Obsessive-Compulsive Disorder: Spectrum Theory and Issues in Obsessive-Compulsive Disorder: Spectrum

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Transcript of Obsessive-Compulsive Disorder: Spectrum Theory and Issues in Obsessive-Compulsive Disorder: Spectrum

  • Obsessive-Compulsive Disorder: Spectrum

    Theory and Issues in Measurement

  • © 2009, Gideon E. Anholt, Vrije Universiteit

    © Cover by Henry Darger, special thanks to Kiyoko Learner

    for permission to print

  • Obsessive-Compulsive Disorder: Spectrum

    Theory and Issues in Measurement


    ter verkrijging van

    de graad van Doctor aan de Vrije Universiteit

    op gezag van Rector Magnificus prof. dr. L.M. (Lex) Bouter,

    volgens besluit van het College voor Promoties

    te verdedigen op donderdag 21 Januarie 2010

    klokke 10:45


    Gideon Emanuel Anholt

    Geboren te Beer-Yaakov

    in 1971

  • Promotiecommissie

    Promotores: Prof. Dr. AJLM van Balkom,Vrije Universiteit

    Dr. P van Oppen,Vrije Universiteit

    Dr. DC Cath,Vrije Universiteit

    Leescommissie: Prof. H Hermesh,Tel-Aviv University Prof. Dr. ATF Beekman,Vrije Universiteit.

    Dr. HJGM van Megen, Psychiatrisch Ziekenhuis Meerkanten, Ermelo

    Prof. Dr. P Cuijpers, Vrije Universiteit Prof. Dr. MA Van Den Hout, Universiteit Utrecht

  • Contents

    Chapter 1 Introduction 6

    Chapter 2 Do patients with OCD and pathological gambling have similar dysfunctional cognitions? 36

    Chapter 3 Do obsessional beliefs discriminate OCD without tic patients from OCD with tic and Tourette’s syndrome patients? 55

    Chapter 4 Autism and ADHD symptoms in patients with OCD: Are they associated with specific OC symptom dimensions or OC symptom severity? 72

    Chapter 5 Sensitivity to change of the Obsessive Beliefs Questionnaire 102

    Chapter 6 Measuring Obsessive-Compulsive Symptoms: Padua Inventory-Revised vs. Yale-Brown Obsessive Compulsive Scale 115

    Chapter 7 The Yale-Brown Obsessive Compulsive scale: factor structure of a large sample 138

    Chapter 8 The process of change in treatment of obsessive compulsive disorder: Cognitive versus behavior therapy 166

    Chapter 9 Summary and Discussion 182

    References 202

    Nederlandse samenvatting 245

    Dankwoord 251

  • Chapter 1


    Chapter 1: Introduction

    History in a nutshell

    Stone (1997) provides a historical account of OCD. As early as

    the tenth century, the Persian Muslim medical doctor Najab ud din

    Unhammad described ruminative states of doubts. Unhammad called

    the condition Murrae Souda and felt it stems from excessive love of

    philosophy and law. Paracelus, a sixteenth century Swiss physician,

    spoke of obsessio as an imperious craving that is derived from one’s

    “animal nature”. H. F. Ellenburger (1970) reminds us that in the

    Catholic theology of Paracelsus’ day, alien, disturbing thoughts and

    tendencies were understood as coming literally from the outside: if this

    occurred while one was asleep, this so-called somnambulic

    phenomenon was called posessio; if it happened while one was awake

    or “lucid”, the term obsessio was used. Under the influence of the

    Protestant Reformation, writers no longer adhered to the belief in

    demonic influences. In the 1650s, the English writer Richard Flecknoe

    spoke of the obsessional person simply as one who, “when he begins to

    deliberate, never makes an end” (Adams, 1973). Among the earliest of

    the modern-sounding comments on the condition is that of the English

    alienist John Haslam, who commented on an obsessional patient:

  • Introduction


    “certain notions are forced into their minds, of which they see the folly

    and incongruity, and complain that they cannot prevent their intrusion”

    (Hunter & Macalpine, 1963). Haslam was aware that many obsessive

    patients harbored extreme religious scruples, but he hastened to add

    that religion itself was not to blame. Rather, certain persons of meager

    education or mental adjustment were prone to misuse and misconstrue

    their religious teachings, exaggerating various precepts into a state of

    religious preoccupation and pathological guilt. Esquirol, arguably the

    most prominent figure in nineteenth-century French psychiatry, wrote

    of them in his 1838 textbook under the heading of monomanie

    raisonnante, implying a state in which one’s rational mind, without

    veering off into delusion (or what we would call psychosis),

    nevertheless was abnormally fixated on certain worries and concerns

    (Stone, 1997). Toward the end of the nineteenth century, Sigmund

    Freud (1895) was to describe a clinical condition showing a mixture of

    phobia and anxiety-neurosis as Zwangsneurose (compulsion-neurosis)

    and noted in the following year that obsessions were a type of self-

    reproach with which one castigated oneself out of guilt over having

    enjoyed childhood sexual acts. Pierre Janet (1903) saw obsessions, tics,

    phobias, and neurasthenia as related phenomena, and described

    obsessional illness as manifesting itself sometimes even in children of

  • Chapter 1


    five or six. Nineteenth century theories about the etiology of OCD

    included autonomic nervous system dysfunction, psychological

    abnormalities concerning the will (Esquirol, 1838), the emotions

    (Morel, 1866), or the intellect (Westphal, 1872). It was Westphal, a

    German psychiatrist, who introduced the term Zwang (compulsion) in

    referring to the behavioral manifestations of OCD (Stone, 1997).

    Blaney and Millon (2008) suggest that the diagnosis of OCD

    has undergone relatively little changes in the different versions of the

    Diagnostic and Statistical Manual of Mental Disorders of the American

    Psychiatry Association (DSM). In the DSM-II, OCD was categorized

    under the classification obsessive-compulsive neurosis. In DSM-III,

    OCD was placed in the new subcategory of anxiety disorders termed

    anxiety states. The definition of OCD remained almost the same in

    DSM-III-R, although the removal of most diagnostic hierarchy rules in

    DSM III allowed OCD to be assigned more frequently (e.g. the

    diagnosis could be made even if it occurred during the course of other

    disorders such as major depression, provided that OCD symptoms were

    not better accounted for by another disorder).

    Current definition of OCD and differential diagnosis

    The DSM VI (1994) classifies OCD as an anxiety disorder,

    characterized by “obsessions or compulsions [that] cause marked

  • Introduction


    distress, are time consuming (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”. Obsessions are

    defined as “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”. Compulsions

    are defined as “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 rules that must be applied rigidly”. The

    behaviors or mental acts are designed to prevent or reduce discomfort

    and the likelihood of a dreaded event’s occurring, but the compulsions

    are either unrealistic or clearly excessive.

    The DSM IV definition specifies that obsessions are not simply

    excessive worries about real life problems, as in generalized anxiety

    disorder (GAD). The troublesome thoughts and ideas of patients with

    GAD may be intrusive and repetitive, but they are current in content,

    and therefore are not resisted, and there is no quality of a phobic

    reaction to these thoughts. In OCD, however, the thoughts are often

    bizarre and alien to the individual. The thoughts themselves may

    produce a phobic or panic reaction and are not often avoided or resisted

  • Chapter 1


    at all cost. Even when the ideas become overvalued and are not

    necessarily resisted, the content seems distinguishable from the usual

    life circumstances that are the focus of GAD. Most individuals with

    OCD recognize that their behavior is excessive or unreasonable,

    although this may not be true of young children who are unable to

    compare their behavior with that of others. Adults with OCD who have

    lost perspective on the rationality of their fears are considered to have

    “poor insight”, a subtype that was added in DSM IV.

    According to DSM IV, to distinguish obsessions from thought

    insertion or delusions characteristic of psychotic disorders, the person

    must recognize that the obsessions are the product of his or her own

    mind and not imposed from outside sources. Bizarreness (in the sense

    that the logic underneath obsessions and compulsi