OCD

• OCD

  • ~2% prevalence 
• Tics

  • Repeating phrases 
  • Blurred lines between compulsion to repeat actions and degradation of tic and motor actions 
  • Frequently comorbid 
• Obsessions

  • Recurrent and persistent thoughts, urges, or images that are unwanted or intrusive and in most individual cases, provoke anxiety or distress
  • Can be bothersome in frequency and troubling 
• examples of obsessions

  • Contamination 
  • Mistakes - leaving doors unlike, leaving the stove on
  • Impulses - to do inappropriate things in settings, thoughts run in mind, idea that may lose control 
  • Order - arranging, symmetry, recurrent thoughts about things being lined up, something awful will happen
• Compulsions

  • Repetitive behaviours or mental acts that the individual does in response to an obsession or a rigid rule
• Ego-Dystonia

  • Refer to idea that people with OCD know the behaviour is unnecessary but despite this, an abnormal excess cannot resist the urge 
  • Loss of connection between conscious and unconscious
• DSM criteria for obsessions

  • Recurrent and persistent thoughts, urges, or images that are unwanted/intrusive and in most cases, provoke anxiety/distress 
  • The individual attempts to ignore, suppress, or neutralise
• DSM criteria for compulsions

  • Repetitive behaviours or mental acts that the individual does in response to an obsession or a rigid rule
  • Aimed at preventing or relieving anxiety/distress or preventing some feared consequence 
  • Not realistic or clearly excessive
• • Higher concordance for OCD among pairs of monozygotic twins (80-87%) than dizygotic twins (47-50%)
• Treatment for OCD is usually SSRIs
• • Response to SSRIs
  • Up to 65% achieve a 20-40% reduction in OCD symptoms 
• • Remission from SSRIs
  •  ≤ 25% of OCD patients achieve remission (i.e., minimal symptoms)
• Treatment for OCD

  • Cognitive Behavioural Therapy (CBT)
  • Exposure and Response Prevention (ExRP)
• Up to 62-80% of patients respond to ExRP
• • Habits are automatic ‘Stimulus-response’ behaviours 
• Goal-directed behaviours are actions that rely on linking actions to outcomes
• DSM-5: Obsessive-Compulsive and related disorders

  1. Obsessive Compulsive Disorder (OCD)
  2. Body Dysmorphic Disorder (BDD)
  3. Hoarding Disorder (HD)
  4. Trichotillomania (Hair-Pulling Disorder)
  5. Excoriation (Skin-Picking) Disorder
• Body Dysmorphic Disorder

  • Preoccupation with imagined or exaggerated flaws in physical appearance
• DSM-5 criteria for BDD

  1. Appearance Preoccupation: preoccupation with one or more perceived defects or flaws in physical appearance, which person believes look ugly, unattractive, abnormal or deformed
  2. Repetitive Behaviours or Mental Acts: e.g., mirror checking, excessive grooming, skin picking, reassurance seeking, disguising/covering areas, comparing appearance with others
  3. Clinical significance and not better explained by another medical or psychiatric condition
• BDD is 44% heritable
• • Environmental factors for BDD: 
  • History of childhood abuse or neglect 
  • Past history of teasing/bullying at school that is appearance related
  • Some cultural specificity in target of preoccupation 
  • Early childhood temperament 
• • Up to 63% of BDD achieve a clinically significant improvement from SSRIs
• • Cognitive Therapy → Identify and question the meaning of the defectiveness (not the defect)
  • Collect information that is inconsistent with these beliefs:
• Hoarding disorder

  • Used to be subtype of OCD
• Hoarding disorder criteria

  • Persistent difficulty discarding or parting with possessions, regardless of their actual value
  • This difficulty is due to a perceived need to save the items and to distress associated with discarding them
  • The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use
  • Clinical significance and not better explained by another medical or psychiatric condition
• Treatment

  • Cognitive Behavioural Therapy
  • Medication (SSRIs, Stimulants)
  • Services (Cleaning and Removal Service, Professional Organiser, Case Management, Court Appointed Guardian)
• Trichotillomania (Hair-Pulling Disorder) and Excoriation (Skin Picking Disorder)

  • Repetitive pulling out of hair from head, eyelashes etc
  • Imbalance between a behaviour which occurs when stressed etc and not being able to control it 
• • Habit reversal training 
  • Monitor pulling to identify situational antecedents (triggers and causes, when do they do it, bored/stress/distracted?)
  • Increase awareness of behaviour and high risk situations
  • Identify a “competing response” that is incompatible with hair pulling
  • Stimulus control. decrease opportunities to pull hair or to interfere with or prevent pulling (i.e., wearing gloves in high-risk situations).
• Dissociation

  • ‘Lack of normal integration of thoughts, feelings and experiences into the stream of consciousness and memory.’
• • Key features of dissociation
  • Disruption of sense of self, sense of body/surroundings, memory (amnesia) or self identification
• • Depersonalisation: Separation of thoughts, emotions and sense of self, can feel like you are outside of your own body
• • Derealisation: Your surroundings appear surreal and dreamlike; detachment from your surroundings
• Depersonalisation/ Derealisation Disorder

  • Recurring, persistent experience of depersonalisation and/or derealisation
  • Insight remains intact during episodes 
  • Causes distress/impairment
• Dissociative Amnesia

  • Inability to recall autobiographical information (usually of a stressful or traumatic nature)
• • Retrograde - past events
  • Anterograde - future events
• Dissociative fugue

  • Unusual situation where during period will take off and engage in purposeful travel
• Dissociative identity disorder

  • Characterised by experience of at least two distinct personality states, described as alters
  • Marked discontinuity in identity
  • Different alters have independent autobiographical/episodic memories, different traits, and sense of agency (but share implicit memories, skills)
  • Recurrent memory gaps
• Billy mulligan 

  • Committed violent sexual assault and maybe murder when they claimed to be embodying another alter
• depersonalisation/derealisation prevalence - 2.5%
• Dissociative amnesia prevalence - 7.5%