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Obsessive Compulsive Disorder,
Trichotillomania, Hoarding Disorder
and Excoriation Disorder
Allison E. Cowan MD
Julie P. Gentile MD
Ohio’s Coordinating Center of
Excellence in MIDD
And
Ohio’s Telepsychiatry Project in ID
Diagnostic Manual-Intellectual Disability
• DSM-V criteria adapted to better fit ID patient
population
• DM-ID published by The National Association
for the Dually Diagnosed (NADD), in
association with The American Psychiatric
Association
• Chapter: Obsessive Compulsive and Related
Disorders (Drs. Benson, Gillig and Fleischer)
DSM-V
• The DSM-V includes a new chapter on
Obsessive Compulsive and Related Disorders
• New disorders also have been identified:
Hoarding Disorder and Excoriation (skinpicking) Disorder
• Similarity among the set of disorders across
symptoms, neurobiological networks,
genetics, course of illness and treatment
response
OCD Cycle
OCD – Prevalence ~2.5%
• Recurrent obsessions and compulsions that are
time-consuming (specifically more than one hour
daily) or causing clinically significant
distress/impairment;
• Must experience obsessions as intrusive and
unwanted;
• Attempts to ignore/suppress the obsessions to
neutralize them with some other thought or
action;
• Anxiety or distress occurs in most individuals but
is not required to make the diagnosis.
Making the Diagnosis
• Obsessive thoughts/compulsive behavior: most
individuals with ID have an element of OCD
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Questions:
Is it disruptive?
Causing individual to be late?
Interfering in relationships and/or schedules?
Lasting more than an hour daily?
Causing mental health symptoms?
Is the individual struggling?
Specific Issues Related to ID
• Document observable/behavioral compulsions
• Decrease in self-report of internal conflict/anxiety
• May be unaware of societal disapproval and
therefore this knowledge may not serve to
reduce the behaviors
• Complicated by co-occurring stereotypies, tics,
dyskinesias, dystonias, akathisia, self-injury, selfstimulatory behavior
• Most common compulsive behaviors - acts of
cleanliness (Complicated in ID?)
Specific Issues Related to ID
• More likely to demonstrate anxiety as opposed to
reporting it
• Compulsions that require abstract thought may
not be possible (i.e. contamination or safety
issues) and counting skills are variable.
• Children and Adolescents: usu. ordering, checking
and cleaning rituals; usu. at home; use caution
depending on developmental stage (toddlers and
preschool: may have rituals; school age: may use
strict rules w games/activities)
Autism vs. OCD
• Repetitive and stereotyped behavior patterns
in ASD can be similar to compulsive symptoms
• More typical of ASD: Regression, religious,
contamination, symmetry, somatic content
• More typical of OCD: Ordering, tapping,
rubbing
• May co-occur
BioPsychoSocial Factors
• Neurotransmitters: serotonin and dopamine.
• Syndromes: Prader Willi syndrome (PWS), Down
syndrome, Fragile X syndrome (FXS), Cornelia de
Lange and Williams syndrome
• Adaptive functioning limitations with
independence issues increase prevalence of all
anxiety disorders
• Psychosocial factors: low self-esteem, fear of
failure, deficits in problem solving, dependency
needs, social stigma, trauma history…
ACES Research
The Adverse Childhood Experiences (ACE) Study
is one of the largest investigations ever
conducted to assess associations between
childhood maltreatment and later-life health
and well-being. The study is a collaboration
between the Centers for Disease Control and
Prevention and Kaiser Permanente's Health
Appraisal Clinic in San Diego. (1995-1997)
ACES Research
• Surveys on childhood maltreatment, household
dysfunction, and other socio-behavioral factors
examined in the ACE Study.
• CEQ designed by our group to reduce risk of retraumatization
• IDD are more likely to experience trauma and
increase in medical and neurologic conditions; this
study will add to the prevalence data to establish
best practices and increased prevention
ACES Pyramid
How IDD “Readjusts” the ACE
Pyramid Risk
ACE Pyramid (1998)
IDD Impact
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Layer 2: Social, Emotional & Cognitive
Impairment
– Present by definition with IDD in
absence of trauma
Layer 3: Adoption of Health Risk
Behaviors
– Challenges in “adherence” and
necessary skills/ understanding as
well as lower standard of care
Layer 4: Disease, Disability, and Social
Problems
– Prevalence of Medical & Mental
Health Conditions in absence of
trauma
Ohio’s Telepsychiatry Project
for Intellectual Disability
 Funders: DODD, ODMHAS, ODDC
 Telepsychiatry services initiated in 2012
 Virtual software which abides by patient privacy
guidelines (HIPAA Compliant)
 Prioritize individuals from Developmental Centers
and State Psychiatric Hospitals
Ohio’s Telepsychiatry Project for ID
• More than 90 engaged were discharged from state
operated institutions and others were in danger of
short-term admission. This saves the state
approximately $80,000/person/year in support costs.
• The patients treated have experienced a decrease of
90% in emergency department visits and 87% in
hospitalizations.
• 775 patients/58 counties
• Currently accepting referrals
Obsessions
Mild/Moderate
Severe/Profound
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.
Recurrent and persistent
thoughts, urges, or images may
not be experienced as intrusive
and unwanted
SAME
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).
May or may not attempt to
ignore or suppress such
thoughts, urges, or images, or
to neutralize them with some
other thought or action
SAME
May be unable to report
wanting to ignore, suppress
or neutralize the
obsessions.
Adaptation of Diagnostic Criteria--OCD
Compulsions
Mild/Moderate
Severe/Profound
Repetitive behaviors or
mental acts that the
individual feels driven to
perform in response to an
obsession or according to
rules that must be applied
rigidly.
May be difficult to elicit
due to cognitive deficits and
limited expressive language
skills. Consider ordering,
telling, asking or repetitive
physical acts (e.g. rubbing)
as compulsions.
Absence of compulsions
that require abstract
thinking less likely;
observe individuals for
compulsions requiring
simple thinking, such as
excessive ordering and
filling/emptying.
The behaviors are aimed at
preventing or reducing
anxiety or distress, or
preventing some dreaded
event or situation
The function of the
compulsive behavior may
not be ascertainable;
recognition of excessiveness
or intent of the behaviors
may not be present.
Adaptation
The criteria regarding
intent of the behavior
does not apply to
children, and does not
apply to individuals
with severe/profound
intellectual disability.
Mild/Moderate
Severe/Profound
Adaptation
The obsessions or
compulsions are timeconsuming (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.
Distress may not occur and/or
may not be ascertainable.
Intense preoccupation may be
observed or drive to perform
the compulsion may be
observed. Challenging
behavior, especially
aggression, and self-injurious
behavior, may occur if the
individual is prevented from
completing the compulsion.
Specify if:
Specifiers should be applied
in the context of the cognitive
and developmental
functioning of the individual.
Good Insight, Fair Insight,
Poor Insight or
Absent/Delusional Beliefs
Medications
• Serotonin (SSRI, SNRI, TCA, Buspirone,
Remeron, etc)
• Dopamine (antipsychotic medications)
• Benzodiazepines: More sensitive to cognitive
side effects; hyperactivity; disinhibition; affects
seizure threshold; paradoxical reactions
• Adjunct agents: mood stabilizers, clonidine,
naltrexone, beta blockers, etc)
Cory
• 48 year old female with Moderate ID,
Schizophrenia, OCD, Trauma history, Post-inst
• Food, crafts, drinking water, changing outfits,
retracing steps, light switch, boyfriends, etc.
• Triggers: staff turnover, UTIs, change in rules
• Interventions: Clozapine; SSRI
• TIC; therapy; BSS; provider agency, SSA
Treatment
• Provide guidelines/boundaries for the
individual; Stick to them as a team
• Reward/acknowledge when individual follows
guidelines
• Psychotherapy (supportive, cognitive, or
behavioral)
• Positive Behavioral Support
• Trauma Informed Approaches
• Be consistent (instills sense of safety)