcohol Dependence: 15% / 9%
  • Substance Dependence: 8% / 5%
• Additional comorbidity data (in broader OCD literature): Nail Biting 25%; Excoriation (skin picking) 24%; Trichotillomania 4%; Kleptomania 3% (varies by sample)

Cognitive Appraisal Model of OCD

• Dysfunctional beliefs drive OCD:
  • Responsibility/Threat
  • Importance/Control Thoughts
  • Perfectionism/Uncertainty
• Trigger → Intrusion → Appraisal → Response

Neuroscientific Models of OCD

• Neuropsychological deficits observed in some studies:
  • Executive functions deficits
  • Attention
  • Visuospatial abilities
  • Non-verbal memory
  • Slowed responses
• Notes:
  • Findings are inconsistent across studies
  • Do not fully account for specific symptomatology or changes over time
  • Memory performance can be intact or even better in some OCD samples
• Overall: not the whole story; biology interacts with learning and cognitive processes

Psychoanalytic/Psychodynamic Approaches

• Analytic theory: ego trapped between intolerable id impulses and hypermoral superego; conscientiousness and perfectionism as attempts to control hostile/sexual wishes; intellectualising as defence
• Object-relations/Adler approaches: control striving to compensate for inferiority; negative self and other properties lead to rigid control to avoid criticism

Behavioral Theories

• Mowrer’s two-stage learning theory (1939, 1960): Classical conditioning followed by operant conditioning
• ERP (Exposure and Response Prevention) to extinguish conditioned stimuli
• Social learning theory vs. inhibitory learning models

Nature vs. Nurture

• OCD arises from an interaction of genes, beliefs, personality factors, and environment
• It is both learned and biological, but biology typically precedes learning
• You can “learn” OCD by accident (Grayson, 2014)

OCD Assessment Measures

• Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al.)
  • Symptom checklist & severity rating scale
• Padua Inventory (Sanavio)
  • Self-rated distress questionnaire; 60-item & 39-item versions
• Obsessive-Compulsive Inventory (Foa & Salkovskis)
  • 18-item self-rated questionnaire; 6 subscales in short version: washing, checking, ordering, obsessing, hoarding, mental neutralising

OCD Treatment

• Exposure and Response Prevention (ERP)
• Acceptance and Commitment Therapy (ACT) – mindfulness-based ERP
• Adjunctive selective serotonin reuptake inhibitors (SSRIs) or other medications
• Psychoeducation
• Healthy living components (exercise, social engagement, etc.)

OCD Treatment - Medications

• See above: SSRIs commonly used; specifics not detailed in this transcript

Differential Diagnosis – Non- OCD-Spectrum Disorders

• Specific phobia: fears object is limited and ritualistic behaviours are less common
• Social anxiety disorder: concerns about rejection; worries limited to social interactions; behaviors target social fear
• Depression: obsessions typically ego-dystonic; no intent to block thoughts via attempts
• Generalized Anxiety Disorder (GAD): worry across domains; not obsession-driven
• Delusional disorder / Psychotic disorder NOS / Schizophrenia: OCD often has greater insight; obsession–compulsion link present
• Obsessive-Compulsive Personality Disorder (OCPD): ego-syntonic; differences in obsessions/compulsions

Differential Diagnosis – OCD-Spectrum Disorders

• Body Dysmorphic Disorder (BDD)
• Illness Anxiety Disorder (Hypochondriasis): preoccupation with health; health-related intrusive thoughts; reassurance seeking
• Impulse-control disorders (Gambling, Kleptomania, Trichotillomania): urges relieved by compulsion; some reward elements
• Tourette’s Disorder / Tic Disorder
• Eating disorders
• Substance dependence

Hoarding Disorder

• Persistent difficulty discarding or parting with possessions regardless of value, due to strong urges to save and distress with discarding
• Results in accumulation that clutter active living areas, impairing use of space
• Significant distress or impairment; can be GMC (General Medical Condition) or another disorder; specify with excessive acquisition; insight (good, poor, absent)
• Features: associated work impairment, obesity, mental/physical illness; threat of eviction, homelessness, fire risk; items hoarded similar to non-hoarders with differences
• Hoarding vs Collecting: collecting brings enjoyment and quality of life; hoarding impairs functioning and security

Hoarding Disorder - Model & Measures

• Model for hoarding: clutter image ratings, hoarding rating scales, structured interviews
• Measures:
  • Interview: Clutter Image Rating (CIR; Frost et al., 2008)
  • Hoarding Rating Scale-Interview (Tolin, Frost & Steketee)
  • Structured Interview for Hoarding Disorder (Pertusa & Mataix-Cols)
  • Self-report: Saving Inventory – Revised (Frost et al., 2004)
  • Compulsive Acquisition Scale (Frost et al., 2002)
  • Home Environment Index (Rasmussen et al., 2010)

Clutter Image Rating Scale

Treatment of Hoarding

• Engagement & motivations
• Psychoeducation
• Exposure to sorting
• Organizing
• Thinking styles
• Controlling acquisition/buying
• Medication: paroxetine, venlafaxine (SNRI)

Body Dysmorphic Disorder (BDD)

• Preoccupation with one or more perceived defects in appearance not observable or slight to others
• Repetitive behaviours (mirror checking, grooming) in response to preoccupation
• Preoccupation not better accounted for by concerns with body fat or weight in an individual with an eating disorder
• Specify: with muscle dysmorphia; insight
• Differential: delusional disorder (somatic type)

Prevalence & Course of BDD

• Late adolescence onset: mean age ~$16\text{ years}$
• Chronic course: mean duration ~$16\text{ years}$ (McGrath et al., 2023)
• Prevalence varies by setting: 1.9% (community), 3.3% (students), 7.4% (adult psychiatric inpatient), 7.4% (adolescent inpatient), 5.8% (psychiatric outpatient), 5.2-20% (cosmetic/dermatology)
• Higher prevalence in women across settings (Australia, 2015: 2.3%)
• Insight: 31% poor; 52.7% absent (delusional); insight may vary over time

Psychosocial Impact & Comorbidity in BDD

• Significant impairment in social, occupational, academic functioning
• Patients often single, unemployed, lower academic achievement
• High distress; suicidal ideation reported by 45%-75%
• Compulsions: compulsive behaviours to examine, improve, seek reassurance about or camouflage perceived flaws
• Comorbidity: major depressive disorder ~61% current / ~72% lifetime; social anxiety ~32% current / 37% lifetime; OCD ~25% current / 35% lifetime
• Dermatological procedures common; guidelines for cosmetic screening (AHPRA 2023)

BDD Assessment & Scales

• BDD-YBOCS (Phillips & Hollander, 1997)
• Dysmorphic Concerns Questionnaire (Oosthuizen, Lambert & Castle, 1998; Mancuso et al., 2010)
• Appearance Anxiety Inventory (Veale et al., 2014)
• Body Image Coping Strategies Inventory (Cash et al., 2005)
• Body Image Concern Inventory (Littleton, Axsom &Pury, 2005)
• Appearance Schemas Inventory – Revised (Cash et al., 2004)

Treatment of BDD

• Cognitive strategies: CBT to identify and challenge maladaptive thoughts (e.g., “people are staring at my nose and think I’m ugly”); cognitive restructuring
• ACT: defusing from self-judgements
• Behavioral: exposure with response prevention to avoid camouflaging; mirror retraining (not excessive mirror use; describe full body at a comfortable conversational distance); align behaviors with values
• Medication: SSRIs (e.g., escitalopram, citalopram, fluoxetine)

Trichotillomania (Hair-Pulling Disorder)

• Recurrent pulling out of one’s hair, resulting in hair loss
• Repeated attempts to decrease or stop pulling hair
• Causes distress/impairment; not GMC (e.g., dermatological condition) and not another disorder (e.g., BDD)
• Often viewed as a body-focused repetitive behaviour (BFRB)
• Statistics (Duke et al., 2010): 2-4% lifetime prevalence; gender equal in community; more females in clinic; onset around 13 years; bimodal (early childhood or adolescence); impairment 5-18% ingest hair; 22%-63% avoidance; 45% negative affect; 70% comorbidity with OCD

Trichotillomania Assessment Scales

• Massachusetts General Hospital Hair Pulling Scale (Keuthen et al., 1995)
• Minnesota Trichotillomania Assessment Inventory – Revised (Christenson, Mackenzie & Mitchell, 1991)
• TTM-YBOCS (Stanley et al., 1993)
• Psychiatric Institute Trichotillomania Scale (Winchel et al., 1992)
• Milwaukee Inventory for Subtypes of Trichotillomania (Flessner et al., 2007)

Excoriation Disorder (Skin Picking)

• Recurrent skin picking with lesions
• Repeated attempts to stop or decrease skin picking
• Distress/impairment
• Not due to a substance (e.g., cocaine) or GMC (e.g., scabies) nor another disorder (e.g., BDD)
• Prevalence: ~2%-5.4% in community & clinical samples; mainly women; impairment includes scarring, infection, surgeries; onset in adolescence; waxing/waning course

Skin Picking Assessment Scales

• Skin Picking Scale (Keuthen et al., 2001)
• NE-YBOCS (Arnold et al., 1999)
• Milwaukee Inventory for the Dimensions of Adult Skin Picking (Walther et al., 2009)

Models of Body-Focused Repetitive Behaviours (BFRBs)

• Triggering situation: visual, tactile, urge
• Motor action: habit activated (e.g., raising hand toward face)
• Search: hair/skin searched for target
• Target achieved: BP/RBP commences
• Manipulation: biting, swallowing, examining, disposing
• Immediate effects: relief/satisfaction
• End of episode: interrupted by external/internal factor; cycle can repeat

Biological Theories

• Inheritable genetic component
• Normal grooming behaviours
• Brain & nervous system involvement
• Neurotransmitters involved

Learning Theories

• Azrin’s Behavioural Model (1973): “nervous habits”; Habit Reversal Training (HRT) and HRT+ models
• Comprehensive Behavioural Model (ComB) – Mansueto et al. (1997; updated 2023)
  • SCAMP framework: Sensory, Cognitive, Affective, Motor, Place

Treatment of BFRBs (ComB framework)

• Cognitive: identify negative consequences; CBT to reframe thoughts; ACT to accept non-serving thoughts
• Behavioral: monitoring triggers & consequences; habit reversal/competing response training; create barriers and plan coping strategies
• Medication: limited evidence; small studies using clomipramine (TCA), glutamate modulators, N-acetylcysteine (NAC), olanzapine (antipsychotic)

Notes on LaTeX/Formulas

• OCD time criterion: \text{Time spent on obsessions/compulsions} > 1\,\text{hour/day}
• Onset and prevalence in percentages: P(A) = p\, (\text{e.g., } p=0.25 \text{ for 25%})
• Mean onset age: $\mu_{\text{onset}} = 19.5\ \text{years}$
• Lifetime prevalence: $P(\text{lifetime prevalence}) \approx 0.01 \text{ to } 0.02$
• Group proportions (e.g., 36%, 63%, 28%, 18%, 31%): denote as $0.36, 0.63, 0.28, 0.18, 0.31$ where relevant

Connections to Foundations & Real-World Relevance

• OCD sits at the intersection of cognitive appraisal, learning theory, and neurobiology; understanding its evolution helps clinicians choose ERP, CBT/ACT approaches, and pharmacotherapy
• Distinguishing OCD from spectrums like BDD, Illness Anxiety Disorder, and OCPD is crucial for accurate diagnosis and targeted treatment
• Hoarding and other BFRBs extend the same learning and cognitive-behavioural principles into novel manifestations, highlighting the need for condition-specific assessment tools and interventions

Practical/Ethical Implications

• Accurate differential diagnosis reduces stigma and supports appropriate treatment pathways (ERP, CBT/ACT, SSRIs, and when indicated, medication management)
• Monitoring comorbidities (depression, anxiety disorders, substance use) is essential for comprehensive care
• Insight levels in BDD and hoarding can impact treatment engagement and prognosis; tailoring psychoeducation and motivational interviewing may be necessary
• Cultural factors influence phenomenology and beliefs about symptoms; clinicians should integrate cultural sensitivity in assessment and intervention with patients