Chapter 9 Obsessive-Compulsive and - PowerPoint Presentation

Slide1

Chapter 9

Obsessive-Compulsive and

Related

DisordersSlide2

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 functioningSlide3

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 

functioningSlide4

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)Slide5

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 functioningSlide6

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 functioningSlide7

Epidemiology

Obsessive-compulsive disorder

12-month prevalence is 1.2%; lifetime prevalence

is 1

%

(Ruscio et al., 2010)

Body

d

ysmorphic

d

isorder

P

oint

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

(

s

kin-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)Slide8

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

B

ehavioral Avoidance Tests (BATs)Slide9

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 interestSlide10

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 varianceSlide11

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:

C

aseness

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 OCDSlide12

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 dizygoticSlide13

Etiology: Behavioral and

Molecular

Genetics cont.

Excoriation

d

isorder

(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) Slide14

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 EDSlide15

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 suggestedSlide16

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

O

verestimated

responsibility and exaggerated threat

P

erfectionism

and intolerance of uncertainty

Overimportance

of thoughts and need to control thoughts

Neurocognitive performance in OCD patients involves impairment in executive functioning

Strategizing

O

rganizingSlide17

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

F

ear

of leprosy in Africa

R

eligious

themes in

M

iddle East

Data

suggest

lower prevalence of OCD among African

Americans;

may reflect lower number of African Americans seeking evidence-based treatmentSlide18

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 RCTsSlide19

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)Slide20

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 neededSlide21

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

a

cceptance

and commitment Therapy (ACT) as well as

dialectical

behavior therapy (DBT)Slide22

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