chapter 3: obsessive- compulsive disorder (ocd) jonathan s. abramowitz laura e. fabricant ryan j....
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Chapter 3: Obsessive-Compulsive Disorder (OCD)
Jonathan S. Abramowitz
Laura E. Fabricant
Ryan J. Jacoby
Diagnosis Overview
Obsessive-compulsive disorder (OCD)Obsessions or compulsions Significant distress Noticeable interference with aspects of role functioning
Obsessions Intrusive thoughts, ideas, images, impulses, or doubts that the
person experiences as senseless and that evoke anxiety
Compulsions Urges to perform overt (e.g., checking, washing) or mental (e.g.,
praying) rituals in response to obsessions or to reduce anxiety or distress
DSM-5 Diagnostic Criteria
A. Presence of obsessions, compulsions, or both:
Obsessions:
1. Recurren, persistent, intrusive, unwanted, causing anxiety or distress.
2. Attempts to ignore or suppress such thoughts, or to neutralize them with some other thought or action
Compulsions:
1. Repetitive behaviors or mental acts driven to perform in response to an obsession, or using rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing anxiety, distress, or some dreaded event
B. The obsessions or compulsions are time-consuming (for example, take more than 1 hour a day) or cause clinically significant distress or impairment
Indicate whether OCD beliefs are currently characterized by good or fair, poor, or absent insight
Diagnosis-Related Conditions
Body Dysmorphic Disorder (BDD)• Both OCD and BDD can involve:
• Intrusive, distressing thoughts concerning one’s appearance• Repeated checking
• The focus of BDD symptoms is limited to one’s appearance• Similar psychological treatments are effective for both conditions.
Hoarding• Once considered to be a symptom of OCD, hoarding is now
understood as a separate problem. • Hoarding symptoms are no more prevalent in OCD patients than
those with other psychological disorders
Diagnosis-Related Conditions
Obsessive-Compulsive Personality Disorder (OCPD)Personality traits such as excessive perfectionism,
inflexibility, and need for control that negatively impact interpersonal relationships and functioning
OCPD is ego-syntonic while the obsessive thoughts experienced by individuals with OCD are ego-dystonic
Other personality disorders, such as avoidant and dependent personality disorder, co-occur with OCD just as frequently
Obsessive-Compulsive and Related Disorders (OCRDs)
• OCD moved from anxiety disorders to OCRDs, which includes trichotillomania (hair-pulling disorder), excoriation (skin-picking), body dysmorphic disorder (muscle dysmorphia specifier added), hoarding, obsessional jealousy & body-focused repetitive disorder
• Many disorders in new category differ substantially from OCD• OCD compulsions are intentional, in contrast to mechanical or
robotic repetitive behaviors such as tics • Repetitive behaviors in addictive disorders or in trichotillomania
or, are carried out because they produce pleasure, distraction, or gratification while in OCD, the repetitive behaviors primarily reduce anxiety
DSM-5 Diagnostic Criteria for OCD
A. Presence of obsessions, compulsions, or both:
Obsessions:
1. Recurrent, persistent, intrusive, unwanted, causing anxiety or distress.
2. Attempts to ignore or suppress such thoughts, or to neutralize them with some other thought or action
Compulsions:
1. Repetitive behaviors or mental acts driven to perform in response to an obsession, or using rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing anxiety, distress or some
dreaded event
B. The obsessions or compulsions are time-consuming (for example, take more than 1 hour a day) or cause clinically significant distress or impairment
Specifier Indicates whether OCD beliefs are currently characterized by:
good/ fair, poor, or absent insight/delusional (specifier can be used for other disorders)
Tic specifier (current or history of)
Symptoms: Obsessions
Examples of Obsessions
Category Example
Contamination What if I get rabies from driving over a dead animal on the street?
Responsibility for harm or mistakes
What if I hit someone with my car without realizing it?
Symmetry/order The books must be evenly placed on the shelf or else I will have bad luck
Unacceptable thoughts with
immoral, sexual, or violent content
Image of my grandparents having sex
Thought about stabbing my husband in his sleep.
Symptoms: Compulsions
Compulsive rituals are often the most conspicuous and functionally impairing symptoms
Compulsive rituals are often performed to reduce obsessional anxiety about feared consequences
Many individuals with OCD also engage in repeated attempts to gain ultimate certainty that obsessional doubts are invalid
Symptoms: Obsessions
Examples of Compulsive Rituals
Category ExampleDecontamination Wiping down all objects brought into the house for fear of
germs from recently applied pesticides on an adjacent lawn
Checking Returning home after seeing a fire engine to make sure the house wasn’t on fire
Repeating routine activities
Going through a doorway over and over to prevent bad luckRetracing one’s steps to make sure that no mistakes were made
Ordering/arranging
Saying the word “left” whenever one hears the word “right”
Mental rituals Canceling a bad thought by thinking of a good thought
Symptoms: Avoidance and Insight
Avoidance behavior is present in most people with OCD Prevents obsessional fears and compulsive urges
altogether
About 4% of patients are convinced that their beliefs are realistic (i.e., poor or absent insight)
Prognosis
OCD is a chronic condition with a low rate of spontaneous remission
Left untreated Symptoms and functional impairment fluctuate, with
worsening during periods of increased life stress
With treatmentIncreased rates of symptom remission. Full recovery,
however, is the exception rather than the rule
Demographics
Lifetime prevalence of OCD estimated at between 0.7% and 2.9%
Slight preponderance of females
Typically begins by age 25, although childhood or adolescent onset is not rare
Mean onset age is earlier in males (about 21 years) than in females (22 to 24 years)
Etiology: Learning Model
Mowrer’s two-stage theory of fear acquisition and maintenance
• First stage: Classical conditioning• Neutral stimulus, aka. the conditioned stimulus (CS), paired
with aversive stimulus, aka. the unconditioned stimulus (UCS)• The CS comes to elicit a conditioned fear response, or CR
• Second stage: Operant conditioning• Avoidance behaviors reduce anxiety; avoidance is negatively
reinforced by the immediate reduction in distress. • Compulsive rituals develop as an escape behavior from
obsessional fear when avoidance is impossible
Etiology: Cognitive Deficit Models
• Proposes that OCD symptoms arise from abnormally functioning cognitive processes, such as memory
• Cognitive deficit models cannot account for:• Heterogeneity of OCD symptoms• The fact that similar mild cognitive deficits are
found in many psychological disorders
• If cognitive deficits play a causal role in OCD, it is most likely to be a nonspecific vulnerability factor
Etiology: Cognitive Behavioral Models
• Based on Beck’s cognitive theory• Emotional disturbance is brought about by how one
makes sense of situations or stimuli
• Unwanted intrusive thoughts (i.e., thoughts, images, and impulses that intrude into consciousness) are a normal experience
• Intrusions develop into a clinical obsession if the person believes they have serious consequences
• Compulsive rituals and avoidance represent efforts to remove intrusions and prevent feared consequences
Etiology: Salkovski’s Model
• Salkovski’s two reasons that compulsions/avoidance become persistent and excessive:1. Negatively reinforced by their ability to reduce distress2. They prevent people from learning their appraisals of
intrusions are exaggerated and unrealistic
• Psychometric research indicates that there are three principal domains of dysfunctional beliefs associated with OCD symptoms• These types of beliefs confer vulnerability to the onset or
worsening of obsessive-compulsive symptoms
Etiology
Domains of Dysfunctional Beliefs in OCD
Belief Description
Inflated responsibility/ overestimation of threat
Belief that one has the power to cause or prevent negative outcomes. Belief that negative events are likely and would be unmanageable
Exaggeration of the importance of thoughts
and need to control thoughts
Belief that the mere presence of a thought indicates that the thought is significant. Belief that complete control over one’s thoughts is both necessary and possible
Perfectionism/intolerance of uncertainty
Belief that mistakes and imperfection are intolerable. Belief that it is necessary and possible to be 100% certain that negative outcomes will not occur
Etiology: Pyschosocial Factors
Dysfunctional relationship patterns can promote the maintenance of OCD symptoms
Accommodation Friend or relative participates in rituals, facilitates avoidance
strategies, assumes daily responsibilities, or helps to resolve problems resulting from obsessional fears and compulsive urges
Prevents the natural extinction of obsessional fear and ritualistic urges
Criticism, hostility, and emotional overinvolvement are associated with premature treatment discontinuation and symptom relapse
Etiology: Serotonin Hypothesis
Obsessions and compulsions arise from a hypersensitivity of the postsynaptic serotonergic receptors
Three potential lines of evidence:
1. Medication outcome studies supportive
2. Studies of biological markers—such as blood and cerebrospinal fluid levels of serotonin metabolites—are inconclusive
3. Results from the pharmacological challenge paradigm largely incompatible
Etiology: Structural Models
Structural models hypothesize that OCD is caused by neuroanatomical and functional abnormalities in particular areas of the brainOrbitofrontal-subcortical circuits connect brain regions
involved in information processing with those involved in the initiation of behavioral responses
Two pathways: direct and indirectOveractivity of the direct pathway is thought to give rise
to OCD symptoms
Etiology: Biological Models
No explanation has been offered for how neurotransmitter or neuroanatomical abnormalities translate into OCD symptoms For example, Why does hypersensitivity of postsynaptic
receptors cause obsessional thoughts or compulsive rituals?
In addition, biological models are unable to explain: OCD symptoms are generally constrained to particular
themes Why someone would experience one type of obsession
(e.g., contamination), but not another (e.g., sexual)
Treatment: CBT
Successful treatment for OCD symptoms must accomplish two things:
1. Correction of maladaptive beliefs and appraisals
2. Termination of avoidance and compulsive rituals preventing self-correction of maladaptive beliefs and extinction of anxiety
Functional assessment Detailed information about antecedents and consequences of target
behaviors and emotionsIncludes:
• Assessment of obsessional stimuli• Assessment of avoidance and compulsive rituals• Self-monitoring
Treatment: Exposure and Response Prevention (ERP)
Confrontation with stimuli that provoke obsessional fear but that objectively pose a low risk of harmSituational or in vivo exposureImaginal exposure
Habituation Over time, the anxiety (and associated physiological
responding) naturally subsides
Treatment: Exposure and Response Prevention (ERP)
FormatFew hours of assessment and treatment planning15 (daily or twice-weekly) treatment sessions, 90 minutes eachIf intensive regimens are impractical, conducting the treatment
sessions on a weekly basis works well for individuals with less severe OCD
Self-supervised exposure homework practice assigned for completion between sessions
Home-based self-supervised exposure exercises must last long enough for the anxiety to dissipate
Treatment: Exposure and Response Prevention (ERP)
Therapist must provide cogent rationale for how ERP will be helpful in reducing OCD
Exposure exercisesBegin with moderately distressing situations, stimuli, and images,
and progress to the most distressing situationsBetween each treatment session, patient continues exposure
exercises for several hours in different environmental contexts without the therapist
Exposure to the most anxiety-evoking stimuli is completed during the middle third of the treatment program
During later sessions, therapist emphases generalization and of continued application of ERP procedures after treatment
Treatment: Exposure and Response Prevention (ERP)
Foa and Kozak hypothesized that ERP produces its effects by correcting patients’ overestimates of danger that underlie obsessional anxiety
Three requirements for successful outcome with ERP1. Physiological arousal and subjective fear are evoked during exposure.
2. Within-session habituation
3. Between-sessions habituation
Inhibitory learningEnhance the recall of the new associations relative to the older, threat-based
associations
Combining exposure and response prevention is more effective than using either of its individual components
Treatment: Exposure and Response Prevention (ERP)
Majority of OCD patients experience substantial short- and long-term benefits~83% of patients are responders (at least 30% symptom reduction)
at posttreatment76% were responders at follow-up
Superior to wait list, progressive muscle relaxation, anxiety management training, pill placebo, and pharmacotherapy with serotonergic medication
Effectiveness studies conducted in real world show that more than 80% of patients who complete treatment achieve clinically significant improvement
Treatment: Cognitive Therapy (CT)
Rational and evidence-based challenging and correction of faulty and dysfunctional thoughts and beliefs that underlie emotional distress
16-session CT include: Learning to conceptualize obsessive intrusions as normal stimuli Identifying and challenging anxiety-provoking thoughts associated
with obsessions with Socratic questioningChanging dysfunctional assumptions to nondistressing beliefsBehavioral experiments to test out the new beliefs
Studies suggest relatively equivalent efficacy of CT and ERPCT reduces drop out from ERP
Treatment: Pharmacological
On average, serotonin medications produce a 20% to 40% reduction in obsessions and compulsions
Advantages ConvenienceLittle effort on the patient’s part
LimitationsRelatively modest improvement and residual symptoms High rate of nonresponse (40% to 60%)Side effects (may be minimized by adjusting the dose)Once terminated, OCD symptoms typically return rapidly