Diagnostic criteria (ICD-11)

Obsession vs compulsion. Reccuring, unwanted thoughts that cause anxiety VS repetitive behavior people do to relieve that anxiety

Common fear: contamination, forgetting something, obsession with number, order and arrangement, unwanted violence thoughts

Diagnosed when occur 1 hour+ a day and negative impact on life

Some patient are aware of their problem (high insight), some has low insight and believe their actions are normal or else bad things will happen (wash hands every minute)\

Mini study: A boy feel something sticky on his skin, afraid to touch honey. He take showers multiple times a day and can’t go to school

MOCI

To classify different OCD symptoms, separate OCD from other disorder and normal people

How to collect data?

Self-report question, 30 true false. 21+ is cut off score

What does it measure?

Statement about daily struggles

“I often check if the door is locked”. True/false

Test-retest

Only true false, no qualitative data. Might lack situation that ppt face in real life\

Cultural differences: Developed using British ppt

Y-BOCS

Assess severity of OCD

How data is collected?

Semi-structured interview, Scale 0-4 on severity of symptoms last week

What does it measure?

5 items about obsession and 5 about compulsion

Inter-rater reliability. 2 doctors assess the same patient give same accurate result

Good test-retest

Nomothetic (rating scale) + idiographic (interview)

Limited severity range

Cultural bias: Developed in Western countries

Biological causes

% parent, sibling, twin
Polygenic
Serotonin
Dopamine
Synapse

36% at least 1 parent with OCD

22% have sibling with OCD

87% MZ, 47% DZ

(OCD the most inheritable disorder. Such difference between MZ and DZ suggest that OCD is due to nature)

230 genes linked to OCD

5-HHT and serotonin (imbalance)

OCD linked to genes related to serotonin receptors & transporter molecule (MAO-A)

Mutation in 5-HTT gene make patient more vulnerable to OCD

DRD4, COMT and dopamine (imbalance)

DRD4: gene codes for D4 dopamine receptor. Dopamine imbalance cause OCD

COMT gene (enzyme breaks down dopamine), low level cause OCD

Polymorphism of COMT as well

SLITRK5 and BDNF

SLITRK5: synapse development and grow

Associated with protein BDNF: maintain connectivity between brain cell

Lack SLITRK5 and BDNF cause OCD

Biological determinism. Scientists remove SLITRK5 gene from mice, and they show compulsive behavior.

Lack nurture view. OCD symptoms differ to society culture. Brazil OCD mostly related to violence, but Singapore OCD is not so.

Biochemical

Serotonin, dopamine and BDNF

Low serotonin, serotonin is used in brain communication, disrupt communication cause OCD

Problems with dopamine receptor & transmitter

Problems with production of BDNF

Use of Oxytocin

High levels of Oxytocin

Caused by upregulation, OCD have too much DNA methylation that decrease OXTR gene (oxytocin producer). Oxytocin irregularities may cause OCD

Understanding biochemical helped make drugs

Holistic, DNA can be changed with impact from environment.

Too reductionist. Didn’t consider environment factor. Negative reinforcement make patient believe their repetitive behavior is necessary to relive tension

Psychological explanation

Cognitive thinking error

• We have lots of thoughts a day. We normally ignore random thoughts. But OCD doesn’t ignore them, thought there are meaning behind those random thoughts.

• If patient try to suppress those thoughts, they will come back even worse cause now that they pay attention to it instead of forgetting it

• Thought-action fusion (believe thinking about a behavior is as bad as actually doing it, like imagine killing parent and blame yourself for thinking about it).

• Thought-event fusion (think about a event will make it come true)

Behavior operant conditioning

Compulsive behavior developed to reduce anxiety, negative reinforcement + avoidance = OCD feel that compulsive behavior is needed to avoid stress

Psychodynamics (Freud theory)

When Id’s desires are not satisfied, they become obsessive thoughts

Unresolved conflict with parents during anal stage. Child become anally retentive and fixated at that stage. Excessive cleaning to resolve childhood trauma.

Situational explanation. Difficult childhood trauma lead to OCD

Only consider nuture, lack nature view. (Thobois et al) A man did surgery & damanged brain worry circuit, develop OCD right after surgery

Individual + situational. OCD is different between people (A fear of contaminating other, B fear of being contaminated). Situational factors worsen stress

Biological treatment

Tricyclics

Stop serotonin transporter (SERT) + noradrenaline transporter (NET) from being reabsorbed into presynaptic cell membranes

More SERT + NET around to bind with receptors

To increase serotonin and noradrenaline level

SSRIs

OCD caused by communication problem in brain, nerve communicate through serotonin

SSRI stop reuptake of serotonin by binding with SERT and stop serotonin from being transported

Increase serotonin to bind with 5HT receptors on postsynaptic cell

Use with risperidone to increase effectiveness

SSRIs side effects: nausea, vomiting, sleep problem

Too reductionist: 60% report no improvement, situation factor like relationship between patient and doctor affect drug effectiveness

Psychological therapy

Exposure + response prevention (ERP)

A type of CBT

• Exposure: expose patient to anxiety-provoking situation

• Response prevention: stop patient from doing compulsive behavior when facing those situations

Patient identify obsession thoughts +environmental trigger that cause compulsive action

Put into SUDS rating, triggering situation arranged into hierarchy

Expose patient to situation until they habituate the stimulus (reduced arousal level)

Therapist teach patient that they are still safe without their compulsive behavior (not washing hands when touching door knob)

Don’t use relaxation technique (keep it realistic)

Alternative for drugs, no side effect

High generalizability, work for multiple OCDs

Difficult for inexperience therapist to deliver

New compulsion can occur unless ERP treat core underlying fear => need patient being honest about trigger stimuli

Mini study:

Jason has OCD

Ten 50 minute sessions of ERP over 16 weeks

Exposure – getting Jason to touch objects like door handle

Response prevention – reducing anxiety and need for behavior by using coping statements

After therapy score on Y-BOCS dropped from 18 to 3

Key study: Telephone CBT (Lovell et al)

Non-inferiority trial: test whether a new treatment is not worse than an existing one
Compare face to face + telephone CBT for OCD

72 (age range 16-65, match age, gender, income) OCD from UK, ppt used medicine are removed. Opportunity

Split into 2 groups randomly, face to face or telephone

Patient complete Y-BOCS, BDI and client satisfaction questionnaire twice (establish baseline twice, to replace control group), the psychologist assessed this did not know which condition ppt is in

Face to face group: 10 one hour weekly sessions of ERP

Telephone group: 8 30 minute weekly telephone sessions of ERP + 2 face to face meetings (first and last session of treatment)

Do the same questionnaire later => No differences in improvement and client satisfaction after 6 months

Telephone is as effective as face-to-face even the time is shorter

Used both Y-BOCS + BDI (good test retest and check for reliability). patient who used drugs were also removed to ensure only CBT affect symptoms

The score between 2 baseline test did not change much, suggesting that symptoms do not improve without ERP (compensate for lack of control group)

Random ppt allocation to 2 groups, avoid ppt variables. Gender, age, income are similar across groups

Psychologist blind

Good size sample and age range

13% revealed to therapist which group they are in, therapist may assess their symptoms differently

Initial depression score was higher in telephone group, suggest that telephone might not work for less severe symptomsno

PPT:

1. Some ppt dropped out, affect similarity between 2 groups

2. Only UK, high individualist culture, not work for collective culture

Ethics: Approved by ethic committee, gave consent

Application: Telephone can save more time