Obsessive-Compulsive Disorders

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder is characterized by intrusive thoughts and repetitive behaviors aimed at reducing anxiety.

Learning Objectives

Summarize the diagnostic criteria, etiology, and treatment of obsessive-compulsive disorder

Key Takeaways

Key Points

  • Obsessive-compulsive disorder (OCD) is characterized by intrusive thoughts (obsessions) that produce anxiety, and by repetitive behaviors or rituals (compulsions) aimed at reducing the associated anxiety.
  • Obsessions are characterized as persistent, unintentional, and unwanted thoughts and urges that are highly intrusive, unpleasant, and distressing.
  • Compulsions are ritualistic behaviors that an individual performs in order to mitigate the anxiety that stems from obsessive thoughts.
  • Symptoms of OCD include excessive washing or cleaning; repeated checking; preoccupation with sexual, violent or religious thoughts; relationship-related obsessions; aversion to particular numbers; and other nervous rituals.
  • Both psychological and biological factors play a role in causing the disorder. Evolutionary psychology indicates that some obsessions/compulsions may have been advantageous, such as monitoring the environment for enemies.
  • Behavioral therapy, cognitive behavioral therapy (CBT), and medications (such as SSRIs) are regarded as first-line treatments for OCD.

Key Terms

  • SSRI: A class of medications typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders.
  • Egosyntonic: Behaviors, values, and feelings that are in harmony with or acceptable to the needs and goals of the ego, or consistent with one’s ideal self-image.
  • Egodystonic: Thoughts and behaviors (dreams, impulses, compulsions, desires) that are in conflict, or dissonant, with a person’s ideal self-image.
  • psychotic: Of, related to, or suffering from a severe mental disorder marked by a loss of contact with reality.

Defining Obsessions and Compulsions

Obsessive-compulsive disorder (OCD) is a mental disorder characterized by intrusive thoughts (obsessions) that produce uneasiness, apprehension, fear, or worry, and by repetitive behaviors or rituals (compulsions) aimed at reducing the associated anxiety. People with OCD may have just the obsessions or a combination of obsessions and compulsions.

Obsessions are characterized as persistent, unintentional, and unwanted thoughts and urges that are highly intrusive, unpleasant, and distressing (APA, 2013). Common obsessions include concerns about germs and contamination, doubts (“Did I turn the water off?”), order and symmetry (“I need all the spoons in the tray to be arranged a certain way”), and urges that are aggressive or lustful. Usually, the person knows that such thoughts and urges are irrational and thus tries to suppress or ignore them, but has an extremely difficult time doing so.

Compulsions are ritualistic behaviors that an individual performs in order to mitigate the anxiety that stems from obsessive thoughts. They often include such behaviors as repeated and extensive hand washing, cleaning, checking (e.g., making sure the oven is off), counting things, hoarding, or ordering (e.g., lining up all the pencils in a particular way). They may also include such mental acts as counting, praying, or reciting something to oneself, as well as nervous rituals like touching a doorknob or opening and closing a door a certain number of times before leaving a room. These compulsions can be alienating and time-consuming, often causing severe emotional, interpersonal, and even financial distress. The ability to relieve their stress is often temporary, and individuals may have a hard time switching from one task to another.

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Compulsion: Excessive hand-washing is a common compulsion found in individuals with OCD.

The acts of those who have OCD may appear paranoid and potentially psychotic, or disconnected from reality; however, OCD sufferers generally recognize their obsessions and compulsions as irrational. Roughly one-third to one-half of adults with OCD report a childhood onset of the disorder.

Colloquial Use of OCD

The phrase obsessive-compulsive is often used colloquially to indicate someone who is excessively meticulous, perfectionistic, or otherwise fixated. Although these signs are present in OCD, a person who exhibits them does not necessarily have OCD; they may instead have an autism spectrum disorder, obsessive-compulsive personality disorder (OCPD), or no clinical condition at all. The main difference between OCD and OCPD is that OCD is egodystonic, meaning that the disorder goes against the patient’s self-concept. Their idea of their “ideal self” would not include the symptoms of OCD, and therefore the disorder causes a lot of distress. OCPD, on the other hand, is egosyntonic, meaning the patient sees the behaviors as appropriate, reasonable, or compatible with their self-image.

DSM-5 Diagnostic Criteria

To be diagnosed with OCD, a person must experience obsessions, compulsions, or both. Such obsessions must be to a degree that lies outside the normal range of worries about conventional problems. A person will tend to recognize the obsessions as idiosyncratic or irrational, but still must perform them. Additionally, the degree of obsessions and compulsions must impair some aspect of the individual’s social, occupational, or daily life functioning.

Etiology

Scholars generally agree that both psychological and biological factors play a role in causing the disorder, although there is disagreement about which plays a greater role. Evolutionary psychology indicates that some obsessions/compulsions may have at one point been advantageous, such as compulsive hygiene, checking the fire in the hearth, hoarding supplies, or monitoring the environment for enemies.

The results of family and twin studies suggest that OCD has a moderate genetic component. The disorder is five times more frequent in the first-degree relatives of people with OCD than in people without the disorder (Nestadt et al., 2000). Additionally, the concordance rate of OCD among identical twins is around 57%; however, the concordance rate for fraternal twins is 22% (Bolton, Rijsdijk, O’Connor, Perrin, & Eley, 2007). Studies have implicated about two dozen potential genes that may be involved in OCD; these genes regulate the function of three neurotransmitters: serotonin, dopamine, and glutamate (Pauls, 2010).

OCD has been linked to abnormalities with the neurotransmitter serotonin, although this could be either a cause or an effect of OCD. Serotonin is thought to have a role in regulating anxiety. The serotonin receptors of OCD sufferers may be under-stimulated, which is consistent with the observation that many OCD patients benefit from the use of selective serotonin reuptake inhibitors (SSRIs), a class of medications that allows more serotonin to be readily available. Additionally, a brain region that is believed to play a critical role in OCD is the orbitofrontal cortex (Kopell & Greenberg, 2008), an area of the frontal lobe involved in learning and decision-making.

Treatment

Behavioral therapy, cognitive behavioral therapy, and medications (such as SSRIs) are regarded as first-line treatments for OCD. A specific technique often used is exposure and ritual prevention, which involves gradually learning to tolerate the anxiety associated with not performing a compulsion or ritual. An example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person habituates to the anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to not checking the lock at all.

Other Obsessive-Compulsive Disorders

Other obsessive-compulsive disorders include body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder.

Learning Objectives

Summarize the similarities and differences in diagnostic criteria, etiology, and treatment options among various obsessive-compulsive disorders

Key Takeaways

Key Points

  • Obsessive-compulsive and related disorders are a group of overlapping disorders that generally involve intrusive, unpleasant thoughts and repetitive behaviors.
  • An individual with body dysmorphic disorder is preoccupied with a perceived flaw in their physical appearance that is either nonexistent or barely noticeable to other people.
  • Hoarding disorder is characterized by excessive acquisition and an inability or unwillingness to discard large quantities of objects, which cover the living areas of the home and cause significant distress or impairment.
  • Trichotillomania is characterized by the compulsive urge to pull out one’s hair, leading to hair loss and balding, distress, and social or functional impairment.
  • Excoriation disorder is characterized by the repeated urge to pick at one’s own skin, often to the extent that damage is caused.

Key Terms

  • cognitive-behavioral therapy: A form of psychotherapy that targets the interaction between a person’s thoughts, feelings, and behaviors.
  • biopsychosocial: Having biological, psychological, and social characteristics; relating to the idea that the mind and body are inseparable entities and are also influenced by social factors.
  • pharmacological: Of or having to do with the science of drugs, including their origin, composition, therapeutic use, and toxicology.

Obsessive-compulsive and related disorders are a group of overlapping disorders that generally involve intrusive, unpleasant thoughts and repetitive behaviors. Included in this category are body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder.

Defining Body Dysmorphic Disorder

An individual with body dysmorphic disorder is preoccupied with a perceived flaw in their physical appearance that is either nonexistent or barely noticeable to other people (APA, 2013). These perceived physical defects cause the person to think they are unattractive, ugly, hideous, or deformed. These preoccupations can focus on any bodily area, but they typically involve the skin, face, or hair. The preoccupation with imagined physical flaws drives the person to engage in repetitive and ritualistic behavioral and mental acts, such as constantly looking in the mirror, trying to hide the offending body part, comparisons with others, and, in some extreme cases, cosmetic surgery (Phillips, 2005). Severely impairing quality of life, body dysmorphic disorder can lead to social isolation and involves especially high rates of suicidal ideation. An estimated 2.4% of the adults in the United States meet the criteria for body dysmorphic disorder, with slightly higher rates in women than in men (APA, 2013).

DSM-5 Diagnostic Criteria

In order to be diagnosed with body dysmorphic disorder, a person must be preoccupied with at least one area of their physical appearance, focusing on a perceived defect. They must also engage in repetitive, often compulsive, behaviors (such as checking in the mirror) or mental acts (such as comparing themselves to others) in relation to their perceived defect(s). This preoccupation must interfere with some aspect of their social, occupation, or daily life, and the symptoms must not be better explained by an eating disorder.

Etiology

As with most psychiatric diagnoses, body dysmorphic disorder seems to have a causation that is biopsychosocial, or an interaction of inherited, genetic, developmental, psychological, and social factors. Although genetic factors appear to contribute, rates of childhood abuse and neglect are markedly elevated among persons experiencing body dysmorphic disorder, suggesting a trauma component. Neuroimaging also suggest weaker connection between the amygdala (the part of the brain involved in basic emotions ) and the orbitofrontal cortex (the part of the brain involved in regulation of emotional arousal ) in people with body dysmorphic disorder.

Treatment

Like many forms of obsessive-compulsive disorder (OCD), people struggling with body dysmorphic disorder often respond well to behavioral therapy or cognitive -behavioral therapy (CBT). Psychodynamic psychotherapy may help in managing some aspects of the disorder; however, more research is needed. Some antidepressant medications may also be helpful, such as the selective serotonin reuptake inhibitors ( SSRIs ).

Defining Hoarding Disorder

Hoarding disorder is a pattern of behavior that is characterized by excessive acquisition and an inability or unwillingness to discard large quantities of objects that cover the living areas of the home and cause significant distress or impairment. Compulsive hoarding behavior has been associated with health risks, impaired functioning, economic burden, and adverse effects on friends and family members. When clinically significant enough to impair functioning, hoarding can prevent typical uses of space, enough so that it can limit activities such as cooking, cleaning, moving through the house, and sleeping. It could also potentially put the individual and others at risk of causing fires, falling, poor sanitation, and other health concerns. Compulsive hoarders may be conscious of their irrational behavior, but the emotional attachment to the hoarded objects far exceeds the motive to discard the items.

Prevalence rates have been estimated at 2-5% in adults, though the condition typically manifests in childhood with symptoms worsening in advanced age. Hoarding appears to be more common in people with psychological disorders such as depression, anxiety, and attention -deficit hyperactivity disorder (ADHD).

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Hoarding Disorder: Those who suffer from hoarding disorder have great difficulty in discarding possessions, usually resulting in an accumulation of items that clutter living or work areas. (credit: “puuikibeach”/Flickr)

DSM-5 Diagnostic Criteria

Researchers have only recently begun to study hoarding, and it was first defined as a mental disorder in the 5th edition of the DSM in 2013. The current DSM lists hoarding disorder as both a mental disability and a possible symptom for OCD.

The DSM-5 diagnostic criteria for hoarding disorder include persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions. This difficulty must be due to strong urges to save items and/or distress associated with discarding. The symptoms result in the accumulation of a large number of possessions that fill up and clutter active living areas of the home or workplace to the extent that their intended use is no longer possible. The symptoms must interfere with some aspect of the person’s social, occupational, or daily life. Importantly, a diagnosis of hoarding disorder is made only if the hoarding is not caused by another medical condition and if the hoarding is not a symptom of another disorder (e.g., schizophrenia) (APA, 2013).

Etiology

Compulsive hoarding does not seem to involve the same neurological mechanisms as more familiar forms of OCD and does not respond to the same drugs as effectively, which target serotonin. In compulsive hoarding, the symptoms are presented in the normal stream of consciousness and as such, they are not perceived as repetitive or distressing like in OCD patients. Some evidence based on brain lesion case studies also suggests that the anterior ventromedial prefrontal and cingulate cortices may be involved in abnormal hoarding behaviors; however, sufferers of such injuries display less purposeful behavior than other individuals that compulsively hoard, thus making the implication of these brain structures unclear. Other neuropsychological factors that have been found to be associated with individuals exhibiting hoarding behaviors include slower and more variable reaction times, increased impulsivity, and decreased spatial attention.

A model that has been suggested to explain hoarding is attachment disorder, which is primarily caused by poor parent-child relationships during childhood. As a result, those suffering from attachment disorder may turn to possessions to fill their need for a loving relationship. Interviews with animal hoarders, in particular, have revealed that hoarders often experienced domestic trauma during childhood, providing evidence for this model. A study in 2010 showed that adults who hoard report a greater lifetime incidence of having possessions taken by force, forced sexual activity as either an adult or a child, and being physically handled roughly during childhood, thus indicating a positive correlation between traumatic events and compulsive hoarding.

Treatment

Like other obsessive-compulsive disorders, hoarding may be treated with various antidepressants from the Tricyclic antidepressant family clomipramine and from the SSRI families. With existing drug therapy, OCD symptoms can be controlled but not cured.

Cognitive-behavioral therapy (CBT) is also a commonly implemented therapeutic intervention for compulsive hoarding. This modality of treatment usually involves exposure and response prevention to situations that cause anxiety and cognitive restructuring of beliefs related to hoarding. Other approaches to treatment that show promise include motivational interviewing, harm reduction, and group therapy.

Defining Trichotillomania

Trichotillomania (also known as trichotillosis or hair pulling disorder) is an obsessive compulsive disorder characterized by the compulsive urge to pull out one’s hair, leading to hair loss and balding, distress, and social or functional impairment. Trichotillomania may be present in infants, but the peak age of onset is 9 to 13. Owing to social implications the disorder is often unreported and it is difficult to accurately predict its prevalence; the lifetime prevalence is estimated to be between 0.6% and 4.0% of the overall population. Common areas for hair to be pulled out are the scalp, eyelashes, eyebrows, legs, arms, hands, nose and the pubic areas.

DSM-5 Diagnostic Criteria

In order to be diagnosed with trichotillomania, a person must repeatedly engage in hair pulling behavior, resulting in the loss of hair. They must experience distress related to this behavior and repeatedly try to stop, and the symptoms must interfere with some aspect of social, occupational, or daily life functioning. Finally, the behavior cannot be due to another medical condition or mental disorder.

Etiology

Anxiety, depression, and other forms of OCD are frequently encountered in people with trichotillomania; the disorder also has a high overlap with post-traumatic stress disorder (PTSD), and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hair pulling as addictive or negatively reinforcing as it is associated with rising tension beforehand and relief afterward. A neurocognitive model sees trichotillomania as a kind of habit disorder. In several MRI studies that have been conducted, it has been found that people with trichotillomania have more gray matter (the regions of the brain involved in muscle control and sensory perception) in their brains than those who do not suffer from the disorder. It is likely that multiple genes confer vulnerability to trichotillomania; however, more research is needed.

Treatment

Trichotillomania is often chronic and can be difficult to treat. Treatment is based on a person’s age; most pre-school age children outgrow it if the condition is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non- pharmacological interventions, including behavior modification programs, may be considered; referrals to psychologists or psychiatrists are considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other psychiatric disorders, and referral to a psychologist or psychiatrist for evaluation and possible treatment with medication is considered best. The hair pulling may resolve when other conditions are treated.

Defining Excoriation Disorder

Excoriation disorder is an obsessive compulsive disorder characterized by the repeated urge to pick at one’s own skin, often to the extent that damage is caused. Episodes of skin picking are often preceded or accompanied by tension, anxiety, or stress. During these moments, there is commonly a compulsive urge to pick, squeeze, or scratch at a surface or region of the body, often at the location of a perceived skin defect. The region most commonly picked is the face, but other frequent locations include the arms, legs, back, gums, lips, shoulders, scalp, stomach, chest, and extremities such as the fingernails, cuticles, and toenails. Most patients with excoriation disorder report having a primary area of the body that they focus their picking on, but they will often move to other areas of the body to allow their primary picking area to heal.

Excoriation disorder can cause feeling of intense helplessness, guilt, shame, and embarrassment in individuals, and this greatly increases the risk of self-harm. Studies have shown that excoriation disorder presented suicidal ideation in 12% of individuals with this condition, suicide attempts in 11.5% of individuals with this condition, and psychiatric hospitalizations in 15% of individuals with this condition.

DSM-5 Diagnostic Criteria

Similar to trichotillomania, excoriation disorder is diagnosed when a person engages in repeated skin picking behavior that results in skin lesions. The person must experience distress about this behavior and repeatedly try to stop. The behavior must interfere with some aspect of the person’s social, occupational, or daily life, and cannot be attributed to a medical condition or another mental disorder.

Etiology

There have been many different theories regarding the causes of excoriation disorder, including biological and environmental factors. Skin picking often occurs as a result of some other triggering cause. Some common triggers are feeling or examining irregularities on the skin and feeling anxious or other negative feelings. A common hypothesis is that excoriation disorder is a coping mechanism to deal with elevated levels of turmoil, arousal, or stress within the individual, and that the individual has an impaired stress response. A review of behavioral studies found support in this hypothesis in that skin-picking appears to be maintained by automatic reinforcement within the individual. In contrast to neurological theories, there are some psychologists who believe that picking behavior can be a result of repressed emotions and/or history of trauma.

Treatment

The two main strategies for treating this condition are pharmacological and behavioral intervention. Knowledge about effective treatments for excoriation disorder is sparse, despite the prevalence of the condition. Individuals with excoriation disorder often do not seek treatment for their condition largely due to feelings of embarrassment, alienation, lack of awareness, or the belief that the condition cannot be treated.

There are several different classes of pharmacological treatment agents that have some support for treating excoriation disorder: (1) SSRIs; (2) opioid antagonists; and (3) glutamatergic agents. In addition to these classes of drugs, some other pharmacological products have been tested in small trials as well. Behavioral treatments include habit reversal training, cognitive-behavioral therapy, acceptance-enhanced behavior therapy, and acceptance and commitment therapy.