Chapter 6 Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive and Related Disorders

Learning Objectives

  • 6.7 Describe the clinical features and potential causes of obsessive-compulsive disorder and how it is treated

  • 6.8 Describe the clinical features of related disorders, such as body dysmorphic disorder, hoarding disorder, and trichotillomania

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Obsessive-Compulsive Disorder (OCD)

  • Definition:

    • Occurrence of obsessive thoughts, alongside compulsive behaviors performed to neutralize such thoughts.

    • Time Requirements:

    • Symptoms are time-consuming, taking more than 1 hour per day.

  • Terms:

    • Obsessions:

    • Defined as persistent and recurrent intrusive thoughts, images, or impulses that are distressing, morally inappropriate, or uncontrollable.

    • Compulsions:

    • Involve repetitive actions performed as lengthy rituals aimed at neutralizing or coping with obsessions.

Types of Obsessions in OCD

  • Most common types of obsessions include:

    • Contamination fears:

    • Fears related to disease, germs, etc.

    • Fears of harm:

    • Concerns about harming oneself or others.

    • Need for symmetry:

    • An enduring necessity for things to be organized in a specific order or symmetry.

    • Sexuality:

    • Unwanted sexual thoughts or images.

    • Religion:

    • Scrupulosity or excessive religious doubts and fears.

Types of Compulsions in OCD

  • Common compulsive behaviors include:

    • Cleaning:

    • Engaging in cleaning rituals distinct from a general germ phobia.

    • Checking:

    • Repetitive verification of tasks or situations (e.g. verified locks, appliances).

    • Repeating:

    • Performing actions multiple times (such as entering and exiting a room).

    • Ordering/arranging:

    • The need to organize items based on personal criteria.

    • Counting:

    • Performing actions or counting items in a certain way, often tied to specific beliefs.

    • Phrases/sayings:

    • Repeating certain words, phrases, or prayers.

    • Excessive reassurance-seeking:

    • Continuously asking others for reassurance regarding one's thoughts or behaviors.

Prevalence, Age of Onset, & Gender Differences

  • Lifetime Prevalence Rate:

    • Estimated at 2-3% of the population.

  • Issues with Treatment-Seeking:

    • Over 90% of treatment-seeking individuals have both obsessions and compulsions.

  • Gender Differences:

    • Little to no gender differences in incidence rates, differing from other anxiety-related disorders.

  • Typical Onset:

    • Late adolescence or early adulthood; childhood onset is associated with greater severity and heritability.

  • Chronic Nature:

    • Typically chronic, although effective treatment can provide relief.

  • Comorbidity:

    • Frequently coexists with anxiety disorders, depressive disorders, tic disorders, and ADHD.

  • Differential Diagnosis:

    • Need to rule out other conditions, such as PTSD and its related intrusions.

Psychological Causal Factors

  • Reinforced Learning:

    • Compulsive rituals maintain obsessions and related distress, influencing therapeutic approaches.

  • Preparedness:

    • Importance of understanding how certain fears and compulsions are ingrained in human psychology.

  • Key Psychological Factors:

    • Non-acceptance of thoughts.

    • Overwhelming moral responsibility for thoughts and actions.

    • Attempts to suppress thoughts may actually exacerbate them.

    • Thought-action fusion:

    • The belief that thinking about a behavior is the same as performing it.

    • Class activities may assist in understanding these factors in a practical way.

Treatments for OCD

  • Behavioral Treatment:

    • Exposure and Response Prevention (ERP):

    • A key therapeutic intervention where patients are exposed to the source of their anxiety while refraining from compulsive responses.

    • Efficacy: About 50-70% of patients who adhere to this treatment show a substantial reduction in symptoms.

    • Full remission is uncommon, indicating that ongoing treatment may be necessary.

    • Referenced: John Grayson’s video on ERP.

  • Medications:

    • Typical medications target neurotransmitter systems, particularly focusing on serotonin levels.

    • Concerns on Medication Discontinuation:

    • Consider the implications for symptom recurrence if medication is stopped.

Classification of Related Disorders

  • Definitions of Related Disorders:

Body Dysmorphic Disorder (BDD)

  • Obsession:

    • Involves obsessive thoughts about perceived or imagined flaws in appearance (often not noticeable to others).

  • Beliefs:

    • Firm belief in one's own disfigurement or unattractiveness.

  • Compulsive Behaviors:

    • Common responses include:

    • Seeking reassurance from others.

    • Excessive mirror checking.

    • Skin picking.

    • Comparisons to others.

    • Checking to ensure flaws are covered up.

  • Impact:

    • Causes clinically significant distress and impairment.

  • Scope:

    • Can focus on any body part; not solely driven by concerns over weight or fat (where they may meet criteria for an eating disorder).

Hoarding Disorder

  • Definition:

    • Characterized by the acquisition of and failure to discard possessions of limited value.

  • Implications:

    • Results in disorganization in living space that interferes with daily life.

  • Prognosis:

    • Generally poorer treatment outcomes compared to OCD.

Other OC and Related Disorders

  • Trichotillomania:

    • Characterized by compulsive hair pulling from any body location.

    • Pulling is typically preceded by tension and followed by pleasure or relief.

    • Must cause clinically significant distress.

  • Excoriation (Skin Picking) Disorder:

    • Involves compulsive skin picking which leads to skin lesions.

  • Somatic Symptom Disorder & Illness Anxiety Disorder:

    • Although distinct in DSM-5, have been argued to be subtypes of obsessive-compulsive disorders.

Additional Notes

  • Prevalence of Body Dysmorphic Disorder:

    • Point prevalence in the general population is estimated at 1-2%.

  • Gender Differences:

    • BDD affects men and women equally, but the types of body obsessions differ between genders.

  • Age of Onset:

    • Typically begins during adolescence.

  • Comorbidity Rates:

    • High rates of comorbidity with social anxiety disorder (SAD), depression, and OCD.

  • Cultural Implications:

    • The role of media and societal pressures on beauty standards influences the prevalence and severity of disorders like BDD.

    • Discussion on potential benefits and drawbacks of restricting social media use among youth.

  • Learning Objectives Recap:

    • Revisit the clinical features and potential causes of OCD along with treatment modalities.

    • Explore related disorders such as BDD, hoarding disorder, and trichotillomania.