Transcript Document

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
The obsessions or compulsions
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 ObsessiveCompulsive 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 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
whether there 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).