Obsessive-Compulsive and Related Disorders PDF

Obsessive-Compulsive and Related Disorders  OBSESSIVE-COMPULSIVE AND RELATED DISORDERS  Obsessive-compulsive disorder was classified as an anxiety disorder until DSM-5  Obsessions are intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or elimin...

Obsessive-Compulsive and Related Disorders  OBSESSIVE-COMPULSIVE AND RELATED DISORDERS  Obsessive-compulsive disorder was classified as an anxiety disorder until DSM-5  Obsessions are intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or eliminate; recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted; this could be wishes, impulses, images, ideas, doubts.  Compulsions are the thoughts or actions used to suppress the obsessions and provide relief; repetitive behaviors or mental acts that an individual feel driven to perform in response to an obsession or according to rules that must be applied rigidly TYPES OF OBSESSIONS AND COMPULSIONS SYMPTOM / OBSESSION COMPULSION SUBTYPE Symmetry / exactness Needing things to be Putting things in a certain order / “just right” symmetrical/aligned just so Repeating rituals Urges to do things over and over until they feel “just right” Forbidden thoughts or Fears, urges to harm self or Checking, avoidance, repeated actions (aggressive/ others Fears of offending God requests for reassurance sexual/religious) Cleaning/ Germs Fears of germs or Repetitive or excessive washing contamination contaminants Using gloves, masks to do daily tasks Hoarding Fears of throwing anything away Collecting/saving objects with little or no actual or sentimental value such as food wrappings  OBSESSIVE-COMPULSIVE AND RELATED DISORDERS  It is common for OCD sufferers to have multiple subtypes.  It is common for tic disorder, characterized by involuntary movement (sudden jerking of limbs, for example), to co-occur in patients with OCD (particularly children)  Cultural beliefs and concerns influence the content of the obsessions and the nature of the compulsions. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS  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  OBSESSIVE-COMPULSIVE DISORDER Diagnostic Criteria A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).  OBSESSIVE-COMPULSIVE DISORDER Diagnostic Criteria Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts.  OBSESSIVE-COMPULSIVE DISORDER Diagnostic Criteria B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) 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 (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder).  OBSESSIVE-COMPULSIVE DISORDER Diagnostic Criteria Specify if: With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true. With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true. Specify if: Tic-related: The individual has a current or past history of a tic disorder. THE CASE OF JOHN John is a 56-year-old man who presents to you for treatment. His symptoms started slowly; he tells you that he was always described as an anxious person and remembers being worried about a lot of things throughout his life. For instance, he reported he was very afraid he’d contract HIV by touching doorknobs, even though he tells you he knew this was “irrational.” He tells you that about 10 years ago, following a few life stressors, his anxiety and intrusive thoughts worsened significantly. He tells you he began washing his hands excessively. He reports he developed an intense fear that someone would break into the house and it would be his fault because he left something unlocked. He states that this fear led him to repeatedly check doors and windows before sleep in a specific order, which was a source of contention with his wife. He says that his fear of making a mistake also leads him to be slow to turn in work for his job, checking many times to make sure there are no mistakes, for which he gets reprimanded on occasion. THE CASE OF JOHN John reports that his symptoms are getting worse, which is why he has sought treatment. For example, currently he washes his hands until he finishes the whole soap bar, and his hands are cracked because they are so dry. He says he continues to check the doors and windows of his house numerous times throughout the day, not just at night, and has on occasion driven home from work to be sure everything truly was locked. If he notices even a speck of dust on the floor, he states he has the urge to clean the whole house and he often complies with that urge. John expresses significant distress over these symptoms, as they are taking up more of his time and robbing him of his confidence, as he is increasingly distracted at work and in his family life.  BODY DYSMORPHIC DISORDER Diagnostic Criteria A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.  BODY DYSMORPHIC DISORDER Diagnostic Criteria Specify if: With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case. Specify if: Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or “I look deformed”). With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true. With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true. THE CASE OF ISAAC In his mid-20s, Isaac was diagnosed with suspected social anxiety disorder, and he was referred to our clinic by another professional. Isaac had just finished rabbinical school and had been offered a position at a synagogue in a nearby city. He found himself unable to accept, however, because of marked social difficulties. Lately, he had given up leaving his small apartment for fear of running into people he knew and being forced to stop and interact with them. Isaac was a good-looking young man of about average height, with dark hair and eyes. Although he was somewhat depressed, a mental status exam and a brief interview focusing on current functioning and past history did not reveal any remarkable problems. There was no sign of a psychotic process (he was not out of touch with reality). THE CASE OF ISAAC We then focused on Isaac’s social difficulties. We expected the usual kinds of anxiety about interacting with people or “doing something” (performing) in front of them. But this was not Isaac’s concern. Rather, he was convinced that everyone, even his good friends, was staring at a part of his body that he found grotesque. He reported that strangers would never mention his deformity and his friends felt too sorry for him to mention it. Isaac thought his head was square! Like the Beast in Beauty and the Beast who could not imagine people reacting to him with anything less than revulsion, Isaac could not imagine people getting past his square head. To hide his condition as well as he could, Isaac wore soft floppy hats and was most comfortable in winter, when he could all but completely cover his head with a large stocking cap. To us, Isaac looked unremarkable.  HOARDING DISORDER Diagnostic Criteria A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).  HOARDING DISORDER Diagnostic Criteria E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome). F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder). Specify if: With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.  HOARDING DISORDER Diagnostic Criteria Specify if: With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. THE CASE OF DEE “Dee” was a 63-year-old divorced woman who lived alone in her house. She described her current hoarding behavior as “difficulty throwing things away.” She was referred to the UCLA Intensive Treatment Program by her daughter, who had been living in New York for the past three decades. Dee’s difficulties with organization and discarding of her possessions had resulted in a clutter-filled environment in her home. As a result, her main disability had been complete social isolation due to embarrassment about others Seeing her home in this state. She had desired to seek treatment but had not taken that step until urged by her daughter. THE CASE OF DEE Dee’s problems with hoarding began in childhood. She admitted to hiding things under her bed so her mother would not discard them. She also recalled being a fearful and anxious child. Dee’s symptoms of hoarding had waxed and waned since childhood. Dee’s problems with severe hoarding began to worsen since moving into her new home 16 years ago, and continued to worsen in the last 10 years. Her family history was significant for hoarding behaviors in her mother and maternal grandmother. Dee also described having mild symptoms of depression. She admitted to “crying spells” and “painful emotions” when thinking about being a failure due to wasted time and inability to control her hoarding problem. Her OCD mainly revolved around compulsive hoarding behaviors, as she denied other symptoms of OCD.  TRICHOTILLOMANIA Diagnostic Criteria A. Recurrent pulling out of one’s hair, resulting in hair loss. B. Repeated attempts to decrease or stop hair pulling. C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition). E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder). THE CASE OF AG A 17 year old boy A.G was referred to the dermatology department with complaints of increasing bald patches in the scalp region. The dermatologist advised him to go for an ultrasound of scalp. No organic cause of baldness was found. However, it came to notice that A.G had been pulling off his hair. With immediate effect, he was referred to the psychiatry department. Assessment was done by a psychiatrist and a psychologist CBT specialist. Hemogram, Renal & Liver function tests were done and were normal. USG abdomen was done to rule out trichophagia (hair ingestion) A.G was eventually diagnosed with Trichotillomania. His mood was euthymic and he acknowledged hair pulling as a problem he wanted to get out of. Insight and self care were good, but over time, TTM had resulted into depression. THE CASE OF AG On a scale of severity, A.G’s hair pulling fell between moderate to severe. Although the patient was not ingesting hair, he used to compulsively pull hair which had resulted in baldness of almost 1/3rd of his scalp. The consequent guilt he experienced, made him feel depressed, unfocussed on studies, and perform poorly in academics. The problem of hair pulling, as reported by the patient had started first two years back when he had noticed his mother plucking her brows with tweezers at home. Upon asking his mother, she had told him that unkempt growth of hair made one look unattractive. Thus, it was a must to keep hair trimmed and short. This had somehow reinforced the belief in him that his scalp and brow hair needed trimming and he needed to do it by pulling it. THE CASE OF AG Further assessment by the psychiatrist & psychologist revealed that high level of tension & discomfort which led him to pull hair. Pulling hair resulted into instant gratification which lasted for a short duration. This would again give rise to the feeling of discomfort. Thus a vicious cycle of hair pulling and low mood had been formed. Diffuse alopecia on the frontal area as a result of hair pulling. Excoriations are also seen on the forehead  EXCORIATION (SKIN-PICKING) DISORDER Diagnostic Criteria A. Recurrent skin picking resulting in skin lesions. B. Repeated attempts to decrease or stop skin picking. C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies). E. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury). A woman, 15-year-old student, ethnic Malay, Muslim, address at Medan Tuntungan, accompanied by her mother to the Psychiatric ward at USU Hospital, complaints of damaged skin on her both hands and feet caused by repeated actions such as scratching and plucking of the skin. This habit has been experienced for about 5 years and getting worse in 1 month. The patient said the habit happened automatically whenever she heard her parents arguing or when her parents forced her to do something she did not like. She lives with her mother and two younger brothers, her parents were divorced when she was 13 years old, the patient’s mother’s occupation was a civil servant, which resulted in the patient rarely seeing her mother. A month ago she was asked by her mother to continue her education to a boarding school, in fact, she preferred to go to a high school near her house as her friends were in that high school. The patient is confused whether to follow her mother’s advice or enter her preferred high school. She also does not dare to object her mother because she thinks that her mother will not accept her choice. The patient’s habit of scratching and plucking of the skin appeared since she was 10 years old. The trigger was hearing her parents arguing. After she scratches her skin, her feelings become calm. Because it had caused wounds and bleeding, her mother took her to a dermatologist and was given a medicine. After further examinations, there was no evidence of damage on her skins in spite her complaints. The dermatologist decided to refer the patient to a psychiatrist. According to the psychiatric interview, her affect is appropriate, her mood is dysphoria, delusions and hallucinations were not found, good orientation, good general knowledge, good concentration and attention, good memory, good intelligence, insight level 4, good judgment. The results of physical examination are multiple wounds on the skin of the hands and feet, vital signs, and neurological signs within normal limits. The diagnosis for the case is excoriation disorder and the pharmacotherapy given is Fluoxetine orally 20 mg/day/ orally, advised to appoint visitation for follow-up within 2 weeks. SUBSTANCE/MEDICATION-INDUCED OCD AND RELATED DISORDERS Diagnostic Criteria OBSESSIVE-COMPULSIVE AND RELATED DISORDER DUE TO ANOTHER MEDICAL CONDITION Diagnostic Criteria  OTHER SPECIFIED OCD AND RELATED DISORDERS Diagnostic This category applies Criteria to presentations in which symptoms characteristic of an obsessive-compulsive and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the obsessive-compulsive and related disorders diagnostic class. The other specified obsessive- compulsive and related disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific obsessive-compulsive and related disorder. This related disorder” followed by the specific reason (e.g., “obsessional jealousy”).  Examples of presentations that can be specified using the “other specified” designation include the following: Body dysmorphic–like disorder with actual flaws: This is similar to body dysmorphic disorder except that the defects or flaws in physical appearance are clearly observable by others (i.e., they are more noticeable than “slight”). In such cases, the preoccupation with these flaws is clearly excessive and causes significant impairment or distress. Body dysmorphic–like disorder without repetitive behaviors: Presentations that meet body dysmorphic disorder except that the individual has never performed repetitive behaviors or mental acts in response to the appearance concerns. Other body-focused repetitive behavior disorder: Presentations involving recurrent body-focused repetitive behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) that are accompanied by repeated attempts to decrease or stop the behaviors and that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning  Obsessional jealousy: This is characterized by nondelusional preoccupation with a partner’s perceived infidelity. The preoccupations may lead to repetitive behaviors or mental acts in response to the infidelity concerns; they cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and they are not better explained by another mental disorder such as delusional disorder, jealous type, or paranoid personality Olfactory reference disorder (olfactory reference syndrome): This is characterized by the individual’s persistent preoccupation with the belief that he or she emits a foul or offensive body odor that is unnoticeable or only slightly noticeable to others; in response to this preoccupation, these individuals often engage in repetitive and excessive behaviors such as repeatedly checking for body odor, excessive showering, or seeking reassurance, as well as excessive attempts to camouflage the perceived odor. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In traditional Japanese psychiatry, this disorder is known as jikoshu-kyofu, a variant of taijin kyofusho.  Shubo-kyofu: A variant of taijin kyofusho (see “Culture and Psychiatric Diagnosis” in Section III) that is similar to body dysmorphic disorder and is characterized by excessive fear of having a bodily deformity. Koro: Related to dhat syndrome (see “Culture and Psychiatric Diagnosis” in Section III), an episode of sudden and intense anxiety that the penis in males (or the vulva and nipples in females) will recede into the body, possibly leading to death.  UNSPECIFIED OBSESSIVE-COMPULSIVE AND RELATED DISORDERS Diagnostic This category applies Criteria to presentations in which symptoms characteristic of an obsessive-compulsive and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the obsessive-compulsive and related disorders diagnostic class. The unspecified obsessive- compulsive and related disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific obsessive-compulsive and related disorder and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings) Theoretical Explanations A. Psychodynamic Perspective The battle between anxiety-provoking id impulses and anxiety- reducing defense mechanisms is not buried in the unconscious but is played out in overt thoughts and actions. Defense mechanisms used: Isolation – disown their unwanted thoughts and experience them as foreign intrusions. Undoing – perform acts that are meant to cancel out their undesirable impulse Reaction formation Fixation in the anal stage Underlying unconscious conflict (displacement) - BDD B. Behavioral Perspective They propose that people happen upon their compulsions quite randomly. In a fearful situation, they happen just coincidentally to wash their hands, say, or dress a certain way. C. Cognitive Perspective Cognitive theorists begin their explanation of obsessive-compulsive disorder by pointing out that everyone has repetitive, unwanted, and intrusive thoughts. Anyone might have thoughts of harming others or being contaminated by germs, for example, but most people dismiss or ignore them with ease. Those who develop this disorder, however, typically blame themselves for such thoughts and expect that somehow terrible things will happen. more depressed than other people have exceptionally high standards of conduct and morality have an inflated sense of responsibility in life and believe that their intrusive negative thoughts are equivalent to actions and capable of causing harm They believe that they should have perfect control over all of their thoughts and behaviors D. Biological Perspective Family pedigree abnormally low activity of the neurotransmitter serotonin abnormal functioning of specific regions of the brain, particularly the orbitofrontal cortex ( just above each eye) and the caudate nuclei (structures located within the brain region known as the basal ganglia). These regions are part of a brain circuit that usually converts sensory information into thoughts and actions (Craig & Chamberlain,2010; Stein & Fineberg, 2007). the circuit begins in the orbitofrontal cortex, where sexual, violent, and other primitive impulses normally arise. These impulses next move on to the caudate nuclei, which act as filters that send only the most powerful impulses on to the thalamus, the next stop on the circuit. If impulses reach the thalamus, the person is driven to think further about them and perhaps to act. Many theorists now believe that either the orbitofrontal cortex or the caudate nuclei of some people are too active, leading to a constant eruption of troublesome thoughts and actions (Endrass et al., 2011; Lambert & Kinsley, 2010). Treatment Exposure and Response Prevention (Exposure and ritual prevention) Victor Meyer (1966) a process whereby the rituals are actively prevented and the patient is systematically and gradually exposed to the feared thoughts or situations (clients are repeatedly exposed to objects or situations that produce anxiety, obsessive fears, and compulsive behaviors, but they are told to resist performing the behaviors they feel so bound to perform. Habit Reversal Training Habit reversal training (HRT) is a therapy that helps you stop or reduce the frequency of an unwanted behavior by replacing it with another Awareness training – identify the habit; self-monitoring Competing Response Training – learning alternative behaviors; practicing the competing response Generalization Training - individuals practice using their competing responses in various settings and situations to help generalize the new behavior beyond the therapy sessions. Social support and reinforcement Example: Out of any other intervention treatment, HRT has received the most empirical support for the effectiveness of treating trichotillomania. HRT aims to help clients uncover the situations that influence the onset of hair-pulling behaviors. These settings are then explored further and encouraged to be avoided when possible. Over time, replacement behaviors are also incorporated. Rather than pulling hair under stress, clients may squeeze a stress ball instead. This process repeats until a person achieves success. Cognitive Behavioral Treatments clients are first taught to view their obsessive thoughts as inaccurate occurrences rather than as valid and dangerous cognitions for which they are responsible and upon which they must act. As they become better able to identify and recognize the thoughts for what they are, they also become less inclined to act on them, more willing to subject themselves to the rigors of exposure and response prevention, and more likely to make gains using that behavioral technique. Biological Treatments Drug therapy The main medicines prescribed are a type of antidepressant called selective serotonin reuptake inhibitors (SSRI). An SSRI can help improve OCD symptoms by increasing the levels of a chemical called serotonin in your brain.