Obsessive Compulsive Disorder: Description and Assessment

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Obsessive Compulsive Disorder Description and
Assessment

• Beth McCreary, Ph.D.
• October 18, 2008

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Overview

• Basic Definitions (obsessions, compulsions, OCD)
• Subtypes
• Prevalence Comorbidity
• Discriminating OC symptoms / OCD from other
  symptoms and diagnoses

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Overview (continued)

• Contributing Factors
• Assessment
• Impact on families

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Basic Definitions (DSM-IV)

• Obsessions . . .persistent ideas, thoughts,
  impulses, or images that are experienced as
  intrusive and inappropriate and that cause marked
  anxiety or distress.

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Defining Features of Obsessions (Clark, 2004
Table 2.2)

• Intrusive Quality
• I dont want to be thinking this right now
• Unacceptability
• I cant stand the emotional distress this
  brings
• Subjective Resistance
• Im not going to let myself think this
• Uncontrollability
• I cant not think this I cant stop it
• Ego-dystonicity
• This just isnt who I am how could I be
  thinking this?

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Basic Definitions (DSM-IV)

• Compulsions . . .repetitive behaviors
• . . .or mental acts . . .the goal of which is
  to prevent or reduce anxiety or distress, not to
  provide pleasure or gratification.

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Basic Definitions (DSM-IV)

• Obsessive Compulsive Disorder
• A. Either obsessions or compulsions
• B. Person (except children) recognized that the
  obsessions or compulsions are excessive/unreasonab
  le
• C. Obsessions or compulsions cause marked
  distress, are time consuming (gt1 hour/day), or
  significantly interfere with normal
  routine/functioning/relationships

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Subtypes of Obsessions

• In order of prevalence (roughly)
• Fear of contamination (Cleaners)
• Pathologic doubt (Checkers)
• Aggression or sexuality (Images / impulses)
• Need for symmetry/precision (Exactness)
• Religious scrupulosity
• Additionally
• Idiosyncratic / Superstitious
• Hoarding

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Subtypes Contamination

• Contracting illness in self (germs)
• Danielle Fears doorknobs, public restrooms,
  restaurants,
• trash, sneezing/coughing
  people, shoes, sex . . .
• Spreading illness to others
• Poisoning self
• Andy intensely anxious after noticing window
  cleaner near milk on counter
• Jill exposed to carcinogenic substance a decade
  earlier
• Poisoning others
• Associated Compulsions
• Excessive cleaning / handwashing / showering /
  laundry / segregating toxins
• Enormous time consumption

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Subtypes Doubt

• Safety Forgetting to turn off appliances or
  lock doors fearing fire/burglary/disaster
• Performance Forgetting to sign the check or
  complete the email fearing embarrassment
• Robin feared being reprimanded at work for
  making mistakes in calculationsgot reprimanded
  for taking too long to complete tasks
• Driving Fearing having hit someone
• Associated Compulsions
• Repeatedly Checking / Reassurance Seeking
• Again, enormous time consumption

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Subtypes Aggression

• Image / impulse to harm someone else
• Joe had visions of pushing baby stroller into
  traffic
• Ellen thought she would stab someone
• Postpartum fears of dropping/throwing baby
• Impulse to harm self
• Step in front of vehicle
• Throw self out window

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Subtypes Sexuality

• Fearing committing an inappropriate or
  unacceptable behavior
• Fearing molesting a child
• Disgust at ones own sexual thoughts
• Thoughts are graphically sexual and may occur
  when person is in public
• Men who fear homosexual thoughts

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Subtype Need for Precision / Symmetry /
Exactness

• Items (e.g., in closet or on desk) must be
  ordered a certain way
• Car has to be pulled into the driveway perfectly
• Behavior must be performed until it feels just
  right
• Fearing feeling upset / uncomfortable and being
  unable to concentrate on other things,
  indefinitely

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Subtype Religious Scrupulosity

• Thinking God is angry / upset with him/her, and
  that s/he may be condemned due to displeasing God
• Stacy thought about all of her unpleasant
  emotions as sins worthy of condemnation
• Blasphemous thoughts while reading Bible,
  profanity in head, intrusive sexual thoughts in
  church or reading Bible
• Steve had graphic sexual images appear in his
  mind whenever looking at the crucifix

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Subtype Idiosyncratic/Superstitious

• Believes ones own behavior will negatively
  affect self or others
• Kate thought if she made a mistake in writing,
  that her mother would suffer a heart attack or
  some other dire health problem
• Gene believed that he had to park in the same
  spot and take the same door and set of stairs at
  work every day, or else bad things would happen
  in his work day
• Tom feared certain numbers and colors indicated
  bad things would happen

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Subtypes Hoarding

• Fears accidentally throwing away something
  important
• Fears needing later something that was
  intentionally discarded

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Prevalence

• 2-3 of the population will suffer from OCD (in
  the lifetime)
• Equally common in males and females
• Age at onset usually adolescence or early
  adulthood
• 6-15 years in males
• 20s in females
• In children, washing, checking, and ordering are
  common presentations (as in adults)

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Comorbidity

• People diagnosed with OCD also often have
• Most often
• Depression (2/3 with OCD will develop depression
  in the lifetime)
• Social Phobia (10-40, lifetime)
• Next
• Other anxiety disorders (e.g., panic, worry
  10-40)
• Eating Disorders
• Tics

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ComorbidityTourettes Syndrome

• In those with TS, 35-50 can also be diagnosed
  with OCD more with OC symptoms
• Of those with OCD, 5-7 can be diagnosed with TS
• Of those with OCD, 20-30 have current or past
  tics
• Some research to say that the exactness subtype
  of OCD is particularly linked to TS

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Discriminations

• Depression
• Rumination about upsetting past events, or
  self-criticisms, may have an obsessional
  nature--but not ego-dystonic. Mood congruent.
• Worry
• Excessive concern about real-life circumstances,
  possible events

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Discriminations

• Hypochondriasis
• Somatic Obsessions? Persistent fears of becoming
  ill (with cancer or AIDS, e.g.)
• Misinterpreting bodily symptoms as signs of
  severe illness

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Discriminations

• Tourettes Syndrome
• Compulsions are intentional behaviors meant to
  neutralize anxiety or prevent something bad from
  happening
• Tics are involuntary and are not intended to
  alleviate anxiety (although they may occur more
  often under anxiety, and one may temporarily
  resist tics but this often results in a
  subsequent increase)

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Contributing Factors to OCDOverview

• Primary
• Genetics
• Environmental influences
• Mediating
• Structural Correlates
• Biochemistry
• Commonality with TS

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Contributing Factors to OCDGenetics

• OCD proposed to be a spectrum of disorders
  (subtypes?) that share some of the same genes
• No specific genes identified
• MZ twins more likely than DZ twins to exhibit OCD
  symptoms

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Contributing Factors to OCDGenetics

• Those with OCD more likely to have parents and
  children with OCD or OC behaviors than those
  without OCD
• Roughly 40 of those with OCD have a biological
  relative with OCD
• Within families, many different specific OC
  behaviorsso not likely learned

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Contributing Factors to OCDEnvironmental

• Brain Injury (damage basal ganglia and
  connections to frontal lobes)
• Caused by anoxia, toxic exposure (e.g., CO
  poisoning), brain infection (e.g. viral
  encephalitis), substance abuse
• Bacterial Infection (again, damage to basal
  ganglia)
• PANDAS pediatric autoimmune neuropsychiatric
  disorders associated with streptococcal
  infections
• Sydenhams chorea

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Contributing Factors to OCDBrain Structures /
Functioning

• Basal Ganglia
• Animal studies Basal ganglia damage leads to
  repetitive behaviors (like compulsive rituals)
• Patients with Parkinsons, Huntingtons chorea,
  or other diseases involving basal ganglia
  deterioration are at increased risk of developing
  OCD symptoms
• Hyperexcitability of basal ganglia pathways seen
  in OCD

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Contributing Factors to OCDBrain Structures /
Functioning

• Amygdala
• Increased activity when exposed to pictures of
  contaminated environments
• Responds differently in those with OCD than in
  controls when exposed to fearful or neutral
  stimuli

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Contributing Factors to OCDBrain Structures /
Functioning

• Increased orbital-frontal region activity
• Some have increased activity in the caudate
  nucleus (part of basal ganglia)
• Orbital-frontal and basal ganglia activity within
  OCD increases with exposure to feared stimuli
• Successful treatment with SSRI or behavioral
  therapy will lead to normalized brain activity in
  these areas

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Contributing Factors to OCDBiochemical

• Most theories concerning OCDs etiology include
  some type of abnormal function in the neural
  circuits between the frontal lobe and the basal
  ganglia within the brain. Serotonin and dopamine
  are the primary neurotransmitters for the neural
  circuits that connect these areas.
• (Steketee Pigott, 2006 p. 59)

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Contributing Factors to OCDBiochemical

• Serotonin
• Seems to be implicated in OCD, but not
  necessarily causative
• Medications that alleviate OCD symptoms often
  affect the serotonin system
• Most people with OCD have normal blood levels of
  serotoninthis doesnt indicate basal ganglia or
  other brain levels
• Serotonin function is implicated in MANY
  behaviorsnot a very specific indicator

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Contributing Factors to OCDCommonality with TS

• Genetics
• Those with OCD are 4 times more likely than those
  without to have a family member with TS or tics.
• Again, tic-related OCD may emerge as a specific
  subtype of OCD, involving the symmetry/exactness
  group of OCD symptoms

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Contributing Factors to OCDCommonality with TS

• Structural
• Basal ganglia dysregulation (hyperexcitability)
  is linked to TS and tics
• Environmental (with structural effects)
• PANDAS
• Sydenhams chorea

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Assessment

• May Include
• Clinical interview
• Self-report instruments
• Structured interviews
• Behavioral observations
• Family reports

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Assessment Clinical Interview

• Individual and Family Psychiatric History
• Comorbid conditions may affect treatment plan and
  prognosis
• Family history helps make diagnosis
• Specific symptomsinternal and external triggers
  for obsessions / compulsions
• Social and Occupational Functioning
• Avoidance behavior
• Impact of rituals on work and socialization
• Medical History

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Assessment Self-Report and Structured Interview
Instruments

• Yale-Brown Obsessive Compulsive Checklist and
  Scale (Y-BOCS)
• Has a self-report version and a structured
  interview version (administered by clinician)
• Padua Inventory
• Self-report instrument

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Assessment Behavioral Observations and Family
Reports

• Behavioral Observations
• Present feared / trigger stimuli and assess
  responses
• Easier for some obsessions/compulsions than for
  others
• Family Reports
• Useful for children/adolescents especially, but
  OCD often has an impact on family (not just when
  the one affected is a child)

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Impact on the Family

• Frustration (not logical how to help?)
• Time-consumption (enabling)
• Disruption of plans / togetherness
• Worry (What will life be for him/her?)
• Self-blame (But OCD is biological . . .)
• Anger/resentment/other-blame