Psych 2AP3 – Obsessive Compulsive and Related Disorders

Obsessive compulsive and related disorders in DSM -5

- Obsessive compulsive disorder (OCD)
- Body dysmorphic disorder
- Hoarding disorder
- Trichotillomania
- Excoriation disorder
- Substance/medication-induced obsessive compulsive and related disorder
- obsessive compulsive and related disorder due to another medical condition
- other specified obsessive compulsive and related disorder
- unspecified obsessive compulsive and related disorder

DSM-5 Criteria: OCD

Either obsessions or compulsions (O/C)
- obsessions: persistent, intrusive thoughts, urges or images that cause anxiety or distress
in most individuals, and that the individual tries to ignore, suppress or neutralize
- compulsions: repetitive behaviours or thoughts individual compelled to perform in
response to an obsession or according to rigid rules
o hand washing, organizing and ordering, checking, rechecking, counting,
repeating words silently
- O/C take more than 1 hour/day or cause clinically significant impairment
- Not due to a substance or another medical condition
- Disturbance not better explained by symptoms of another mental disorder

Obsessive-Compulsive Disorder
- 1% annual, 1.5% lifetime prevalence in U.S.
- Usually starts in adolescence, early adulthood ( can begin in childhood)
- For adult OCD, males = females
- For childhood OCD, Male:female ratio 3:1

Comorbidity in OCD
- Depression most common comorbid condition
o 10x more common in OCD than in population generally (Denys et al)
o 33% of OCD patients have MDD when evaluated (Tukeletal)
o 20% lifetime comorbidity with bipolar disorder ( faravellietal)

Etiology of OCD
Behavioral symptoms:
- Ritualistic & repetitive behaviours
o Compulsion in OCD
Cognitive Symptoms
- Intrusive thoughts
 o Obsessive in OCD
Classical conditioning of fear:
- OCD:
o Fear conditioned to environmental event
o Anxiety-reducing behaviours reinforced
- But..
o What about obsessions? Behaviourists ignore cognitions
o What about cases in which no prior conditioning can be identified

Cognitive-Behavioral Model (Rachman & Hodgson)

- Difficulty dismissing mildly obsessive thought
- Difficulty  anxiety, causing more difficulty
- Compulsive rituals relieve anxiety

Psychodynamic Perspective:
- Symptom has symbolic link to underlying conflict
- Conflict often localized to anal period due to concerns with order, cleanliness

Etiology of OCD: Neurochemical

- Reduced serotonin inhibitory activity in OCD?
- Clomipramine (tricyclic antidepressant) blocks serotonin reuptake, helps OCD
- But…
- Serotonin agonist increases OCD obsessions
- Reduced OCD coincides with lower blood, CSF level of serotonin metabolites
- Metabolites in CSF may not come from brain

Etiology of OCD: neurostructural

- Damage to basal ganglia in OCD?
o Caudate nucleus, putamen, substantia nigra, subthalmic nucleus
- OCD symptoms in Sydenhams chorea
- PET scans more metabolic activity in caudate in OCD than controls
- CAT scans  caudate 25% smaller in OCD than controls

Etiology of OCD: evolutionary

- Judith Rapaport: compulsions = left-over ‘programs’ from evolutionary past
o Washing= grooming
o Checking = predator search
- Arcal lick in dogs = animal model of OCD
o Responds to clomipramine
o Problem located in basal ganglia

Etiology of OCD: Genetic

- Taylor, Jang & Asmundson (2010)
 o Heritability of 50% for OCD Symptoms
 Obsessing, ordering, checking, hoarding, obsessing
o Remaining variance= non-shared environment
- Taylor & Jang (2011)
o Structural equation modelling supports belief causation model of OCD:
o Genetic environmental factors influence beliefs, symptoms: beliefs also influence
symptoms
o Environment = 47%, genetics =36%, beliefs =18% of variance in symptoms

Treatments for OCD: Pharmacological

- Antidepressants (higher doses for OCD than depression)
o Paxil (paroxetine) -SSRI
o Prozac (fluoxetine) – SSRI
o Zoloft (sertraline) – SSRI
o Anafranil (clomipramine) – tricyclic SNRI
- Antipsychotic medications:
o Only used as adjuncts to SSRI therapy; not effective on their own

Treatments: psychological
- Flooding (exposure)
- Response prevention
- Modeling
- Cognitive therapy

Comparing OCD Treatments

- Clomipramine works better than behavioural treatment for first 5-10 weeks
- Behaviour therapy longer lasting than drugs
- Behaviour therapy alone better than clomipramine alone
- Combination better than either behaviour therapy or clomipramine alone