Obsessive-Compulsive and Related Disorders PDF

Obsessive-Compulsive and Related Disorders Prepared by: Adrian Kwachinangol What is OCD? OBSESSIVE COMPULSIVE AND RELATED DISORDERS (DSM -5) Obsessive compulsive disorder Body dysmorphic disorder Hoarding disorder Trich...

Obsessive-Compulsive and Related Disorders Prepared by: Adrian Kwachinangol What is OCD? OBSESSIVE COMPULSIVE AND RELATED DISORDERS (DSM -5) Obsessive compulsive disorder Body dysmorphic disorder Hoarding disorder Trichotillomania (hair pulling disorder) Excoriation disorder (skin picking) Substance/medication induced OCD and related disorders Obsessive compulsive disorders due to medical condition Other specified obsessive compulsive disorder Unspecified obsessive compulsive disorder Debunking the myths of OCD MYTH 1: REPETITIVE BEHAVIOR OR RITUALISTIC BEHAVIORS ARE SYNONYMOUS WITH OCD. MYTH 2: THE MAIN SYMPTOM OF OCD IS EXCESSIVE HAND WASHING MYTH 3: INDIVIDUALS WITH OCD DON’T UNDERSTAND THAT THEY ARE ACTING IRRATIONALLY. OCD IS CHARACTERIZED BY THE PRESENCE OF OBSESSIONS AND/OR COMPULSIONS. What is obsession? Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, Obsession and persistent thoughts, impulses, or images that cause distressing emotions such as anxiety or disgust. These intrusive thoughts cannot be settled by logic or reasoning. Typical obsessions include excessive concerns about contamination or harm, the need for symmetry or exactness, or forbidden sexual or religious thoughts Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. Although the compulsion may bring some relief to the worry, the obsession returns and the cycle repeats over and over. Some of the common compulsions include cleaning, repeating, checking, ordering and arranging , Mental compulsions e.t.c (OCD) is a chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over. These obsessions and compulsions are severe enough to cause significant distress or impairment in the social, occupational and other important areas of functioning Obsessive-Compulsive Disorder  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). 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.  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; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin- picking] disorder;  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. Specifiers Many individuals with obsessive-compulsive disorder (OCD) have dysfunctional beliefs. These beliefs can include an inflated sense of responsibility and the tendency to overestimate threat; perfectionism and intolerance of uncertainty; and over-importance of thoughts(e.g., believing that having a forbidden thought is as bad as acting on it) and the need to control thoughts. Up to 30% of individuals with OCD have a lifetime tic disorder. This is most common in males with onset of OCD in childhood. These individuals tend to differ from those without a history of tic disorders in the themes of their OCD symptoms, comorbidity, course, and pattern of familial transmission. Development and Course  In the United States, the mean age at onset of OCD is 19.5 years, and 25% of cases start by age 14 years. Onset after age 35 years is unusual but does occur. Males have an earlier age at onset than females: nearly 25% of males have onset before age 10 years. The onset of symptoms is typically gradual; however, acute onset has also been reported. Compulsions are more easily diagnosed in children than obsessions are because compulsions are observable. However, most children have both obsessions and compulsions (as do most adults). ETIOLOGICAL FACTORS PSYCHOANALYTIC THEORY  when unacceptable wishes and impulses from the id are only partially repressed. Freud viewed OCD as a manifestation of unresolved conflicts, often linked to childhood experiences and repressed emotions.  OCD may reflect a struggle between the ego and superego, where the superego imposes strict moral standards  PSYCHOSOCIAL FACTORS: Disturbed mother child relationship Fear of abandonment Recent object loss Emotional neglect Childhood abuse (physical, emotional or sexual) Cognitive Theory: Dysfunctional beliefs are the route cause for OCD and the strength with which it is held determines the risk of developing OCD Biological Factors: First degree relatives. Identical twins 2.Neurotransmitters Imbalance in serotonin , dopamine and glutamate 3.Neuroanatomical Factors: There is evidence of abnormal brain structure and activity in patients with OCD. TREATMENT EXPOSURE RESPONSE PREVENTION ACCEPTANCE COMMITMENT THERAPY “ Body Dysmorphic Disorder ” Body Dysmorphic Disorder: DSM-5 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. Specify if: With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular.  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 BDD beliefs are definitely or probably not true, or that they may or may not be true.  With poor insight: The individual thinks that the BDD beliefs are probably true.  With absent insight / delusional beliefs: The individual is completely convinced that the BDD beliefs are true.  BDD is not vanity: It is just the opposite. People with BDD believe or fear that they are ugly or deformed Appearance obsessions: Usually about multiple body parts; can be specific or vague; any part of the body can be involved Most common body parts involved: Skin, Face, Hair, Nose, Stomach, Teeth, Breasts, Genitals, Muscles Intense shame and disgust regarding the area of their body with which they are preoccupied C Poor insight 70% of patients with BDD have ideas of reference (IOR) 35-50% are delusional about their appearance Poorer insight correlated with higher negative affect, lower positive affect, and lower self-esteem in BDD Across time, self-esteem and insight influenced each other reciprocally, with comparatively stronger effects for the prediction of poorer insight by previously lower self-esteem (Phillips et al, 2014; Schulte et al, 2021) Clinical presentation Compulsions: grooming, mirror-checking, skin-picking, camouflaging, comparing own body to others’, reassurance-seeking, etc. 70% of patients with BDD have cosmetic, dermatological, or plastic surgery; the vast majority are dissatisfied with its results Severe avoidance: of school, work, social events; most are unmarried Severe functional impairment and low Quality of life (QOL) (Phillips 1991; Phillips & Kelly, 2021) Epidemiology  Prevalence  ONSET  1.9% point prevalence in  Mean age 16+/- 7 (range 4-43) community Changes with age (2%  Usually begins gradually adolescents, 4% 18-44; 1.4% > 45)  Mean onset of Sub-clinical BDD at  10-12% in psychiatric outpatients 12.9 6-15% in plastic surgery patients 3-15% in dermatological settings  second peak of incidence after Male : Female = 1:1 menopause Comorbidity Major Depression: 75-80% lifetime prevalence OCD: 20-35% prevalence in BDD patients; 10-25% of OCD patients have BDD Substance Abuse: 49% lifetime Social Phobia: 37-39% lifetime, 31-34% current Eating Disorders: 20-33% lifetime Panic Disorder: 20% lifetime Personality Disorders: 40% (mostly Avoidant and Dependent) (Phillips et al, 2005) CASUSES AND TREATMENT Childhood abuse Reported rates of abuse Self-reported origins Emotional Neglect or Abuse: 28-68% Being bullied in childhood Physical Abuse: 14-35% External critique of appearance Sexual Abuse: 22-28% Rejection, Shame, Feeling Severe Maltreatment: 40% Inadequate Emotional and Physical Abuse (Didie et al, 2006; Neziroglu et al, 2006; Malcolm et al, 2021) (Craythorne et al, 2022; Longobardi et al, 2022) Assessment measures Body Dysmorphic Disorder Questionnaire (BDDQ) Excellent quick screening tool Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) Rates severity of BDD symptoms Brown Assessment of Beliefs Scale (BABS) Rates insight in multiple domains CBT for BDD Appearance vs body image Objective vs subjective The focus of treatment is the client’s personal evaluation of their features and their responses to the interpretation Responses will reinforce maladaptive interpretation HOARDING DISORDER KWEK KWEK The acquisition and failure to discard a large number of items that appear to be useless or of limited value. Living spaces are significantly cluttered preventing engagement in activities for which those spaces were designed or intended. Significant distress or impairment in functioning caused by the hoarding DSM V 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).  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  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.  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. Hoarding Disorder now falls under the category of OCD and related conditions. Is similar to OCD in that there are obsessions and compulsions. Difference is that the obsessions are not bizarre, unwanted or intrusive. Compulsions are designed to produce relief in both, however in compulsive hoarding there is a pleasurable aspect PREVALENCE AND STATISTICS Usually starts in adolescence, around age 12, and tends to get worse with age. Average age is 50, single and living alone. Education ranges and thought to occur more in men than women. More likely to hoard if they have close family members who engage in compulsive hoarding. What is the Difference Between a Collector and a Hoarder? Collector: Admires, enjoys, and can use or display the items. Brings pleasure to the person acquiring the items that have a home. Hoarding: Excessive number of items; repeat purchase of items; items get lost or damaged; no system to the items acquired; have no home. Excoriation Disorder Excoriation disorder, also known as dermatillomania, skin-picking disorder and neurotic or psychogenic excoriation, is a new entry in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). A disorder of impulse control characterized by the urge to pick at the skin, even to the extent that damage is caused. Obsessive picking at the skin has undoubtedly taken place for centuries, but the first formal description of acne excorieé was published by Louis Brocq at the end of the 19th Century (Brocq, 1898). Excoriated acne was placed by dermatologists in the category of neurodermatitis, representing a neurotic reaction to acne (Adamson, 1915) or the exacerbation of urticaria by anxiety (Wrong, 1954) SYMPTOMS  The cardinal symptom is a compulsive urge to pick, squeeze or scratch an area of skin, often a perceived skin defect, when under stress or experiencing anxiety (Dell’Osso et al., 2006)  The face is predominantly involved, followed by the extremities and scalp; there is often a primary site of skin picking, but the skin picking is sometimes shifted to allow an injured area to heal (Orlaug and Grant, 2010)  Picking is usually done for brief periods at a time but may be engaged in incessantly, particularly by developmentally disabled patients (Lang et al., 2010).  The fingers are usually used to pick, but some patients excoriate the skin with tools such as needles or tweezers, and are apt to do this in response to feeling anxious or depressed or after examining the skin and finding perceived irregularities (Stein et al., 2010). DIAGNOSTIC CRITERIA  A. Recurrent skin picking  The individual engages in recurrent skin-picking behaviors, resulting in skin lesions.  B. Repeated attempts to stop  The individual has made repeated efforts to decrease or stop the behavior.  C. Distress or impairment  The skin-picking behavior causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.  D. Not attributable to a substance or medical condition  The behavior is not due to the physiological effects of a substance (e.g., cocaine) or a medical condition (e.g., scabies). ANO ANG SAY NG DSM?  The justification for a separate DSM-5 diagnosis is that skin excoriation can occur as a primary disorder without other obsessions or compulsions and with no concerns about bodily abnormality, appears to be common in the population and can be effectively treated if patients can be encouraged to seek help for a disorder  It has been suggested that skin-picking disorder is more like substance abuse than obsessive- compulsive disorder (Orlaug and Grant, 2010) Skin-picking has been analogized to the compulsive hair pulling of trichitillomania because both are obsessive ritualistic behaviors but are not preceded by obsessive thoughts, both are triggered by anxiety or depression Epidemiology  The prevalence of the condition is estimated between 1.4 and 5.4 percent of the population. Community surveys have suggested that 4 to 5 percent have skin-picking, while telephone surveys have found skin-picking to the point of causing lesions in 16 percent and criteria for the diagnosis in 1 to 2 percent, and 2 percent of dermatology patients have skin excoriation  About half of patients have onset before age 10, with a significant minority developing dermatillomania between 30 and 45 years of age (Orlaug and Grant, 2010) Causes  In addition to self-disfigurement to reduce attractiveness due to psychosexual conflicts, psychodynamic explanations of skin excoriation have invoked repressed rage of children against authoritarian parents (Lang et al., 2010).  Dermatillomania has also been suggested to be a maladaptive coping mechanism for stress or anxiety in individuals with impaired coping, such as with developmental disability (Lang et al., 2010). Use of drugs that enhance dopamine levels or effect, such as cocaine and methamphetamine, can cause intense skin-picking, while dopamine antagonists will ameliorate skin-picking, and in particular naltrexone, which blocks the dopaminergic reward system and is used to treat addiction, is sometimes effective against dermatillomania.  Treatment of Excoriation Disorder  SSRI antidepressants are the mainstay of treatment of other obsessive-compulsive disorders but have not been systematically studied here; tricyclic antidepressants (doxepin, clomipramine), typical and atypical neuroleptics (pimozide, olanzapine)  Habit reversal training is coupled with awareness training to focus attention on the picking behavior, and competing response training teaches patients to execute a different motor response, for example making a fist, in situations that usually trigger skin-picking (Lang et al., 2010). Acceptance and commitment therapy and cognitive behavioral therapy have been effective in cognitively-intact patients (Ruiz, 2010), TRICHOTILLOMANIA (HAIR-PULLING DISORDER) Trichotillomania, also known as hair pulling disorder (HPD), is a psychiatric illness affecting up to 4% of the population. Individuals with trichotillomania feel compelled to pull hairs, either from their head or elsewhere, resulting in hair loss and other forms of impairment. Trichotillomania is an impulse control psychiatric disorder within the group of conditions known as body-focused repetitive behaviors (BFRBs). Such conditions are characterized by self-grooming through pulling, picking, scraping or biting the hair, nails or skin, often causing damage. An individual with trichotillomania experiences an irresistible urge to pull out hair from the scalp or other places, such as the eyelashes or eyebrows The condition most commonly presents at or following the onset of puberty and is more prevalent among females than males at a ratio of 10:1. The onset for trichotillomania is typically in early adolescence  Symptoms Constant pulling or twisting hair Bald patches or hair loss Uneven hair appearance Denial of the hair pulling Obstructed bowels if the hair is consumed Tension before hair is pulled and relief or gratification after Other self-injury behaviors Poor self-image Feeling sad, depressed or anxious five main criteria that one must meet to formally be diagnosed with trichotillomania, according to the DSM-5  1. Noncosmetic hair removal: The main criterion for this disorder is that one must repetitively remove hair from anywhere on the body for noncosmetic reasons.  2. Multiple attempts to decrease/stop pulling: An individual who pulls his or her hair must have made repeated attempts to decrease or stop hair pulling in order to receive a formal diagnosis of trichotillomania. 3. Distress and/or functional impairment: For one to formally be diagnosed with trichotillomania, one must also endorse subjective distress and/or functional impairment as a result of his or her pulling behaviors. Individuals sometimes experience very high levels of distress from their pulling, noting that these behaviors may cause embarrassment, shame, or self-consciousness. If one is not distressed about his or her pulling, there must be evidence of some impairment in one or more areas of life functioning (i.e., work, school, and/or social functioning). 4. Not caused by another medical condition: The presence of an underlying medical etiology as the cause of any hair-pulling behavior or depilated areas of the body must be ruled out. 5. Not caused by another mental disorder: In some cases, individuals will present with hair pulling behavior that resembles trichotillomania; however, the underlying cause will be another mental disorder  Causes There is no single known cause for trichotillomania. Genetics, as well as environmental factors, likely play a role in the development of the disorder. Other factors that may contribute to the onset of trichotillomania include: A chemical imbalance in the brain Hormonal changes during puberty A coping mechanism for dealing with stress A form of self-harm to relieve distress LIVING WITH TRICHOTILLOMANIA People affected by trichotillomania can be mildly or severely affected by the condition. While some individuals might find the disorder frustrating or annoying, others may be embarrassed or ashamed of their condition, becoming withdrawn and avoiding social situations out of fear that the disorder should be discovered.  Someone with trichotillomania may also be susceptible to a number of physical effects, including infection, tissue damage and injuries to the muscles or joints as a result of repetitive motion.  TREATMENT FOR TRICHOTILLOMANIA  Cognitive behavioral approaches are the first-line treatment for trichotillomania and have consistently demonstrated efficacy in research trials.  Habit Reversal Therapy (HRT) with stimulus control is utilized. In a typical course of HRT + stimulus control for trichotillomania, patients will: Try to understand the triggers that cause them to pull their hair; Develop a competing response that they can do instead of pulling at their hair; Identify someone in their life who can serve as a support person (or persons) in encouraging them to engage in this alternative response to pulling When the urge arises, instead of pulling out hair, sufferers can try: - Using a fidget toy or squeezing a stress ball - Relieving stress by taking a hot bath - Breathing deeply until the urge has subsided - Tensing the arm to form a fist - Keeping hair cut short or wearing a tightly-fitting hat - Exercising - Repeating a phrase out loud until the urge has passed Medication fluoxetine (Prozac) sertraline (Zoloft) fluvoxamine (Luvox) paroxetine (Paxil) clomipramine (Anafranil) valproate (Depakote) lithium (Lithobid, Eskalith)