Obsessive Compulsive

and Related Disorders

  In DSM-IV-TR, Obsessive-Compulsive and Related Disorders and
Trauma-Related Disorders were included with Anxiety Disorders
DSM-IV-TR vs.  Some common symptoms, risk factors, and treatments with anxiety
disorders
DSM-5  DSM-5 creates new chapters for Obsessive-Compulsive and
Related Disorders and Trauma-Related Disorders
Table 1: Diagnoses of Obsessive-Compulsive and Related
Disorders

© 2015 John Wiley & Sons, Inc. All rights reserved.

  Obsessive-Compulsive Disorder (OCD) is defined as excessive or
unreasonable obsessions or compulsions which cause marked
distress in the individual experiencing them (American Psychiatric
Association, 2013).
 Obsessions: Repetitive, intrusive thoughts, ideas or impulses that
Obsessive - are recognized as a foreign or repugnant to the individual. They
are involuntary, seemingly uncontrollable thoughts, images or
Compulsive impulses that occur over and over again in the mind.

Disorder (OCD)  Compulsions: Repetitive behaviors or mental acts that are

attempts to prevent or reduce distress as a response to an
obsession but which are clearly excessive and usually not
realistically connected to the event they should prevent.
 Compulsive gambling, eating, etc. NOT considered compulsions,
because they are pleasurable
 Compulsions only server reduce anxiety, not give pleasure
 Obsessions often have themes to them, such as:
 Fear of contamination or dirt
 Needing things orderly and symmetrical
 Aggressive or horrific thoughts about harming yourself or others
 Unwanted thoughts, including aggression, or sexual or religious
subjects

Examples of obsession signs and symptoms include:

Themes and
 Fear of being contaminated by touching objects others have touched
Examples of  Doubts that you've locked the door or turned off the stove
Obsessions  Intense stress when objects aren't orderly or facing a certain way
 Images of hurting yourself or someone else that are unwanted and
make you uncomfortable
 Thoughts about shouting obscenities or acting inappropriately that are
unwanted and make you uncomfortable
 Avoidance of situations that can trigger obsessions, such as shaking
hands
 Distress about unpleasant sexual images repeating in your mind
 Compulsions typically have themes, such as:
 Washing and cleaning
 Checking
 Counting
 Orderliness
 Following a strict routine
Themes and  Demanding reassurances
Examples of Examples of compulsion signs and symptoms include:
Compulsions • Hand-washing until your skin becomes raw
• Checking doors repeatedly to make sure they're locked
• Checking the stove repeatedly to make sure it's off
• Counting in certain patterns
• Silently repeating a prayer, word or phrase
• Arranging your canned goods to face the same way
  Obsessional thoughts found in 90% of
people
 It is well replicated that 80%+ of people have
intrusive thoughts
 There thoughts are similar in content and form
OCD and to OCD patients
“Normal”  Compulsions
Experience  Many people have compulsions such as
stereotyped or superstitious behaviors
 66% of normal people report some form of
checking behavior
 Is OCD qualitatively distinct?
 OCD
A man who washes his hands
100 times a day until they are
red and raw
A women who locks and relocks
her door before going to work
every day – for half an hour
OCD
Experiences A college student who must tap
on the door frame of every
classroom 14 times before
entering
A man who stores 19 years of
newspapers “just in case” – with
no system for filling or retrieving
https://www.youtube.com/watch?v=pKq4zzpya7k
Not OCD
A woman who unfailingly
washer her hands before
every meal
A woman who double-
checks that her apartment
door and windows are
locked each night before
she goes to bed.
A musician who practices a
difficult passage over and
over again until its perfect
A woman who dedicates all
her spare time and money
to building her record
collection
  Develops either before age 10 or during late
adolescence/early adulthood.
 Two-thirds of cases have their onset earlier than age 25,
and only 15% occur after age 35. About one-third of cases
have onset in childhood or early adolescence. Males tend
to have earlier onset and undergo a more malignant
course.
 More common in women
 1.5 times more common than in men
OCD Facts  Males:, high prevalence of checking
and Figures  Females:, high prevalence of washing
 OCD often chronic
 Pattern of symptoms is similar across cultures
 Prevalence: Current estimates are that approximately 1 in
40 adults in the U.S. (about 2.3% of the population) and 1
in 100 children have this condition.
 Patients with obsessive-compulsive disorder (OCD) often
have comorbid psychiatric disorders, such as depression,
bipolar disorder, psychotic disorders, and eating disorders,
DSM-IV
Disorder Class: Anxiety Disorders
Either obsessions or compulsions:
Obsessions as defined by (1),(2), (3) and (4):
1. Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as
intrusive and inappropriate and that cause marked anxiety or distress.
2. The thoughts, impulses, or images are not simply excessive worries about real-life problems.
3. The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them with some other
thought or action.
4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed DROPPED
from without as with thought insertion).
Compulsions as defined by (1) and (2):
1. 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 the rules that must be applied rigidly.
2. 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.
At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or
unreasonable.
The obsessions and compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly
interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with
food in the presence of an eating disorder, hair pulling in the presence of trichotillomania; concern with appearance in the
presence of body dysmorphic disorder: preoccupation with drugs in the presence of a substance use disorder: preoccupation with
having a serious illness in the presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a
paraphilia: or guilty ruminations in the presence or major depressive disorder).
The disturbance is not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a general
medical condition.
Specify if:
With poor insight: If, for most of the time during the current episode, the person does not recognize that the obsessions and
compulsions are excessive or unreasonable.
DSM-5
Disorder Class: Obsessive-Compulsive and Related Disorders
Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges or images that are experienced, at some time during the disturbance, as intrusive,
unwanted, and that in most individuals cause marked anxiety or distress.
DROPPED
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some thought or
action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. SAME
2. SAME
DROPPED
The obsessions or compulsions are time consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized
anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possession,
as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking]
disorder); stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation
with substances or gambling, as in substance-related and addictive disorders; sexual urges or fantasies, as in paraphilic disorders;
impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought
insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of
behavior, as in autism spectrum disorder).
SAME
Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive beliefs are definitely or probably not true or that
they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
Specify if:
Tic related: The individual has a current or past history of a tic disorder.
  This rating scale is designed to rate the severity and
type of symptoms in patients with obsessive
compulsive disorder (OCD).
 In general, the items depend on the patient's report;
however, the final rating is based on the clinical
YALE-BROWN judgment of the interviewer. Rate the characteristics of
each item during the prior week up until and including
OBSESSIVE the time of the interview.
COMPULSIVE  Intended for use as a semi-structured interview. The
interviewer should assess the items in the listed order
SCALE (Y- and use the questions provided. However, the
BOCS) interviewer is free to ask additional questions for
purposes of clarification.
 Child Version: CY-BOCS
 This scale is designed to rate the severity of obsessive
and compulsive symptoms in children and
adolescents, ages 6 to 17 years.
  A 35-year-old man loses his beloved uncle suddenly to an accident. Two years
later, he developed an obsession that harm would result to loved ones if he did
not move or walk in a special way. He knew the idea was strange and silly, but
he could not stop thinking about it. The man developed elaborate compulsions
that involved stepping in a just right way. The process became time consuming
and cumbersome. Going out in public by himself or with family became an
ordeal

 The William Hammond case was one of the earliest compulsive hand washing
cases in history. Hammond was a physician and neurologist who saw a female
patient who was completely obsessed and worried about being contaminated.
After some time, the patient’s OCD got so bad that she couldn’t come into
contact with any surface without having to wash her hands. Imagine how she
Case Examples would have functioned at work. Her mother stated the girl washed her hands
more than 200 times every day, and keep in mind, this was in the nineteenth
century when people were not nearly as concerned about germs as they are
today. The girl even considered other people sources of contamination.

 Great inventor Nikola Tesla, who created the foundations for X-Rays, radar, and
radio, had a very obsessive mind. Although he had a fantastic memory, he
suffered with chronic OCD. Not only did Tesla have a serious germ phobia, but
he really liked the number three, so he would often walk around the block three
times before entering a building. Tesla also was scared of round objects,
especially women’s jewelry, and refused to shake hands with people or touch
anyone’s hair. Not only did he count his jaw movements during dinnertime,
which guests found disruptive, but he would always require eighteen napkins
and would never eat with only a woman present.
  Mowrer’s two-stage theory of fear and its maintenance.
 Individuals first learn anxiety or discomfort from associations
between those feelings and an originally neutral stimulus .
Through conditioning, the originally neutral stimulus becomes a
conditioned anxiety stimulus to which the person goes on to
develop avoidance and escape responses.
 These responses, through their effectiveness at reducing the
original anxiety, are strengthened and maintained over time. In
Behavioural other words, a neutral stimulus becomes a conditioned fear
stimulus via classical conditioning processes, and this fear is
Explanations then maintained via negative reinforcement.

 Limitation: This cycle of conditioning and responses provides

ample explanation for the formation of ritualistic behaviors
associated with the compulsion aspect of OCD. However, it was
insufficient to fully account for all aspects of the disorder,
particularly the nature of obsessions, and this conceptual
inefficiency
 1. The Effects of Attempting to Suppress Obsessive Thoughts

 When normal people attempt to suppress unwanted thoughts they

may sometimes experience a paradoxical increase in those thoughts
later
 For example, when people with OCD were asked to record intrusive
thoughts in a diary, both on days when they were told to try to
suppress those thoughts and on days without instructions to
suppress, they reported approximately twice as many intrusive
thoughts on the days when they were attempting to suppress them
Cognitive- (Salkovskis & Kirk, 1997)

Behavioural 2. Appraisals of Responsibility for Intrusive Thoughts

Explanations  Distinguish between obsessive or intrusive thoughts

 negative automatic thoughts and catastrophic appraisals that people
have about experiencing such thoughts.
 People with OCD often seem to have an inflated sense of
responsibility. In turn, in some vulnerable people, this inflated sense
of responsibility can be associated with beliefs that simply having a
thought about doing something is morally equivalent to actually
having done it, or that thinking about committing a sin increases the
chances of actually doing so. This is known as thought–action fusion
 Exposure & Response Prevention

1. develop a hierarchy of upsetting stimuli and rate them on a 0 to 10 scale

according to their capacity to evoke anxiety, distress, or disgust.
2. expose themselves repeatedly (either in guided fantasy or directly) to stimuli
that will provoke their obsession (such as, for someone with compulsive
Cognitive- washing rituals, touching the bottom of their shoe or a toilet seat in a public
bathroom).
Behavioural 3. Following each exposure, they are asked to not engage in the rituals that they
ordinarily would engage in to reduce the anxiety or distress provoked by their
Treatments obsession
4. Preventing the rituals is essential so that they can see that if they allow
enough time to pass, the anxiety created by the obsession will dissipate
naturally down to at least 40 to 50 on the 100-point scale, even if this takes
several hours.

https://www.youtube.com/watch?v=eatUEP8wD6Y
 1. Body Dysmorphic Disorder :
• People with BDD are obsessed with some perceived or imagined flaw or flaws in
their appearance to the point they firmly believe they are disfigured or ugly
• Although it is not considered necessary for the diagnosis, most people with
BDD have compulsive checking behaviors (such as checking their appearance in
the mirror excessively or hiding or repairing a perceived flaw).
• In severe cases, they may become so isolated that they lock themselves up in
their houses and never go out, even to work

Other Related 2. Trichotillomania:

• Trichotillomania (also known as compulsive hair pulling) has as its primary
Disorders symptom the urge to pull out one’s hair from anywhere on the body (most often
the scalp, eyebrows, or arms), resulting in noticeable hair loss.
https://www.youtube.com/watch?v=KCJjDvE-ywQ
3. Hoarding Disorder
 Mr. D is male who was admitted to the adolescent inpatient unit following
an automobile collision. He has a history of major depression, school
absences, and declining grades. His depression began at the onset of
puberty. He reported that his automobile crash was not intentional, but
that he was looking at his nose and acne in the rear-view mirror when he
lost control of his car on the freeway. No one else was with him; he has
no friends and prefers to stay at home with his parents because he feels
that his nose is hideous. He has never dated, avoids school functions,
does not participate in sports, and believes that others laugh at the size
of his nose. He is six feet tall, lanky, and thin. He has a full head of curly
brown hair, a large nose, severe acne, and a pleasant demeanor.
Cases While on the adolescent psychiatric unit, he spent a lot of time in the
bathroom picking at his face, looking at his nose in reflective surfaces,
and trying to manipulate his way out of group activities. He often had his
hand over his nose and insisted on wearing a large hat and glasses on
field trips. In spite of these behaviors, he was well-liked by others on the
unit. Dermatology was consulted and his acne improved. Later that year,
he had a rhinoplasty and his outlook was more positive. Two years later,
he was readmitted following a suicide attempt after a breakup with his
first girlfriend. At the second admission, he became convinced that he
would be more appealing to women if he had cosmetic dentistry and
began a bodybuilding regimen to achieve more definition of the muscles
in his arms. At a five-year follow-up, he had quit high school and was
living at home with his parents, not working, and on psychiatric disability.