Obsessive Compulsive Disorder

1. Obsessive Compulsive Disorder

2. Features of OCD • Obsessions • Recurrent and persistent thoughts; impulses; or images of violence, contamination, and the like • intrusive and distressing • Individual tries to ignore, suppress, or neutralize • Compulsions • Repetitive behaviors individual feels driven to perform • Ritualistic/need to follow a set of rules • Intended to prevent or reduce distress or some dreaded event

3. DSM-IV Criteria • See webpage

4. OCD Features • Data from the Epidemiological Catchment Area (ECA) survey found a 6-month point prevalence of 1.6% and a lifetime prevalence of 2.5% in the general population • Sex ratio is 1:1.1 (men to women) • Mean age of onset is 20.9 years (SD=9.6) • Males is 19.5 years (SD = 9.2) • Females is 22.0 years (SD = 9.8) • Most develop their illness before the age of 25 • Symptoms can be remembered as far back as the onset of puberty.

5. Comorbidity • Major depression is the most common comorbid disorder • 1/3 have concurrent MDD • 2/3 have a lifetime history of MDD • Other Axis I disorders include panic disorder with agoraphobia, social phobia, generalized anxiety disorder, Tourette’s syndrome, trichotillomania, schizophrenia • Axis I comorbid disorders can effect the severity and treatment of OCD.

6. Comorbidity • Obsessive-compulsive personality disorder (OCPD) is an Axis II disorder. OCPD differs from OCD by the lack of true obsessions and compulsions. OCPD behaviors are ego-syntonic, whereas OCD is ego-dystonic

7. More features • Types of Obsessions • Aggressive obsessions • Contamination obsessions • Sexual obsessions • Hoarding/saving obsessions • Religious obsessions • Symmetry/exactness • Somatic obsessions

8. Types of compulsions • Cleaning/washing compulsions • Checking compulsions • Repeating rituals • Counting compulsions • Ordering/arranging • Hoarding/collecting • Mental rituals

9. Most people experience intrusive thoughts throughout their life • Individuals who develop OCD may react more negatively to their intrusions

10. Neurobiology/physiology • No chronic hyperarousal • Over activation of the orbitofrontal cortex (thought generation) and under activation of the caudate nuclei (thought suppression)

11. Psychosocial • Learning • Animal models • High stress or repeated frustration leads to increase in ritualistic-like behaviors • Fixed action pattern- innate and adaptive behavioral sequences to specific stimuli • Biological preparedness • Washing and checking may have once promoted survival

12. Cognitive deficits • Increased attention allocated to fear related stimuli • Tend to encode negative stimuli more indepth than neutral and positive stimuli, leading to better memory for negative stimuli • Overattention to detailh

13. Cognitive theory of OCD • Obsessional thoughts: • If obsessions occur frequently in normal populations, why don’t most people suffer from OCD? • It’s not the thought itself that is disturbing, but rather the interpretation of the thought. • Example: having an unacceptable sexual thought leads to beliefs that the person is depraved, perverted, abnormal, evil, etc…., which leads to affective states such as anxiety and depression. • The issue of responsibility is believed to be a core belief or cognitive distortion of people with OCD.

14. Compulsive behaviors: • Neutralizing, either through compulsive behaviors or mental strategies, is aimed at preventing terrible consequences, or averts the possibility of being responsible • Seeking reassurance is another form of neutralizing, as it can serve to spread responsibility to others, thus diluting that of the individual • Avoidance, though not an overt neutralizing behavior, is often used to prevent contact with particular stimuli

15. Model: • Stimuli in the form of unpleasant intrusive thoughts, of either external or internal origins are experienced • The thought is ego-dystonic, that is, it is inconsistent with the individual’s belief system • The NAT usually involves an element of blame, responsibility, or control, which interacts with the content of the intrusive thought • Disturbances in mood and anxiety follow, which in turn lead to neutralizing behavior

16. There are three main consequences of neutralizing behavior • It results in reduced discomfort, which leads to the development of compulsive behavior as a tool for dealing with stress. This reinforcing behavior may result in a generalization of this strategy • Neutralizing will be followed by non-punishment, and can lead to an effect on the perceived validity of the beliefs (NAT) • The neutralizing behavior itself becomes a powerful and unavoidable triggering stimulus. The neutralizing behavior serves to reinforce the belief that something bad may happen

17. Treatment • CBT • Exposure and response prevention was first used by Meyer in 1966 • The principle behind EX/RP is to expose the individual to the triggering stimuli (obsession) and block the neutralizing behavior • As a result, the individual learns: • Anxiety is temporary • The feared catastrophic consequence never transpires • Their interpretation of the obsession weakens • Obsessional thoughts are harmless • Imaginal exposure is also used when in-vivo is not possible

18. Components of EX/RP • Group treatment is comprised of 2 individual sessions and 12 group sessions • Individual treatment is also time limited and comprises approximately 12 to 14 sessions • Psychoeducation • Pre-treatment assessment of severity of OCD and depression • Hierarchy construction and explanation of SUDS

19. Treatment session: • Homework review • In-vivo exposure and response prevention, including monitoring SUDS level • Review of exposure • Homework assigned and next session’s exposure discussed • Termination session • Following a time limited (12-weeks) CBT approach, symptom reduction is maintained

20. Problems with CBT • 25% of people refuse to engage in CBT • CBT alone is ineffective when there is a severe comorbid major depression, over valued ideation, tic disorder, schizoid personality disorder • There is limited availability of therapists trained in CBT for OCD

21. Pharmacotherapy • Serotonin (5-HT) neurotransmission abnormalities have been implicated in the pathophysiology and treatment • Antidepressant medications of the Serotonin Reuptake Inhibitor classification and specific tryciclic antidepressants (Clomipramine) have been proven to be effective in the treatment of OCD

22. Currently there are 6 SRIs that are FDA approved for the treatment of OCD • Clomipramine (Anafranil) • Fluoxetine (Prozac) • Fluvoxamine (Luvox) • Paroxetine (Paxil) • Sertraline (Zoloft) • Citalopran (Celexa) • The goal of a SRI is to increase the level of 5-HT transmission within the synapse