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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 – – – – – – – Aggressive obsessions Contamination obsessions Sexual obsessions Hoarding/saving obsessions Religious obsessions Symmetry/exactness Somatic obsessions • Types of compulsions – – – – – – – 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: • • • • 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 – – – – – – 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