Questions and Answers
The Adult Psychiatric Morbidity Survey found that mixed anxiety and depression affects about 20% of adults.
False
Cothymia is a term used to describe a condition where anxiety and depressive symptoms are severe enough for diagnosis.
False
Adjustment disorder is diagnosed when anxiety and depressive symptoms are unrelated to life changes.
False
Studies have shown that childhood adversity is associated with anxiety and depressive disorders in adulthood.
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The prognosis for mixed anxiety and depressive disorders is generally better than that for specific anxiety disorders.
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Antidepressant medication is the least commonly used treatment for mixed anxiety and depression.
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Cognitive behaviour therapy has shown significant improvement effects in mixed anxiety and depression compared to pure anxiety disorders.
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Persistent anxiety can lead to secondary depression, making depression onset more common in people with persistent anxiety.
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In some cultures, symptoms of anxiety disorders are characterized more by psychological complaints than somatic ones.
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Koro primarily affects women in India, South China, and Japan.
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In Yoruba, the phrase used to describe anxiety is 'the heart is at rest'.
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The belief associated with Koro includes the fear that the penis will retract into the abdomen and potentially cause death.
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Taijin-kyofu-sho is a form of social phobia prevalent in Japan.
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Obsessive-compulsive disorder is characterized by a lack of any feeling of compulsion to carry out certain actions.
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Epidemics of Koro have been linked to social stressors.
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In many cases, obsessive thoughts are perceived by the patient as appropriate and sensible.
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The phrase denoting anxiety in some cultures is a direct translation of the English word 'anxiety'.
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Obsessive-compulsive behaviors can involve quasi ritual performances to relieve anxiety.
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Obsessional thoughts are recognized by patients as external influences rather than their own.
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Obsessional ruminations often involve internal debates about completing everyday actions.
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Obsessional impulses are generally urges to perform acts that are always socially acceptable.
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Obsessional rituals can include both mental activities and repeated senseless behaviors.
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Obsessional slowness is a feature that can occur in individuals with OCD and is typically unrelated to other symptoms.
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The presence of obsessional phobias suggests a tendency to avoid distressing situations connected to obsessional thoughts.
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Depersonalization in obsessional patients is well understood and has a clear relationship with other OCD features.
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Anxiety is a minor component of OCD and does not significantly impact compulsive rituals.
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It has been observed that a subset of obsessional patients may also experience different types of personality disorders.
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Obsessional thoughts are usually pleasant and easy for patients to dismiss.
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The diagnosis of OCD requires the presence of either obsessions, compulsions, or neither.
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Symptoms of OCD must cause clinically significant distress or impairment in social or occupational function.
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In the DSM-5, there is no distinction made in the degree of insight a patient may have regarding their OCD.
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The presence of obsessional symptoms is uncommon in the context of schizophrenia.
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Obsessional symptoms must be present for at least two consecutive days according to ICD-10 criteria.
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Obsessive-compulsive disorder can be mistaken for a primary depressive disorder.
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Compulsive acts associated with OCD are typically considered to provide immediate gratification.
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The lifetime risk of developing OCD has been reported as 1.2% in certain studies.
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The most notable instances of OCD symptoms are observed in patients with encephalitis lethargica.
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Individuals with obsessive-compulsive symptoms often experience periods of relief during depressive episodes.
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The prognosis of OCD is worse when there is a personality disorder.
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Clomipramine is frequently used as a first-line treatment for OCD.
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Selective Serotonin Uptake Inhibitors (SSRIs) are associated with fewer dropouts from treatment compared to other medications.
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Dynamic psychotherapy is often effective for managing OCD symptoms.
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Medication and exposure with response prevention rarely work well together.
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About two-thirds of patients with moderately severe OCD rituals can expect substantial improvement with appropriate treatment.
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Anxiolytic drugs should be prescribed for long-term use in OCD treatment.
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A thorough search for depression is important in all patients presenting with OCD.
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The accompanying obsessional thoughts usually improve when rituals respond to exposure and response prevention treatment.
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Higher doses of antidepressants might be beneficial for all OCD patients.
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Deep brain stimulation has been widely studied and proven effective for all patients with OCD.
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Cognitive therapy encourages patients to suppress their obsessional thoughts to reduce their frequency.
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Exploratory psychotherapy techniques help patients gain insight into their obsessive behaviors.
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The clinically useful effect of clomipramine may not be reached until after 6 weeks of treatment.
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Higher doses of SSRIs are generally less effective than lower doses for OCD treatment.
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SSRIs are typically considered first-line medication for treating OCD.
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Exposure and Response Prevention is less effective for obsessional thoughts that occur with rituals.
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Patients are encouraged to continuously seek reassurance about their obsessions.
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According to Freud, obsessional symptoms stem from conscious urges of an aggressive or sexual nature.
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Compulsivity is characterized by a tendency to act impulsively to gain instant gratification.
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The cognitive theory of OCD suggests that intrusive thoughts are not the real problem but the inability to control them is.
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About one-third of OCD cases show improvement within a year.
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Impulse control difficulties in people with OCD are linked to dysfunction in the cortico-striatal-thalamic loops in the brain.
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Thought-action fusion refers to the belief that one's thoughts have no impact on real-life events.
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Compulsions in OCD are ineffective in reducing anxiety and do not reinforce compulsive behaviors.
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It is common for compulsivity and impulsivity to coexist in individuals with OCD.
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The concordance rate for OCD is higher in dizygotic twins compared to monozygotic twins.
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70% of cases of Sydenham's chorea are reported to have obsessive-compulsive symptoms.
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Brain imaging studies have shown a significant increase in grey matter volume in the orbitofrontal cortex in patients with OCD.
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The symptoms of OCD have been linked to dysfunction in the cortico-striatal-thalamic loops.
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Familial studies indicate that the risk of OCD in first-degree relatives is nearly threefold compared to control rates.
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Molecular studies on OCD have consistently replicated findings related to the glutamate transporter gene.
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The development of OCD in children can be linked to group A streptococcal infections.
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Increased activity in the thalamus indicates a lack of compulsive behavior in OCD patients during psychological challenges.
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The response of obsessive-compulsive symptoms to drugs that increase 5-HT function suggests that 5-HT mechanisms may not be abnormal in OCD.
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Gilles de la Tourette's disorder initially included symptoms similar to those found in OCD.
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Study Notes
Clinical Features of OCD
- OCD manifests through obsessional thinking and compulsive behaviors, often accompanied by anxiety and depression.
- Obsessional thoughts are intrusive, typically unpleasant, and recognized by patients as their own.
- Forms of obsessional thoughts include words, phrases, images, and ruminations, often revealing inner conflict and guilt.
- Compulsive behaviors, or rituals, include repetitive mental activities and physical actions (e.g., excessive hand washing).
- Obsessional symptoms can lead to severe functional impairment and cause emotional distress.
- Notable phenomena include obsessional slowness and obsessional phobias, which worsen in specific contexts.
Aetiology and Genetic Factors
- Healthy individuals can experience intrusive thoughts, but in OCD, these are more frequent and intensive.
- Genetic studies show higher concordance rates for OCD in identical twins compared to fraternal twins, indicating a genetic predisposition.
- First-degree relatives have a fourfold increased risk for developing OCD.
- Associations found with genetic markers suggest abnormalities in glutamate and serotonin function, although findings vary.
Brain Function and Imaging Studies
- Patients with OCD show structural and functional brain changes, particularly in the striatum, orbitofrontal cortex, and anterior cingulate cortex.
- Errors in cortico-striatal-thalamic circuits may underpin the symptoms of OCD, affecting areas related to executive function and emotional processing.
- Links between OCD and other neurological concerns (e.g., encephalitis lethargica) indicate possible broader implications of brain health on OCD symptoms.
Transcultural Variations in OCD
- Anxiety disorders, including OCD, exhibit different cultural expressions; somatic symptoms are more pronounced in non-Western cultures.
- Koro is described as acute anxiety around the fear of retraction of the penis, primarily observed in certain Asian cultures.
- Social phobia has culturally specific manifestations, such as taijin-kyofu-sho in Japan, emphasizing the influence of cultural context on mental health.
OCD Diagnostic Criteria
- DSM-5 outlines that OCD diagnosis requires either obsessions, compulsions, or both, contributing to significant impairment or distress.
- Symptoms must occur for more than one hour daily and cannot be attributed to other medical conditions or disorders.
Comorbidity and Prognosis
- Depression frequently co-occurs with OCD, with increased obsessional symptoms during depressive episodes.
- Prognosis improves with identifiable precipitating events and good social functioning, while early-onset and personality disorders worsen it.
Treatment Approaches
Medication
- Clomipramine, a tricyclic antidepressant, historically treated OCD but is now superseded by SSRIs for first-line therapy.
- SSRIs are effective and similar in efficacy to clomipramine; higher doses may yield better results.
- Short-term use of anxiolytics can alleviate symptoms but is not recommended for prolonged periods.
Cognitive Behavioral Therapy (CBT)
- Exposure and Response Prevention (ERP) is a key therapeutic strategy, showing substantial improvement in rituals for many patients.
- Cognitive therapy focuses on reducing avoidance and suppression of obsessional thoughts to reduce their frequency.
- Behavioral treatments have shown limited success for thoughts without associated rituals, indicating a need for tailored approaches.### Suppression and Avoidance
- Driven by the belief that thinking negatively can cause those thoughts to materialize.
- Techniques include reviewing evidence against such beliefs, exposure to recorded thoughts, and discussing cognitive distortions.
Obsessive-Compulsive Disorder (OCD)
Freud's Theory
- Obsessions arise from unconscious aggressive or sexual urges, leading to anxiety.
- Defense mechanisms like repression help manage anxiety associated with those urges.
Neuropsychological Function
- Compulsivity involves repetitive behaviors to avoid negative outcomes, distinct from impulsivity driven by instant gratification.
Cognitive Theory
- The issue lies in the inability to control intrusive thoughts rather than the thoughts themselves.
- Feelings of personal responsibility for harmful consequences lead to compulsive behaviors, avoidance, and reassurance-seeking.
Key Cognitive Processes
- Thought-action fusion: Belief that negative thoughts lead to real outcomes.
- Inflated Responsibility: Heightened sense of duty to prevent harm to others.
- Compulsions: Temporary relief from anxiety reinforces these behaviors.
- Overestimation of Harm: Exaggerated fears of potential negative events.
- Intolerance of Uncertainty: Difficulty managing unknown outcomes.
- Need for Control: Strong desire for order in personal environments.
Prognosis
- Approximately two-thirds see improvement within a year.
- Some cases may linger with fluctuating stability, while others show steadiness.
Impulsivity and Compulsivity
- Impulsivity and compulsivity can coexist due to dysfunction in brain circuits involving the ventral striatum, anterior cingulate cortex, and ventrolateral prefrontal cortex.
Difficulties in Impulse Control
- Individuals with OCD and their relatives may struggle with impulse control, affecting task performance.
- This dysfunction might contribute to obsessional symptoms by failing to inhibit inappropriate actions.
Effective Treatments for OCD
Cognitive Behavioural Therapy (CBT)
- Incorporating cognitive methods into behavior therapy increases effectiveness.
- Successful treatments typically combine cognitive and behavioral elements.
Dynamic Psychotherapy
- Traditional exploratory psychotherapy is generally ineffective for OCD and may exacerbate symptoms.
Neurosurgery and Deep Brain Stimulation
- Can significantly alleviate distress, although long-term outcomes remain unclear.
- Controlled trials needed to assess efficacy; long-term results show limited success and complications.
Management of OCD
- OCD often follows a fluctuating path with remissions.
- Co-occurring depression warrants treatment, often resulting in improved OCD symptoms.
What Patients Need to Know
- Symptoms do not signify insanity; education and reassurance are crucial.
- Involving family members in support while resisting participation in rituals is important.
- Continuous reassurance about obsessions can be counterproductive.
Choice of Treatment
- Medication can help manage symptoms, but there is a risk of relapse upon cessation.
- Exposure with response prevention leads to long-term results, especially when symptoms are manageable.
- Medication may be initiated if there are delays in accessing therapy.
Medication
- First-line treatment typically involves SSRIs; alternatives include another SSRI or clomipramine if the first fails.
- Augmenting with antipsychotics may also be considered.
- Higher doses may be beneficial, and long-term maintenance therapy may be necessary.
Resources
- Consult Veale and Roberts (2014) for additional management strategies for OCD.
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Description
Explore the clinical features and aetiology of Obsessive-Compulsive Disorder (OCD) in this quiz. Delve into how obsessional thoughts and compulsive behaviors manifest, including their emotional and functional impacts. Understand the genetic factors that contribute to OCD development.
