9 Obsessionality & Compulsivity

Reminders

  • Mid-Term Progress Note #1 due Monday, 3/2

  • Need to return Exam 1!

  • Exam 2 on 3/4 (one week from Wednesday)

Obsessionality & Compulsivity

Clinical Description & Epidemiology

Quotes

  • “To resist a compulsion with willpower alone is to hold back an avalanche by melting the snow with a candle. It just keeps coming and coming and coming.” – David Adam, The Man Who Couldn’t Stop

  • “Imagine experiencing pervasive and perpetual sensations of dread and shame, the sort of visceral response that you might have when your body reacts to a physical threat. Envision how distressing it would be if you experienced these exact same feelings after viewing yourself in a reflective surface or a photograph.” – Arie Winograd, Face to Face with Body Dysmorphic Disorder

Key Terms

  • Obsessions

    • Definition: Persistent and recurrent intrusive thoughts, images, or impulses.

    • Characteristics:

    • Experienced as disturbing, inappropriate, or uncontrollable.

    • Individuals who have obsessions often try to actively resist, suppress, or neutralize them.

  • Compulsions

    • Definition: Repetitive behaviors or rituals driven by an urge to perform them, often according to rigid rules.

    • Characteristics:

    • Individuals can feel compelled to perform these actions while also regarding them as excessive.

    • Compulsions are usually not pleasurable; they provide some comfort or relief instead.

DSM-5 Diagnoses of Obsessive-Compulsive and Related Disorders

  • Obsessive-Compulsive Disorder (OCD)

  • Body Dysmorphic Disorder (BDD)

  • Compulsive Hoarding

  • Compulsive Hair-Pulling (Trichotillomania)

  • Compulsive Skin-Picking (Excoriation)

Changes in DSM-5 Classification

  • OCD:

    • Previously classified as an anxiety disorder.

  • BDD:

    • Previously classified as a somatoform disorder.

  • All these disorders involve repeated unwanted thoughts and/or compulsive actions.

  • Highlighted that these disorders may share comorbidity and have similarities in neurobiology.

DSM-5 Criteria for Obsessive-Compulsive Disorder

A. Presence of obsessions, compulsions, or both:

  • Obsessions defined by:

    1. Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, often causing marked anxiety or distress.

    2. The individual attempts to ignore or suppress these thoughts, urges, or images, or to neutralize them with another thought or action (i.e., performing a compulsion).

  • Compulsions defined by:

    1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting) the individual feels driven to perform in response to an obsession or according to rigid rules.

    2. Aimed at preventing/reducing anxiety or preventing a dreaded event, but not realistically connected to what they are intended to neutralize or are clearly excessive.

  • Note: Young children may not articulate the aim of these behaviors.

B. Time-consuming obsessions or compulsions (e.g., take more than 1 hour per day) or clinically significant distress or impairment in functioning.

C. Symptoms not attributable to the physiological effects of a substance or another medical condition.

D. Disturbance not better explained by symptoms of another mental disorder (e.g., excessive worries in generalized anxiety disorder, preoccupation with appearance in body dysmorphic disorder).

Compulsions

  • May include unobservable acts (e.g., repeating a phrase silently).

  • Obsessions and compulsions can be adaptive in moderation and under appropriate circumstances.

  • Many people experience some degree of obsessions and compulsions, but in OCD they are more pronounced, persistent, and distressing.

Body Dysmorphic Disorder (BDD)

  • Most individuals dislike some aspect of their body.

  • Average time spent thinking about body-related concerns: 3-8 hours/day.

  • Focal points of concern are often socialized, yet symptoms are consistent across cultures.

Compulsive Hoarding

  • Individuals often collect or have difficulty discarding objects that are not practically useful or monetarily valuable.

  • Question arises at which point hoarding qualifies as a disorder.

Clutter Image Rating Scale

  • Tool to assess clutter in environments (e.g., a living room):

    • Options range from clear (1) to severe clutter (9).

Epidemiology of OCD

  • Lifetime prevalence of OCD: 2-3%.

  • Prevalence is roughly equal among genders and ethnicities.

  • Typical onset occurs in childhood through young adulthood.

  • Symptoms can persist for years, with fluctuation in severity.

  • Approximately 40% seek treatment; a notable lag exists between onset and diagnosis.

  • Often co-occurs with anxiety disorders, depression, tic disorders.

Epidemiology of BDD

  • Prevalence: More common than previously thought (1-2%).

  • Experiences of body dysmorphia are often kept secret.

  • Gender distribution is similar, but specific preoccupations vary (e.g., muscle dysmorphia more common in men).

  • Typical age of onset: adolescence to early adulthood, with potential for decades of persistence if untreated.

Epidemiology of Hoarding

  • Compulsive hoarding occurs in 3-6% of adults.

  • Lifetime prevalence of hoarding disorder (per DSM-5): possibly 1-3%.

  • Problems often emerge during adolescence but usually become apparent later in life.

  • Significantly impairs functional capabilities, leading to high unemployment rates and social alienation.

Risk Factors and Etiological Models

  • Focus on OCD.

Biological Processes in OCD

  • Moderate heritability with most traits not specific to OCD; shared genetic risks exist with other conditions (e.g., depression, anxiety).

  • Neurotransmitters implicated include serotonin, glutamate, GABA, and dopamine.

    • Exact roles of these remain unclear.

  • Altered function of orbitofrontal loop circuits, featuring:

    • Components: Orbitofrontal cortex, cingulate, striatum, globus pallidus, thalamus.

    • Related to habit formation, decision-making, inhibition, behavioral flexibility, worry, and error detection.

  • Individuals with OCD may face difficulty inhibiting “prepotent” actions (e.g., feeling dirty triggering hand-washing).

  • Heightened neurological responses to making errors noted through EEG/ERP studies.

  • Baxter suggests stray thoughts and minor errors that typically go unnoticed become focal points of attention in OCD.

Behavioral Processes in OCD

  • Conditioned learning plays a significant role; superstitions may arise from coincidental events.

  • Familiar rituals provide comfort, reinforcing compulsive avoidance behavior.

  • Compulsions may mirror grooming/nesting behaviors in non-human animals.

    • Once associated with avoidance, actions become difficult to discontinue, even if the original threat is no longer present.

  • Gillan et al. (2014) found OCD individuals struggle more to change actions learned for harm avoidance.

    • Habits are resistant to change, particularly in those with OCD, often due to a reduced sensitivity to reinforcement learning.

Cognitive Processes in OCD

  • The relationship between obsessions (O) and compulsions (C) is complex, considering whether compulsions lead to obsessions.

  • Individuals often demonstrate attentional and perceptual biases, focusing disproportionately on obsession-related stimuli.

  • Catastrophic meanings can be assigned to intrusive thoughts, fostering feelings of guilt, disgust, and shame.

  • Thought-action fusion (Rachman): belief that one’s thoughts can lead to actions, resulting in guilt and self-blame.

  • Commonly held beliefs among individuals with OCD include the necessity to control their thoughts, leading to significant efforts to neutralize them.

  • Ironic process (Wegner, 1994): Reminder not to think of something often leads to obsession with that thought.

  • Traits such as perfectionism, high moral standards, and overresponsibility contribute to anxiety and worry, increasing compulsive behaviors.

Difficulty with Checking

  • Difficulty in tolerating uncertainty, low confidence in one's judgments, and concerns about errors contribute to incessant checking behaviors.

  • Yedasentience: The internal sensation ascertaining one has done enough regarding a goal, facilitating the completion of actions.

  • Questions whether OCD affects individuals' capacity to recognize yedasentience effectively.

Ingenious Study of “Contaminated Pencils” (Tolin et al., 2004)

  • Presented a clean pencil that had been contaminated multiple times (with each pencil wiped on the previous) and asked participants to assess perceived contamination levels.

  • Investigated how perceptions of contamination develop through successive contamination exposure.

General Psychological Vulnerabilities Involved in OCD

  • Includes biological and environmental factors, stress from life events, and specific psychological vulnerabilities concerning intrusive thoughts.

Factors Implicated in Body Dysmorphic Disorder (BDD)

  • Environmental Factors: Focus on appearance.

  • History: Reinforcement or bullying related to appearance.

  • Beliefs: 60% of those with BDD agreed that a “defective appearance equates to worthlessness.” (Buhlmann & Wilhelm, 2004).

  • Body-focused perfectionism and biased attention toward physical features can exacerbate BDD symptoms.

Factors Implicated in Hoarding

  • Evolutionary Aspects: Stockpiling resources seen as protective.

  • Trauma: High rates of trauma linked with hoarding behavior.

  • Cognitive Challenges: Difficulty in organizing possessions and negative beliefs about self and objects.

    • People often see possessions as irreplaceable and central to their identity, exacerbating hoarding behaviors.

Treatment Options

Exposure and Response Prevention (ERP)

  • Involves exposure to situations that trigger obsessions and prevention of compulsive behaviors.

  • 50-75% show significant, durable improvement.

  • Access remains limited due to misconceptions about ERP effectiveness.

  • Approaches for BDD and hoarding include similar strategies, with emphasis on organization and decluttering.

Cognitive Components of Treatment

  • Treatment focuses on understanding symptoms and evaluating unrealistic beliefs around responsibility and consequences of non-engagement in compulsions.

  • Post-exposure processing encourages clients to reflect on their exposure experiences.

Biocentric Treatments

  • Medications: SSRIs/SNRIs

    • Higher doses and duration required vs. general anxiety disorders.

    • Discontinuation often leads to relapses.

  • Deep Brain Stimulation (DBS) and transcranial Magnetic Stimulation (dTMS) may be alternatives for treatment-resistant OCD.

  • Approximately 50% experience significant relief from DBS/dTMS.

Closing Thoughts

  • Combination of medication and therapy generally provides the most potential for symptom relief.

  • The DSM's evolving approach to OCD illustrates changes in understanding these disorders over time.

  • Ongoing debates exist regarding whether OCD appropriately fits within anxiety disorder classifications.

  • Obsessive-compulsive symptoms frequently present as continua; they may overlap with various other disorders such as eating disorders or substance use disorders, suggesting they may share transdiagnostic mechanisms.

Bonus Slides

OCD and Eating Disorders

  • Overview of co-occurrence between OCD and eating disorders with multiple hypotheses presented about their relationship.