Chapter 6: OCD CYU

1. How did the classification of obsessive-compulsive and related disorders change from DSM-IV to DSM-5?

  • DSM-IV: OCD was classified under Anxiety Disorders. Hoarding, BDD, trichotillomania, and excoriation were not separate disorders.

  • DSM-5: OCD was moved to its own category: Obsessive-Compulsive and Related Disorders (OCRDs).

    • This new category includes: OCD, Hoarding Disorder, Body Dysmorphic Disorder (BDD), Trichotillomania, and Excoriation (Skin-Picking).

2. Define OCD and explain it from behavioural, cognitive, and biological perspectives.

  • Definition: A chronic disorder where people experience intrusive, uncontrollable thoughts (obsessions) and feel compelled to perform repetitive behaviours or mental rituals (compulsions) to reduce anxiety.

Theories:

  • Behavioural: Compulsions are learned behaviours reinforced by temporary anxiety reduction (negative reinforcement). Memory issues (e.g., “did I turn off the stove?”) may also contribute.

  • Cognitive: Obsessions involve catastrophic misinterpretations of intrusive thoughts.

    • Key factors: inflated responsibility, thought-action fusion (thinking something = as bad as doing it), and over-self-consciousness (“thinking about thinking”).

  • Biological:

    • Genetics: 1st-degree relatives more likely to have OCD.

    • Brain: ↑ activity in frontal lobes + basal ganglia; overlaps with Tourette’s.

    • Neurotransmitters: serotonin deficits (supported by SSRI treatment, though only 40–60% respond).

    • Cognitive deficits: attention, memory, executive dysfunction.


3. Describe therapies for OCD.

  • Psychoanalytic: Aims to uncover repressed conflicts (e.g., unresolved aggression/sexual impulses, harsh toilet training). Not very effective.


  • Behavioural: Exposure and Response Prevention (ERP) = expose to feared stimulus (e.g., touching dirt) while preventing ritual (hand-washing). Leads to extinction of anxiety response.

    • CBT: Decreases thalamus volume ; Increases orbitofrontal cortex volume


  • Cognitive: CBT with ERP, plus inference-based modification (targets faulty logic behind obsessional inferences).


  • Biological: SSRIs are first-line meds. Severe, treatment-resistant cases may use psychosurgery (cingulotomy) or deep brain stimulation.

4. Define hoarding disorder + biological theory.

  • Definition: Persistent difficulty discarding possessions → clutter dominates life. Added as separate disorder in DSM-5 (used to be lumped under OCD). Prevalence 2–5% (twice as common as OCD).

  • Biological theory:

    • Genetic + neural activity differences from OCD.

    • Evidence for moderate heritability.

    • Brain imaging shows unique physiological differences (not just OCD with clutter).

    • Difficulty thinking about categories, distractability

5. Therapies for hoarding disorder.

  • Medication: SSRIs and SNRIs (some show >50% response).

  • CBT: Targets avoidance of discarding + maladaptive beliefs. Includes:

    • Exposure (not acquiring + discarding)

    • Cognitive restructuring of faulty beliefs about possessions

    • Skills training (organization, decision-making, problem-solving)

    • Motivational interviewing

    • Home visits for real-world practice.

6. Define BDD + cognitive-behavioural theory.

  • Definition: Preoccupation with imagined/exaggerated physical defects (skin, hair, nose, height, body hair, etc.).

    • Chronic,

    • Begins in adolescence,

    • Highly comorbid with depression, eating disorders, substance use. Very high suicide risk.

  • Cognitive-behavioural model: Misinterpretation of appearance-related thoughts → catastrophic thinking → maladaptive coping (mirror checking, avoidance, camouflaging). Maintained by core beliefs like “If I’m not perfect, I’m unlovable”.

7. Treatments for BDD.

  • Biological: SSRIs effective.

  • Behavioural: ERP (exposure without mirror-checking, avoidance, etc.).

  • Cognitive: Challenge self-defeating beliefs and core thoughts; develop more realistic beliefs; relapse prevention.

  • Evidence: CBT more effective than meds alone, though both help. Modular CBT and inference-based therapy also effective.

8. Define trichotillomania & excoriation + biological & cognitive theories.

  • Trichotillomania: Recurrent, irresistible hair-pulling → hair loss, shame, attempts to stop but can’t. Onset = adolescence.

  • Excoriation: Chronic skin-picking → lesions. Common sites: face, arms, hands. Co-occurs with trichotillomania, BDD, depression.

Theories:

  • Biological:

    • Genetic overlap between trichotillomania & excoriation.

    • Brain differences: cortical thickness, ventral striatum (reward system), parahippocampal gyrus.

  • Cognitive/behavioural:

    • Emotion regulation model: pulling/picking reduces negative emotion (negatively reinforcing).

    • Frustrated action model: triggered by boredom or frustration; behaviour relieves tension.


9. Treatments for body-focused repetitive behaviours.

  • Pharmacological: Some benefit from SSRIs or other meds, but evidence is mixed.

  • Habit reversal training (HRT): Most common behavioural approach.

    • Awareness training (identify triggers)

    • Competing response training

    • Stimulus control

    • Can be combined with acceptance-based CBT.


DEFINITIONS


Key Term

Definition

Habit reversal training

A behavioural approach to treating body-focused repetitive behaviour disorders. Involves identifying triggers (e.g., negative emotions) and using competing responses (e.g., sitting on hands) to prevent the behaviour until the urge passes.

Prospective memory

The ability to look forward and remember to perform an intended action at the right place and time.

Retrospective memory

The ability to recall events and experiences that have already occurred.

Body-focused repetitive behaviours

Category of behaviours that includes excoriation (skin-picking disorder) and trichotillomania (hair-pulling disorder).

Exposure and response prevention (ERP)

A behavioural treatment for OCD where the person is exposed to the obsession (e.g., germs) and prevented from performing the compulsion (e.g., handwashing).


PEOPLE + NAMES + CULTURAL THINGS


Name

High-Yield Exam Info

Rachman

Cognitive theory of OCD → obsessions are catastrophic misinterpretations of intrusive thoughts.

  • Key factors: inflated responsibility and thought–action fusion (thinking about something bad makes it more likely to happen, or morally equivalent to doing it).

Alfred Adler

Psychoanalytic view of OCD → results from feelings of incompetence due to an inferiority complex. Caused when children are prevented from developing competence (e.g., by overprotective/dominating parents), leading to compulsive rituals to gain control and feel proficient.

Salzman (1985)

Psychoanalytic perspective → indecision in OCD stems from a need for guaranteed correctness before acting. Treatment focus = teaching clients to tolerate uncertainty and anxiety, since absolute certainty/control is impossible in life.


Dr Siskin = OCD results when fear is reduced by compulsions


CASE STUDIES / STUDENT PERSPECTIVES / HISTORY


Case / Study

High-Yield Exam Points

Bernice (OCD contamination rituals)

Onset after father’s death → stress can trigger OCD. Obsessions = contamination (germs, silver flecks, random triggers). Compulsions = hours-long washing, soap scraping, extreme food rituals (3 bites, chew 300x), husband involved in rituals. Life dominated by OCD, severe impairment. Shows irrational, time-consuming compulsions not logically connected to fear.

Exercise & OCD (Asmundson & Rector, 2015)

Exercise = free, accessible, low stigma. Pilot study (Toronto, 11 clients): CBT (ERP early, cognitive later) + aerobic exercise 3x/week, gradually increasing to 45 min. Adherence >80%. Results: greater symptom improvement than CBT alone. Limitations: small sample, no control group. Next step = large RCT comparing 4 groups (exercise, CBT, combo, control). Key point: exercise may enhance CBT outcomes, but not a replacement.