Obsessive-Compulsive Disorder

Thien-An Le

Obsessive-Compulsive Disorder 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

All characterized by preoccupations and by repetitive behaviors or mental acts in response to the preoccupations.

Obsessive-Compulsive Disorder and Related Disorders

A) Presence of obsessions, compulsions, or both:◦ Obsessions:

Recurrent and persistent thoughts, urges, or images that are experienced, as intrusive and unwanted, and cause marked anxiety or distress.

The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action

Not pleasurable or voluntary

◦ Compulsions: Repetitive behaviors or mental acts that the individual feels

driven to perform in response to an obsession or according to rules that must be applied rigidly.

The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation Not connected in a realistic way with what they are designed to

neutralize or prevent, or are clearly excessive.

DSM-V Review: Diagnostic Criteria

B) The obsessions or compulsions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C) The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance or another medical condition.

D) Not better explained by the symptoms of another mental disorder. 

Specify if:◦ With good or fair insight◦ With poor insight◦ With absent insight/delusional beliefs◦ Tic-related

DSM-V Review: Diagnostic Criteria

DSM-V: Diagnostic Criteria Examples

Obsessions Compulsions Persistent thoughts

of contamination Ruminations Images of violent or

horrific scenes Urges to stab

someone

Ritualizing Washing Checking Counting Repeating words

silently Hoarding

Including:◦ Cleaning

contamination obsessions and cleaning compulsions◦ Symmetry

Symmetry obsessions and repeating, ordering, and counting compulsions

◦ Forbidden or taboo thoughts Aggressive, sexual, or religious obsessions and related

compulsions and ◦ Harm

Fears of harm to oneself or others and checking compulsions

Occur across different cultures

Relatively consistent over time in adults with the disorder

May be associated with different neural substrates

DSM-V Review: Diagnostic CriteriaThemes

Culture-Related Diagnostic Issues:◦ OCD occurs across the world. ◦ Similarity across cultures in the gender distribution, age at onset, and

comorbidity (Lewis-Fernández et al. 2010). ◦ Similar symptom structure involving cleaning, symmetry, hoarding,

taboo thoughts, or fear of harm (Bloch et al. 2008). ◦ Regional variation in symptom expression◦ Cultural factors may shape the content of obsessions and compulsions.

Gender-Related Diagnostic Issues:◦ Males have an earlier age at onset & are more likely to have comorbid

tic disorders. ◦ Females more likely to have symptoms in the cleaning dimension ◦ Males more likely to have symptoms in the forbidden thoughts and

symmetry dimensions. ◦ Onset or exacerbation of OCD & symptoms that can interfere with the

mother-infant relationship

DSM-V Review: Diagnostic Issues

Cleaning Symmetry Taboo thoughts Harming self or others Hoarding

Increased suicide risks Panic attacks Agoraphobia Distress Avoid:

◦ people, ◦ places, and ◦ things that trigger obsessions and compulsions

DSM-V: Associated and Secondary Features

United States: 1.2%

Internationally: 1.1%–1.8%

Females are affected at a slightly higher rate than males in adulthood,

Males are more commonly affected in childhood (Ruscio et al., 2010; Weissman et al., 1994)

DSM-V: Prevalence

United States, mean onset: 19.5 years◦ 25% start by age 14 years (Kessler et al. 2005; Ruscio et

al. 2010)

Onset after age 35 years is unusual

Males have an earlier age at onset than females◦ nearly 25% of males have onset before age 10 years

(Ruscio et al. 2010).

Onset of symptoms is typically gradual. ◦ Acute onset has also been reported.

DSM-V: Onset

Usually chronic◦ Often with waxing and waning symptoms (Ravizza et al.,

1997; Skoog & Skoog 1999)

Onset in childhood or adolescence can lead to a lifetime OCD

40% of individuals with onset of OCD in childhood or adolescence may experience remission by early adulthood (Stewart et al. 2004)

Pattern of symptoms in adults can be stable over time, but it is more variable in children (Mataix-Cols et al. 2002; Swedo et al. 1989).

May be based on developmental stage

DSM-V: Course

Greater internalizing symptoms

Higher negative emotionality, and

Behavioral inhibition in childhood ◦ (Coles et al. 2006; Grisham et al. 2011).

DSM-V: Risk and Prognostic FeaturesTemperamental

Physical and sexual abuse and other stressful or traumatic events (Grisham et al., 2011)

Sudden onset of symptoms associated with different environmental factors◦ Infectious agents and a post-infectious

autoimmune syndrome (Singer et al., 2012; Swedo et al., 2004).

DSM-V: Risk and Prognostic FeaturesEnvironmental

Rate of OCD among first-degree relatives of adults with OCD is approximately two times that among first-degree relatives of those without the disorder

Among first-degree relatives increased 10-fold onset (Pauls 2010)

Familial transmission ◦ 0.57 for monozygotic ◦ 0.22 for dizygotic (Pauls 2010)

Dysfunction ◦ Orbitofrontal cortex, ◦ Anterior cingulate cortex, and ◦ Striatum (Millad and Rauch 2012).

DSM-V: Risk and Prognostic FeaturesGenetic and physiological

Anxiety disorder: 76% Depressive or bipolar disorder: 63% Major depressive disorder: 41% Obsessive-compulsive personality

disorder:23%-32% Body dysmorphic disorder Trichotillomania Excoriation disorder ODD Tic Disorder

DSM-V: Comorbidity

DSM- V Model:

Components of OCDAs per extant literature

Presence of distressing intrusive, unwanted, thoughts, impulses, fears or images (obsessions), and/or repetitive behaviors or mental rituals (compulsions)

Knowledge that the thoughts and actions are senseless and unreasonable (Turner et al., 1985)

Rituals usually serve an anxiety-reducing function (Turner et al., 1985)

Diagnostic Criteria:

Diagnostic Criteria

Obsessions Compulsions Fear of germs Fear of harm

befalling self or others

Need for order or symmetry

Washing Cleaning Checking Counting Repeating Touching Straightening

(March et al., 2004)

Cleaning and contamination◦ Checking

Hoarding Symmetry and ordering

◦ Repeating and counting

Sexual and religious obsessions ◦ Aggression, somatic issues, and checking

Diagnostic Criteria:4 Symptom Dimensions

Diagnostic Criteria:Symptom Prevalence

(Mataix-Cols et al., 2008)

Diagnostic Criteria: Obsession-Compulsion Relationship

Must occur before puberty

Difficult to diagnose in children◦ Lack insight to realize obsessions are irrational (Kalra et al., 2009)◦ Prognosis is worse for children with poor insight◦ Lack of insight militates against the benefits of cognitive-behavioral therapy

(CBT)

40% of children deny compulsions are driven by obsessive thoughts

Diagnosing in Children

Symptom presentation◦ Change of obsessions/compulsions over time (Weiss, 2008)◦ Obsessions/compulsions vague, magical, or superstitious (Franklin, 2004)◦ Children have trouble describing their obsessions (Weis, 2008)◦ Fear that stating obsessions aloud will make them come true (Weis, 2008)◦ More likely to have tic-like compulsions

Patterns of comorbidity◦ ADHD◦ Tics: 2/3 children

Boys more likely to have comorbid◦ Tourette’s syndrome: 20-80%

Compulsions may be less severe

Sex distribution ◦ Boys more likely: 2-3:1◦ At or after puberty: 1:1.35 (m:f)

Degree insight Etiopathogenesis

OCD Differences in Children

1%-4% of children and adolescents

At least 1/3 of adult OCD subjects had the onset of symptoms in childhood (Rasmussen & Eisen, 1992).

Children and adolescents share similar features with the exception of age at onset and OCD symptom expression. (Mancebo, 2008)

Consistent across lifespan (Stewart, 2007)

Diagnostic Onset and Course

Adult patients with EOCD were characterized by ◦ (1) male gender predominance,

◦ (2) greater number of clinically significant obsessions and compulsions,

◦ (3) higher frequency of rituals repetition,

◦ (4) an increased severity of obsessive–compulsive symptoms at baseline, and

◦ (5) greater number of required therapeutic trials during the follow-up

Diagnostic Onset and Course:EOCD

EOCD:◦ More premature onset.

◦ More aggressive course.

◦ More obsessions and compulsions.

◦ May represent a more severe variety of the disorder.

◦ Higher frequency of tic-like compulsions.

◦ Higher frequency sensory phenomena .

◦ Higher frequency comorbid tic disorders.

◦ Worse short-term therapeutic response to SSRIs.

Diagnostic Onset:EOCD v.s LOCD

Lifetime prevalence :1%-3% (Pauls, 2010)

Juveniles more likely to be males

Males: earlier onset (Mancebo, 2008)◦ At puberty, the sex ratio of affected individuals

switches from pre- dominantly males to predominantly females (Kalra et al., 2009)

Prevalence

Higher suicide attempts Depression Anxiety

Celibacy rates:72% (Coryell, 1981)◦ Especially in men◦ Proportional to severity of the illness.

Marry later (Turner & Michelson, 1984). Lower rates of fertility (Turner & Michelson, 1984) Higher parental stress (Coles et al., 2006) Interference in school, social, work, and family (Piacentini &

Bergman, 2000)◦ Doing assigned chores at home: 61%◦ Getting ready for bed: 56%◦ Concentrating at school: 62%◦ Getting along with parents: 56%◦ Getting along with siblings: 53%

Associated & Secondary Features

Tic Disorder: 26% Anxiety Disorder Tourette’s disorder:18-25% ADHD: 34-51% Major depression: 33-39% ODD: 17-51% Overanxious disorder: 16% Specific development: 24% Simple phobias: 17% Adjustment disorder w/depressed mood: 13% CD: 7% Separation anxiety: 7% Enuresis: 4%

Juveniles: lower rates of mood, substance use and eating disorders compared to adults.

Comorbidity

Comorbidity: OCD overlap with Tic Disorder

(Franklin et al., 2012)

45% variance for younger sample (Hudziak et al., 2004)

Prenatal (Santangelo et al., 1994) :◦ Labor complications◦ Maternal smoking◦ Excessive caffeine or alcohol ◦ Difficulty getting pregnant: 53% (Vasconcelos et al., 2007)◦ Preexisting medical problems: 51% (Vasconcelos et al., 2007)

Parenting style (Albano, 2004)◦ Over controlling parents◦ Low parental acceptance

Aversive reaction to change (Zohar & Felz, 2001)◦ child tries to enforce consistency on objects and significant others

Family Size (Guerrero et al. ,2003) Substance abuse ( Fontenelle & Hasler, 2007)

Risk and Prognostic Features Environmental Factors

Behavioral Inhibition ◦ Over- protective parenting (Coles et al., 2006)◦ Significantly predicted levels of OCD (Coles et al., 2006)◦ High levels of restraint, withdrawal, and avoidance of

novel stimuli, of both a social and nonsocial nature (Garcia-Coll et al., 1984)

Higher internalizing problems (Zohar & Felz, 2001)◦ More Shy ◦ More emotional◦ More fearful

Risk and Prognostic Features Temperament

Twin studies ◦Bolton et al., 2007:

57% variance in MZ twins 22% in DZ twins

◦ Van Grootheest et al., 2005: 45-65% genetic influences

Ritual repetition may represent a behavioral marker for a specific genotype.

10-25% youths have at least 1 parent w/OCD

Risk and Prognostic Features Genetic Factors

Serotonergic systems◦ Central role◦ Only discovered by administering treatment and observing

effects

Dopaminergic systems◦ Reported by adult patients w/ basal ganglia disorders◦ OCD, TS, Sydenham Chorea, Huntingon Chorea

Glutamatergic system ◦ Primary excitatory neurotransmitter ◦ Key role in the functioning of the fronto-striato-thalamo-

cortical circuit (CSTC Circuit)

Risk and Prognostic Features Neurochemical Factors

Can be triggered by infections◦ Group A β-hemolytic streptococci (GABHS) are the most studied initial

autoimmune response–inciting event◦ Viruses◦ Mycoplasma pneumonia ◦ Borrelia burgdorferi ◦ Pediatric autoimmune neuropsychiatric disorders associated with

streptococcal infections—PANDAS

Parallels between:◦ Sydenham chorea, ◦ Neurological manifestation of rheumatic fever, and childhood-onset OCD

Dysfunction in orbitofrontal-striatal circuit◦ Involved in the mediation of emotional responses to biologically

significant stimuli

Risk and Prognostic Features Neuroimmune Dysfunction

Fronto-striato-thalamo-cortical circuit Explains behavioral loop

fMRI studies:◦ Global and local deviant topological properties

Disturbances in brain network balance Reduced small world efficacy @ baseline Changes in modular structure Basis of the inability to disengage from reverberating internal stimuli (Shin et al., 2013)

◦ Reduced volume: Left putamen (Hoexter et al., 2012) Left medial orbitofrontal cortex (Hoexter et al., 2012) Right medial orbitofrontal cortex (Hoexter et al., 2012) Right anterior cingulate cortex (Hoexter et al., 2012) Caudate (Saxena et al., 1999) Thalamus (Saxena et al., 1999)

Risk and Prognostic Features Neurobiological Substrates

Increased glutamatergic signals from the frontal cortex increase excitation in the striatum

increases inhibitory GABA signals to the GPi and SNr

Decreases inhibitory output via GABA from Gpi and SNr to thalamus thalamic excitatory glutamatergic output to the frontal cortex.

External loop composed of the GPe and subthalamic nucleus (STN) is postulated to contribute to a steady state of excitation/inhibition

Risk and Prognostic Features Neurobiological Substrates: cortico-striato-thalamo-cortical circuit dysfunction

Glutamate

Glutamate Excitation

Inhibition

Inhibition GABA

Increased glutamatergic signals from the frontal cortex increase excitation in the striatum

increases inhibitory GABA signals to the GPi and SNr

unknown dysfunction at the striatum and GPe.

Decreased inhibition on the GPe leads to increased inhibition of the STN,

decreases its excitation of the GPi/SNr GPi/SNr then decreases its inhibitory

output on the thalamus, resulting in excitatory output to the frontal cortex

Risk and Prognostic Features Neurobiological Substrates: cortico-striato-thalamo-cortical circuit dysfunction

Belief and Appraisal Model (Beck, 1976)◦ Obsessions & compulsions are from specific

sorts of dysfunctional beliefs. ◦ Strength of belief influences insight to OCD.

Salkovskis’s Model (Salkovskis, 1985)◦ Most people experience intrusions/normal

obsessions.◦ “Idea generator” ◦ Individual appraises the intrusions Obsession◦ Compulsions are efforts to remove the

intrusions and to prevent perceived harm.

Current Models of OCD

Reinforcement Model of OCD

Literature Based Model

Literature Based Model

Reward Processing

More excitatory glutamatergic output

INCR inhibition GABA

Rein

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Error ProcessingRumination of Obsessions

DECR inhibitory output

Excitatory

Glutamate

output

AnxietyPrompts Action Compulsion

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