ocd_2024.pdf

PSYC30014 P S Y C H O PAT H O LO G Y O F E V E R Y D AY L I F E OBSESSIVE – COMPULSIVE AND RELATED DISORDERS PROF LISA PHILLIPS TODAY’S LECTURE AIMS TO… 1 2 3 4 Introduce you to the Develo...

PSYC30014 P S Y C H O PAT H O LO G Y O F E V E R Y D AY L I F E OBSESSIVE – COMPULSIVE AND RELATED DISORDERS PROF LISA PHILLIPS TODAY’S LECTURE AIMS TO… 1 2 3 4 Introduce you to the Develop an understanding Introduce you to some of Introduce you to some of features of the disorders about why these the contemporary models the controversial issues included in the DSM5 disorders are considered for understanding the associated with these section ‘OCD and related together in the DSM5; development and/or disorders. disorders’; maintenance of these disorders; DSM5: OC AND RELATED DISORDERS Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Trichotillomania (Hair-Pulling Disorder) Excoriation (Skin-Picking 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  OCD- DIAGNOSTIC CRITERIA (DISTILLED!) The experience of obsessions, compulsions or both; These experiences cause marked distress, are time consuming (>1 hr/day) or significantly interfere with functioning and relationships. Specify if: – Good/fair insight – Poor insight – Absent insight/delusional beliefs  OBSESSIONS Persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and cause marked anxiety or distress; Individual may recognize these experiences as products of their own mind.  OBSESSIONS: COMMON TYPES Fears of contamination Repeated doubts (safety, scruples) Need to have things in a particular order Sexual, horrific or blasphemous imagery Aggressive or inappropriate impulses Nonsensical thoughts or images  COMPULSIONS Repetitive behaviour (handwashing, checking) or mental acts (praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety; Can include rigid/stereotyped acts according to elaborate rules without any real explanation of them. COMPULSIONS: COMMON TYPES Washing and cleaning Checking Repeating Ordering Mental rituals (eg. Counting, prayers) Reassurance seeking Compulsive shopping RATES OF SYMPTOMS IN GENERAL POPULATION Up to 80% of population may experience intrusive, unpleasant, unwanted thoughts; More than 50% population may engage in ritualised behaviour Crino, Slade & Andrews, 2005  PREVALENCE OF OCD SYMPTOM DIMENSIONS 14 12 10 8 6 4 2 0 Fullana et al., 2010  OCD 12 month prevalence: 1.2% Lifetime prevalence: 2.3% US Data- Ruscio et al., 2010 No difference in prevalence rates between mae and female adults Average of onset- ~19 years- but childhood onset and later age onset not unknown; No difference b/w OCD and non-OCD in gender, marital status, education, migration status, urbanicity; Usually fluctuating course- often waxing and waning in conjunction with stress levels; Chronic course in approx 50% of cases. CHILDHOOD ONSET OCD Between one third and one half of adult patients report that they first developed OCD during childhood; Childhood onset OCD more common in boys than girls? – Geller et al., 1998; Geller, Biederman, Faraone, Bellordre et al., 2001; Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989;Tükel et al., 2005; Zohar et al., 1997  COMMON SYMPTOM PROFILES 90% of patients with OCD have obsessions and compulsions 8-20% have obsessions and mental rituals, but not behavioural compulsions OCD- gender 18 16 14 12 10 8 6 4 2 0 Gender Male Gender Female Fullana et al., 2010 OCD- GENDER 90 80 70 60 50 40 30 20 10 0 Total cohort Men Women Torresan et al., 2013  OCD- COMORBIDITY major depressive disorder: 28.4%; obsessive–compulsive personality disorder: 24.5%; generalized anxiety disorder: 19.3%; specific phobia: 19.2%; social phobia: 18.5%; Suicidal ideation within the last month:6.4%; Lifetime history of suicide attempt: 9.0% Brakoulias et al., 2017  CAUSES OF OCD Learned responses Genetic predispositions – Mutations in hSERT gene linked to OCD Environmental factors – Early life experiences may increase vulnerability Brain structure and function OCD AND THE BRAIN RATES OF SYMPTOMS IN GENERAL POPULATION Up to 80% of population may experience intrusive, unpleasant, unwanted thoughts; More than 50% population may engage in ritualised behaviour Crino, Slade & Andrews, 2005  OCD- COGNITIVE BEHAVIOURAL MODEL 1. Begins with the premise that intrusive thoughts are normal 2. However, certain individuals place meaning on these thoughts, and thus respond to them in some way (avoid, suppress, ritualise etc). 3. These responses increase vigilance for the intrusive thoughts and protects the meaning of the intrusion. Salkovskis, P. (1985). Obsessional- compulsive problems: A cognitive- behavioural analysis. Behaviour Research and Therapy, 23, 571-583.  OCD- cognitive model I touched a letter which might have Trigger been touched by someone with HIV I may have been infected, I will pass on the infection Obsession/intrusion to my family and I will be held I feel better because responsible I acted responsibly Relief Anxiety I can’t tolerate these thoughts Compulsion Handwashing Avoidance Avoids touching objects From: Salkovskis, Forrester & Richards, 1998 OCD- COGNITIVE FACTORS Intrusive thoughts might become obsessions if they are evaluated as: Overly important (‘if I’m thinking this way, it must be important’); Highly threatening (‘if I continue to think like this, something bad will happen’); Requiring complete control (‘I’ve got to stop thinking this way’); Necessitating a high degree of certainty (‘I need to be certain that nothing bad will happen’) Associated with a state of perfection (‘I can’t stop thinking about this until I do it perfectly’) Clark & O’Connor, 2005  OCD AND COVID-19 A sizable proportion of people with OCD (but not all) experienced/reported symptom worsening during the pandemic, especially during initial restrictions (approximately 20–65 % of cases in longitudinal studies); Some evidence for a particularly worse course for those with contamination symptoms, COVID-19 became a central theme for many people with OCD, particularly those with contamination symptoms participants in specialty care reported less impact from the pandemic OCD AND COVID-19 Guzick, A.G., Candelari, A., Wiese, A.D. et al. Obsessive–Compulsive Disorder During the COVID-19 Pandemic: a Systematic Review. Curr Psychiatry Rep 23, 71 (2021). https://doi.org/10.1007/s11920-021-01284- 2 Grant, J.E., Drummond, L., Nicholson, T.R., Fagan, H., Baldwin, D.S., Fineberg, N.A., & Chamberlain, S.R. (2022). Obsessive-compulsive symptoms and the Covid-19 pandemic: A rapid scoping review, Neuroscience & Biobehavioral Reviews, 132, 1086-1098, DOI: 10.1016/j.neubiorev.2021.10.039. Zaccari V., D'Arienzo, M.C., Caiazzo T., Magno A., Amico G., & Mancini, F. (2021) Narrative Review of COVID-19 Impact on Obsessive-Compulsive Disorder in Child, Adolescent and Adult Clinical Populations. Frontiers in Psychiatry, 12, DOI: 10.3389/fpsyt.2021.673161.  BODY DYSMORPHIC DISORDER  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 BODY individual has performed repetitive behaviors (e.g., mirror DYSMORPHIC checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her DISORDER- appearance with that of others) in response to the appearance concerns. DIAGNOSTIC C. The preoccupation causes clinically significant distress or CRITERIA impairment in social, occupational, or other important areas of functioning. (DISTILLED!) 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.  BDD: PREVALENCE 0.7- 2.4% (Buchanan et al., 2011) Higher rates amongst dermatology, cosmetic surgery, adult orthodontic and oral/maxillofacial surgery patients;  BDD: ONSET AND COURSE The mean age at disorder onset is 16–17 years- although not usually diagnosed until 10-15 years later. Patients generally present to services for secondary or associated disorder (OCD, depression etc); Approximately 25% patients attempt suicide; Disorder usually chronic, although improvement is likely when evidence-based -treatment is received; Individuals with disorder onset before age 18 years are more likely to attempt suicide, have more comorbidity, and have gradual (rather than acute) disorder onset than those with adult-onset body dysmorphic disorder.  BDD: GENDER DIFFERENCES No difference in prevalence rates; More similarities than differences in most clinical features—for example, disliked body areas, types of repetitive behaviors, symptom severity, suicidality, comorbidity, illness course, and receipt of cosmetic procedures; However, males are more likely to have genital preoccupations, and females are more likely to have a comorbid eating disorder. Muscle dysmorphia occurs almost exclusively in males BDD: IMPACT ON FUNCTIONING Can range from moderate (e.g., avoidance of some social situations) to extreme and incapacitating (e.g., being completely housebound); – job, academic, or role functioning (e.g., as a parent or caregiver), which is often severe (e.g., performing poorly, missing school or work, not working) – social functioning (e.g., social activities, relationships, intimacy), – psychiatric hospitalisation  BDD: COGNITIVE PROCESSES Compared to healthy controls individuals with BDD: – Evaluate appearance more negatively – Endorse assumptions about appearance such as “If my appearance is defective then I am worthless” – Overvalue physical appearance and attractiveness – Experience more anxiety and discomfort after mirror gazing – Experience more distress and self-focussed attention after mirror gazing – Engage in ruminative thinking- such as ‘Why am I so ugly’ – Engage in repeated reviews of past-appearance related experiences – Kollei & Martin, 2014 BDD & MEDICAL INTERVENTIONS Of 268 patients seeing dermatologist ~12% met criteria for BDD (Phillips et al., 2000); Approx 45% of BDD pts seeking dermatological treatment and 23% seeking plastic surgery (Phillips et al., 2001) Therefore individuals with BDD: Make up a significant proportion of people seeking assistance from dematology or plastic surgery- BUT Unlikely to be happy with the result, may return time and again for treatment and can be litigious. BDD AND CULTURE What is the role of culture or social pressures in development of BDD? Muscle Dysmorphia HOARDING DISORDER  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. HOARDING C. The difficulty discarding possessions results in DISORDER: the accumulation of possessions that congest and clutter active living areas and substantially DIAGNOSTIC compromises their intended use. If living areas CRITERIA are uncluttered, it is only because of the interventions of third parties (e.g., family (DISTILLED) 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: PREVALENCE Estimated to be between 2-6% adults in Europe and US Nordsletten et al. (2013)- 1.5% adults in South London Affects males and females- possibly more common in males (although more females present for treatment); More common in older adults than younger adults. COGNITIVE FACTORS ASSOCIATED WITH HOARDING BEHAVIOUR Control over possessions Concern about memory Responsibility over possessions – (After age, mood (depression and anxiety), OCD symptoms and other OCD-related cognitive variables controlled for) Steketee, Frost and Kyrios, 2003  HOARDING ANIMALS The compulsive need to collect and own animals for the sake of caring for them that results in accidental or unintentional neglect or abuse. Animals may provide a conflict-free relationship with the individual, unconditional love; Alternatively, perceptions of being a refuge for unloved animals may provide the individual with a sense of purpose, a special role, means that they are loving and caring; BUT… In many cases, everyone suffers with animal hoarding—the animals, the hoarder, and those who love the hoarder. TRICHOTILLOMANIA A N D E X C O R I AT I O N  TRICHOTILLOMANIA (HAIR PULLING) 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).  TRICHOTILLOMANIA Prevalence – 1-2% adults (Stein et al., 2010) – ?More females affected Course of illness – Usually chronic- but can wax and wane Functional consequences – Social/occupational impairment – musculoskeletal injury (e.g., carpal tunnel syndrome; back, shoulder and neck pain), – blepharitis, – dental damage (e.g., worn or broken teeth due to hair biting). – Swallowing of hair (trichophagia) may lead to trichobezoars, with subsequent anemia, abdominal pain, hematemesis, nausea and vomiting, bowel obstruction, and even perforation (taken from DSM5) EXCORIATION (SKIN-PICKING) DISORDER 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).  EXCORIATION Prevalence 1-2% adults (Stein et al., 2010) ?More females affected Course of illness Usually chronic- but can wax and wane Functional consequences Social and occupational impairment tissue damage, scarring, infection frequently requires antibiotic treatment for infection, and on occasion it may require surgery (taken from DSM5)  TRICHOTILLOMANIA AND EXCORIATION: PSYCHOLOGICAL ASPECTS Motivated by stimulation of positive mood or feelings (i.e., pleasure, gratification or relief) or regulation of states of high or low arousal (i.e., anxiety or boredom); Approximately 1/5- 1/3 people with SPD or trich report being in a trance/feeling mesmerized/ experiencing depersonalisation while picking/ hair pulling; Substantial proportion of sufferers in both groups report little or no reflective awareness of the act as it occurs – Two subtypes proposed “automatic pulling/picking” that occurs out of reflective awareness in sedentary situations; “focused pulling/picking”, happens in full awareness in response to urges or negative affective states. (Snorrason et al., 2012)  TRICHOTILLOMANIA AND EXCORIATION: PSYCHOLOGICAL CONSEQUENCES Shame, distress, embarrassment; BUT Hair pulling and scratching also reduce unpleasant emotions OCD AND RELATED DISORDERS- SUMMARY Considered together in Can all be highly DSM because they are all distressing and associated Are all amenable to characterised to some with severe levels of psychological treatment- extent by intrusive disability, dysfunction and but motivation is the key. thoughts and repetitive comorbidity; behaviours;