OCD and related disorders How repetitive thoughts and actions can impair our lives.
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Transcript of OCD and related disorders How repetitive thoughts and actions can impair our lives.
OCD and related disorders
How repetitive thoughts and actions can impair our lives
DSM 5 switch
• Previously these disorders were listed in the chapter with anxiety disorders
• While these disorders surely involve anxiety and certain meds help both
• The underlying causes of anxiety disorders and OCD differ significantly
• Accordingly, in DSM 5 they were placed in different but nearby chapters
OCD – the basics
• Marked by two symptoms: Obsessions – repetitive thoughts and urges & Compulsions – an irresistible need to engage
in various acts or mental acts• Both are perceived as “unstoppable”• They are distressing, uncomfortable, and
require a lot of time and energy
Similar
• Body Dysmorphic Disorder and Hoarding\• Both involve significant anxiety• 1/3 of Body Dysmorphic fit OCD criteria at
some point• ¼ of Hoarders, do as well• Many similarities with respect to cause and
treatment
Clinical Description of OCD
• Intrusive, repetitive, overwhelming obsessions and compulsions
• Far beyond what the rest of us endure
• Interfere with everyday activities
More Obsessions
• Obsessions: onrushing, uncontrollable thoughts, images, or impulses
• Often involve: fear of contamination sexual or aggressive impulses perceived body problems religious matters symmetry and order• Often are perceived as unreasonable
Compulsions
• Repetitive, clearly excessive behaviors or mental acts that must be performed to prevent some catastrophe
• Often involve Cleanliness and orderliness (often rituals) Repetitive, magically protective acts Unceasing checking • Often repeated thousands of times
More on Compulsions
• Contrary to “compulsive” gamblers or shoppers, these activities are never pleasurable
• Onset before 10 or in late adolescence • 1% experience every year, 2% over a lifetime• More women than men• Often comorbid w/ anxiety, depression and
substance abuse – 1/3 show hoarding
Body Dysmorphic
• Preoccupied with one or more perceived defects in appearance
• No matter what other’s may think• Also performance of repetitive actions or
mental acts due to appearance fears• Has to be more than worries about fat or
weight
More Body concerns
• Women focus on skin, breasts, and thighs• Men – height, penis size, body hair, size of
muscles• Spend lots of time (8 hrs!) agonizing over this• Also ritualized, compulsive behaviors,
especially checking themselves in the mirror • Hide or camouflage defects• Seek reassurance, or avoid mirrors
No fun at all
• Many (1/3) carry delusions, people staring or laughing at them
• Lots (1/4) resort to plastic surgery, but that doesn’t seem to help
• Some consider suicide
Functional ramifications
• Feel profound shame, humiliation, and depression
• Leads to avoiding contact with others for fear of being ridiculed
• Some even become housebound
• 40% can’t work
Demographics
• Afflicts more women • But only 2% of even women• 5-7% of women seeking plastic surgery
• Usually begins in late adolescence• Within 8 years, 75% recover
Miscellaneous
• While symptoms appear similar worldwide, body parts at issue vary for culture to culture
• Many US college students complain about appearance but few have are severe enough for diagnosis
• Virtually all are comorbid with another condition – MDD, OCD, Social Anxiety Disorder, Substance Abuse and the PDs
Hording
• Formerly subsumed within OCD• Now carries its own diagnosis• It’s not just collecting a lot of junk, it’s the
inability to throw away any of it• Strongly resist any effort to clear out mess • 2/3s are unaware of the severity of the
problem
If hording things wasn’t bad enough
• 1/3 also horde animals• Many more women then men• Though they view themselves as helping the
animals, just the opposite plays out• Frequently leads to sick, starving, and
neglected animals• If they’re not already dead
Consequences of Hording
• Problems extend far beyond a messy house• Case studies describe overpowering odors
from rotted food and feces• Health concerns• Junk accumulation makes for great difficulty
moving about, cooking, sanitation, etc• Many can’t even use stove, fridge, even toilet
More Problems
• Some threatened with evection or sanctions• Often spend to much money purchasing items• Often conditions lead to estrangement with
families• Some can’t work – poverty, homelessness• 2% admit problems • Few seek treatment• Often severe problems don’t arise to middle age
Causes
• All 3 seem to have similar root causes• Show family histories• In the brain, the orbitofrontal cortex and
caudate nucleus, and anterior cingulate appear overactive
• All kick into hyperdrive when OCD sees a dirty glove or a BD glimpses a picture of her face
Specific causes of OCD
• Heritability rates run between 30-50%
• Cognitive and Behavioral factors must contribute
Cognition and OCD
• Why can’t some of us turn off the obsessions?• Failure of Yedasentience – the ability to stop
thinking about something• When more rumination won’t help, most of
us can move on to something else• Not those with OCD
Behavioral explanations for OCD
• Turn to Operant Conditioning for the answer• Performing the compulsive behavior reduces
anxiety and is therefore reinforcing – likely to happen again
• After all, after performing compulsive behaviors, anxiety does drop
But why all the checking?
• Wouldn’t one check be enough?• The stove won’t turn on by itself, will it?• OCD involves a lack of confidence in memory
Thought Suppression
• Perhaps they try so hard not to think about the obsessions they think about them even more
• These effects can last for days
Causes of Body Dysmorphic
• Cognitive – how they perceive what they see• They focus on certain features (eyes) or facial
symmetry that are key re attractiveness• Then they find tiny, insignificant details and
over-exaggerate their importance• Also view attractiveness as much more
important than others• Ignore the positive, fret over tiny flaws
Why horde?
• Evolution – horde because it was to our advantage to accumulate goods and foods
• But why so so so much?
• Cognitive approach offers 3 possible explanations
1) they can’t organize – trouble giving the attention necessary, categorizing – too many categories, making decisions, and feel loads of anxiety even trying
So they buy too many (decisions) Can’t settle where to put (categorizing) Feel too much stress to discard (anxiety) and can’t pull together a solution (attention)
Strange beliefs
• Form strong emotional connection with junk• Feel comfort from them• Fear their loss• Find them the center of their identity• These beliefs can be even stronger with
animals• All this leads sufferers to avoid any thought of cleaning up, or, worse, throwing anything away
Treatment
• Treatment for all three are similar
• Use SSRIs• Apply Exposure and Response Prevention
(ERP) techniques
Meds for OCD
• The antidepressant Clomipramine caused a 50% drop in OCD symptoms
• But the SSRIs work just as well and cause fewer side-effects
• Not so sure about hording, but one trial showed that Paxil (a SSRI) helped horders
ERP & OCD
• Place in situation which will trigger obsessive thoughts
• Prevent performance of compulsion• Anxiety will run full-force but eventually
subside and go through extinction • ERP works across settings and types of
patients• Facing obsession is difficult - 25% won’t try
BD - ERP
• Techniques tailored to fit • Forced interactions w/ someone critical of
looks• Prevented from looking in mirrors• At same time irrational thoughts/beliefs are
challenged• Cognitive techniques aid recovery
Hording - ERP
• Exposure – make them face greatest fear – parting with things
• Prevention – prevent rituals – buying more, sorting, counting, etc.
Other considerations - Hording
• Work on insight – what’s wrong and why things should change
• Then behavioral strategies (organizational skills) are taught
• Rushing doesn’t help – they quit treatment• Family relationships are often strained, if they
have survived at all• Try to build rapport, trust and doable outcomes