Etiologies of Obsessive Compulsive Disorder

Obsessive Compulsive Disorder (OCD)

Global prevalence: 1.1 - 1.8%.
More common in males during childhood, females in adulthood.
Early age of onset: mean age 19.5, with 25% manifesting before age 14.

What is OCD?

Obsessions: Recurrent, persistent, intrusive, unwanted thoughts, urges, or images causing distress or anxiety.- Individuals may try to ignore, suppress, or 'neutralize' obsessions with compulsions.
- Example: Fear that something bad will happen to their child, leading to rituals like folding clothes six times.
Compulsions: Repetitive behaviors that the person feels driven to perform to neutralize obsessive thoughts.- Behaviors are disproportionate or irrelevant to the feared outcome.
- Example: Washing hands for hours or repeating the periodic table to cancel out sexual thoughts.

The OCD Cycle

Obsessions \rightarrow Anxiety \rightarrow Compulsions \rightarrow Temporary Relief
The relief is temporary, and obsessions return sooner.
Clinicians must rule out drug use or underlying medical conditions before diagnosing OCD.
Symptoms can trigger avoidance and other conditions like panic disorder or agoraphobia.

Categories of OCD

Manifestations vary based on personal experiences and cultural beliefs.
People may have symptoms in multiple categories.- Checking: Compulsion to prevent harm to self or others (e.g., checking the stove).
- Contamination: Obsessional fear of being dirty, leading to washing or avoidance of public spaces.
- Symmetry and ordering: Need for perfect alignment to prevent discomfort or harm.

Diagnosis of OCD

Symptoms must be experienced for at least one hour a day.
Distress and dysfunction are important indicators for treatment.
Clinicians may use psychometric tests like the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) or Maudsley Obsessive-Compulsive Inventory (MOCI).- Y-BOCS: Clinician-administered checklist; rates symptom severity (0-4 scale).
- MOCI: Self-report data; 30 true/false statements to classify symptoms.

Statistics

WHO ranks OCD as one of the top 20 causes of illness-related disability, with a 2% global prevalence.
Lifetime risk is higher in females, typically developing in adolescence.
Average age of onset: 19, with 25% of cases by age 14.
High suicide risk: 63% with suicidal thoughts, 26% with attempted suicide.

Diagnosis with DSM 5

Must experience obsessions, compulsions, or both.
Specify diagnosis:- With good insight: Recognizes OCD beliefs are not true.
- With poor insight: Thinks OCD beliefs are probably true.
- With delusional beliefs: Completely convinced OCD beliefs are true.
Obsessions/compulsions are time-consuming (more than one hour per day) or cause significant distress/impairment.
Obsessions: Recurrent, persistent thoughts, urges, or images that are intrusive and unwanted.
Compulsions: Repetitive behaviors or mental acts driven by an obsession to reduce distress or prevent a feared event.- Not realistically connected to what they are designed to "neutralize."

Why is diagnosis difficult?

No physiological tests (e.g., blood tests) for OCD; blood tests only rule out other causes.
Often only those with moderate to severe symptoms seek help.
Linked to the stigma of the disorder.
High comorbidity with other psychological disorders (depression, anxiety, substance abuse, PTSD).

Conditions That May Be Misdiagnosed as OCD

ADHD: Need to do things "just right" mimics ADHD; determine if mental rituals interfere with focus.
Anxiety disorder: Worry mimics obsessive thinking; anxiety focuses on real-life problems.
Autism spectrum disorders: Repetitive behaviors seen as natural; OCD individuals view compulsions as excessive.
Depression: Rumination mistaken for obsession; ruminations are of a depressed theme.
Psychotic disorder: Delusional beliefs; OCD individuals recognize thoughts are irrational but cannot control them.
Tourette syndrome: Motor or vocal tics are involuntary; OCD behaviors result from cognitive sources.

Measurement

Validity of tests is important, concerns about Y-BOCS test.
Memory distortion may affect responses; researchers are aware of this.
Responses ranked on a 1-4 scale to avoid gravitating toward the mean.
Self-reported data is the only way to gather information about cognitive symptoms.
Concept of "control" is vague and may be interpreted differently.
Y-BOCS test is standard, but limitations exist.

Biological Factors: OCD

The biological approach argues that OCD may be rooted in the brain and genetics.
Reductionist: Explains a complex behavior by reducing it to a singular biological mechanism.
Deterministic: Ignores the role of free will.
Symptoms may only be expressed under certain environmental circumstances.

Localization of function: Worry Circuit

Specific neural circuit connecting orbitofrontal cortex (OFC) and basal ganglia may be responsible for obsessive thoughts and compulsive behaviors.
The OFC is linked to urges for sex, aggression, and bodily excretion.
The caudate nucleus (part of the basal ganglia) is associated with initiating and inhibiting movements, cognition, emotion, attention, and habit formation.
Overactivity in the neural pathway connecting the OFC and caudate nucleus could trigger compulsive behavior.
One strength of this neurological explanation of compulsive behavior is that it is supported by research evidence.

Causality

Case studies give us a lot of data, but they cannot determine causality. However, they raise questions about causality that could potentially be studied experimentally.
Much of the research is quasi-experimental, using both OCD patients and healthy controls. Even though an IV may be manipulated, the participants cannot be randomly allocated to conditions. As sample sizes get larger, the reliability of the data is established, leading to potential causal relationships, but again, no causality can be determined.
Animal research is a way to manipulate an IV to see its effect on a DV. This means that causality can be established. However, there is the question of how well we can generalize from animal research. Is "compulsive behavior" witnessed in mice the same as in humans? Are we able to measure "obsessions" in mice? The research may lack construct validity, which compromises internal validity. This means that we have to be cautious about drawing conclusions about causality.

Evaluating Theories

Localization of function as an explanation for OCD

Measurement

Animal research is problematic in that only some of their behaviours are correlated with OCD in humans.
Much of the human research is correlational and causality cannot be determined.
Case studies are rather unique; the researcher has no control over extraneous variables, so internal validity is compromised.
Sample sizes tend to be small, making it difficult to generalize to a wider population.

Perspective

It is a biological perspective. This is not a bias. It is simply one lens for looking at a problem.
It is a reductionist perspective. This theory does not necessarily take into account personal history or environmental factors, outside of recognizing the potential role of trauma.

Genetic explanations of OCD

Early studies of OCD were often family studies. These studies found that OCD tends to run in families.

Candidate genes

As many as 230 genes have been linked to OCD, making it a polygenic disorder. Both serotonin and dopamine may be linked in some way to OCD. The enzyme that breaks down dopamine is called catechol-O-methyltransferase [COMT], and the gene that codes for this enzyme is called the COMT gene.
Another gene that has received more recent attention is the SLITRKS gene. This gene plays an important role in learning from our experiences as it has links with neuronal growth and neuroplasticity. This gene is involved in coordinating processes controlled by BDNF (brain-derived neurotrophic factor), which is essential to our neural networks' healthy growth and function.

Evaluating biological explanations of OCD

Strengths- Genetic studies and case studies of brain damage have been consistent, establishing the reliability of the findings.
Limitations- Correlational studies do not establish a cause-and-effect relationship.
- Animal models may give insights into compulsions, but obsessive thoughts cannot be observed or measured.
- It is impossible to isolate variables and separate out social factors in twin studies.

Cognitive Models: OCD

People with OCD experience intrusive thoughts that are more intense, distressing, and longer-lasting.
Individual differences exist in how we process thoughts and our behavioral responses.

Cognitive Models: Inflated Responsibility Model

Salkovskis (1985) proposed that intrusive thoughts activate dysfunctional beliefs about the degree of responsibility individuals should have over their own or a significant others' safety.
These beliefs lead to the conclusion that something must be done about the thought to put matters right again.
Taking actions to neutralize the thoughts reinforces the belief that one's actions-the compulsion-played a key role in protecting oneself or others. The reinforcement of these thoughts then makes the thoughts more likely.

Cognitive Models: Catastrophic Misinterpretation

Rachman (1997) argues that obsessive thinking results from "catastrophic misinterpretation" of the significance of one's intrusive thoughts.
Obsessions develop when the individual believes that an intrusive thought reveals something meaningful and, up until now, unknown about themselves, that it is a warning sign that a negative event will happen or the individual is in danger of losing control. The obsession will persist as long as the thought is interpreted as catastrophic.
Thought-action fusion [TAF]: A patient with OCD experienced intrusive images of throwing hot coffee in her daughter's face or pushing her face underwater when she was bathing her. These images were so terrifying to the patient that she would no longer allow herself any physical contact with her daughter. She could not determine that the thought itself was not the same as the act or the threat of carrying out the act.

Evaluating Cognitive Models of OCD

Support from experimental studies such as Lopatka and Rachman (1995) and Myers and Wells (2013) have strong internal validity and demonstrate that altering one's beliefs can lead to changes in behaviors associated with OCD.
Biological research supports the theory that cognitive activity plays a role in OCD.
The practical application of the theories has led to successful treatments that have improved some people's lives.
Participants in supporting research studies are often people with a pre-existing diagnosis, meaning it is impossible to track the acquisition of dysfunctional beliefs or schema.
Cognitive research relies on self-reported data, which is open to memory distortion and cannot always be verified for accuracy.
The theories suffer from bi-directional ambiguity. It is not clear whether OCD leads to certain patterns of thinking or whether patterns of thinking lead to OCD.
It can be argued that cognitive arguments are an overly simplistic explanation of the disorder.

Environmental Factors: OCD

The family environment plays a significant role in the development, maintenance, and treatment of Obsessive-Compulsive Disorder (OCD).
Parenting styles that are overly critical, rigid, or controlling may contribute to OCD in susceptible individuals, as they can heighten anxiety, perfectionism, and fear of making mistakes-all of which are often related to OCD.
Conversely, a parenting style that balances clear expectations with warmth and support may help reduce OCD tendencies by fostering self-compassion, emotional regulation, and tolerance of uncertainty.

Parenting Styles

Psychologist Diana Baumrind, a developmental psychologist, researched how a parent's interactions with their children may affect their behavior and development.
She proposed three parenting styles: authoritative, authoritarian, and permissive/indulgent. Later, researchers Maccoby and Martin added another style to denote a lack of parenting: uninvolved/neglectful parenting.
Authoritative Parenting: parents are nurturing, responsive, and supportive yet set firm limits for their children. They attempt to control children's behavior by explaining rules, discussing, and reasoning. They listen to a child's viewpoint but don't always accept it.- According to the APA, children raised with this style tend to be friendly, energetic, cheerful, self-reliant, self-controlled, curious, cooperative, and achievement-oriented.
Authoritarian Parenting: is an extremely strict parenting style. It places high expectations on children but provides little emotional support or warmth. An authoritarian parent focuses on obedience, discipline, and control. Children are given little independence or freedom to make their own choices. The parents typically make decisions, and children are expected to follow them without question. Children tend to develop perfectionist traits and feel a high level of responsibility for their actions.
Permissive Parenting: parents are warm but lax. They fail to set firm limits, monitor children's activities closely, or require appropriately mature behavior from their children. Children raised with this parenting style tend to be impulsive, rebellious, and low in self-reliance, self-control, and achievement.
Uninvolved Parenting: parents are unresponsive, unavailable, and rejecting. Children raised with this parenting style tend to have low self-esteem and little self-confidence and seek other, sometimes inappropriate, role models to substitute for the neglectful parent.

Adverse Childhood Experiences (ACES)

Adverse childhood experiences (ACES) can significantly contribute to the development and exacerbation of Obsessive-Compulsive Disorder in various ways. While not everyone who experiences ACEs will develop OCD, research suggests a strong correlation between these early negative experiences and the onset or severity of OCD symptoms.
ACES: Abuse(Physical, emotional, sexual), Neglect ( Physical,emotional), Household dysfunction (Mental illness, incarcerated relative, Mother treated violently, Substance Abuse, Divorce)

Evaluation of Environmental Explanations of OCD

Strengths- Numerous studies have established correlations between ACES, parenting styles, and the development of OCD. Many clinicians observe that individuals with OCD often report stressful life events.
Limitations- Focusing solely on environmental factors downplays the role of genetic predispositions.
- Establishing direct causation is challenging. Many individuals with ACEs do not develop OCD, and vice versa, indicating that other factors must be considered.
- Environmental theories often focus on childhood experiences, potentially neglecting the ongoing impact of adult environments, relationships, and stressors on OCD symptoms.

Sociocultural Approach

The sociocultural approach assumes that people's thoughts, feelings, and behaviours are products of sociocultural conditioning by family, friends, community, and the wider society. Although many Westerners believe OCD has a neurobiological basis, this does not explain the range of obsessions and compulsions that characterize different populations. This chapter will explore the role of cultural factors in the disorder.
Cultural differences: OCD- In the West, OCD is associated with checking, cleaning, and ordering, but in societies where religion plays a more central role in daily life, sexual urges and symptoms rooted in religious/taboo topics are common. Cultures that emphasize the importance of thoughts may lead people to become overly concerned with controlling their thoughts; this explains the correlation between religiosity and OCD symptoms that exist in many parts of the world.

Why are prevalence rates different in different cultures?

In some cultures, mental health issues may carry a stigma, leading individuals to underreport symptoms or avoid seeking help.
In some cultures, certain obsessive thoughts or compulsive behaviors may be seen as more acceptable or common, which could affect how symptoms are recognized or reported.
Clinicians in different regions may have varying levels of training regarding OCD, which can influence diagnosis rates. In areas with less awareness of mental health disorders, OCD may be underdiagnosed.
In some cultures, there may be a lack of access to mental health services, resulting in lower reported prevalence due to fewer individuals receiving a diagnosis. In some cultures, individuals may turn to traditional or alternative forms of medicine before seeking psychiatric help.

Religion and OCD

It has been estimated that between 10 to 30% of patients with OCD have obsessive ideas about religion. Individuals might experience intrusive thoughts about saying or doing something offensive to a deity or religious figure. These thoughts are often perceived as sinful or disrespectful, causing significant guilt and anxiety. In response to these obsessions, people with religious OCD often engage in various compulsive behaviors, including excessive prayer, mental checking, seeking reassurance from religious leaders, confession, or avoiding situations where they fear sinning.
Scrupulosity refers to an excessive preoccupation with 'doing the right thing' according to one's religious beliefs, and this is linked with moral perfectionism, a dysfunctional belief highlighted as a trigger for OCD.

Evaluation of Cultural Explanations of OCD

Much of the research adopts an etic approach-that is, a cross-cultural approach that compares non-Western cultures to Western cultures. Many of the supporting studies use the Y-BOCS framework to guide interviews, which can also mean cultural nuances are overlooked as researchers seek symptoms that fit a more Western conception of the disorder.
Studies are conducted with individuals who are already showing symptoms, making it unclear whether deeply religious people, for example, may develop OCD or whether people with OCD find religious institutions with clear rules about how to structure one's life appealing. There is the problem of bidirectional ambiguity.
It can be difficult to recruit participants for cultural research on OCD due to stigma and a lack of trust of people touside the cultural group.
Sociocultural theories may be more descriptive than explanatory. There is no clear explanation of how sociocultural factors lead to the onset of OCD symptoms, but it does provide a framework for understanding cultural differences in symptoms.