Chapter 9 Obsessive-Compulsive and Related Disorders.

Chapter 9

Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder (OCD)

• Characterized by obsessions, compulsions, or both– Obsessions include recurrent and persistent

thoughts, urges, or images– Compulsions are repetitive behaviors or mental acts

• Time consuming (more than 1 hour per day)• Cause significant distress or impairment in social,

occupational, or other important areas of functioning

Body Dysmorphic Disorder (BDD)

• Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

• Repetitive behaviors (mirror checking, excessive grooming, reassurance seeking) or mental acts (comparing self to others) occur in response to the appearance concerns

• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Hoarding Disorder (HD)• New to DSM-5• Persistent difficulty discarding or parting with

possessions, regardless of their actual value• Perceived need to save the items and distress

associated with discarding the items• Results in an accumulation of possessions that

congest and clutter living areas• The hoarding causes clinically significant distress or

impairment in social, occupational, or other important areas of functioning (such as an unsafe home environment)

Trichotillomania (TTM)

• Recurrent pulling out of one’s hair, resulting in hair loss– May pull from any part of body– Scalp, eyelids, and eyebrows are most common

• Repeated attempts to decrease or stop hair pulling

• The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Excoriation Disorder (ED)

• New to DSM-5• Recurrent skin picking resulting in lesions– May occur on any area of the body– Most commonly occurs on the face, arms, and

hands• Repeated attempts to stop picking• The hair pulling causes clinically significant

distress or impairment in social, occupational, or other important areas of functioning

Epidemiology• Obsessive-compulsive disorder

• 12-month prevalence is 1.2%; lifetime prevalence is 1% (Ruscio et al., 2010)

• Body dysmorphic disorder• Point prevalence of BDD is 2.4% (Koran et al., 2008)

• Other rates vary by setting (1.8% OP; 13.1–16% IP)

• Hoarding disorder (data obtained from OCD with hoarding)• Weighted community prevalence is 5.3% (Samuels et al., 2008)

• Trichotillomania (hair-pulling disorder)• Community sample 0.6% to 1.2% (Duke et al., 2009)

• Psychiatric setting 3.4% and 4.4%, point and lifetime prevalence

• Excoriation (skin-picking) disorder• Community sample 1.4% to 5.4% (Hayes et al., 2009)

• 4.2% college students using proposed DSM-5 criteria (Odlaug et al., 2013)

Assessment• General medical condition must always be ruled out• Semistructured interviews

— OCD: ADIS-IV; SCID-CV; Y-BOCS— BDD: SCID-CV; BDDE; Y-BOCS-BDD— HD: HRS-I— TTM and ED: Only self-reports at this time

• Self-report measures– OCD: Y-BOCS-SR; OCI– HD: SI-R– TTM: MGH-HPS; MIST-A– ED: MIDAS

• Behavioral Avoidance Tests (BATs)

Etiology: Behavioral and Molecular Genetics

• OCD has a complex etiology involving both genetic and environmental factors

• Heritability suggested by higher prevalence rate in first-degree relatives of OCD probands versus comparison relatives (8.2% vs. 2%)

• In a large twin study, genetic factors accounted for 36% of the variance; remaining 64% environmental

• Specific genetic markers for OCD are largely unknown, but several studies have identified genomic areas of interest

Etiology: Behavioral and Molecular Genetics cont.

• Heritability is also an important part of the variance of BDD etiology

• 8% of individuals with BDD have a first-degree relative with a lifetime diagnosis of BDD (3 to 8 times greater than general population)

• Some evidence of shared heritability with OCD• Twin study of BDD revealed genetic factors

accounted for 44%; nonshared environmental factors accounted for remainder of variance

Etiology: Behavioral and Molecular Genetics cont.

• Information regarding the etiology of HD is primarily from OCD patients with and without hoarding symptoms

• UK twin registry: Caseness was found in 2.3% of the sample

• Heritability in twins associated with genetic (50%) and non-shared environmental factors

• Linkage of compulsive hoarding to Chromosome 14 in families with OCD

Etiology: Behavioral and Molecular Genetics cont.

• Etiology of trichotillomania (TTM) is most likely an interaction (bio-psycho-social)

• Early genetic research indicated that hair-pulling occurs at increased rates (5% to 8%) in family members of TTM probands

• Twin study: Concordance rate for TTM was 38.1% for monozygotic compared to 0% for dizygotic

Etiology: Behavioral and Molecular Genetics cont.

• Excoriation disorder (ED) also appears to have a familial component

• Of 60 patients with ED, 28.3% of first-degree relatives also met criteria for the disorder

• Another study of 40 patients with ED found 43% had first-degree relatives with skin picking symptoms

• 1.2% female twins: Higher concordance for monozygotic (genetic factors: 40% variance)

Etiology: Neuroanatomy and Neurobiology

• Association between OCD and impairment of the corticostriatal systems, which include organized neural circuits that connect the basal ganglia, thalamus, and cortex

• MRI studies with BDD patients have shown caudate nucleus asymmetry and orbitofrontal cortex volume abnormalities (increased white matter)

• Hoarding symptoms may have a different neural substrate than OCD

• Subcortical limbic structures and the ventromedial prefrontal/cingulate and medial temporal regions may be involved in hoarding behavior

• White matter abnormalities have also been shown in TTM and ED

Etiology: Learning, Modeling, and Life Events

• Trauma may be associated with increased symptom severity in OCD

• In BDD, early sexual, emotional, and physical abuse, as well as early social interactions, may be associated

• HD may be a conditioned emotional response; anxiety is avoided by acquisition and hoarding

• TTM and ED have similar environmental risk factors, such as lack of stimulation or boredom; severe activity restriction has also been suggested

Etiology: Cognitive Influences

• A cognitive model of OCD suggests that it is not the content of the thought per se, but the interpretation of the thought that leads to preoccupation and anxiety

• Three types of dysfunctional beliefs have been proposed to contribute to OCD– Overestimated responsibility and exaggerated threat– Perfectionism and intolerance of uncertainty– Overimportance of thoughts and need to control thoughts

• Neurocognitive performance in OCD patients involves impairment in executive functioning – Strategizing– Organizing

Sex and Racial/Ethnic Considerations

• Men and women are equally likely to suffer from OCD• Obsessional content in men is more likely to encompass

sexual themes, whereas women were more likely to present with symptoms related to contamination

• Contamination and checking are OCD themes consistently found across cultures– Fear of leprosy in Africa– Religious themes in Middle East

• Data suggest lower prevalence of OCD among African Americans; may reflect lower number of African Americans seeking evidence-based treatment

Course and Prognosis: OCD

• OCD chronic and disabling; rarely remits without treatment

• Biological and behavioral therapies have been shown to be effective

• SSRIs (Prozac or Zoloft) also effective• Exposure with response-prevention (ERP)• CBT for OCD outperformed control conditions

across 16 RCTs

Course and Prognosis: BDD

• BDD typically begins in adolescence, a stage marked by hormonal changes and accelerated growth

• Also a time of increased peer rejection and ridicule (also acne)

• Individual and group CBT are effective with elements of psychoeducation, cognitive restructuring, and ERP (relative to controls)

Course and Prognosis: HD

• The idea that hoarding develops in response to deprivation (both emotional and material) has not been supported overall

• Some evidence for high levels of trauma or stressful life events

• Course of HD is typically chronic, with symptoms starting as early as adolescence but causing impairment later in life

• Treatment is challenging; in OCD patients, the presence of hoarding is associated with higher dropout rates

• RCTs needed

Course and Prognosis: TTM

• TTM may occur at any age, with an average onset of 12.9 years of age

• Course is chronic, with waxing and waning symptom severity

• CBT thought of as treatment of choice; early work with Habit Reversal Training (HRT)

• More recently, HRT has been combined with acceptance and commitment Therapy (ACT) as well as dialectical behavior therapy (DBT)

Course and Prognosis: ED

• Age of onset varies; average is 13.5 years old• Symptoms appear to be similar regardless of age

and culture• Social, academic, or occupational impairment may

be mild to severe• Infection or permanent skin damage may occur• CBT and SRIs shown to be effective• Habit reversal has been used; ACT and DBT have

been added with promising results