Obsessive Compulsive Disorder

Features of OCD

• Obsessions– Recurrent and persistent thoughts; impulses; or images

of violence, contamination, and the like– intrusive and distressing– Individual tries to ignore, suppress, or neutralize

• Compulsions– Repetitive behaviors individual feels driven to perform– Ritualistic/need to follow a set of rules– Intended to prevent or reduce distress or some dreaded

event

DSM-IV Criteria

• See webpage

OCD Features• Data from the Epidemiological Catchment Area (ECA)

survey found a 6-month point prevalence of 1.6% and a lifetime prevalence of 2.5% in the general population

• Sex ratio is 1:1.1 (men to women)• Mean age of onset is 20.9 years (SD=9.6)

– Males is 19.5 years (SD = 9.2) – Females is 22.0 years (SD = 9.8)

• Most develop their illness before the age of 25 • Symptoms can be remembered as far back as the onset

of puberty.

Comorbidity

• Major depression is the most common comorbid disorder – 1/3 have concurrent MDD – 2/3 have a lifetime history of MDD

• Other Axis I disorders include panic disorder with agoraphobia, social phobia, generalized anxiety disorder, Tourette’s syndrome, trichotillomania, schizophrenia

• Axis I comorbid disorders can effect the severity and treatment of OCD.

Comorbidity

• Obsessive-compulsive personality disorder (OCPD) is an Axis II disorder. OCPD differs from OCD by the lack of true obsessions and compulsions. OCPD behaviors are ego-syntonic, whereas OCD is ego-dystonic

More features

• Types of Obsessions– Aggressive obsessions – Contamination obsessions – Sexual obsessions – Hoarding/saving obsessions – Religious obsessions – Symmetry/exactness – Somatic obsessions

• Types of compulsions– Cleaning/washing compulsions – Checking compulsions – Repeating rituals – Counting compulsions – Ordering/arranging – Hoarding/collecting – Mental rituals

• Most people experience intrusive thoughts throughout their life

• Individuals who develop OCD may react more negatively to their intrusions

Neurobiology/physiology

• No chronic hyperarousal• Over activation of the orbitofrontal cortex

(thought generation) and under activation of the caudate nuclei (thought suppression)

Psychosocial

• Learning– Animal models

• High stress or repeated frustration leads to increase in ritualistic-like behaviors

• Fixed action pattern- innate and adaptive behavioral sequences to specific stimuli

– Biological preparedness• Washing and checking may have once promoted

survival

• Cognitive deficits– Increased attention allocated to fear related

stimuli– Tend to encode negative stimuli more indepth

than neutral and positive stimuli, leading to better memory for negative stimuli

– Overattention to detailh

Cognitive theory of OCD

• Obsessional thoughts:– If obsessions occur frequently in normal populations,

why don’t most people suffer from OCD?– It’s not the thought itself that is disturbing, but rather

the interpretation of the thought. • Example: having an unacceptable sexual thought leads to

beliefs that the person is depraved, perverted, abnormal, evil, etc…., which leads to affective states such as anxiety and depression.

– The issue of responsibility is believed to be a core belief or cognitive distortion of people with OCD.

• Compulsive behaviors:– Neutralizing, either through compulsive

behaviors or mental strategies, is aimed at preventing terrible consequences, or averts the possibility of being responsible

– Seeking reassurance is another form of neutralizing, as it can serve to spread responsibility to others, thus diluting that of the individual

– Avoidance, though not an overt neutralizing behavior, is often used to prevent contact with particular stimuli

• Model:– Stimuli in the form of unpleasant intrusive

thoughts, of either external or internal origins are experienced

– The thought is ego-dystonic, that is, it is inconsistent with the individual’s belief system

– The NAT usually involves an element of blame, responsibility, or control, which interacts with the content of the intrusive thought

– Disturbances in mood and anxiety follow, which in turn lead to neutralizing behavior

– There are three main consequences of neutralizing behavior

• It results in reduced discomfort, which leads to the development of compulsive behavior as a tool for dealing with stress. This reinforcing behavior may result in a generalization of this strategy

• Neutralizing will be followed by non-punishment, and can lead to an effect on the perceived validity of the beliefs (NAT)

• The neutralizing behavior itself becomes a powerful and unavoidable triggering stimulus. The neutralizing behavior serves to reinforce the belief that something bad may happen

Treatment• CBT

– Exposure and response prevention was first used by Meyer in 1966

– The principle behind EX/RP is to expose the individual to the triggering stimuli (obsession) and block the neutralizing behavior

– As a result, the individual learns:• Anxiety is temporary • The feared catastrophic consequence never transpires• Their interpretation of the obsession weakens• Obsessional thoughts are harmless

– Imaginal exposure is also used when in-vivo is not possible

• Components of EX/RP– Group treatment is comprised of 2 individual

sessions and 12 group sessions– Individual treatment is also time limited and

comprises approximately 12 to 14 sessions– Psychoeducation– Pre-treatment assessment of severity of OCD

and depression– Hierarchy construction and explanation of

SUDS

• Treatment session:– Homework review– In-vivo exposure and response prevention,

including monitoring SUDS level– Review of exposure– Homework assigned and next session’s

exposure discussed– Termination session

• Following a time limited (12-weeks) CBT approach, symptom reduction is maintained

• Problems with CBT– 25% of people refuse to engage in CBT– CBT alone is ineffective when there is a severe

comorbid major depression, over valued ideation, tic disorder, schizoid personality disorder

– There is limited availability of therapists trained in CBT for OCD

Pharmacotherapy

• Serotonin (5-HT) neurotransmission abnormalities have been implicated in the pathophysiology and treatment

• Antidepressant medications of the Serotonin Reuptake Inhibitor classification and specific tryciclic antidepressants (Clomipramine) have been proven to be effective in the treatment of OCD

• Currently there are 6 SRIs that are FDA approved for the treatment of OCD– Clomipramine (Anafranil)– Fluoxetine (Prozac)– Fluvoxamine (Luvox)– Paroxetine (Paxil)– Sertraline (Zoloft)– Citalopran (Celexa)

• The goal of a SRI is to increase the level of 5-HT transmission within the synapse