Obsessive Compulsive Disorder

Features of OCD Obsessions 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 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

See webpage: See webpage: state.edu/ocd1.htm state.edu/ocd1.htm DSMIV

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 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) Sex ratio is 1:1.1 (men to women) Mean age of onset is 20.9 years (SD=9.6) 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 Most develop their illness before the age of 25 Symptoms can be remembered as far back as the onset of puberty. Symptoms can be remembered as far back as the onset of puberty.

Comorbidity Major depression is the most common comorbid disorder 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 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. 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. Obsessive-compulsive personality disorder (OCPD) is an Axis II disorder. OCPD differs from OCD by the lack of true obsessions and compulsions.

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

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

IS OCD Experienced by the Normal Population?? Most people experience intrusive thoughts throughout their life Most people experience intrusive thoughts throughout their life Individuals who develop OCD may react more negatively to their intrusions Individuals who develop OCD may react more negatively to their intrusions

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

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

Cognitive deficits 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 detail

Cognitive theory of OCD Obsessional thoughts: 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. 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.

–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 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) 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 The neutralizing behavior itself becomes a powerful and unavoidable triggering stimulus. The neutralizing behavior serves to reinforce the belief that something bad may happen

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

Currently there are 6 SSRIs that are FDA approved for the treatment of OCD Currently there are 6 SSRIs that are FDA approved for the treatment of OCD –Clomipramine (Anafranil) –Fluoxetine (Prozac) –Fluvoxamine (Luvox) –Paroxetine (Paxil) –Sertraline (Zoloft) –Citalopran (Celexa) –See Graybiel article for hypotheses regarding neural etiology of disease state!!