Obsessive Compulsive Disorder: Description and Assessment

Beth McCreary, Ph.D. October 18, 2008

Overview
Basic Definitions (obsessions, compulsions, OCD) Subtypes Prevalence & Comorbidity Discriminating OC symptoms / OCD from other symptoms and diagnoses

Overview (continued)
Contributing Factors Assessment Impact on families

Basic Definitions (DSM-IV)

Obsessions: . . .persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress.

Defining Features of Obsessions (Clark, 2004; Table 2.2)

Intrusive Quality

I dont want to be thinking this right now

I cant stand the emotional distress this brings

Unacceptability

Subjective Resistance

Im not going to let myself think this

I cant not think this; I cant stop it This just isnt who I am; how could I be thinking this?

Uncontrollability

Ego-dystonicity

Basic Definitions (DSM-IV)

Compulsions: . . .repetitive behaviors . . .or mental acts . . .the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification.

Basic Definitions (DSM-IV)

Obsessive Compulsive Disorder: A. Either obsessions or compulsions B. Person (except children) recognized that the obsessions or compulsions are excessive/unreasonable C. Obsessions or compulsions cause marked distress, are time consuming (>1 hour/day), or significantly interfere with normal routine/functioning/relationships

Subtypes of Obsessions

In order of prevalence (roughly):

Fear of contamination (Cleaners) Pathologic doubt (Checkers) Aggression or sexuality (Images / impulses) Need for symmetry/precision (Exactness) Religious scrupulosity Idiosyncratic / Superstitious Hoarding

Additionally

Subtypes: Contamination

Contracting illness in self (germs)

Danielle: Fears doorknobs, public restrooms, restaurants, trash, sneezing/coughing people, shoes, sex . . .

Spreading illness to others Poisoning self

Andy intensely anxious after noticing window cleaner near milk on counter Jill exposed to carcinogenic substance a decade earlier

Poisoning others Associated Compulsions:

Excessive cleaning / handwashing / showering / laundry / segregating toxins Enormous time consumption

Subtypes: Doubt

Safety: Forgetting to turn off appliances or lock doors; fearing fire/burglary/disaster Performance: Forgetting to sign the check or complete the email; fearing embarrassment

Robin feared being reprimanded at work for making mistakes in calculationsgot reprimanded for taking too long to complete tasks

Driving: Fearing having hit someone Associated Compulsions:

Repeatedly Checking / Reassurance Seeking Again, enormous time consumption

Subtypes: Aggression

Image / impulse to harm someone else

Joe had visions of pushing baby stroller into traffic Ellen thought she would stab someone Postpartum fears of dropping/throwing baby

Impulse to harm self

Step in front of vehicle Throw self out window

Subtypes: Sexuality

Fearing committing an inappropriate or unacceptable behavior

Fearing molesting a child

Disgust at ones own sexual thoughts

Thoughts are graphically sexual and may occur when person is in public Men who fear homosexual thoughts

Subtype: Need for Precision / Symmetry / Exactness

Items (e.g., in closet or on desk) must be ordered a certain way Car has to be pulled into the driveway perfectly Behavior must be performed until it feels just right Fearing feeling upset / uncomfortable and being unable to concentrate on other things, indefinitely

Subtype: Religious Scrupulosity

Thinking God is angry / upset with him/her, and that s/he may be condemned due to displeasing God

Stacy thought about all of her unpleasant emotions as sins worthy of condemnation

Blasphemous thoughts while reading Bible, profanity in head, intrusive sexual thoughts in church or reading Bible

Steve had graphic sexual images appear in his mind whenever looking at the crucifix

Subtype: Idiosyncratic/Superstitious

Believes ones own behavior will negatively affect self or others

Kate thought if she made a mistake in writing, that her mother would suffer a heart attack or some other dire health problem Gene believed that he had to park in the same spot and take the same door and set of stairs at work every day, or else bad things would happen in his work day Tom feared certain numbers and colors indicated bad things would happen

Subtypes: Hoarding
Fears accidentally throwing away something important Fears needing later something that was intentionally discarded

Prevalence

2-3 % of the population will suffer from OCD (in the lifetime) Equally common in males and females Age at onset usually adolescence or early adulthood

6-15 years in males 20s in females

In children, washing, checking, and ordering are common presentations (as in adults)

Comorbidity

People diagnosed with OCD also often have:

Most often

Depression (2/3 with OCD will develop depression in the lifetime) Social Phobia (10-40%, lifetime) Other anxiety disorders (e.g., panic, worry; 10-40%)

Next

Eating Disorders Tics

ComorbidityTourettes Syndrome

In those with TS, 35-50% can also be diagnosed with OCD; more with OC symptoms Of those with OCD, 5-7% can be diagnosed with TS Of those with OCD, 20-30% have current or past tics Some research to say that the exactness subtype of OCD is particularly linked to TS

Discriminations

Depression:

Rumination about upsetting past events, or self-criticisms, may have an obsessional nature--but not ego-dystonic. Mood congruent.
Excessive concern about real-life circumstances, possible events

Worry:

Discriminations

Hypochondriasis:
Somatic Obsessions? Persistent fears of becoming ill (with cancer or AIDS, e.g.) Misinterpreting bodily symptoms as signs of severe illness

Discriminations

Tourettes Syndrome:
Compulsions are intentional behaviors meant to neutralize anxiety or prevent something bad from happening Tics are involuntary and are not intended to alleviate anxiety (although they may occur more often under anxiety, and one may temporarily resist tics but this often results in a subsequent increase)

Contributing Factors to OCD: Overview

Primary
Genetics Environmental influences

Mediating
Structural Correlates Biochemistry

Commonality with TS

Contributing Factors to OCD: Genetics

OCD proposed to be a spectrum of disorders (subtypes?) that share some of the same genes No specific genes identified MZ twins more likely than DZ twins to exhibit OCD symptoms

Contributing Factors to OCD: Genetics

Those with OCD more likely to have parents and children with OCD or OC behaviors than those without OCD Roughly 40% of those with OCD have a biological relative with OCD Within families, many different specific OC behaviorsso not likely learned

Contributing Factors to OCD: Environmental

Brain Injury (damage basal ganglia and connections to frontal lobes)

Caused by anoxia, toxic exposure (e.g., CO poisoning), brain infection (e.g. viral encephalitis), substance abuse

Bacterial Infection (again, damage to basal ganglia)

PANDAS: pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections Sydenhams chorea

Contributing Factors to OCD: Brain Structures / Functioning

Basal Ganglia
Animal studies: Basal ganglia damage leads to repetitive behaviors (like compulsive rituals) Patients with Parkinsons, Huntingtons chorea, or other diseases involving basal ganglia deterioration are at increased risk of developing OCD symptoms Hyperexcitability of basal ganglia pathways seen in OCD

Contributing Factors to OCD: Brain Structures / Functioning

Amygdala
Increased activity when exposed to pictures of contaminated environments Responds differently in those with OCD than in controls when exposed to fearful or neutral stimuli

Contributing Factors to OCD: Brain Structures / Functioning

Increased orbital-frontal region activity Some have increased activity in the caudate nucleus (part of basal ganglia) Orbital-frontal and basal ganglia activity within OCD increases with exposure to feared stimuli Successful treatment with SSRI or behavioral therapy will lead to normalized brain activity in these areas

Contributing Factors to OCD: Biochemical

Most theories concerning OCDs etiology include some type of abnormal function in the neural circuits between the frontal lobe and the basal ganglia within the brain. Serotonin and dopamine are the primary neurotransmitters for the neural circuits that connect these areas. (Steketee & Pigott, 2006; p. 59)

Contributing Factors to OCD: Biochemical

Serotonin
Seems to be implicated in OCD, but not necessarily causative Medications that alleviate OCD symptoms often affect the serotonin system Most people with OCD have normal blood levels of serotoninthis doesnt indicate basal ganglia or other brain levels Serotonin function is implicated in MANY behaviorsnot a very specific indicator

Contributing Factors to OCD: Commonality with TS

Genetics
Those with OCD are 4 times more likely than those without to have a family member with TS or tics. Again, tic-related OCD may emerge as a specific subtype of OCD, involving the symmetry/exactness group of OCD symptoms

Contributing Factors to OCD: Commonality with TS

Structural

Basal ganglia dysregulation (hyperexcitability) is linked to TS and tics

Environmental (with structural effects)

PANDAS Sydenhams chorea

Assessment

May Include
Clinical interview Self-report instruments Structured interviews Behavioral observations Family reports

Assessment: Clinical Interview

Individual and Family Psychiatric History

Comorbid conditions may affect treatment plan and prognosis Family history helps make diagnosis Specific symptomsinternal and external triggers for obsessions / compulsions
Avoidance behavior Impact of rituals on work and socialization

Social and Occupational Functioning

Medical History

Assessment: Self-Report and Structured Interview Instruments

Yale-Brown Obsessive Compulsive Checklist and Scale (Y-BOCS)

Has a self-report version and a structured interview version (administered by clinician) Self-report instrument

Padua Inventory

Assessment: Behavioral Observations and Family Reports

Behavioral Observations
Present feared / trigger stimuli and assess responses Easier for some obsessions/compulsions than for others

Family Reports

Useful for children/adolescents especially, but OCD often has an impact on family (not just when the one affected is a child)

Impact on the Family

Frustration (not logical; how to help?) Time-consumption (enabling) Disruption of plans / togetherness Worry (What will life be for him/her?) Self-blame (But OCD is biological . . .) Anger/resentment/other-blame