This action might not be possible to undo. Are you sure you want to continue?
Introduction Many prestigious hotels do not have a 13th floor: after the 12th comes the 14th floor. I was uncomfortable writing a 13th chapter. This is an example of a “superstition”; many healthy individuals have vague superstitions, which they know are “silly”, but they prefer not to transgress. Superstitions and Obsessive-compulsive disorder (OCD) is not related, but superstitions and how we respond to them have something of the nature of OCD. That is, some ideas which lack a factual basis can make us a little uncomfortable if we don’t behave in a certain manner. This analogy is not perfect and should not be extended any further. Students trained predominantly on inpatient units may see little OCD. This disorder is usually managed on an outpatient basis. Patients are often reluctant 1) admit to OCD symptoms (which they know are “silly”), and 2) to enter hospitals (where they may catch germs, and are removed from the relative security of their homes and routines). Also, treatment can often be adequately and cost-effectively delivered in office practice. Nevertheless, OCD is not uncommon and is a cause of great suffering and disability for the patient and distress for the family.
Illustration. This is a newspaper report from 1997. It tells that a man who shot his 16 year old son and then himself, as a result of the distress caused by his son’s OCD. This is a most unusual occurrence, and other factors were probably involved. However, the story illustrates the frustration which can occur in families in which one member is suffering OCD.
edu. but the clinical manifestations are different. separate from the anxiety disorders. and found the following: Prevalence • overall 1. will itself. Last modified: March. 2010). 2013. “the concept of OCD-related conditions seems fluid” (Murphy et al. 2010). and autism. • 25% have a history of attempted suicide. The proposed OC spectrum disorders might include OCD. body dysmorphic disorder (Bjornsson et al. Marchand and McEnany. 0. and 34% have both obsessions and compulsions. The position of OCD in the two major diagnostic systems is different. OCPD is not a prominent risk factor for the development of OCD.1% • decreasing with age [1. hoarding (separated from OCD. perfection and control. Chapter 13. OCPD is not marked by the presence of obsessions or compulsions.2% at 65-74 yrs] • slightly higher in women. pathological gambling (Black et al. Of people with OCD • 55% have obsessions only. what is currently considered OCD. 2010). In the DSM-IV. It is likely that in the more distant future. There is an indication that OCD will be removed from the anxiety disorders in DSM-V (under discussion) and placed in an independent “OC spectrum disorders” category (Bartz & Hollander. OCD is listed under the heading of Anxiety Disorders.4% at 16-24 yrs. . Epidemiology The British National Psychiatric Morbidity Survey (Torres et al. However. The diagnostic criteria of these two distinct disorders are listed later in this chapter. • 62% have an additional mental disorder [particularly depression and anxiety] • 20% had alcohol dependence and 13% had drug dependence • frequent. 2006) looked at the general population with respect to OCD. but is characterised by a pervasive pattern of preoccupation with orderliness. http://eprints. often doing odd things such as touching objects unnecessarily. 2012). Download of Psychiatry. in the ICD-10.utas. and unable to complete their daily activities on time. OCD and Obsessive-compulsive personality disorder (OCPD) sound similar.Pridmore S. who experience unwelcome thoughts which they know are their own. certain eating disorders.au/287/ 2 The manifestations of OCD are peculiar: patients are usually intelligent people who are not deluded. marked social and occupational impairment. it stands as an entity. 2006). be split up into a spectrum of disorders with various aetiologies and treatments. 11% have compulsions only.
g.edu. A comparison of the symptoms of patients in Israel and England suggest a similar OCD phenotype (Zor et al..Pridmore S. The individual is unable to control them. The goal of compulsions is to prevent or reduce anxiety or distress which accompanies an obsession. impulses. The individual with obsessions about contamination may wash his/her hands until the skin is damaged.. . Both.g. spontaneous remission and progressive deterioration can occur. but fluctuating (exacerbation and remission).. Onset following stressful events. to hurt one’s child or shout an obscenity in church). aggressive or horrific impulses (e. The individual feels driven to perform the compulsion. or a stove switched on). These symptoms often cause self-doubt and a sense of shame. The most common obsessions are repeated thoughts about contamination (e. 41% had persistent OCD.g. Compulsions are repetitive behaviours (e. Approximately 50% were still receiving treatment.g. Considerable numbers had developed other psychiatric diagnoses. OCD is a chronic disorder with a guarded prognosis. repeating words silently). repeated doubts (e.g..au/287/ 3 Prognosis 142 children and adolescents with OCD were followed up after 9 years (Heyman et al. checking) or mental acts (e. meaning they are experienced as ‘alien’: not the kind of thoughts/events the individual would usually experience. thoughts. The individual is able to recognise that the obsessions/events are the product of his/her own mind and not imposed from outside (that is..g. Download of Psychiatry. 1999).g. a need to have things in a particular order (e. compulsive behaviour may not be connected in a realistic way with what it are designed to neutralize (e. http://eprints. such as pregnancy/childbirth is often reported. Last modified: March. there is frequently a 5-10 year delay before they come to psychiatric attention. intense distress when objects are out of order). worrying about having left a door unlocked. intrusive ideas.. becoming contaminated by shaking hands). counting. The highest estimate of spontaneous and enduring remission is 20% (Skoog & Skoog. Generally the course is chronic. praying. hand washing. 2010). 2010). Alternatively. Clinical features The onset of symptoms may be gradual or sudden..utas. touching the back of a particular chair to reduce the anxiety by the thought that one might swallow a knife). 2013. Thus. individuals distressed by unwanted blasphemous thoughts may find relief in counting or saying preyers. ordering. Chapter 13. Obsessions are persistent. Obsessions are “ego-dystonic”. or images that are experienced as inappropriate and that cause anxiety or distress. individuals are often reluctant to disclose such symptoms. Accordingly. they are not related the psychotic experience of thought insertion or control). and sexual imagery.
At some point during the course of the disorder . praying. hand washing. or images that are experienced. checking) or mental acts (e. or images are a product of his or her own mind (not imposed from without as in thought insertion) Compulsions as defined by 1&2 (1) repetitive behaviours (e. Last modified: March. 2010). however.Pridmore S. The obsessions or compulsions cause marked distress. are time consuming (take more than 1 hour per day).utas. but grave potential dangers poses unique adaptive challenges…OCD may result from the failure of mechanisms by which engagement in precautionary behavior normally terminates activation of the system” (Woody and Szechtman. or images are not simply excessive worries about real-life problems (3) the person attempts to ignore or suppress such thoughts. counting. • “an inflated sense of responsibility” (Smari et al. and as a consequence of attempts to resist the compulsion. Either obsessions or compulsions: Obsessions as defined by 1-4 (1) recurrent and persistent thoughts. B. • “The risk of improbable. or significantly interfere with the person’s normal routine.. or images.au/287/ 4 Anxiety may exist at several levels. a consequence of the loss of autonomy (distress at being unable to control own thoughts). at some time during the disturbance. repeating words silently) that the person feels driven to perform in response to an obsession. impulses. a consequence of the illogicality/”silliness” of a compulsion. impulses. Chapter 13. there is universal fear of mental illness. http://eprints.edu. Current theoretical/etiological studies suggest some interesting ways of understanding these experiences/symptoms: • “Individuals with OCD often report compulsions aimed at reducing feelings of something not being just right…not just right experiences (NJREs). impulses. these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.g. . impulses. or usual social activities or relationships. Download of Psychiatry. 2010) Diagnostic criteria: Obsessive-compulsive disorder (DSM-IV) A.. 2013. the person has recognized that the obsessions or compulsions are excessive or unreasonable C. or according to rules that must be applied rigidly (2) the behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. Anxiety may be an inherent part of the obsession/thought (“Throw the baby out of the window”).produce distress and urges to change something” (Coles et al. or to neutralize them with some other thought or action (4) the person recognizes that the obsessional thoughts. 2010).g. ordering. uncertain. In addition. occupational (or academic) functioning.. D. as intrusive and inappropriate and that cause marked anxiety (2) the thoughts.
edu. Personality disorders are highly prevalent among people with OCD. OCD may be co-morbid with the so-called OC spectrum disorders. It is hoped that treatments will be developed for each clinical sub-type. Not surprisingly. 2006) co-morbid with other psychiatric disorders (particularly depression and anxiety) and it may be difficult to determine which is the primary condition. Stewart et al. • Symmetry and ordering obsessions and compulsions. 2013. but other sub-types remain difficult to treat.utas. Washing and checking rituals are moderately responsive to the “exposure-response prevention” paradigms. It is possible for people with OCD to develop delusions. There has been nothing definitive to this point. The cluster C personality disorders (avoidant. histrionic and schizotypal also occur. but little progress has been made (Pauls. but borderline. 2006). 2005). 2013). A number of genome-wide linkage studies and 80 candidate gene studies have been published. Last modified: March. . Current evidence indicates that OCD and schizophrenia are separate entities. • Hoarding obsessions and compulsions. Download of Psychiatry. Other co-morbid conditions which occur not infrequently include eating disorders and Tourette’s syndrome. but the dopamine D4 receptor gene continues to receive attention (Taj et al. However. Canadian.au/287/ 5 Symptom-based sub-typing of OCD There have been various attempts to find subtypes of OCD on the basis of clinical presentation (Castle et al. twin studies have been inconsistent in demonstrating a higher concordance among dizygotic pairs. Genetics Family studies have consistently demonstrated more people with OCD among the first-degree relatives of patients with childhood onset OCD than among the firstdegree relatives of patients with later onset OCD (Starcevic. and checking compulsions. obsessive-compulsive) are the most common. • Contamination obsessions and cleaning compulsions. but only rarely does schizophrenia develop. such as hypochondriasis. sexual. 20% have alcohol dependence and 13% have drug dependence (Torres et al. Chapter 13. and religious obsessions. 2010. 2012). Comorbidity OCD is often (56-83%. It is assumed that those with early onset OCD have a stronger genetic contribution. dependent. twin studies support the heritability of obsessive-compulsive symptoms (van Grootheest et al. body dysmorphic disorder and trichotillomania. 2006). When a “dimensional approach” is employed. 2005). Factor analytic studies have described a four-factor model: • Aggressive.Pridmore S. http://eprints.
Magnetic resonance spectroscopy (MRS) has shown decreased N-acetylaspartate (NAA) in the frontal cortex. The VTA projects dopamine neurons. midbrain). 2012). particularly the medial prefrontal cortex (mPFC. 2012. 1992).Pridmore S. including the lateral orbitofrontal cortex was demonstrated in OCD patients and their clinically unaffected close relatives. implicated in the pathogenesis of obsessions. The specifics of this theory have not yet been substantiated. and enlargement of cerebrospinal fluid spaces around the frontal opercula. there was a loss of functional connectivity of the ventral striatal regions and the ventral tegmental area (VTA. 2009). 2012). Ruda et al (2010) found common as well as distinct neural substrates when comparing people with OCD and other anxiety disorders.edu. whereas abnormalities in the striatum are involved in the pathogenesis of compulsions and repetitive motor acts (Insel. Aoki et al. implicating the orbitofrontal cortex and surrounding areas. 2010) has shown OCD is associated with a shortening of the anterior-posterior dimension of the frontal lobes and basal ganglia. Download of Psychiatry.au/287/ 6 Neuroimaging The corticostriatal hypothesis of OCD postulates dysfunction in the cortco-striatothalamo-cortical circuits. The specific strength of connectivity between ventral caudate/nucleus accumbens and the anterior orbitofrontal cortex predicted the overall symptom severity (Harrison et al. 2008). Individuals with OCD had increased bilateral gray matter volumes in the lenticualte/caudate nuclei (compared to individuals with other anxiety disorders and healthy controls) The same group (Pujol. Immune factors OCD-like disorder is caused by childhood streptococcal infections and is termed PANDAS (Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). There has been little recent progress in this field (Dale and Brilot. .utas. Harrison et al 2013). Abnormally reduced activation of several cortical regions. 2013. 1994). http://eprints. A large percentage of children who have suffered this complication of rheumatic fever have antibodies directed against the caudate (Swedo et al. According to this model. in this study. and this finding may fit with the use of antipsychotics as second line treatment agents. Chapter 13. Also. This carries genetic as well as pathophysiological implications Significantly increased functional connectivity (DTI study) was demonstrated along a ventral cortico-striatal axis. disturbances in the pathways between the cortex and the thalamus are. but good neuroimaging progress has been made (Peng et al. Last modified: March. in a learning task and fMRI (Chamberlain et al. Both groups showed decreased bilateral gray matter volumes in the dorsomedial frontal/anterior cingulate gyri.
OCD has been conceived as dysfunction in an appraisal process (Husted et al. Decision making involves the dorsolateral. These interact with limbic structures which retain a memory of emotional rewards. 2010). Last modified: March. There is good empirical evidence of efficacy (Foa. 2010) Psychological therapy The behavioural therapy of OCD is composed of two parts: exposure and response prevention (ERP). Exposure consists of either self. unnoticed. functional imaging supports the theory. such a clenching a fist. in public settings. Functional imaging indicates that the neurocircuitry of OCD and disgust are similar. Response prevention: once confrontation has been achieved. Other current theories include “not just right experiences” (Coles et al. 2006). which may have an evolutionary function: encouraging the avoidance of contamination and disease. patients are asked to refrain from performing rituals.utas. Disgust is a basic human emotion. Another recent theory observes that indecision is a feature of OCD and proposes the disorder is a result of disturbed decision making strategies (Sachdev &Malhi. and the basal ganglia which is involved in behavioural execution.Pridmore S. at which point thought stopping can be performed. Common techniques include shouting “stop” or applying an aversive stimulus such as a sting on the wrist with an elastic band. and neuroimaging studies show the same changes in cerebral metabolism with successful behaviour therapy as with successful pharmacotherapy (Swartz et al. . Behavioural therapy is as effective as pharmacotherapy. The same structures appear to be involved in OCD. 1996). behaviour therapy can be difficult to apply if the patient does not have overt rituals (mental rituals and obsessional slowness). http://eprints. 2005). Download of Psychiatry.edu.au/287/ 7 Current theories OCD is yet to be fully understood.or therapist-guided confrontation with the feared object or circumstances. In thought stopping the patient (or initially the therapist) applies a stimulus which counteracts or interrupts the obsessional preoccupation. This would fit with OCD in which there are contamination concerns. 2005). 2013. One recent theory proposes a connection between disgust and OCD. 2010). However. Again. This approach is unacceptable to some patients and ineffective in others (Abramowitz et al. failure of the ability to terminate improbable but grave danger concerns (Woody and Szechtman. Behavioural therapy has an advantage over pharmacotherapy as the beneficial effects last longer after therapy has ceased. Eventually shouting or stinging can be replaced by less dramatic act. both are ineffective in 25% of patients with OCD. 2010) and “an inflated sense of responsibility” (Smari et al. However. Chapter 13. orbitofrontal and anterior cingulate cortices.
2013) and granisetron (a serotonin 3 receptor agonist. because the newer medications have less side-effects and are less dangerous in overdose. Seth et al. by helping patients improve their functioning and adjustment. Pharmacological therapy 70% of treatment naïve OCD patients will improve at least moderately with the use of SSRIs (Rasmussen et al. . 2013. 2012) may have places as add-on therapies in moderate to severe OCD. Askari et al. When response is unsatisfactory. All SSRIs appear to be effective. especially when complicated by depressive disorder. Download of Psychiatry. a tricyclic antidepressant. applied when the response to SSRIs has been unsatisfactory. 2010). 2012). Last modified: March. Treatment of OCD with SSRIs requires larger than the usual antidepressant dose to be sustained for up to 12 weeks for the full effect to become apparent (Kellner. Kellner. Ghaleiha et al. Deep brain stimulation (DBS) is considered a “promising option” (Kopell and Greenberg. http://eprints. Its use has declined in favour of the SSRIs. sustained and safe (Jung et al. 1993). 2008). 2010). 2012).utas. However.edu. clomipramine (which is a strong SRI) retains an important place as a second-line agent. Single reports suggests memantine (an NMDA antoagonist. 2006. has been reported to be effective. augmentation of an SSRI with an antipsychotic is recommended (Shekelle et al. Electroconvulsive therapy (ECT) and TMS ECT has a place in intractable. and indefinite treatment or very gradual withdrawal is recommended.au/287/ 8 Supportive psychotherapy has a place in managing OCD. Neurosurgery Cingulotomy. disconnecting the outflow of from the orbitofrontal cortex. Transcranial magnetic stimulation (TMS) may prove effective in the future (Gomes et al. 2007. Chapter 13. Relapse often occurs soon after cessation of medication. which was the first pharmacological agent to be effective in the management of OCD. severe cases.Pridmore S. Clomipramine is an older medication.
However. Hoarding.Pridmore S. Download of Psychiatry. and surfaces covered in inches of animal waste. occurring in 1842% of patients. 70 decomposing corpses. . anxiety or depression. Illustration. autism and mental retardation (Stein et al. Hoarding usually receives little clinical attention. however. and 2) those who hoard animals. eating disorders. http://eprints. “Chubbers Animal Rescue” (Caroline County. 1997). A PET study of OCD patients revealed that those with hoarding had significantly lower metabolism in the dorsal anterior cingulate than those without hoarding. dementia. 2013. worthless items even after they appear (to others) to have no value (Frost & Gross. This was taken to support the notion of a neurobiologically distinct sub-group (Saxena et al. indicates that hoarding is as responsive as other OCD symptoms to paroxetine (Saxena et al. Maryland).utas. It is the acquisition of. Illustration. The animal welfare organization found 300 cats being kept in a residential house.edu. Both forms may damage real-estate values and the public health. 2007). Last modified: March. but it has both mental health and public health aspects. saving and collecting” is one possible OCD subtype. and inability to discard. “hoarding. suggest Rufer et al (2006) why it is relatively treatment resistant to CBT. Recent work. it is most commonly found in OCD. Hoarding inside the home may leave people with almost no living space.au/287/ 9 Hoarding As mentioned. which may explain. 2004) Most OCD hoarders suffer low self-esteem. This behaviour appears to relieve anxiety. with material extending outside the house. Hoarding of animals. Chapter 13. The media frequently report on two types of hoarders: 1) those who clutter the outside of their houses with what appears to the neighbours to be unsightly rubbish. It may be a feature of schizophrenia. 1993).
and it is unlikely that punishment is the appropriate remedy. Illustration.utas. notebooks (unused) and keys (to unknown locks) were among the belongings carried in a bag by an itinerant man with chronic schizophrenia. . It was not possible to get upstairs. Last modified: March. Not all hoarding is a result of OCD. these watches may have had delusional value to the owner. various dials. As the hoarding progresses. Download of Psychiatry. these individuals are unable to care for their animals adequately. Animal hoarders generally have good will toward animals. The collecting of such items may not satisfy the definition of hoarding.Pridmore S. rings. Not shown in this picture is that the bag was stuffed full of old newspaper clippings and other “rubbish”. Chapter 13. as they may have monetary value (although.edu. The collection of timepieces is an accepted hobby. This picture is looking up a stair case. Hoarding is frequently associated with other psychopathology. 2013. Hoarding inside a house. none of watches were in working order). and not all hoarding reaches the extremes which makes it “newsworthy”. And further. http://eprints. These ten watches.au/287/ 10 Illustration. however. but are unable to give them up.
Last modified: March.au/287/ 11 Illustration. It was recommended by Morarji Desai (Prime Minister of India. Chapter 13. leaving at 16 years of age. http://eprints. To many in the west.utas. but was the result of a delusion. 5:15) and other religious documents. Speculation on the drinking of urine Drinking one’s own urine was advocated by Hippocrates and is mentioned in the Bible (Proverbs.edu. Ms K. this practice is followed by devotees in a number of countries. The author has met 2 patients who have had a strong desire (to which they yielded) to drink their own urine. . on the other hand. However. A well dressed young man with schizophrenia carried his faeces in a backpack. single female who lived at her parent’s home along with both parents and her only sibling. Case history. This may qualify as “hoarding”. He believed it contained “gold dust”. In neither case was the individual psychotic and in neither case was the thought egoalien. the thought of drinking one’s urine is unattractive. Ms K.Pridmore S. 2013. Download of Psychiatry. 1977-9). who was 17 years of age. 1 Ms D was a 20 year old unemployed. was very successful at school and was expecting to commence university next year. Ms D had not completed high school. The author wonders if drinking one’s own urine could have anything to do with hoarding.
She was able to leave her bed unmade and largely ignore the letter R. it was simply that the word made her intensely uncomfortable. Ms D did not have a particular fear of being raped herself. when stressful events appeared to have triggered minor set-backs. and could not leave her room until she was convinced there were none. rat. After almost three years she was relatively symptom free. “rape. “I’m just stupid”. tap. She was then distracted by the psychiatrist during supportive psychotherapy and discussions about medication were conducted. but she felt powerless to conduct her life in the manner she wished. Download of Psychiatry. Ms D was referred by her GP. Chapter 13. She was reluctant to talk and gave as the reason for referral as. Ms D was commenced on escitalopram which was gradually increased to 60 mg daily. and was found suitable receptionist office work. After six months she was referred back to her GP. He was unemployed and lived in a small house with a railway track at the back. i. topping. laughing”. hopping. before the interview commenced. Ms D was seen for a few sessions on two subsequent occasions in the following two years. She was shown the letter R and instructed to shout STOP and then switch her attention directly back to the task at hand. Last modified: March. She was placed in a work rehabilitation program. top. It was revealed that Ms D developed symmetry and ordering obsessions in school. She was able to tolerate this exposure and commenced resisting her compulsion at home. Folds and wrinkles were made in the sheet by the psychiatrist at the start of each interview. She was an intelligent individual with a good understanding of her problems. she was asked not to remove them. She was distressed by the letter “R” because it suggested “rape”. engaged to be married. At subsequent interviews Ms D’s attention was increasingly directed to the creased sheet by the psychiatrist. There was an examination couch with a covering sheet in the office. The compulsion to repeat words after seeing the letter R was treated with thought stopping. starting with the word “rape” and then moving off to totally unrelated words. Eventually Ms D was asked to place the creases in the sheet herself. When she saw the letter “R” on a signpost or advertisement she have the compulsion of saying various words to herself. She was unduly concerned about her bed covers having creases. rap. 2 Mr E was 55 years of age at the time of presentation.Pridmore S. employed in suitable position. At this stage she was much improved. Ms D was treated with combined ERP and an SSRI. Case history. He had been known to the psychiatrist 25 years earlier when he was . Within one week she was able to forcefully say STOP to herself.. She had secured only menial part-time employment. 2013.e.utas. and switch to a productive task. http://eprints. She was slow and unable to complete tasks and left school prematurely because of the pressure to complete assignments and the disgrace of poor achievement.au/287/ 12 Father owned a small business and mother worked part-time in an office. He lived with a very supportive second wife. She did not want responsible jobs because they were more difficult for her to complete. and about to move out of her parent’s home. Mother was described as being critical of her husband and Ms D.edu.
threatened to prosecute. Mr E did not give a full history. his condition improved and he was able to use the toilet. He stated that he would not have been able to come alone because leaving his home was anxiety provoking. He and been housebound for 8 years. Chapter 13. His hands were dirty and his nicotine stained nails were over 1 cm long and curling over the ends of his fingers. Over some weeks. but the stress of having another person in his flat was too much to contemplate. However. Mr F could afford a plumber. Initially he opened his bowels in his bed. Mr F was brought to the psychiatrist’s office by a male friend. 3 Mr F was a 54 year old divorced.edu. of opening his bowels at the side of the railway track behind his house.utas. 2013. He had two friends from the distant past and had maintained contact with them by telephone. This case illustrates the paradox of some OCD patients who are concerned about cleanliness. Rather than risk getting germs from his toilet he had been in the habit. Case history. a daughter living in a distant part of the country. A small dose of an atypical antipsychotic was added. At presentation Mr E was very unclean and odoriferous. . he was asked to use the toilet and interact with staff and other patients in the appropriate manner. Last modified: March. Download of Psychiatry. He stated that his medication was not correct because he developed light-headedness at 10:23 every morning. living alone in a Housing Department unit. Mrs E explained that the patient was concerned about the cleanliness of all toilets. including that in his own home. http://eprints. He was already taking a sufficient dose of and SSRI.Pridmore S. He was soon talking about his various hypochondriacal concerns. Mr F’s mother was alive but he stated he “hated” her and had not communicated with her in over a decade. Mrs E also stated that she was feeling overwhelmed by looking after her husband and doubted she would be able to remain with him. He reported that there had been a problem with his kitchen tap and he had not been able to turn it on for 7 years. He could not co-operate with behavioural therapy designed for his particular obsessions and compulsions. His marriage had ended 20 years previously and he one child.au/287/ 13 profoundly hypochondriacal and supported by his wife in his (mistaken) belief that he had various medical complaints which needed medical treatment. but began talking about the need for cleanliness and about the health dangers of toilets. Mrs E benefited from the rest and was happy to continue to support her husband at home. but who are themselves. which may have caused a worsening in his mental state. for some years. Mr E was admitted to hospital. It seems that their concerns and the anxiety are so great and preoccupying that they are unaware of the facts of their actual situation. Mr E had again been threatened with prosecution in the week before admission. Public officials had become aware of this practice and had. quite unclean. on a number of occasions. unemployed former clerk. He had made no new friends. however. When asked about his neglected personal hygiene he did not address the question.
However. he seemed unable to do so himself. concrete front drive (about the size of a room) to make sure that the post-man had not dropped a letter before putting it into the box.] . After 4 years Mr F telephoned his psychiatrist that he was again feeling depressed.edu. http://eprints. he would then open the door completely. and then began to come alone. [The psychiatrist was subsequently criticised by the Coroner for allowing the patient access to dangerous medication. Last modified: March. He said that none had helped in the slightest and he had experienced severe side effects with most of them. Mr F would then slowly open the door of his letter-box by one or two centimetres and peep in over the top to see if there were any letters. This searching of a blank flat surface could take half an hour. old magazines and broken electrical equipment. The opinion was formed that Mr F had been hoarding for years and that with the assistance of medication and supportive therapy he was now able to discard some of this material. there were symptoms of OCD.utas.Pridmore S. at which time the dose of the SSRI was increased. He had tried a vast range of medications over the years. He was already taking a sufficient dose of an effective antidepressant and as change was almost impossible. Mr F and his psychiatrist decided to wait for natural remission. Mr F assured his psychiatrist he was not suicidal. At the time of presentation he had given up all resistance. Chapter 13. The most difficult stage then followed: he would again have to search the concrete drive to make sure that no letters had dropped out when he had opened the door. He began bringing the psychiatrist up to 4 plastic shopping bags of old belongings. and would not accept hospitalization. Mr F was humiliated by his disorder. In the past he had resisted his compulsion. This occurred after some weeks. Mr F believed he may get some help from a particular SSRI and asked for it to be prescribed. Irrespective. His reluctance to leave the house appeared to be agoraphobia. Mr F then seemed to improve considerably. and he would not co-operate with ERP or any other form of behaviour therapy. This was agreed. He did not arrive at his next appointment and was found in his unit of an overdose. When he approached his letter-box he first searched the small. and this caused him distress. After one year Mr F described what may have been a depressive episode which lasted a month. Mr F was aware that the psychiatrist would probably discard these belongings. He would then close the box. He knew that he was behaving illogically. Download of Psychiatry. He knew their names. He appeared to enjoy his meetings with the psychiatrist and would always bring word and number puzzles. The process of checking his letter-box could take one hour or more. he did not object. Supportive psychotherapy was provided and attempts were made (unsuccessful) to encourage Mr F to participate in pleasurable activities.au/287/ 14 Mr F was rigid and uncompromising in his manner. 2013. He was accompanied back to the psychiatrist’s office on half a dozen occasions by his friend. His next appointment was one week away. He was disabled by an obsession that he may lose letters from his letter-box. He said he could not come to an earlier appointment. take out any letters and then feel around inside the box for some minutes to make sure there were no letters left. He said it was less anxiety provoking to comply with this compulsion than to resist.
or tidy the contents of your desk.g.g.com. order. Do you worry excessively about speaking or acting in a manner that you think is harmful. to make them symmetrical or “just right”? 13. particularly major depression. Do you wash your hands or shower more often or for longer periods of time than most other people? 7. but also anxiety disorders and hypochondriasis. turning off light switches or the stove)? 10. household items.g. Do you often have repetitive. unwanted thoughts that make you anxious. Warning! it is over 20 pages in length. sexually inappropriate.au/287/ 15 This case underscores the point mentioned above. Do you often repeat routing. Do you repeatedly count mundane items that do not really merit counting (e. Do you repeatedly ask others for reassurance that you have not done something “wrong”. Yale-Brown obsessive-compulsive scale (YBOCS) The YBOCS (Goodman et al. Do you repeatedly ruminate about unwanted thoughts in an effort to prove to yourself that you will not act in a manner that you think is harmful. old newspapers. sexually inappropriate. etc. bed sheets. and that you can’t get out of your mind no matter how hard you try? 2. Do you excessively clean objects (e.g. There are two parts. violent. or “harmful”? 12.. A printable version is freely available at www. http://eprints.. ceiling or floor tiles. Do you often repeat routine behaviours (e.g.utas. Do you unnecessarily straighten common household objects such as window blinds or rugs in an effort to make them symmetrical of “just right”? 14.g. violent. empty food containers)? . bookshelves. Download of Psychiatry. “Did I lock the door?”)? 11. that OCD is often comorbid with other psychiatric disorders. clothes. Do you repeatedly visually check to be sure you have properly performed a just-completed task (e. etc)? 8. your car interior. looking to be sure you have signed a check. 2013. towels. Do you unnecessarily arrange. However.edu. closet. Do you frequently ask others for reassurance that tasks have been properly completed (e. locking doors. cabinets. intrusive.cnsforum. Do you have great difficulty discarding things that have no practical value and that most other people would consider rubbish (e. lights. cars etc)? 15. 1989) is the most commonly used OCD scale. Do you recite prayers or certain phrases in an effort to rid yourself of unwanted thoughts or to ensure that nothing bad happens? 5.. or sacrilegious? 3. or sacrilegious? 4. “bad”. Chapter 13. immoral.g. The symptom check list has questions similar to the following: 1. clothing you have worn for years. Last modified: March.. 1) a symptom check list... daily activities to ensure that you did not harm someone (e. it is protected by copyright an only the flavour can be here presented. immoral.. and 2) a severity rating scale. driving back to a certain place in the road to reassure yourself that you did not run over a pedestrian)? 6.Pridmore S. reopening a mailbox to be sure you have deposited a letter)? 9.
money is viewed as something to be hoarded for future catastrophes (8) shows rigidity and stubbornness . Chapter 13.edu. and efficiency. is unable to complete a project because his or her own overly strict standards are not met) (3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) (4) is overconscientious.au/287/ 16 The severity rating scale is similar to the following: Item 1 Time spent on obsessions 2 Interference from obsessions 3 Distress from obsessions 4 Resistance to obsessions 5 Control over obsessions Range 0 h/day 0 None 0 None 0-1 h/day 1 Mild 1-3 h/day 3-8 h/day >8 h/day 0 Always resist 0 Complete control 0 2 3 4 Definite but Substantial Incapacitating manageable impairment 1 2 3 4 Little Moderate Severe Near constant.utas. and inflexible about matters of morality. organization. 2013. the diagnostic criteria of OCPD are listed: A pervasive pattern of preoccupation with orderliness. Download of Psychiatry. openness. OCD and OCPD sound similar. scrupulous. as indicated by 4 or more of the following: (1) is preoccupied with details.. lists. or values (not accounted for by cultural or religions identification) (5) is unable to discard worn-out or worthless objects even when they have no sentimental value (6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things (7) adopts a miserly spending style toward both self and others. but refer to distinct disorders.Pridmore S. For the sake of completeness [OCD symptom?]. but disabling manageable 1 2 3 4 Much Some Often Completely resistance resistance yields yields 1 2 3 4 Much Some Little No control control control control 1 2 3 4 Obsession subtotal (add items 1-5) _________ Diagnostic criteria: Obsessive-compulsive personality disorder (DSM-IV) As mentioned. perfectionism. beginning by early adulthood and present in a variety of contexts. or schedules to the extent that the major point of the activity is lost (2) shows perfectionism that interferes with task completion (e. at the expense of flexibility.g. order. ethics. Last modified: March. http://eprints. rules. and mental and interpersonal control.
Body dysmorphic disorder. use and reliability. Steketee G.Pridmore S. Journal of Neuropsychiatry and Clinical Neuroscience 2012. et al. Chamberlain S. 11:1470-1781. Autoimmune basal ganglia disorders. Gomes P. 73:321-328. Graisetron adjunct to fluvoxamine for moderate to severe obsessive-compulsive disorder. Harrison B. Suckling J et al. CNS Drugs 2012. Archives of General Psychiatry 1989. Heyman M. Obsessive-compulsive spectrum disorders: a defensible construct? Australian and New Zealand Journal of Psychiatry 2006. 43: 153-167. 66: 1189-1200. Reduction of N-acetylaspartate in the medial prefrontal cortex correlated with symptom severity in OCD: meta-analyses. Brilot F. Long-term outcomes of obsessive-compulsive disorder: follow-up of 142 children and adolescents. Didie E. et al. Menzies L. Cognitive Behaviour Therapy 2005. Orbitofrontal dysfunction in patients with obsessive-compulsive disorder and their unaffected relatives. Chapter 13. 2013. A randomized. Canadian Psychiatric Association. Allam N. 12: 175-185. Entezari N. Soriano-Mas C. 30: 338-352 Bjornsson A. 46:1006-1011. The hoarding of possessions. Dialogues in Clinical Neurosciences 2010. et al. Gross R. McKay D. Cognitive behavioral therapy of obsessive-compulsive disorder. Ghaleiha A. Canadian Journal of Psychiatry 2006. Phillips K. et al. Biological Psychiatry 2013. 12: 221-232. 34:140-147.. Brain corticostriatal systems and the major clinical symptom dimensions of obsessive-compulsive disorder. et al. The Yale-Brown Obsessive Compulsive Scale 1: Development. Shaw M.au/287/ 17 References Abramowitz J. Rasmussen S. Not just right experiences and obsessivecompulsive features: experimental and self-monitoring perspectives. Ortiz M. 24:437-443. in press.utas. Blum N. Download of Psychiatry. Aoki A. Science 2008. Last modified: March. Pathological gambling and compulsive buying: do they fall within an obsessive-compulsive spectrum? Dialogues in Clinical Neuroscience 2010. Memantine add-on in moderate to severe obsessive-compulsive disorder. Suwa H. 51 (Suppl 2): 1S-90S. Pujol J. Bartz J. Cardoner N.edu. British Journal of Psychiatry 2010. Pride L. double-blind trial of repetitive transcranial magnetic stimulation in obsessive-compulsive disorder. Behavior Research and Therapy 2005. Dialogues in Clinical Neuroscience 2010. Goodman W. http://eprints. et al. Journal of Child Neurology 2012. 31:35-46. Coles M. Black D. Askari N. Castle D. 321: 421-422. Archives of General Psychiatry 2009. Altered corticostriatal functional connectivity in obsessive-compulsive disorder. Journal of Psychiatric Research 2013. Is obsessive-compulsive disorder an anxiety disorder? Progress in Neuropsychopharmacology and Biological Psychiatry 2006. 197: 128-134. Dale R. Heimberg R. Potentials and limitations of cognitive treatments for obsessive-compulsive disorder. Management of Anxiety Disorders. Frost R. Hampshire A. Hilton K. Modabbernia A. Tranl Psychiatry 2012. Brasil-Neto J. Sanati M. Aoki Y. Behaviour Research and Therapy 1993. Perez M. Pujol J. et al. Moin M. 12: 199-207. in press. Taylor S. Phillips K. 40:114-120. . Harrison B. 47:175180. Clinical Practice Guidelines. Foa E. Hollander E. Frost R.
Current issues in the pharmacological management of obsessive-compulsive disorder.au/287/ 18 Hollander E. Wheaton M. Miao G. Greenberg B. Dialogues in Clinical Neuroscience 2010. Neuroscience Biobeihavioral Reviews 2008. Sheth S. Smith E. Marcel Dekker Inc.edu. Baxter L. Australian and New Zealand Journal of Psychiatry 2005. Chang J. Maglione M. Brain structural abnormalities in obsessive-compulsive disorder: converging evidence from white and grey matter. Husted D. Bossa M et al. Mataix-Cols D. Surguladaze S. Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behaviour therapy outcome. Journal of Psychiatric Research 2007. 54:4s-9s. Bagley S Suttorp M et al. Limbic surgery for treatment-refactory obsessive-compulsive disorder. Issues Ment Health Nurs 2012. Kopell B. Goodman W. Anatomy and physiology of the basal ganglia: implications for DBS in psychiatry. Obsessive-compulsive behaviour: a disorder of decision-making.: 07-EHC003-EF. Archives of General Psychiatry 2010. Zohrabi N. Chung S. or a newly listed disorder. 67: 701-711. Greenberg B. Tangherlini F. Dialogues in Clinical Neuroscience 2010. Brody A. Baxter L. 113: 440-446. Pujol J. Bilateral anterior cingulotomy for refractory obsessive-compulsive disorder: long-term follow-up results. . The genetics of obsessive-compulsive disorder: a review. 32: 408-422. Moritz F. 41: 481-487. Sachdev P. Journal of Neurosurgery 2012. Maidment K. Chan R. Last modified: March. Rasmussen S. Chapter 13. Maidment K. Radua J. comparison of voxel-based morphometry studies in obsessive-compulsive disorder vs other anxiety disorders. Baker S. Progress in Neuropsychopharmacology and Biological Psychiatry 2006. Report No. New York. Eisen J. Dialogues in Clinical Neuroscience 2010. 49:739-744. 161:1038-1048. Stein D. Efficacy and comparativeness of off-label use of atypical antipsychotics. 56:584-590. et al. Stereotactic and Functional Neurosurgery 2006. Neale J. Saxena S. Obsessive-Compulsive Disorders. Chang J.Pridmore S.utas. Cheung E. Download of Psychiatry. Jing J. in press. Saxena S. Brody A. 12: 149-163. Asian Journal of Psychiatry 2012. van den Heuvel O. 84:184-189. Shekelle P. Toward a neuroanatomy of obsessive-compulsive disorder. Archives of General Psychiatry 1992. Rufer M. Skoog I. Kim C. Lui S. Gispert J. 2013. Variations in the shape of the frontobasal brain region in obsessive-compulsive disorder. Katz E. 1997. Hand K. Jung H. 5:290-296.. Paroxetine treatment of compulsive hoarding. Malhi G. 39:757-763. The neurocircuitry of obsessive-compulsive disorder and disgust. Skoog G. Park Y. Acta Psychaitrica Scandinavica 2006. Obsessive-compulsive disorder and its related disorders: a reappraisal of obsessive-compulsive spectrum concepts. 33:591-597. Murphy D. Cerebral glucose metabolism in obsessive-compulsive hoarding. Drug treatment of obsessive-compulsive disorder. Pauls D. Insel T. 30: 389-399. Kellner M. 12: 187-197. Peng Z. Marchand S. Timpano K. 12: 131-148. Journal of Clinical Psychiatry 1993. American Journal of Psychiatry 2004. Jin Z. Human Brain Mapping 2010. http://eprints. A 40 year follow-up of patients with obsessive-compulsive disorder. Phillips McEnany G. Meta-analytical. Shapira N. in press. Pato M. Miguel E. Soriano-Mas C. AHRQ Comparative Effectiveness Reviews 2007. Archives of General Psychiatry 1999. Hoarding’s place in the DSM-5: another symptom.
Seedat S. 38: 535-544. Marais E. Beekman A. Purushottam M. Leonard H. and held-seeking in the British National Psychiatric Morbidity Survey of 2000. Hoarding symptoms in patients on a geriatric psychiatry inpatient unit. Boomsma D. impact. Genome-wide association study of obsessive-compulsive disorder. van Grootheest D. Download of Psychiatry.utas. Systemic changes in cerebral glucose metabolic rate after successful behaviour modification treatment of OCD. Baxter L. Hermesh H. responsibility attitudes and obsessive-compulsive symptoms: factor structure and test of mediational model. Molecular Psychiatry 2012. Chapter 13. Stein D. Adaptation to potential threat: the evolution. Are there between-country differences in motor behavior of obsessive-compulsive disorder patients? CNS spectrums 2010. Starcevic V. Bebbington P. neurobiology. Taj M.Pridmore S. American Journal of Psychiatry 2006. Anxiety Disorders in Adults. et al. 41:18-23. Cath D. Torres A. 87:11381140. 93:323-326. Archives of General Psychiatry 1996.edu. Zor R. Neuroscience Biobehav Review 2010. . Kiessling L. South African Medical Journal 1997. comorbidity. Behavioral and Cognitive Psychotherapy 2010. Pathways to inflated responsibility beliefs. http://eprints. in press. Woody E. 163:1978-1985. et al. Szechtman H. Prince M. Twin studies on obsessivecompulsive disorder: a review. et al. and psychopathology of security motivation system. Fineberg N. 2013. Speculations on anti neuronal antibody-mediated neuropsychiatric disorders of childhood. Last modified: March. Swartz J. Stoessel P.au/287/ 19 Smari J. 2005. 15: 445-455. 8:450-458. et al. 53:109-113. Swedo S. Agha H. Pediatrics 1994. in press. Obsessive-compulsive disorder: prevalence. Stewart S. Asigo G. Laszio B. DRD4 gene and obsessive compulsive disorder: do symptom dimensions have specific genetic correlates? Prog Neurophsychopharmacol Biol Psychiatry 2013. Viswanath B. Oxford University Press: Oxford. Potocnik F. Eilam D. Twin Research and Human Genetics 2005. Nelson S.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.