Obsessive Compulsive Disorder

Features of OCD Obsessions –Recurrent and persistent thoughts; impulses; or images of violence, contamination, and the like –intrusive and distressing –Individual tries to ignore, suppress, or neutralize Compulsions –Repetitive behaviors individual feels driven to perform –Ritualistic/need to follow a set of rules –Intended to prevent or reduce distress or some dreaded event

DSM-IV Criteria See webpage

OCD Features Data from the Epidemiological Catchment Area (ECA) survey found a 6-month point prevalence of 1.6% and a lifetime prevalence of 2.5% in the general population Sex ratio is 1:1.1 (men to women) Mean age of onset is 20.9 years (SD=9.6) –Males is 19.5 years (SD = 9.2) –Females is 22.0 years (SD = 9.8) Most develop their illness before the age of 25 Symptoms can be remembered as far back as the onset of puberty.

Comorbidity Major depression is the most common comorbid disorder –1/3 have concurrent MDD –2/3 have a lifetime history of MDD Other Axis I disorders include panic disorder with agoraphobia, social phobia, generalized anxiety disorder, Tourette’s syndrome, trichotillomania, schizophrenia Axis I comorbid disorders can effect the severity and treatment of OCD.

Comorbidity Obsessive-compulsive personality disorder (OCPD) is an Axis II disorder. OCPD differs from OCD by the lack of true obsessions and compulsions. OCPD behaviors are ego-syntonic, whereas OCD is ego-dystonic

More features Types of Obsessions –Aggressive obsessions –Contamination obsessions –Sexual obsessions –Hoarding/saving obsessions –Religious obsessions –Symmetry/exactness –Somatic obsessions

Types of compulsions –Cleaning/washing compulsions –Checking compulsions –Repeating rituals –Counting compulsions –Ordering/arranging –Hoarding/collecting –Mental rituals

Most people experience intrusive thoughts throughout their life Individuals who develop OCD may react more negatively to their intrusions

Neurobiology/physiology No chronic hyperarousal Over activation of the orbitofrontal cortex (thought generation) and under activation of the caudate nuclei (thought suppression)

Psychosocial Learning –Animal models High stress or repeated frustration leads to increase in ritualistic-like behaviors Fixed action pattern- innate and adaptive behavioral sequences to specific stimuli –Biological preparedness Washing and checking may have once promoted survival

Cognitive deficits –Increased attention allocated to fear related stimuli –Tend to encode negative stimuli more indepth than neutral and positive stimuli, leading to better memory for negative stimuli –Overattention to detailh

Cognitive theory of OCD Obsessional thoughts: –If obsessions occur frequently in normal populations, why don’t most people suffer from OCD? –It’s not the thought itself that is disturbing, but rather the interpretation of the thought. Example: having an unacceptable sexual thought leads to beliefs that the person is depraved, perverted, abnormal, evil, etc…., which leads to affective states such as anxiety and depression. –The issue of responsibility is believed to be a core belief or cognitive distortion of people with OCD.

Compulsive behaviors: –Neutralizing, either through compulsive behaviors or mental strategies, is aimed at preventing terrible consequences, or averts the possibility of being responsible –Seeking reassurance is another form of neutralizing, as it can serve to spread responsibility to others, thus diluting that of the individual –Avoidance, though not an overt neutralizing behavior, is often used to prevent contact with particular stimuli

Model: –Stimuli in the form of unpleasant intrusive thoughts, of either external or internal origins are experienced –The thought is ego-dystonic, that is, it is inconsistent with the individual’s belief system –The NAT usually involves an element of blame, responsibility, or control, which interacts with the content of the intrusive thought –Disturbances in mood and anxiety follow, which in turn lead to neutralizing behavior

–There are three main consequences of neutralizing behavior It results in reduced discomfort, which leads to the development of compulsive behavior as a tool for dealing with stress. This reinforcing behavior may result in a generalization of this strategy Neutralizing will be followed by non-punishment, and can lead to an effect on the perceived validity of the beliefs (NAT) The neutralizing behavior itself becomes a powerful and unavoidable triggering stimulus. The neutralizing behavior serves to reinforce the belief that something bad may happen

Treatment CBT –Exposure and response prevention was first used by Meyer in 1966 –The principle behind EX/RP is to expose the individual to the triggering stimuli (obsession) and block the neutralizing behavior –As a result, the individual learns: Anxiety is temporary The feared catastrophic consequence never transpires Their interpretation of the obsession weakens Obsessional thoughts are harmless –Imaginal exposure is also used when in-vivo is not possible

Components of EX/RP –Group treatment is comprised of 2 individual sessions and 12 group sessions –Individual treatment is also time limited and comprises approximately 12 to 14 sessions –Psychoeducation –Pre-treatment assessment of severity of OCD and depression –Hierarchy construction and explanation of SUDS

Treatment session: –Homework review –In-vivo exposure and response prevention, including monitoring SUDS level –Review of exposure –Homework assigned and next session’s exposure discussed –Termination session Following a time limited (12-weeks) CBT approach, symptom reduction is maintained

Problems with CBT –25% of people refuse to engage in CBT –CBT alone is ineffective when there is a severe comorbid major depression, over valued ideation, tic disorder, schizoid personality disorder –There is limited availability of therapists trained in CBT for OCD

Pharmacotherapy Serotonin (5-HT) neurotransmission abnormalities have been implicated in the pathophysiology and treatment Antidepressant medications of the Serotonin Reuptake Inhibitor classification and specific tryciclic antidepressants (Clomipramine) have been proven to be effective in the treatment of OCD

Currently there are 6 SRIs that are FDA approved for the treatment of OCD –Clomipramine (Anafranil) –Fluoxetine (Prozac) –Fluvoxamine (Luvox) –Paroxetine (Paxil) –Sertraline (Zoloft) –Citalopran (Celexa) The goal of a SRI is to increase the level of 5-HT transmission within the synapse