OBSESSIVE COMPULSIVE DISORDER PRESENTED BYMrs Shalini Chhabra Department

OBSESSIVE COMPULSIVE DISORDER PRESENTED BYMrs. Shalini Chhabra Department Of Psychology DAV College For Girls, Yamunanagar

Obsessive Compulsive Disorder (OCD) is defined by the occurrence of unwanted and intrusive obsessive thoughts or distressing images ; these are usually accompanied by compulsive behaviours designed to neutralize the obsessive thoughts or images or to prevent some dreaded event or situation.

According to DSM- IV, obsessions involve persistent and recurrent intrusive thoughts, images, or impulses that are experienced as disturbing and inappropriate. People who have such obsessions try to ignore or suppress them, or to neutralize them with some other thought or action.

Most Common Obsessions: 1. Repeated thoughts about contamination (e. g. , becoming contaminated by shaking hands). 2. Repeated doubts (e. g. , wondering whether one has performed some act such as having hurt someone in a traffic accident or having left a door unlocked).

3. A need to have things in a particular order (e. g. , intense distress when objects are disordered or asymmetrical). 4. Aggressive or horrific impulses (e. g. , to hurt one’s child or to shout an obscenity in church). 5. Sexual imagery (e. g. , a recurrent pornographic image).

Acc to DSM-IV Compulsions are repetitive behaviours (e. g. , hand washing, ordering, checking) or mental acts (e. g. , praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification. In most cases, the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession or to prevent some dreaded event or situation.

Most Common Compulsions: 1. Individuals with obsessions about being contaminated may reduce their mental distress by washing their hands until their skin is raw. 2. Individuals distressed by obsessions about having left door unlocked may be driven to check the lock every few minutes. 3. Individuals distressed by unwanted blasphemous thoughts may find relief in counting to 10 backward and forward 100 times for each thought.

Diagnostic criteria for Obsessive - Compulsive Disorder A. OBSESSION: 1. Recurrent and persistent thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.

2. The thoughts, impulses or images are not simply excessive worries about reallife problems. 3. The person attempts to ignore or suppress such thoughts, impulses or images or to neutralize them with some other thought or action. 4. The person recognizes that the obsessional thoughts, impulses or images are a product of his or her own mind( not imposed from without as in thought

B. COMPULSIONS : 1. Repetitive behaviours (e. g. , hand washing, ordering, checking) or mental acts (e. g. , praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.

2. The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

C. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply on children. D. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

E. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e. g. , preoccupation with food in the presence of an Eating Disorder; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; guilty ruminations in the presence of Major Depressive Disorder).

F. The disturbance is not due to the direct physiological effects of a substance (e. g. , a drug of abuse, a medication) or a general medical condition. Specify if : With Poor Insight: if, for most of the time during the current episode, the person doesnot recognize that the obsessions and compulsions are excessive or unreasonable.

ASSOCIATED FEATURES AND DISORDERS obsessions or compulsions The 1. Cause marked distress. 2. Be time consuming (take more than 1 hour per day). 3. Significantly interfere with the individual’s normal routine, occupatinal functioning, or usual social activities or relationships with others.

4. Can displace useful and satisfying behaviour and can be highly disruptive to overall functioning. 5. Obsessive intrusions can be distressing, result in inefficient performance of cognitive tasks that require concentration, such as reading or computation. 6. Many individuals avoid objects or situations that provoke obsessions or compulsions.

Such avoidance can become extensive and can severely restrict general functioning. 7. Hypochondriacal concerns are common, with repeated visits to physicians to seek reassurance. 8. Guilt, a pathological sense of responsibility, and sleep disturbances may be present. 9. There may be excessive use of alcohol or of sedative, hypnotic or medications.

10. Performing compulsions may become a major life activity, leading to serious marital, occupational, or social disability. 11. Pervasive avoidance may leave an individual housebound. 12. Obsessive-Compulsive Disorder may be associated with Major Depressive Disorder, other Anxiety Disorders (Specific Phobia, Social Phobia, Panic Disorder) Eating, and Obsessive. Compulsive Personality Disorders.

SPECIFIC CULTURE, AGE, AND GENDER FEATURES 1. Presentations of Obsessive-Compulsive Disorder in children are generally similar to those in adulthood. 2. Washing, checking, and ordering rituals are particularly common in children. 3. Children generally do not request help, and the symptoms may not be egodystonic.

4. The problem is identified by parents, who bring the child in for treatment. 5. Gradual declines in schoolwork secondary to impaired ability to concentrate have been reported. 6. Like adults, children are more prone to engage in rituals at home than in front of peers, teachers, or strangers. 7. This disorder is equally common in males and females.

COURSE OF THE DISORDER 1. Obsessive-Compulsive Disorder usually begins in adolescence or early adulthood, it may begin in childhood. 2. Modal age at onset is earlier in males than in females: between ages 6 and 15 years for males and between ages 20 and 29 years for females. 3. For the most part , onset is gradual, but acute onset has been noted in some cases.

GENDER DIFFERENCES IN THE ANXIETY DISORDERS: LIFETIME PREVALENCE ESTIMATES DISORDER PREVALENCE IN MEN (%) IN WOMEN(%) OCD 2. 0 2. 9 Sources: (Barlow, 1988; Eaton et al. , 1994; Karno et al. , 1988; Kessler et al. , 1994; Magee et al. , 1996)

CASUAL FACTORS IN OCD 1. The Psychoanalytic viewpoint i. Acc to Freud’s psychoanalytic view, a person with OCD has been unable to cope up with the instinctual conflicts of the Oedipal stage and has either never advanced beyond this stage or has regressed back to an earlier stage of psychosexual development.

Specifically, such a person is thought to be fixated in the anal stage of development. ii. Acc to this theory, the intense conflict that may develop between impulses from the id to let go, and the ego to control and withhold, leads to the development of defense mechanisms that may ultimately produce obsessivecompulsive symptoms.

iii. The four primary defense mechanisms thought to be used are (1) isolation, (2)displacement, (3) reaction formation, and (4) undoing (Nemiah, 1975; Sturgis, 1993). iv. Unfortunately, there has been virtually no empirical research documenting any of the major tenets of this theory, and the treatment that stems from it has not proved to be useful in treating OCD.

2. The Behavioural viewpoint i. The dominant behavioural view of obsessive-compulsive disorder derives from O. H. Mowrer’s two process theory of avoidance learning (1947). Acc to this theory, neutral stimuli become associated with aversive stimuli through a process of classical conditioning and come to elicit anxiety. For example, touching a doorknob or shaking hands might become associated with the scary idea of

Once having made this association, the person may discover that the anxiety produced by shaking hands or touching a doorknob may be reduced by an activity like hand washing. By washing his or her hands extensively, the anxiety would be reduced and the washing response would be reinforced, making it more likely to occur again in the future when anxiety about contamination was evoked in other situations (Rachman and Shafran, 1998).

Once learned, such avoidance responses are extremely resistant to extinction (Mineka and Zinbarg, 1996; Salkovskis and Kirk, 1997). ii. OCD and Preparedness: The contents of the great majority of both obsessions and phobias were rated as highly prepared, as were the ratings of most compulsive behaviours.

iii. The Role of Memory: Cognitive factors have also been implicated in obsessivecompulsive disorder. (Sher, Frost, and Otis 1983; Sher et al. , 1989), for example, have shown that people with checking compulsions show poor memory for their behavioural acts, such as “Did I check to see if the stove was off? ” Having a poor memory for one’s actions could easily be seen as contributing to the repetitive nature of checking rituals.

More recently, there is increasing evidence that people with OCD do indeed have impairments in their nonverbal memory but not their verbal memory (Trivedi, 1996). They also have low confidence in their memory ability (Gibbs, 1996; Trivedi, 1996).

iv. The Effects Of Attempting To Suppress Obsessive Thoughts: It has now been shown that when normal people attempt to suppress unwanted thoughts they may find a paradoxical increase in those thoughts later (Wegner, 1994).

3. The Biological viewpoint In the past 20 years there has been an explosion of research investigating the possible biological basis for obsessivecompulsive disorder. i. Some studies have sought to discover whethere is a genetic contribution to this disorder. a. Genetic studies have included both twin studies and family studies.

Evidence from twin studies reveals a moderately high concordance rate for monozygotic twins and a lower rate for dizygotic twins. A recent review of 14 published studies included 80 monozygotic twins, of whom 54 were concordant for the diagnosis of OCD, and 29 dizygotic twins, of whom 9 were concordant. This is consistent with a moderate genetic heritability (Billett, Richter, and Kennedy, 1998).

b. Most family studies have also found substantially higher rates of OCD in first degree relatives of OCD clients than would be expected based on current estimates of the prevalence of OCD, with estimates that about 10 percent of first degree relatives have diagnosable OCD (Pauls et al. , 1995).

ii. Structural brain abnormalities associated with OCD, and abnormalities in specific neurotransmitter systems associated with OCD. a. Abnormally active metabolic levels in the orbital prefrontal cortex, the caudate nucleus, and the cingulate cortex ( Cottraux & Gerard, 1998; Trivedi, 1996). b. Abnormalities in the functioning of the basal ganglia (Cottraux and Gerard, 1998; Insel, 1992; Trivedi, 1996).

c. Baxter et al. , (1991) have speculated that the primary dysfunction in OCD may be in an area of the brain called the striatum, which is involved in the preparation of appropriate behavioural responses. When this area is not functioning properly inappropriate behavioural responses may occur, including repeated behaviours such as occur in OCD.

d. In OCD there is a dysfunctional interaction of Striatum with certain areas of the cortex, leading those higher brain areas to become abnormally active. This causes sensations, thoughts, and behaviours that would normally be inhibited (if the striatum were functioning properly) to not be inhibited in clients with OCD.

iii. The accumulating evidence from all three kinds of studies is that biological casual factors are probably more clearly implicated in the causes of OCD than in any of the other anxiety disorders. a. Pharmacological studies of obsessivecompulsive disorder intensified with the discovery that a drug called Anafranil (clomipramine) is often effective in the treatment of obsessive-compulsive disorder.

b. Clomipramine is more effective with OCD than the other tricyclics because it has greater effects on the neurotransmitter serotonin, which is now strongly implicated in OCD. c. OCD may be characterized by deficiences in serotonin levels. The complex picture that seems to be emerging is that increased serotonin activity and increased sensitivity of some brain structures to serotonin may be involved in OCD symptoms.

TREATMENT 1. Medications that affect the neurotransmitter serotonin seem to be the only class of medication studied to date that has reasonably good effects in treating persons with OCD. These selective serotonin-reuptake inhibitors (such as clomipramine or Anafranil, and fluoxetine or Prozac) appear to reduce the intensity of the symptoms of this

2. A major disadvantage of drug treatment for OCD, as for other anxiety disorders, is that relapse rates are very high following discontinuation of the drug (approximately 90%, Dolberg et al. , 1996). 3. With OCD, a behavioural treatment involving a combination of exposure and (compulsive) response prevention may be in the long run the most effective approach to the difficult problem of obsessive-compulsive disorders (e. g. , Foa, Franklin, & Kozak, 1998; Steketee, 1993).

4. Some of the psychologists believe that it is very important to alter the abnormal interaction within family members, which may be responsible for reinforcing this particular disorder. 5. Some of minor tranquilizers such as librium or valium may help the patients of OCD. The Monoamine Oxidase Inhibitors and tricyclics also help the OCD patients. The selective serotonin reuptake inhibitors such as Prozac help in allivating the symptoms of OCD patients.

6. Finally, because OCD in its most severe form is such a crippling and disabling disorder, in recent years psychiatrists have begun to reexamine the usefulness of certain neurosurgical techniques for the treatment of severe intractable OCD (which may be the case for as many as 10% of people diagnosed with OCD) (Mindus, Rasmussen, & Lindquist, 1994).

Before such surgery is even contemplated the person must have had severe OCD for at least 5 years and not responded to all of the known treatments discussed so far (both behaviour therapy and several medications).