Obsessive Compulsive Disorder Ashwini Sabnis, M.D

DSM -5 OCD Criteria Obsessions Recurrent & persistent thought, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate & that cause marked anxiety or distress. The thoughts, impulses, or images aren’t simply excessive worries about life problems. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action. The person recognizes that the obsessional thoughts, impulses, or images are a product of his/her own mind (not imposed from without as in thought insertion).

Compulsions Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

Epidemiology of OCD 2.5% lifetime prevalence Prevalence is similar for men and women Onset occurs typically occurs during adolescence or early adulthood Onset is earlier for males than females Tends to be chronic without treatment with periods of waxing and waning of symptoms Onset after age 35 in females is unusual but is possible

Associated Disorders Depression Body Dysmorphic Disorder ADHD Eating disorders Tourette’s disorder and motor tics Generalized Anxiety Disorder

Behavior theory Mowrer’s 2-Factor Theory – Obsessions come to evoke anxiety through classical conditioning – Anxiety is reduced through compulsion, which are, therefore, reinforced (operant conditioning) Evidence: – Animals learn to avoid aversive stimuli in an “obsessive” way But: – Aren’t intrusive thoughts aversive to being with? – Why doesn’t everyone develop OCD?

Causes of OCD Elevated activity in the Frontal Lobe and Basal Ganglia Activity is not typical in people without mental illness PET (Positron emission Tomography) scan used in brain imaging

Brain Activity

Functional Classification (Foa et al, 1985) Internal fear cues External fear cues Fears of harm or disastrous consequences

Obsessions Fear/Anxiety Compulsions Reduction in Distress Piacentini et al, 2006)

OCD cycle

Common Themes Contamination and cleaning (hand washing) Self doubt and checking, re-writing, repeating, hoarding Organizing / need for symmetry Scrupulosity (religious obsessions) Aggressive obsessions (fear of harming others)

Treatment COGNITIVE BEHAVIORAL THERAPY Highlight the role of dysfunctional beliefs and interpretations that sustain rituals – More appropriate and applicable to treating adults Cognitive therapy must be done carefully – Can reinforce rituals or engender new ones Use CT to externalize OCD symptoms or motivate children – The OCD monster – Let’s try an experiment

CBT Assessment Psychoeducation Socialization to treatment – For child and family Development of an OCD symptoms hierarchy Engage in exposures and active treatment Conclude treatment Offer booster sessions as needed

Assessments Office Visits The Anxiety Disorder Interview Schedule – Revised (ADIS-R) The Yale-Brown Obsessive-Compulsive Symptom Checklist (Y-BOC) The Leyton Obsessional Inventory (Lol) The State Trait Anxiety Inventory of Children (STAIC)

Overestimation of the importance of thoughts – Distorted thinking – Thought-action fusion – Magical thinking Responsibility Perfectionism – Need for certainty – Need to know – Need for control

Psychoeducation Emphasize that exposures will be gradual May need to motivate some youth – Be dispassionate and firm – Motivational interviewing techniques Exposure intensity corresponds with positive treatment outcomes The therapist should establish rapport – Convey warmth, optimism, confidence,

Information Gathering Phase (2 sessions) – Session 1 (2 hrs.) Obtaining info on OCD symptoms History of the problem Defining the disorder Rationale for treatment Overview of treatment Program Teaching patients to Monitor symptoms

Information Gathering Phase (2 sessions) – Session 2 (2 hrs.) Inspection of patient’s self-monitoring Collecting information about obsessions and compulsions Generating the treatment plan Rules for selection of exposure situations Develop clear contract between therapist and patient Teaching patients to Monitor symptoms Homework assignment

Obsessions – external fear cues – internal cues – consequences of external and internal cues Avoidance Patterns – Passive avoidance – Rituals – Relationship between avoidance patterns and fear cues

Treatment Phase (15 daily sessions, 120 min. each) – Format of exposure session – Implementation of exposure – Homework assignments – Comments during exposure sessions – Response prevention Rules Return to normal behavior – Common difficulties during sessions

For Washer – Session 1: walk with therapist through the building touching doorknobs, holding each for several minutes – Session 2: Repeat above and add contact with sweat by having patient touch armpit and inside of shoe – Session 3: Repeat above but introduce having patient touch toilet seats – Session 4: Repeat above but introduce urine by having patient hold a paper towel dampened in his own urine – Session 5: Repeat above but introduce fecal material by having patient hold toilet paper lightly soiled with his own fecal material – Sessions 6-15 Daily exposure to the three most fear-provoking activities are repeated.

For Checker – Session 1: turn the lights on and off once, turn stove on and off once, open and close doors once (leave room immediately without checking) – Session 2: Repeat above and add flushing of toilet without looking in the bowl – Session 3: Repeat above but introduce opening gate to the basement and allowing daughter to play near the gate – Session 4: Repeat above but introduce carrying daughter on concrete floor – Session 5: Repeat above but introduce driving on highway without retracing route – Sessions 6-15 Daily exposure to the three most fear-provoking activities are repeated.

No ritualistic checking is permitted One check (normal checking) is permitted Designated relative or friend supervises response prevention adherence at home Therapist/supervisor is to stay with patient until urge to check diminishes Violations of home practice are reported to therapist

Non-compliance with response prevention instructions Continued passive avoidance Arguing/balking about exposure/response prevention requirements Emotional overload Family reactions

Development of symptom hierarchy Day 1 or 2 (the easiest part of treatment) Work with child to develop a list of feared stimuli or situations Write down everything and ask clarifying questions Rank order items on a scale (1 – 10; 1 – 100) “Everything is a 10!” “Nothing scares me” Use of anchor points and contrasts

OCD Hierarchy SUDS Level 99 Touching an unknown sticky substance, without washing 95 Holding loose hair 90 Touching known sticky substances (e.g. egg), without washing 85 Touching unknown trash articles 60 Using a public restroom 60 Witnessing a political argument 60 Witnessing other sensitive-subject arguments (i.e. religion)

OCD Hierarchy 60 Seeing parents spend a lot of money at one time 60 Touching loose hair with finger 55 Touching known sticky substance (e.g. syrup),without washing 50 Touching a known sticky substance (e.g. soda), without washing 30 Touching a dirty railing 30 Walking into a public bathroom

Exposure and Response Prevention  CBT with exposure and response prevention (ERP) is the best established psychological treatment for OCD.  Gold standard (DeRubeis & Crits-Christoph, 1998).  63% to 83% of participants obtained some benefit, many long term after ERP (Abramowitz, 1997; Foa & Kozak, 1996; Stanley & Turner, 1995).

ERP. With repeated exposure to the same cue or trigger without using compulsions, anxiety and distress reactions also decrease until the cue becomes significantly less bothersome.

ERP Part One - Imaginal Scripting – Using your hierarchy formed in the previous activity create an imaginal script or exposure for a distressing item (SUDS around 7 or 8). – Examples – Funeral of a loved one – Skydiving

ERP Part Two - En Vivo ERP – Form into groups of three – be the therapist / student – Take turns leading one another through your exposure – Monitor SUDs level! – Do not flood – Do not go above a 5 or 6… – Proceed until SUDS level drops by half

Check list

Pharmacological Treatments for OCD Clomipramine* SSRIs Fluoxetine Fluvoxamine* Sertraline

Prognosis OCD tends to last for years, even decades. The symptoms may become less severe from time to time, and there may be long intervals where symptoms are mild For most, the symptoms are chronic With a combination of pharmacotherapy and behavior therapy, symptoms can be controlled