OC personality traits do not interfere with functioning, ADLs

Behavioral Medicine II
AY 2015-2016
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
Bookbased PPT/Lecturer
Obsession recurrent intrusive thought, feeling, idea, or sensation
Compulsion - conscious, standardized, recurrent, behavior, eg. Counting,
checking, avoiding motor, acting out an obsession
Diverse group of symptoms that are time-consuming and interfere significantly
with normal routine, occupational functioning, usual social activities, or
relationships
Patient realizes the irrationality of the disorder
Experiences the disorder as ego-dystonic (e.g unwanted-behavior), but he
cant help himself
Compulsive act carried out in an attempt to reduce anxiety form the
obsession may even increase the anxiety
Anxiety also increased when person resists carrying out compulsion

Epidemiology
Lifetime prevalence: 2 to 3%
Fourth most common pyschiatric dx (after phobia, substance related disorders,
2nd leading cause of morbidity by age 20
and major depression)
adolescent M > F
Women = men adults
Mean-age of onset:20 yrs
Single persons affected more frequently

Etiology
Biologic factors
o
Neurotransmitters
Serotonergic system
Dysregulation of serotonin
Reduction in 5-HT due to increased metabolism
Increased in CSF 5-HIAA metabolite of serotonin
makes serotonin more readily available = resolution of s/sx Success of serotonergic drugs e.g SSRIs
Noradrenergic system
Dysregulation of NE
Increased NE anxiety, OCD
NE antagonist --> lose OCD s/sx
Success of Clonidine in lowering NE
anti-HTN --> hypotension
release from presynaptic terminals
SSRI > clonidine
o
Neuroimmunology
?link between OCD and Group A-hemolytic
streptococcal infection increased antibodies
o
Brain Imaging
Dysfunctional
neurocircuitry between orbitofrontal
OCD is a basal ganglia dx
basal ganglia
cortex, caudate, and thalamus
particularly the caudate
nucleus
PET: increased activity in frontal lobes, basal ganglia,
and cingulum affecting amygdale
CT/MRI, smaller caudate bilaterally
o
Genetics
Relatives have three to fivefold higher probability of
OCD or OC features
o
Other biological data
EEG and neuroendocrine studies:
commonality with major depression,
tourettes disorder, and chronic motor tics
vocal and motor tics - jerky movements and bad words
Behavioral factors
o
Learning theory
Obsessions are conditioned stimuli
traumatic event in formative
Neutral stimulus becomes associated with fear or
years engrained in the mind so
when similar stimulus is
anxiety by being paired with events that are noxious
encountered, obsessions and
or anxiety producing
compulsions manifest
Person discovers an action that reduces anxiety
attached to an obsession, he develops active
avoidance strategies (compulsions or ritualistic
behavior) to control the anxiety
Because of the efficacy of reducing anxiety these
avoidance strategies decompulsion
Psychosocial factors
o
Personality factors no particular personality type is associated with OCD
OCD different from OC personality disorder

Diagnosis

if can cope and function normally = NOT a disorder

DSM-5 now a separate category from anxiety

Obsession and compulsions essential features time-consuming --> interfere w/ functioning
Idea or impulse intrudes itself insistently and persistently into conscious
awareness
Anxious dread accompanies central manifestation
Compulsion reduces anxiety associated with obsession
Person recognizes OC as absurd
Strong desire to resist however if they resist it additional anxiety
Obsessive Compulsive Disorder
Diagnostic criteria
300.3 (F42)
A. Presence of obsessions, compulsions, or both
Obsessions are defined by (1) and (2):
1.
Recurrent and persistent thoughts, urges, or images that we
experienced at some time during the disturbance, as intrusive and
unwanted, and that in most individuals cause marked anxiety or
distress
2.
The individual attempts to ignore or suppress such thoughts, urges,
or images or to neutralize them with some other thought or action (i.e
by performing a compulsion)
Compulsions are defined by (1) and (2):
1.
Repetitive behaviors ( e.g hand washing, ordering, checking) or metal
acts (e.g praying, counting, repeating words silently) that the
individual feels driven to perform in response to an obsession or
according to rules that must be applied rigidly.
2.
The behaviors or mental acts are aimed at preventing or reducing
anxiety or distress, or preventing some dreaded event or situation;
however, these behaviors or mental acts are not connected in a
realistic way with what they are designed to neutralize or prevent, or
are clearly excessive.
Note: Young children may not be able to articulate what their aims are in
performing these behaviors or mental acts.
B.
The obsessions or compulsions are time-consuming (e.g., take more
than 1 hour per day) or cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
C.

The obsessive-compulsive symptoms are not attributable to the

physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.

D.

The disturbance is not better explained by the symptoms of another

mental disorder (e.g., excessive worries, as in generalized anxiety
disorder; preoccupation with appearance, as in body dysmorphic
disorder; difficulty discarding or parting with possessions, as in
hoarding disorder; hair pulling, as in trichotillomania [hair-pulling
disorder]; skin picking, as in excoriation [skin-picking] disorder;
stereotypies, as in stereotypic movement disorder; ritualized eating
behavior, as in eating disorders; preoccupation with substances or

OBSESSIVE COMPULSIVE AND RELATED DISORDERS

Co-morbidity
Major depressive disorder 67%
Social phobia 25%
Alcohol use disorders
Generalized anxiety disorder
Specific phobia
Panic disorder
Eating disorder
Personality disorders

OC Personality disorder: usually the sx have been

present for a long time just like any personality
disorder, sometimes the sx just appear during early
adulthood or adolescent period. And usually they are
obsess with perfection, with details hardest, untreatable
OCD they do not have pre-morbid compulsive
symptoms etiology does not include personality
Psychodynamic factors
Secondary gain patient unconsciously hangs on to
his OCD sx to gain attention
Family accommodation may result in dysfx family
interrelationships (when the family accommodate the
compulsive behavior it may lead to a dysfx family
which may increase anxiety) OCD is tolerated by family
Recognition of precipitants that initiate or exacerbate
sx for example dysfx interrelationships, it can lead to
anxiety
Sigmund Frued
based on Psychoanalytic theory
Obsessive-compulsive neurosis regression
form oedipal to anal phase
If OCD patients become threaten
because of the loss of a significant
love object Ambivalence
Ambivalence OCD patients feel both love and
hate towards an object, resulting in doing and
undoing, and in paralyzing doubt
Magical thinking omnipotence of thought,
persons believe that an event may occur just by
merely thinking about it.
Due to this magical thinking they may
fear these aggressive thoughts

Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive
disorder beliefs are definitely or probably not true or that they may or may not be
true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs
are probably true.
With absent insight/delusional beliefs: The individual is completely convinced
that obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder.
Symptom Pattern

CPISO

Contamination
Most common
Feeling of contamination
Excessive hand washing,
bathing
Avoidance of contaminated
object
Unable to leave home for fear
of contamination
They believe that even with the
slightest touch they will be
contaminated
Madikit lang ng konti,
handwashing na or even take a
bath
Commonly see: px uses
handkerchief or tissue to open
the doorknob, if the hand
touches the doorknob or door,
they immediately wash their
hands
They are unable to leave home
because of fear of
contamination
Intrusive thoughts e.g. LSS
Third most common
Intrusive obsessional thoughts
without compulsion
Repetitious thoughts of sexual
or aggressive act that is
reprehensible
If the patient would have these
aggressive thoughts,
sometimes he would report
himself to the police.
Natatakot ako baka pwede
akong makapatay
Sexual obsessions they
might even go to the priest and
confess

Pathological Doubt
Second most common
Intrusive obsessional thoughts
followed by compulsion of
checking
Lights, stove, doorlocks
Back-ups they even need to
go back home just to check
these things (nailock ko ba?
Napatay ko ba yung ilaw?)
Time consuming!
Natatkot sila baka manakawan
They fear that they might have
done something

o
Co-morbid personality disorder
Good prognosis
o
Good social and occupational adjustment
o
Presence of precipitating event
o
Episodic nature fleeting
**obsessional content has relation to the prognosis? -- NONE
Treatment
Pharmacotherapy:
o
SSRI

Fluoxetine, Paroxetine, Sertaline, Citalopram, fluvoxamine

Clomipramine most selective among tetracyclic drugs
o
Others Valproate, Lithium, Carbamazepine if tx with clomipramine or SSRI
is unsuccessful
needs to traverse BBBoso Initial effects in 4 to 6 weeks, maximal in 8 to 16
weeks
effect is not immediate
Behavior therapy tx of choice for OCD
o
Exposure and response prevention
o
Desensitization, thought stopping, flooding, implosion therapy,
aversive conditioning
Psychotherapy
Combination of pharmacotherapy and behavior therapy and consistently
shown best results
supporting the family, helping reduce marital discord
Other therapies:
resulting from disorder and building a tx alliance with the
o
Family therapy family members for the good of the patient
o
Group therapy
o
Deep brain stimulation

first drug to be FDA approved for the

o
tx of OCD; good serotonergic activity

Related Disorders
Body dysmorphic disorder
Hoarding disorder
Hair-pulling disorder (trichotillomania)
Excoriation (skin picking) disorder

BODY DYSMORPHIC DISORDER

Preoccupation with an imagined defect in appearance that causes clinically
significant distress or impairment in important areas of functioning
o Usually involves the face, the nose
Excessive and bothersome concern over even a slight physical anomaly
Dysmorphophobia (Emil Kraepelin) compulsive neurosis
Obsession de la honte du corps obsession with shame of the body
(Pierre Janet)
Before it was under somatic disorders now DSM 5 related to OC
Patients likely to go to dermatologists, internists, plastic surgeons rather
than psychiatrists
Etiology: cause is unknown, may involve serotonin
(dysfunctional serotonergic systems - success of
Most onsets: 15 to 30 y/o
SSRIs) and may be related to other mental disorders
Women>men
Psychodynamic theory: displacement of sexual/
More among unmarried persons
emotional conflict unto a nonrelated body part
Comorbidity
o Major depression
o Anxiety disorder
o psychosis

anxiety increases if compulsion is not acted out

implies some danger of violence

Symmetry
Need for symmetry, precision
Compulsion of slowness slow
because everything needs to
be done in exactly the same
way rigid system of doing things
Rituals
Everything to be done in
exactly the same way
Patients may walk in the
corridor, should be at the
middle to the point of
measuring it

Diagnosis

Preoccupation of a perceived defect in appearance

Overemphasis of a slight defect
Compulsive behavior
o
Mirror checking
o
Excessive grooming
o
Comparing appearance to others
Clinical Features
Most common concerns involve the face usually the nose
Other common body parts: hair, breasts, genitalia
Concern may be to increase body mass men (muscles!)
Other symptom patterns: religious obsessions and compulsive hoarding, compulsive hair pulling and nail biting, masturbation
Symptoms:
Course and Prognosis
o
Delusion of reference
More than half sudden onset, usually after stressful event (50-70%)
o
Excessive mirror checking or avoidance of reflections
OCPD long duration, has been there for a long time
DDx:
They may even cover the mirrors
Course usually long and variable (fluctuating or constant) Sydenham's chorea and
o
Attempts to hide presumed deformity
Huntington's disease - basal
Improvement
ganglia disorder
Putting too much makeup or literally cover it up
o
20 to 30%: significant improvement
Tourette's disorder - recurrent
o
Avoid social and occupational exposure
vocal and motor tics
o
40 to 50%: moderate improvement
May attempt suicide tingin nila sila pinakapangit
OC personality disorder,
o
20 to 40%: remain ill or worsen
suicide is a risk for all patients with OCD
psychosis, major depressive
Treatment:
Poor prognosis
disorder = cannot cope vs
SSRI Fluoxetine
personality disorders
o
Yielding to, instead of resisting, compulsion
Clomipramine
o
Childhood onset
Others
o
Bizarre compulsions
o
Buspirone
o
Hospitalization
o
Lithium
o
Co-morbid major depression
o
Methylphenidate
o
Delusional beliefs
o
Anti-psychotics
o
Overvalued ideas

OBSESSIVE COMPULSIVE AND RELATED DISORDERS

gambling, as in substance-related and addictive disorders;

preoccupation with having an illness, as in illness anxiety disorder;
sexual urges or fantasies, as in paraphilic disorders; impulses, as in
disruptive, impulse-control, and conduct disorders; guilty
ruminations, as in major depressive disorder; thought insertion or
delusional preoccupations, as in schizophrenia spectrum and other
psychotic disorders; or repetitive patterns of behavior, as in autism
spectrum disorder).

Common and often disabling phenomenon associated with impairment in such

functions as eating, sleeping and grooming

Acquiring and not discarding things that are deemed to be of little or no value,,
resulting in excessive clutter of living space
Obsessive fear of losing important items that a person believes may be of use
in the future
Distorted beliefs about the importance of possessions
Extreme emotional attachment to possessions back-ups
Epidemiology
2 to 5% of general population
Men = women
More common in single persons
Usually begins in early adolescence and persists throughout life
Co-morbidity
OCD
Compulsive buying kahit hindi kailangan (bags, shoes)
Personality disorders dependent, avoidant, schizotypal, paranoid types
Generalized anxiety disorder (27%)
ADHD
Social anxiety disorder (14%)
Schizophrenia
and may follow surgery resulting in
Dementia frontotemporal.
structural defects in prefrontal and orbitofrontal cortex
Eating disorders, depression, anxiety disorders, substance use disorders,
kleptomania, compulsive gambling
Etiology
80% have a first degree relative with hoarding behavior genetic
Lower metabolism in posterior cingulum and occipital cortex
Markers on chromosomes 4q, 5q, 17q
DDx: OCD, dementia, schizophrenia, bipolar mood disorder

Diagnosis
Acquiring and failure to discard a large amount of possessions that are
deemed useless or of little value
Greatly cluttered living areas precluding normal activities may be dangerous,
attract pest, fire, etc.
Significant distress and impairment in function due to hoarding

Object loss recent

Substance abuse
?genetic

DDx: OCD, malingerers, factitious dx

Smaller volume of the left putamen and left lenticulate areas

Diagnosis
Increase tension before hair pulliung; sense of release or gratification after hair
pulling
All areas of body affected, most commonly the scalp
Two types:
o
Focused pulling intentional act to control unpleasant personal
experiences, e.g. urge, bodily sensation (itching, burning) or thought
often during sedentary
o
Automatic pulling occurs outside awareness most
activities
Tricophagy eating the hair after pulling, may cause intestinal obstruction

Hair pulling is not reported as being painful but pruritus and tingling may occur in the involved area
Head banging, nail biting, scratching, gnawing, excoriation, and other acts of self-mutilation may be present

Treatment

Psychiatrists and dermatologists jointly

SSRIs
Pimuzide DA receptor antagonist
Behavioral treatment biofeedback, self-monitoring desensitization, and
habit reversal
Insight-orirented psychotherapy
?Hypnotherapy
Children wear socks sa hands, so that they cannot pull their hair
No consensus exists on the best tx modality for hair-pulling disorder

EXCORIATION (SKIN PICKING) DISORDER

Compulsive and repetitive picking of the skin
May leady to severe tissue damage result in the need for various dermatological tx
Skin picking syndrome, emotional excoriation, nervous scratching artifact,
epidermotillomania, paraartificial excoriation
1 to 5% prevalence in general population
Women > men
DDx:
Mostly adolescent
Eczema
Factitious dermatitis - skin picking is

Co-morbidity
target of self-inflicted injury, more
elaborate methods
OCD
OCD
Hair-pulling disorder
Body dysmorphism
Substance dependence
Major depression
Anxiety disorder
Body dysmorphic disorder
Borderline and obsessive-compulsive personality disorders

Clinical Features
Fear of losing items that patient believes will be needed later
Distorted belief about or an emotional attachment possessions
Hoarders do not perceive their behavior to be a problem, and is part of their
identity
Most commonly hoarded: Newspapers, magazines, old clothes, books, bags,
Etiology cause of skin picking is unknown
notes, photographs
Manifestation of repressed rage and authoritarian parents; self-assertion
Inability to organize possessions and avoidance to make a decision to discard
Relief of stress from marital conflicts, passing of loved-ones, unwanted
Course and Prognosis:
them
pregnancies
Chronic condition w/ a tx-resistant
goal in tx is to get rid of a significant amt of possessions
Treatment Tx studies using SSRIs have shown mixed results
course
Psychoanalytic theory skin is an erotic organ; masturbatory equivalent
Tx
seeking
does
not
usually
occur
Cognitive Behavior Therapy (CBT)
o
Skin picking is a source of erotic pleasure
until patients are in their 40s-50s,
o
Training in decision making and categorizing even if the hoarding began during
Serotonin, dopamine, glutamate dysregulation
o
Exposure and habituation to discarding
adolescence
Symptoms may fluctuate throughout Diagnosis
o
Cognitive restructuring
the course of the disorder but full
Recurring skin picking resulting in skin lesion
remission is rare
HAIR-PULLING DISORDER (TRICHOTOLLOMANIA)
Repeated attempts to decrease or stop picking
Clinical relevant distress or impairment in functioning
Chronic repetitive hair pulling
Clinical Findings
Trichotilomania (Francois Hallopeau)
Face most common site
Increased tension prior to hair pulling; relief of tension or gratification after hair
Legs, arms, torso, hands, cuticles, fingers, scalp
pulling
Tension prior to picking; relief and gratification after picking
Relief of stress and other negative feelings
Epidemiology
Patients often feel guilty and embarrassment at their behavior
Prevalence in underestimated because of underreporting
Two forms:
< 17 years
Treatmnent:
o
More serious, chronic form early to mid adolescence, Female >
SSRIs Fluoxetine
male; 10:1 only child or oldest child in the family
o
Childhood type girls = boys, less serious dermatologically and
Lamotrigine
psychologically resolves in adulthood
Habit reversal and brief cognitive-behavioral therapy (CBT)
Co-morbidity
Psychotherapy for underlying emotional factors
OCD
Course and Prognosis:
Mean age: early teens, <17 years
Anxiety disorders
The course of the disorder is not well known;
Tourettes disorder
both chronic and remitting forms occur
Depression
Eating disorder
Personality Disorder
Etiology
Disturbances in mother-child relationship
Fear of being left alone

OBSESSIVE COMPULSIVE AND RELATED DISORDERS

HOARDING DISORDER