DSM-5: OCD Dx
Previously grouped with anxiety disorders (up until DSM-IV) => Removed and put into its own category in DSM-5
- Anxiety not as stable a feature?
- Different, specific treatments?
Now grouped with other more similar diagnoses => Lack of agreement regarding this decision
DSM-5:
- Presence of obsessions, compulsions, or both
- Time consuming (more than 1 hour per day) and cause distress and/or impairment
Specify insight: Good or fair insight vs Poor insight vs Absent insight / delusional beliefs
Epidemio
- 2-3% lifetime prevalence
- Less clear gender differences
- Onset typically in adolescence or early adulthood
- Chronic course => But early detection and intervention improves recovery rates
- Often co-occurs with anxiety and mood disorders
- Comorbid MDD predicts increased risk of suicidality
=> Functional Impairment
World Health Organization (2008) ranked OCD as a leading cause of disability worldwide
Psychosocial impairments:
- Basic self care
- Work/school
- Family and social functioning
Comparable to impairments found in physical illnesses and schizophrenia
Obsessions
Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and cause marked anxiety and distress
- Ego-dystonic (because intrusive and “inappropriate”) => vs. eating disorders are ego-syntonic
- Sense of lack of control
Types of obsessions:
- Contamination (most common) *
- Uncertainty *
- Aggressive
- Symmetry/Exactness
- Sexual
- Religious
- Somatic (physical/mental)
=> OCD vs Schizo
- Person recognizes that his-her thoughts are irrational
- Continuum of insight
- Distinguishes OCD from schizo (don’t realize it’s irrational) or psychosis => no delusional thought system
=> OCD vs GAD
- Obsessions and worry share similarities: Intrusiveness and uncontrollability of thoughts
- How to differentiate? => Obsessions tend to be more bizarre, Involve more imagery
- Not just worries about everyday real-life problems (like in GAD)
Intrusive Thoughts and Acting on Them
Obsessions and compulsive beh exist on a continuum
OCD is differentiated based on:
- Frequency
- Intensity
- Degree of distress/impairment
Many OCD patients feel shame about content of thoughts => Therapy involves normalizing
=> Likelihood of acting on obsession
- People with OCD almost never act on their urges and impulses regarding their obsession ex: harm and sexual obsessions
- Unlike other kinds of intrusive thoughts because these are ego-dystonic => Urges with OCD are not pleasurable
Compulsions
Repetitive beh or mental acts that attempt to neutralize or suppress obsession => Person must perform the beh
=> Designed to reduce anxiety from the obsession NOT designed to bring pleasure or gratification
Common compulsions => Sometimes simple actions, sometimes very bizarre and complex *Frequently represent a neutralization (Prevent, cancel, or “undo” the feared consequence and distress caused by the obsession)
- Washing / Cleaning *
- Checking *
- Repeating
- Mental (ex: scenario where sme survives)
Biological Factors
Genetic Factors
- Mild to moderate heritability estimates =>Twin and family studies
- Earlier onset shows greater genetic influence
- Over 30 potential genes have been investigated => Nothing conclusive yet in terms of specific genes
Brain Abnormalities
Overactivity:
- Basal ganglia (emotion)
- Orbital frontal cortex (primitive urges; “the stuff of obsessions”)
Underactivity:
- Frontal cortex (higher level planning and inhibition)
- Structural (volume) and/or functional (connectivity) abnormalities
Serotonin Hypothesis
- Clomipramine was the first effective drug treatment reported for OCD => Backwards logic (just like depression)
- Led researchers to conclude that abnormalities in serotonin neurotransmission plays in a role in the etiology of OCD (But evidence for its causal role is inconclusive)
Psychological Factors
Learning Theory => Anxiety and fear are acquired through learning history (develops with classical cond and maintained with operant cond)
*Neg reinforcement when wash hands to reduce distress
Consequences of neutralization => Negatively reinforces beh and maintains the obsession, Believes that neutralization prevented feared outcome (and therefore necessary to keep doing it)
=> If prevent neutralization:
- Learning that feared event X did not occur
- Leaning that anxiety produced from obsession diminishes on its own (even in the absence of neutralization)
Neutralization Study: Neutralize rn or 20min later => neutralization reduces anxiety but urge to neutralize and anxiety goes down when neutralization is delayed or prevented
Cognitive Model (4)
1- Obsessive thoughts are very common – but not everyone develops OCD => Why?
- Intrusive thoughts = stimuli
- Cognitive responses (negative automatic thoughts) to stimuli (i.e., intrusive thoughts) is what creates distress *Personally significant appraisals
2- Value systems
Content of obsessions often reflect themes that are most important to the person’s system of values ex: A person with very high religious standards will be upset by intrusion of sinful thoughts
3- Catastrophic misinterpretations => Of one’s intrusive thoughts, images, and impulses
- Obsessions persist as long as misinterpretations continue
- Turns neutral stimuli into threatening stimuli
- Frequency of obsessions will decrease when misinterpretations are changed
4- Personal Responsibility
- OCD have inflated sense of personal responsibility and self- blame
- Attach undue significance to presence of intrusive thought ex: think that it means something negative about their character
- This attached meaning is what causes the distress
Study: With OCD, SAD, non-anxious and low/oc-relevant/high risk risk
Ratings of personal responsability:
- OCD score higher than non-anxious AND socially anxious in low-risk and OC-relevant situations
- But socially anxious also score higher than non- anxious controls in OC- relevant situations
- No difference between group in high-risk situation
Cognitive Model - Thought-Action Fusion
Moral TAF:
Unwanted thoughts about disturbing actions are equivalent to the actions themselves
Likelihood TAF:
Thinking about a disturbing event makes the event more probable => Self, Other
“Magical Thinking”
Memory Deficits
When OCD patients are asked why they perform checking rituals, they often express dissatisfaction with their memory => Early theories that OCD (especially checkers) have objective memory impairments
Study: Memory Deficit or Poor Memory Confidence?
Participants who repeatedly checked the stove (vs. sink) showed:
- Decrease in metamemory variables (confidence, vividness, detail)
- Decrease in memory accuracy
- Same effect for clinical OCD and non-clinical controls
- No memory differences between OCD and controls at baseline
*Self-perpetuation/doubting mechanism
Intolerance to Uncertainty (2) and Disgust
Intolerance of Uncertainty => Experience uncertainty as negative, dangerous, or unfair and OCD engage in compulsive rituals (ex: checking) to restore certainty
Types of IU
Prospective IU
- Desire for predictability
- Negative cognitive responses to future uncertainties
- Related to all types, but especially checking
Inhibitory IU
- Behavioral inaction related to uncertainty (belief that uncertainty compromises functioning)
- Especially related to contamination and “unacceptable” thoughts types => Lacking coping or problem solving skills to manage themselves
*Not specific to OCD – present in many disorders (ex: GAD)
Role of Disgust => Many OCD patients report feeling “disgusted” (not “frightened”) in response to relevant stimuli
- Disgust = basic emotion =>Disease avoidance function (evolutionarily)
Disgust Proneness => Personality trait that reflects the tendency to experience disgust frequently and intensely
- DP has strong link with OCD *Especially with contamination subtype => But also other subtypes (ex: ordering, hoarding)
- Also plays role in other dx ex: spider phobia => “Once in contact always contaminated”
- Very hard to counter-condition => Can explain some of the challenges in treatment-resistant OCD
Treatments (3)
1- Exposure and Response Prevention
- Exposure to stimuli that provoke obsessions
- Refrain from engaging in their usual rituals
- Usually do this gradually (re: fear hierarchy)
Outcomes?
- At least half show reduction in sx
- Majority maintain gains at follow-ups
- Superior effects to medication
How does it work?
Fear conditioning: Association between CS (doorknob) and US (“scary”) => Reduce this through extinction: Present CS without US
=> Historically, thought to be beh habituation-based mechanism
- “Unlearn” or “erase” obsessional fears
- Emphasis is on reduction of fear during exposure (i.e., habituation)
*Not consistently supported by research
2- Inhibitory Learning Model
Assumes that original CS-US association is not erased => Instead, new, secondary inhibitory learning about the CS-US develops
- Specifically, learn new safety information (ex: “doorknobs are generally safe”) that inhibits existing obsessional fear (ex: “doorknobs are dangerous”)
3- Cognitive Therapy
Psychoeducational component
- Normalizing obsessions
- Model of obsessive thoughts and compulsive beh
Reappraisal strategies:
- Replace catastrophic misinterpretations with more realistic and benign interpretations
Distancing strategies:
- Targets thought-action fusion
