Chapter 3: Obsessive-Compulsive Disorder (OCD) Jonathan S. Abramowitz Laura E. Fabricant Ryan J. Jacoby

Diagnosis Overview Obsessive-compulsive disorder (OCD) Obsessions Obsessions or compulsions  Significant distress Noticeable interference with aspects of role functioning Obsessions  Intrusive thoughts, ideas, images, impulses, or doubts that the person experiences as senseless and that evoke anxiety Compulsions  Urges to perform overt (e.g., checking, washing) or mental (e.g., praying) rituals in response to obsessions or to reduce anxiety or distress

DSM-5 Diagnostic Criteria A. Presence of obsessions, compulsions, or both: Obsessions: 1. Recurren, persistent, intrusive, unwanted, causing anxiety or distress. 2. Attempts to ignore or suppress such thoughts, or to neutralize them with some other thought or action Compulsions: 1. Repetitive behaviors or mental acts driven to perform in response to an obsession, or using rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing anxiety, distress, or some dreaded event B. The obsessions or compulsions are time-consuming (for example, take more than 1 hour a day) or cause clinically significant distress or impairment Indicate whether OCD beliefs are currently characterized by good or fair, poor, or absent insight

Diagnosis-Related Conditions Body Dysmorphic Disorder (BDD) Both OCD and BDD can involve: Intrusive, distressing thoughts concerning one’s appearance Repeated checking The focus of BDD symptoms is limited to one’s appearance Similar psychological treatments are effective for both conditions. Hoarding Once considered to be a symptom of OCD, hoarding is now understood as a separate problem. Hoarding symptoms are no more prevalent in OCD patients than those with other psychological disorders

Diagnosis-Related Conditions Obsessive-Compulsive Personality Disorder (OCPD) Personality traits such as excessive perfectionism, inflexibility, and need for control that negatively impact interpersonal relationships and functioning OCPD is ego-syntonic while the obsessive thoughts experienced by individuals with OCD are ego-dystonic  Other personality disorders, such as avoidant and dependent personality disorder, co-occur with OCD just as frequently

Obsessive-Compulsive and Related Disorders (OCRDs) OCD moved from anxiety disorders to  OCRDs, which includes trichotillomania (hair-pulling disorder), excoriation (skin-picking), body dysmorphic disorder (muscle dysmorphia specifier added), hoarding, obsessional jealousy & body-focused repetitive disorder Many disorders in new category differ substantially from OCD OCD compulsions are intentional, in contrast to mechanical or robotic repetitive behaviors such as tics Repetitive behaviors in addictive disorders or in trichotillomania or, are carried out because they produce pleasure, distraction, or gratification while in OCD, the repetitive behaviors primarily reduce anxiety

DSM-5 Diagnostic Criteria for OCD A. Presence of obsessions, compulsions, or both: Obsessions: 1. Recurrent, persistent, intrusive, unwanted, causing anxiety or distress. 2. Attempts to ignore or suppress such thoughts, or to neutralize them with some other thought or action Compulsions: 1. Repetitive behaviors or mental acts driven to perform in response to an obsession, or using rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing anxiety, distress or some dreaded event B. The obsessions or compulsions are time-consuming (for example, take more than 1 hour a day) or cause clinically significant distress or impairment Specifier Indicates whether OCD beliefs are currently characterized by: good/ fair, poor, or absent insight/delusional (specifier can be used for other disorders) Tic specifier (current or history of)

Symptoms: Obsessions Category Example Examples of Obsessions Contamination What if I get rabies from driving over a dead animal on the street? Responsibility for harm or mistakes What if I hit someone with my car without realizing it? Symmetry/order The books must be evenly placed on the shelf or else I will have bad luck Unacceptable thoughts with immoral, sexual, or violent content Image of my grandparents having sex Thought about stabbing my husband in his sleep.

Symptoms: Compulsions Compulsive rituals are often the most conspicuous and functionally impairing symptoms Compulsive rituals are often performed to reduce obsessional anxiety about feared consequences Many individuals with OCD also engage in repeated attempts to gain ultimate certainty that obsessional doubts are invalid

Examples of Compulsive Rituals Repeating routine activities Symptoms: Obsessions Examples of Compulsive Rituals Category Example Decontamination Wiping down all objects brought into the house for fear of germs from recently applied pesticides on an adjacent lawn Checking Returning home after seeing a fire engine to make sure the house wasn’t on fire Repeating routine activities Going through a doorway over and over to prevent bad luck Retracing one’s steps to make sure that no mistakes were made Ordering/ arranging Saying the word “left” whenever one hears the word “right” Mental rituals Canceling a bad thought by thinking of a good thought

Symptoms: Avoidance and Insight Avoidance behavior is present in most people with OCD Prevents obsessional fears and compulsive urges altogether  About 4% of patients are convinced that their beliefs are realistic (i.e., poor or absent insight)

Prognosis OCD is a chronic condition with a low rate of spontaneous remission Left untreated Symptoms and functional impairment fluctuate, with worsening during periods of increased life stress With treatment Increased rates of symptom remission. Full recovery, however, is the exception rather than the rule

Demographics Lifetime prevalence of OCD estimated at between 0.7% and 2.9% Slight preponderance of females Typically begins by age 25, although childhood or adolescent onset is not rare Mean onset age is earlier in males (about 21 years) than in females (22 to 24 years)

Etiology: Learning Model Mowrer’s two-stage theory of fear acquisition and maintenance First stage: Classical conditioning Neutral stimulus, aka. the conditioned stimulus (CS), paired with aversive stimulus, aka. the unconditioned stimulus (UCS) The CS comes to elicit a conditioned fear response, or CR Second stage: Operant conditioning Avoidance behaviors reduce anxiety; avoidance is negatively reinforced by the immediate reduction in distress. Compulsive rituals develop as an escape behavior from obsessional fear when avoidance is impossible

Etiology: Cognitive Deficit Models Proposes that OCD symptoms arise from abnormally functioning cognitive processes, such as memory Cognitive deficit models cannot account for: Heterogeneity of OCD symptoms The fact that similar mild cognitive deficits are found in many psychological disorders If cognitive deficits play a causal role in OCD, it is most likely to be a nonspecific vulnerability factor

Etiology: Cognitive Behavioral Models Based on Beck’s cognitive theory Emotional disturbance is brought about by how one makes sense of situations or stimuli Unwanted intrusive thoughts (i.e., thoughts, images, and impulses that intrude into consciousness) are a normal experience Intrusions develop into a clinical obsession if the person believes they have serious consequences Compulsive rituals and avoidance represent efforts to remove intrusions and prevent feared consequences

Etiology: Salkovski’s Model Salkovski’s two reasons that compulsions/avoidance become persistent and excessive: Negatively reinforced by their ability to reduce distress They prevent people from learning their appraisals of intrusions are exaggerated and unrealistic Psychometric research indicates that there are three principal domains of dysfunctional beliefs associated with OCD symptoms These types of beliefs confer vulnerability to the onset or worsening of obsessive-compulsive symptoms

Etiology Domains of Dysfunctional Beliefs in OCD Belief Description   Etiology Domains of Dysfunctional Beliefs in OCD Belief Description Inflated responsibility/ overestimation of threat Belief that one has the power to cause or prevent negative outcomes. Belief that negative events are likely and would be unmanageable   Exaggeration of the importance of thoughts and need to control thoughts Belief that the mere presence of a thought indicates that the thought is significant. Belief that complete control over one’s thoughts is both necessary and possible Perfectionism/intolerance of uncertainty Belief that mistakes and imperfection are intolerable. Belief that it is necessary and possible to be 100% certain that negative outcomes will not occur

Etiology: Pyschosocial Factors Dysfunctional relationship patterns can promote the maintenance of OCD symptoms Accommodation Friend or relative participates in rituals, facilitates avoidance strategies, assumes daily responsibilities, or helps to resolve problems resulting from obsessional fears and compulsive urges Prevents the natural extinction of obsessional fear and ritualistic urges Criticism, hostility, and emotional overinvolvement are associated with premature treatment discontinuation and symptom relapse

Etiology: Serotonin Hypothesis Obsessions and compulsions arise from a hypersensitivity of the postsynaptic serotonergic receptors Three potential lines of evidence: Medication outcome studies supportive Studies of biological markers—such as blood and cerebrospinal fluid levels of serotonin metabolites—are inconclusive Results from the pharmacological challenge paradigm largely incompatible

Etiology: Structural Models Structural models hypothesize that OCD is caused by neuroanatomical and functional abnormalities in particular areas of the brain Orbitofrontal-subcortical circuits connect brain regions involved in information processing with those involved in the initiation of behavioral responses Two pathways: direct and indirect Overactivity of the direct pathway is thought to give rise to OCD symptoms

Etiology: Biological Models No explanation has been offered for how neurotransmitter or neuroanatomical abnormalities translate into OCD symptoms For example, Why does hypersensitivity of postsynaptic receptors cause obsessional thoughts or compulsive rituals? In addition, biological models are unable to explain: OCD symptoms are generally constrained to particular themes Why someone would experience one type of obsession (e.g., contamination), but not another (e.g., sexual)

Treatment: CBT Successful treatment for OCD symptoms must accomplish two things: Correction of maladaptive beliefs and appraisals Termination of avoidance and compulsive rituals preventing self-correction of maladaptive beliefs and extinction of anxiety Functional assessment Detailed information about antecedents and consequences of target behaviors and emotions Includes: Assessment of obsessional stimuli Assessment of avoidance and compulsive rituals Self-monitoring

Treatment: Exposure and Response Prevention (ERP) Confrontation with stimuli that provoke obsessional fear but that objectively pose a low risk of harm Situational or in vivo exposure Imaginal exposure Habituation Over time, the anxiety (and associated physiological responding) naturally subsides

Treatment: Exposure and Response Prevention (ERP) Format Few hours of assessment and treatment planning 15 (daily or twice-weekly) treatment sessions, 90 minutes each If intensive regimens are impractical, conducting the treatment sessions on a weekly basis works well for individuals with less severe OCD Self-supervised exposure homework practice assigned for completion between sessions Home-based self-supervised exposure exercises must last long enough for the anxiety to dissipate

Treatment: Exposure and Response Prevention (ERP) Therapist must provide cogent rationale for how ERP will be helpful in reducing OCD Exposure exercises Begin with moderately distressing situations, stimuli, and images, and progress to the most distressing situations Between each treatment session, patient continues exposure exercises for several hours in different environmental contexts without the therapist Exposure to the most anxiety-evoking stimuli is completed during the middle third of the treatment program During later sessions, therapist emphases generalization and of continued application of ERP procedures after treatment

Treatment: Exposure and Response Prevention (ERP) Foa and Kozak hypothesized that ERP produces its effects by correcting patients’ overestimates of danger that underlie obsessional anxiety Three requirements for successful outcome with ERP Physiological arousal and subjective fear are evoked during exposure. Within-session habituation Between-sessions habituation Inhibitory learning Enhance the recall of the new associations relative to the older, threat-based associations Combining exposure and response prevention is more effective than using either of its individual components

Treatment: Exposure and Response Prevention (ERP) Majority of OCD patients experience substantial short- and long-term benefits ~83% of patients are responders (at least 30% symptom reduction) at posttreatment 76% were responders at follow-up Superior to wait list, progressive muscle relaxation, anxiety management training, pill placebo, and pharmacotherapy with serotonergic medication  Effectiveness studies conducted in real world show that more than 80% of patients who complete treatment achieve clinically significant improvement

Treatment: Cognitive Therapy (CT) Rational and evidence-based challenging and correction of faulty and dysfunctional thoughts and beliefs that underlie emotional distress 16-session CT include: Learning to conceptualize obsessive intrusions as normal stimuli Identifying and challenging anxiety-provoking thoughts associated with obsessions with Socratic questioning Changing dysfunctional assumptions to nondistressing beliefs Behavioral experiments to test out the new beliefs Studies suggest relatively equivalent efficacy of CT and ERP CT reduces drop out from ERP

Treatment: Pharmacological On average, serotonin medications produce a 20% to 40% reduction in obsessions and compulsions Advantages Convenience Little effort on the patient’s part Limitations Relatively modest improvement and residual symptoms High rate of nonresponse (40% to 60%) Side effects (may be minimized by adjusting the dose) Once terminated, OCD symptoms typically return rapidly