OCD and related disorders

How repetitive thoughts and actions can impair our lives

DSM 5 switch

• Previously these disorders were listed in the chapter with anxiety disorders

• While these disorders surely involve anxiety and certain meds help both

• The underlying causes of anxiety disorders and OCD differ significantly

• Accordingly, in DSM 5 they were placed in different but nearby chapters

OCD – the basics

• Marked by two symptoms: Obsessions – repetitive thoughts and urges & Compulsions – an irresistible need to engage

in various acts or mental acts• Both are perceived as “unstoppable”• They are distressing, uncomfortable, and

require a lot of time and energy

Similar

• Body Dysmorphic Disorder and Hoarding\• Both involve significant anxiety• 1/3 of Body Dysmorphic fit OCD criteria at

some point• ¼ of Hoarders, do as well• Many similarities with respect to cause and

treatment

Clinical Description of OCD

• Intrusive, repetitive, overwhelming obsessions and compulsions

• Far beyond what the rest of us endure

• Interfere with everyday activities

More Obsessions

• Obsessions: onrushing, uncontrollable thoughts, images, or impulses

• Often involve: fear of contamination sexual or aggressive impulses perceived body problems religious matters symmetry and order• Often are perceived as unreasonable

Compulsions

• Repetitive, clearly excessive behaviors or mental acts that must be performed to prevent some catastrophe

• Often involve Cleanliness and orderliness (often rituals) Repetitive, magically protective acts Unceasing checking • Often repeated thousands of times

More on Compulsions

• Contrary to “compulsive” gamblers or shoppers, these activities are never pleasurable

• Onset before 10 or in late adolescence • 1% experience every year, 2% over a lifetime• More women than men• Often comorbid w/ anxiety, depression and

substance abuse – 1/3 show hoarding

Body Dysmorphic

• Preoccupied with one or more perceived defects in appearance

• No matter what other’s may think• Also performance of repetitive actions or

mental acts due to appearance fears• Has to be more than worries about fat or

weight

More Body concerns

• Women focus on skin, breasts, and thighs• Men – height, penis size, body hair, size of

muscles• Spend lots of time (8 hrs!) agonizing over this• Also ritualized, compulsive behaviors,

especially checking themselves in the mirror • Hide or camouflage defects• Seek reassurance, or avoid mirrors

No fun at all

• Many (1/3) carry delusions, people staring or laughing at them

• Lots (1/4) resort to plastic surgery, but that doesn’t seem to help

• Some consider suicide

Functional ramifications

• Feel profound shame, humiliation, and depression

• Leads to avoiding contact with others for fear of being ridiculed

• Some even become housebound

• 40% can’t work

Demographics

• Afflicts more women • But only 2% of even women• 5-7% of women seeking plastic surgery

• Usually begins in late adolescence• Within 8 years, 75% recover

Miscellaneous

• While symptoms appear similar worldwide, body parts at issue vary for culture to culture

• Many US college students complain about appearance but few have are severe enough for diagnosis

• Virtually all are comorbid with another condition – MDD, OCD, Social Anxiety Disorder, Substance Abuse and the PDs

Hording

• Formerly subsumed within OCD• Now carries its own diagnosis• It’s not just collecting a lot of junk, it’s the

inability to throw away any of it• Strongly resist any effort to clear out mess • 2/3s are unaware of the severity of the

problem

If hording things wasn’t bad enough

• 1/3 also horde animals• Many more women then men• Though they view themselves as helping the

animals, just the opposite plays out• Frequently leads to sick, starving, and

neglected animals• If they’re not already dead

Consequences of Hording

• Problems extend far beyond a messy house• Case studies describe overpowering odors

from rotted food and feces• Health concerns• Junk accumulation makes for great difficulty

moving about, cooking, sanitation, etc• Many can’t even use stove, fridge, even toilet

More Problems

• Some threatened with evection or sanctions• Often spend to much money purchasing items• Often conditions lead to estrangement with

families• Some can’t work – poverty, homelessness• 2% admit problems • Few seek treatment• Often severe problems don’t arise to middle age

Causes

• All 3 seem to have similar root causes• Show family histories• In the brain, the orbitofrontal cortex and

caudate nucleus, and anterior cingulate appear overactive

• All kick into hyperdrive when OCD sees a dirty glove or a BD glimpses a picture of her face

Specific causes of OCD

• Heritability rates run between 30-50%

• Cognitive and Behavioral factors must contribute

Cognition and OCD

• Why can’t some of us turn off the obsessions?• Failure of Yedasentience – the ability to stop

thinking about something• When more rumination won’t help, most of

us can move on to something else• Not those with OCD

Behavioral explanations for OCD

• Turn to Operant Conditioning for the answer• Performing the compulsive behavior reduces

anxiety and is therefore reinforcing – likely to happen again

• After all, after performing compulsive behaviors, anxiety does drop

But why all the checking?

• Wouldn’t one check be enough?• The stove won’t turn on by itself, will it?• OCD involves a lack of confidence in memory

Thought Suppression

• Perhaps they try so hard not to think about the obsessions they think about them even more

• These effects can last for days

Causes of Body Dysmorphic

• Cognitive – how they perceive what they see• They focus on certain features (eyes) or facial

symmetry that are key re attractiveness• Then they find tiny, insignificant details and

over-exaggerate their importance• Also view attractiveness as much more

important than others• Ignore the positive, fret over tiny flaws

Why horde?

• Evolution – horde because it was to our advantage to accumulate goods and foods

• But why so so so much?

• Cognitive approach offers 3 possible explanations

1) they can’t organize – trouble giving the attention necessary, categorizing – too many categories, making decisions, and feel loads of anxiety even trying

So they buy too many (decisions) Can’t settle where to put (categorizing) Feel too much stress to discard (anxiety) and can’t pull together a solution (attention)

Strange beliefs

• Form strong emotional connection with junk• Feel comfort from them• Fear their loss• Find them the center of their identity• These beliefs can be even stronger with

animals• All this leads sufferers to avoid any thought of cleaning up, or, worse, throwing anything away

Treatment

• Treatment for all three are similar

• Use SSRIs• Apply Exposure and Response Prevention

(ERP) techniques

Meds for OCD

• The antidepressant Clomipramine caused a 50% drop in OCD symptoms

• But the SSRIs work just as well and cause fewer side-effects

• Not so sure about hording, but one trial showed that Paxil (a SSRI) helped horders

ERP & OCD

• Place in situation which will trigger obsessive thoughts

• Prevent performance of compulsion• Anxiety will run full-force but eventually

subside and go through extinction • ERP works across settings and types of

patients• Facing obsession is difficult - 25% won’t try

BD - ERP

• Techniques tailored to fit • Forced interactions w/ someone critical of

looks• Prevented from looking in mirrors• At same time irrational thoughts/beliefs are

challenged• Cognitive techniques aid recovery

Hording - ERP

• Exposure – make them face greatest fear – parting with things

• Prevention – prevent rituals – buying more, sorting, counting, etc.

Other considerations - Hording

• Work on insight – what’s wrong and why things should change

• Then behavioral strategies (organizational skills) are taught

• Rushing doesn’t help – they quit treatment• Family relationships are often strained, if they

have survived at all• Try to build rapport, trust and doable outcomes