😵Abnormal Psychology Unit 6 – Obsessive-Compulsive & Related Disorders

Key Concepts and Definitions

• Obsessive-Compulsive Disorder (OCD) characterized by persistent, intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) aimed at reducing anxiety
• Obsessions recurrent and persistent thoughts, urges, or images that cause marked anxiety or distress
• Compulsions repetitive behaviors or mental acts performed in response to obsessions or rigid rules, aimed at preventing or reducing anxiety or distress
• Insight refers to the degree to which an individual recognizes their obsessions and compulsions as excessive or unreasonable
  • Good or fair insight: Acknowledges thoughts and behaviors as excessive or unreasonable
  • Poor insight: Believes thoughts and behaviors are reasonable and necessary
  • Absent insight/delusional beliefs: Completely convinced thoughts and behaviors are true and necessary
• Ego-dystonic thoughts or behaviors experienced as inconsistent with one's self-image, values, or desires
• Ego-syntonic thoughts or behaviors experienced as consistent with one's self-image, values, or desires
• Related disorders include body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder

Diagnostic Criteria and Symptoms

• Presence of obsessions, compulsions, or both
  • Obsessions defined by recurrent and persistent thoughts, urges, or images that are intrusive, unwanted, and cause marked anxiety or distress
  • Compulsions defined by repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or rigid rules
• Obsessions and compulsions are time-consuming (more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
• Obsessive-compulsive symptoms not attributable to physiological effects of a substance or another medical condition
• Specifiers include insight level (good/fair, poor, absent/delusional beliefs) and tic-related
• Common obsessions include contamination, harm, symmetry/exactness, and taboo thoughts (aggressive, sexual, or religious)
• Common compulsions include cleaning/washing, checking, ordering/arranging, counting, and seeking reassurance
• Avoidance of triggers or situations that may provoke obsessions or compulsions

Types of OCD and Related Disorders

• Contamination OCD obsessions about germs, dirt, or contamination; compulsions may include excessive cleaning or handwashing
• Harm OCD obsessions about causing harm to oneself or others; compulsions may include checking behaviors or seeking reassurance
• Symmetry/Ordering OCD obsessions about symmetry, order, or exactness; compulsions may include arranging objects or performing actions in a specific way
• Taboo Thoughts/Pure O OCD obsessions about aggressive, sexual, or religious themes without overt compulsions; may involve mental rituals or avoidance
• Hoarding Disorder persistent difficulty discarding possessions regardless of their value, leading to clutter that disrupts living spaces and causes distress or impairment
• Body Dysmorphic Disorder preoccupation with perceived defects or flaws in physical appearance that are not observable or appear slight to others; may involve repetitive behaviors (mirror checking, excessive grooming) or mental acts (comparing appearance to others)
• Trichotillomania (Hair-Pulling Disorder) recurrent pulling of one's hair, resulting in hair loss and repeated attempts to decrease or stop hair pulling
• Excoriation (Skin-Picking) Disorder recurrent picking of one's skin, resulting in skin lesions and repeated attempts to decrease or stop skin picking

Causes and Risk Factors

• Genetic factors twin and family studies suggest a genetic component to OCD and related disorders
  • Heritability estimates range from 45-65% for OCD
  • Specific genes associated with OCD include SLC1A1, SLC6A4, and COMT
• Environmental factors stressful life events, childhood trauma, or streptococcal infections (PANDAS) may trigger or exacerbate symptoms
• Neurobiological factors abnormalities in brain structure and function, particularly in the cortico-striato-thalamo-cortical (CSTC) circuits
• Cognitive factors inflated sense of responsibility, overestimation of threat, perfectionism, and intolerance of uncertainty
• Behavioral factors negative reinforcement of compulsions through temporary reduction of anxiety and distress
• Developmental factors average age of onset for OCD is late adolescence or early adulthood; earlier onset associated with increased severity and comorbidity
• Comorbidity high rates of comorbidity with other psychiatric disorders, including anxiety disorders, mood disorders, and tic disorders

Neurobiology and Brain Structures Involved

• Cortico-striato-thalamo-cortical (CSTC) circuits implicated in OCD and related disorders
  • Hyperactivity in orbitofrontal cortex (OFC), anterior cingulate cortex (ACC), and caudate nucleus
  • Hypoactivity in dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC)
• Orbitofrontal cortex (OFC) involved in decision-making, reward processing, and emotional regulation; hyperactivity may contribute to obsessions and compulsions
• Anterior cingulate cortex (ACC) involved in error detection, conflict monitoring, and emotional processing; hyperactivity may contribute to heightened anxiety and distress
• Caudate nucleus part of the basal ganglia involved in habit formation and goal-directed behavior; hyperactivity may contribute to repetitive behaviors and compulsions
• Dorsolateral prefrontal cortex (DLPFC) involved in executive functions, such as planning, working memory, and cognitive flexibility; hypoactivity may contribute to difficulty inhibiting obsessions and compulsions
• Neurotransmitter systems serotonin, dopamine, and glutamate implicated in the pathophysiology of OCD and related disorders
  • Serotonin hypothesis: Dysregulation of serotonin neurotransmission, particularly in the CSTC circuits
  • Dopamine hypothesis: Hyperactivity of dopamine in the basal ganglia, leading to excessive habit formation
  • Glutamate hypothesis: Abnormalities in glutamate neurotransmission, particularly in the CSTC circuits

Assessment and Diagnosis

• Structured clinical interviews (SCID-5, MINI) to assess for presence of OCD and related disorders based on DSM-5 criteria
• Yale-Brown Obsessive Compulsive Scale (Y-BOCS) semi-structured interview to assess severity of obsessions and compulsions
  • Obsessions and compulsions rated on a scale from 0 (no symptoms) to 4 (extreme symptoms) across five dimensions: time spent, interference, distress, resistance, and control
  • Total score ranges from 0 to 40, with higher scores indicating greater severity
• Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) assesses severity across six symptom dimensions: contamination, responsibility for harm, unacceptable thoughts, symmetry, hoarding, and miscellaneous
• Obsessive-Compulsive Inventory-Revised (OCI-R) self-report measure assessing severity of OCD symptoms across six subscales: washing, checking, ordering, obsessing, hoarding, and neutralizing
• Differential diagnosis rule out other psychiatric disorders (generalized anxiety disorder, depression, psychotic disorders) and medical conditions (neurological disorders, substance use)
• Comorbidity assessment evaluate for presence of comorbid psychiatric disorders, as OCD and related disorders often co-occur with anxiety disorders, mood disorders, and tic disorders

Treatment Approaches

• Cognitive-Behavioral Therapy (CBT) first-line treatment for OCD and related disorders
  • Exposure and Response Prevention (ERP): Gradual exposure to feared stimuli while refraining from compulsive behaviors, leading to habituation and decreased anxiety
  • Cognitive Restructuring: Identifying and challenging irrational thoughts and beliefs related to obsessions and compulsions
• Pharmacotherapy serotonin reuptake inhibitors (SRIs) are first-line medications for OCD and related disorders
  • Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram
  • Clomipramine: Tricyclic antidepressant with potent serotonergic effects
  • Higher doses and longer treatment duration often required compared to other psychiatric disorders
• Combination therapy CBT and pharmacotherapy may be more effective than either treatment alone, particularly for severe or treatment-resistant cases
• Deep Brain Stimulation (DBS) neurosurgical treatment for severe, treatment-resistant OCD targeting the anterior limb of the internal capsule or the subthalamic nucleus
• Transcranial Magnetic Stimulation (TMS) non-invasive neuromodulation technique targeting the dorsolateral prefrontal cortex (DLPFC) or orbitofrontal cortex (OFC) for treatment-resistant OCD
• Family involvement psychoeducation, support, and accommodation reduction for family members to improve treatment outcomes and reduce caregiver burden

Impact on Daily Life and Relationships

• Functional impairment OCD and related disorders can significantly interfere with daily activities, work, school, and social functioning
  • Time-consuming nature of obsessions and compulsions may lead to difficulty completing tasks or engaging in activities
  • Avoidance of triggers or situations may limit participation in social events or travel
• Interpersonal difficulties obsessions and compulsions can strain relationships with family, friends, and romantic partners
  • Secrecy or shame surrounding symptoms may lead to social isolation or withdrawal
  • Excessive reassurance-seeking or involving others in rituals may cause frustration or conflict
• Occupational challenges OCD and related disorders can impact job performance, attendance, and career advancement
  • Difficulty concentrating or completing tasks due to obsessions or compulsions
  • Avoidance of certain work environments or situations that trigger symptoms
• Quality of life individuals with OCD and related disorders often report lower quality of life and life satisfaction compared to the general population
  • Chronic nature of symptoms and functional impairment can lead to feelings of hopelessness or despair
  • Stigma and misunderstanding surrounding these disorders may contribute to feelings of isolation or shame
• Caregiver burden family members and loved ones of individuals with OCD and related disorders may experience significant stress and emotional burden
  • Accommodating or participating in rituals can reinforce symptoms and maintain the disorder
  • Balancing support with encouraging independence and treatment adherence can be challenging