Download Obsessive Compulsive Disorder

Obsessive Compulsive Disorder
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
DSM-IV Criteria
• See webpage
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.
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.
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
More features
• Types of Obsessions
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Aggressive obsessions
Contamination obsessions
Sexual obsessions
Hoarding/saving obsessions
Religious obsessions
Symmetry/exactness
Somatic obsessions
• Types of compulsions
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Cleaning/washing compulsions
Checking compulsions
Repeating rituals
Counting compulsions
Ordering/arranging
Hoarding/collecting
Mental rituals
• Most people experience intrusive thoughts
throughout their life
• Individuals who develop OCD may react
more negatively to their intrusions
Neurobiology/physiology
• No chronic hyperarousal
• Over activation of the orbitofrontal cortex
(thought generation) and under activation of
the caudate nuclei (thought suppression)
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
• 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
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.
• 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
• 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
– 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
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:
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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
• 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
• 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
• 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
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
• Currently there are 6 SRIs that are FDA
approved for the treatment of OCD
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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