OCD and Related Disorders

Obsessive-Compulsive Disorder (OCD)

  • Characterized by obsessions, compulsions, or both.
  • Exposure and Response Prevention: Exposing individuals to triggers and preventing compulsive actions.

Key Differences for Exam

  • Distinguishing OCD from other disorders (beta depressive, adjustment disorder, acute stress disorder, generalized anxiety disorder) is crucial for clinical practice and the exam.

Core Components

  • Obsessions: Recurrent, persistent, intrusive, and unwanted thoughts, urges, or images causing anxiety or distress.
    • Attempts are made to ignore, suppress, or neutralize these.
  • Compulsions: Repetitive behaviors or mental acts performed in response to an obsession or rigid rules.
    • Aimed at reducing anxiety or distress, even if recognized as illogical.
Examples:
  • An individual obsessed with being a sexual deviant might self-isolate without engaging in compulsive behaviors but still meet OCD criteria.
  • A friend with OCD who took a misstep felt compelled to take four steps back and repeat the action, not necessarily driven by obsession but by a compulsive need for correct stepping.
Time Consumption
  • Obsessions and compulsions must take up more than one hour a day to be considered pathological.

Diagnostic Criteria (DSM-5)

  • Symptoms not due to substance use or medical condition.
  • Not better explained by another mental disorder.

Specifiers

  • Insight:
    • Good or fair insight: Recognizes beliefs/compulsions may not be true but are uncontrollable.
    • Poor insight: Thinks obsessions/beliefs are probably true.
    • Absent insight/delusional beliefs: Fully convinced beliefs are true.

Common Patterns

  • Contamination: Obsessive cleaning or handwashing.
  • Pathologic Doubt: Persistent worry about forgetting to turn off appliances, etc., leading to excessive checking.
  • Symmetry/Precision: Extreme distress if things are not perfectly orderly.
  • Intrusive Obsessive Thoughts: Distressing thoughts without associated compulsions.

What is Pathological?

  • Significant distress or impairment is key. Not just safety concerns or irrational thoughts.
  • Checking behaviors must impair functioning to confirm OCD.

Clinical Evaluation

  • Yale-Brown Obsessive Compulsive Scale: Assesses time spent, freedom from obsessions, control, distress, and interference.
  • Follows DSM-5 outline.
    • How much time is this taking you?
    • How much time are you free from thinking about this obsession?
    • Do you have control over it or not?
    • Are you distressed by it?
    • What's the level of interference?

Treatment

  • First-line: Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention.
    • Subjecting patients to anxiety-provoking stimuli and preventing compulsive behaviors.
  • Second-line: Pharmacotherapy, ideally combined with CBT.
    • Treatment duration: Typically two to three years.
    • Remission likelihood increases with exposure and response prevention.
  • First-Line Medications: SSRIs (high doses).
    • Fluvoxamine (Luvox): Particularly effective for OCD.
    • Sertraline (Zoloft): First-line for children.
    • Avoid Celexa due to QT prolongation risks at high doses.
  • Second-Line Medications:
    • Clomipramine (Anafranil): A TCA with significant side effects.
  • Augmentation Strategies:
    • Adding clomipramine or atypical antipsychotics (Abilify, Risperdal, Zyprexa) to SSRIs.
  • Avoid:
    • Benzodiazepines: Due to addiction potential.
    • Gabapentin: Primarily used for non-hormonal hot flashes and peripheral neuropathy, not OCD.
    • oxybutynin is actually for, like, overactive bladder.

Body Dysmorphic Disorder

  • Preoccupation with a perceived flaw that is barely observable or slight to others.
  • Repetitive behaviors (checking, picking, comparing) related to the perceived flaw.
  • Causes distress or impairment.
  • Not better explained by concerns about body fat or weight.
Example:
  • A patient believes a barely visible scar causes severe disfigurement, leading to excessive mirror checking, seeking medical attention, and social avoidance.

Differentiation from OCD

  • Belief: Patients genuinely believe their body area is abnormal.
  • Insight: Little to no insight.
  • Behaviors: Driven by correcting perceived imperfection, not preventing feared outcomes.

Common Concerns

  • Skin (scars, acne, wrinkles, paleness).
  • Hair (too much or too little).
  • Nose (size or shape).
  • Symmetry, genitalia appearance, lips, teeth, weight.

Repetitive Behaviors

  • Mirror checking, excessive selfies, grooming, comparing, seeking reassurance, cosmetic procedures, covering up, skin picking.

Treatment

  • Same as OCD.
    • First-line: CBT with exposure and prevention therapy.
    • Second-line: Medications (SSRIs).
      • Fluoxetine (Prozac) is generally the preferred SSRI.
      • Clomipramine or Zyprexa can be added for incomplete improvement.

Hoarding Disorder

  • Difficulty discarding possessions, regardless of value.
  • Distress associated with discarding.
  • Accumulation of items that clutter living spaces.
  • Significant distress or impairment.
  • Not attributable to another medical condition or mental disorder.

Reasons for Hoarding

  • Belief in future usefulness.
  • Sentimental value.
  • Sense of responsibility towards items.
  • Fear of losing something important.

Key Features

  • Discarding items is emotionally distressing.
  • Saving is intentional.
  • Clutter disrupts living spaces; may extend to cars and yards.
  • Uncluttered spaces result from third-party intervention.
  • Lack of organization.

Trichotillomania

  • Recurrent pulling out of one's hair, resulting in hair loss.
  • Attempts to stop pulling, but unable to do so.
  • Causes distress or impairment.
  • Not due to another medical condition and not better explained by another mental disorder (e.g., body dysmorphic disorder).

Clinical Manifestations

  • Patchy hair loss, often concealed.
  • May involve unconscious awareness or conscious relief.
  • Oral fixation may be present (e.g., eating hair).
  • Triggers may include anxiety, boredom, tension, stress, or relief after pulling.

Excoriation Disorder

  • Recurrent skin picking resulting in skin lesions.
  • Attempts to decrease or stop skin picking.
  • Causes clinically significant distress or impairment.
  • Not attributable to substance use (e.g., meth, cocaine) or another medical condition (e.g., scabies).
  • Not better explained by another mental disorder.

Substance/Medication-Induced OCD and Related Disorders

  • Obsessions, compulsions, skin picking, or hair pulling symptoms.
  • Evidence that symptoms began during/after substance intoxication, withdrawal, or medication exposure/withdrawal.
  • Not better explained by primary OCD and related disorders.
  • Symptoms do not occur exclusively during delirium.
  • Causes clinically significant distress or impairment.

Timeline

  • Symptoms lasting longer than a month after discontinuation of the substance/medication are less likely to be substance-induced.

Common Substances

  • Meth, cocaine, stimulants, heavy metals, toxins.

Differential Diagnosis

  • Distinguishing OCD and related disorders from other conditions is essential.

Disclaimer

  • Charts and summarized content should not be the only source of information.