Obsessive-Compulsive Disorder (OCD)

DSM-IV-TR Criteria

• A. Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4):

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 real-life 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 or his or her own mind (not imposed from without as in thought insertion).

Compulsions as defined by (1) and (2):

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

• B. 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 to children.
• C. 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.
• D. 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; hair pulling in the presence of trichotillomania; concern with appearance in the presence of body dysmorphic disorder; preoccupation with drugs in the presence of a substance use disorder; there is some presentation of a preoccupation with having a serious illness in the presence of hypochondriasis, or thinking that one is ill the majority of the time; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder).
• E. 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 does not recognize that the obsessions and compulsions are excessive or unreasonable).

Associated Features

Although a diagnosis of OCD requires only that a person either has obsessions or compulsions, not both, approximately 96% of persons experience both. For almost all people with OCD, being exposed to a certain stimuli (internal or external) will then trigger an upsetting or anxiety-causing obsession, which can only be relieved by doing a compulsion. For example, I touch a doorknob in a public building, which causes an obsessive thought that I will get sick from the germs, which can only be relieved by compulsively washing my hands to an excessive degree.Some of the most common obsessions include unwanted thoughts of harming loved ones, persistent doubts that one has not locked doors or switched off electrical appliances, intrusive thoughts of being contaminated, and morally or sexually repugnant thoughts. Commonly seen compulsions include hand washing, ordering or arranging objects, checking, praying, counting, and thinking good thoughts to undo bad ones.

Given that obsessions almost always trigger a compulsion, there are certain patterns of the two seen together. For example, contamination obsessions are almost always followed by some sort of compulsive cleansing, such as washing hands, taking a shower, or using hand sanitizer. There is some disagreement in the literature about just how many dimensions OCD symptoms fall into, with some finding four factors and others five based on different analytic techniques.

Up to 75% of persons with OCD also present with comorbid disorders. The most common in pediatric cases are ADHD, disruptive behavior disorders, major depression, and other anxiety disorders. In adults, the most prevalent comorbids are social anxiety, major depression, and alcohol abuse. Interestingly, the presence of comorbid diagnoses predict quality of life (QoL) more so than OCD severity. Different primary O/C are also associated with certain patterns of comorbidity, in both adults and youth. Primary symmetry/ordering symptoms are often seen with comorbid tics, bipolar disorder, obsessive-compulsive personality disorder, panic disorder, and agoraphobia, while those with contamination/cleaning symptoms are more likely to be diagnosed with an eating disorder. Those with hoarding cluster symptoms, on the other hand are especially likely to be diagnosed with personality disorders, particularly Cluster C disorders.

Almost all adults and children with OCD report that their obsessions cause them significant distress and anxiety, as opposed to similar, intrusive thoughts in persons without OCD. In terms of QoL, persons with OCD report a pervasive decrease compared to controls. Youth show problematic peer relations, academic difficulties, and participate in fewer recreational activities than matched peers. Overall, there is a lower QoL in pediatric females than males, but in adults similar disruptions are reported. When compared to other anxiety disorders and unipolar mood disorders, a person with OCD is less likely to be married, more likely to be unemployed, and more likely to report impaired social and occupational functioning.

Daily, there are a number of problems that people with OCD face. One is the avoidance of situations in which the objects of the obsessions are present. For example, a person may avoid using public restrooms or shaking hands with people because doing so will trigger their contamination obsession, which will lead to them having to do a cleansing compulsion. Some people will not leave their homes because that is the only way to avoid objects and situations that will trigger their obsessions. Frequent doctor visits may also occur because they fear that something is wrong with them physically, just like a hypochondriac would feel. Feelings of guilt can also be present, along with disrupted sleep patterns and extreme feelings of responsibility. Self-medication may also be present in adults, with alcohol and sedatives the most often abused substances.

Child vs. Adult Presentation

Presentation of OCD symptoms is generally the same in children and adults. Unlike many adults, though, younger children will not be able to recognize that their obsessions and compulsions are both unnecessary (e.g., you don’t really need to wash your hands) and extreme (e.g., washing hands for 15-20 seconds is fine, but 5 minutes in scalding water is too much) in nature. In young children, compulsions often occur without the patient being able to report their obsessions, while adolescents are often able to report multiple obsessions and compulsions. Children and adolescents are also more likely to include family members in their rituals and can be highly demanding of adherence to rituals and rules, leading to disruptive and oppositional behavior. As such, youth with OCD are generally more impaired than adults with the same type of symptoms.

Gender and Cultural Differences in Presentation

While OCD is equally present in males and females in adulthood (although some studies have found much higher rates in females), the disorder is heavily male in pediatric patients. There are some differences in comorbidity as well. Among men, hoarding symptoms are most often associated with GAD and tic disorders, but in women social anxiety, PTSD, body dysmorphic disorder, nail biting, and skin picking are more often observed.

There is strong evidence that cultural differences do not play a prominent role in presence of OCD, with research showing few epidemiological differences across different countries and even between European and Asian populations. Similar symptom categories are seen across cultures, but culture can impact the content of obsessions and compulsions. In Bali, for example, heavy emphasis on somatic symptoms and need to know about members of their social network is found. Perhaps the best example is in religious obsessions, which are very common. Type of religious upbringing has been related to different types of primary obsessions, such as emphasis on cleanliness and order in Judaism, religious obsessions in Muslim communities, aggressive aggressions in South American samples, and dirt and contamination worries in the United States. Worries about blasphemy and going to hell might be common in evangelical Christina societies, but would not be seen in a Buddhist background. It is also important to note that many cultures have rituals that are deep-rooted in their history and do not indicate OCD. It is only when these rituals exceed the cultural norms that OCD may be a concern.

Epidemiology

In the U.S., the lifetime prevalence rate of OCD is estimated at 2.3% in adults and around 1-2.3% in children and adolescents under 18. The 1-year prevalence of OCD in adults is 1.2% in adults and around 0.7% in children. There is a fairly substantial number of “sub-clinical” cases of OCD (around 5% of the population), where symptoms are either not disturbing or not disruptive enough to meet full criteria. As noted above, pediatric OCD is heavily male dominated, with some studies showing that there is an evening out within the genders by adulthood, and some showing that the numbers reverse and females become predominant.

Etiology

Family studies have indicated that OCD is modestly heritable for adult onset (27-47% of the variance in symptoms), but shows a much higher heritability for child onset (45-65%). These numbers, though, emphasize that environment is still a very important contributor to development of OCD. Biologically, dysfunctions of the neurotransmitters serotonin, glutamate, and dopamine are all implicated. Frontal cortico-striatal circuitry appears to mediated the presence of OCD, with over activity of the direct pathway from the ventromedial caudate to the globus pallidus and substantia nigra thought to be associated with OCD symptoms. This in turn disrupts functioning of the mediodorsal thalamus.

A recent field of inquiry has attempted to link sudden, pediatric onset of OCD to strep infections. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS) is a highly controversial area of research. Children with PANDAS are reported to develop obsessions, compulsions, and tics with no prodromal symptoms or indications during the course of a streptococcal infection, and these symptoms can be alleviated with treatment of the infection. As mentioned, this is a emerging and contentious idea, with many prominent researchers and clinicians not convinced by the evidence.

Psychologically, the most well-supported model for development of OCD is the cognitive-behavioral one. It proposes that obsessions and compulsions arise from dysfunctional beliefs that one holds; the greater the strength of the beliefs, the greater the chance that a person will develop OCD. One of the major research findings to support this idea is that unwanted cognitive intrusions are experienced by most people, with similar contents to clinical obsessions, but are not believed and as such cause little to no distress. Conversely, in people with OCD, these intrusive thoughts can become obsession if they are appraised as personally important, highly unacceptable or immoral, or posing a threat for which the individual is personally responsible. These types of appraisals will lead to high amounts of distress, which one then attempts to alleviate via compulsions. These compulsions result in anxiety reduction, but it is only temporary and actually reinforces the maladaptive beliefs that led to the negative appraisal in the first place, thus perpetuating the cycle of obsessions and compulsions. This model is the basis for CBT for OCD, which attempts to break this cycle of reinforcement and correct those negative appraisals and maladaptive beliefs.

Empirically Supported Treatments

There are both pharmacological and psychological treatments for OCD that are supported by research evidence. Overall, pharmacology with serotonin reuptake inhibitors (SRIs) shows large effect sizes in adults (0.91), but only moderate effect sizes in youth (0.46). Even with effective medication, most treatment responders show residual symptoms and impairments. There is also a very high relapse rate seen across numerous studies (between 24-89%). SRIs can be supplemented with adjunctive antipsychotics, but only a third of patients will show improvements. Across subtypes of OCD, there are medication differences seen. For example, the presence of tics appears to decrease selective SRI effects in children, but it is unclear if it has the same effect in adults. Another known difference is that OCD with comorbid tics responds better to neuroleptics than OCD without tics does.

The treatment of choice for OCD, in both adults and children and backed by numerous clinical trials, is cognitive-behavioral therapy, particularly the exposure with response prevention aspect of it (EX/RP). It is superior to medications alone, with effect sizes ranging from 1.16-1.72. There is a low (12%) relapse rate, but it is important to note that up to 25% of patients will drop out prior to completion of treatment due to the nature of treatment. The structure of treatment is very similar to what is used to treat phobias, but the course of therapy generally lasts between 12-16 sessions due to the larger number of anxiety/obsession triggering stimuli. It has been found that those with hoarding cluster symptoms respond less well to CBT, in part due to reluctance to engage in exposures. For them and others who are not engaging in exposures as needed, a treatment module focusing on motivational enhancement may be required. Research has also shown that individuals with comorbidity respond equally well to treatment, and that treatment of OCD often results in decreases of other anxious and depressive symptoms. Intriguingly, group therapy that uses CBT and EX/RP has been shown to be equally as effective as individual therapy and, for persons with mild OCD, computer-assisted self-treatment has been shown to be very effective (e.g., BT-STEPS).

As with OST for phobias, the first step is an assessment to determine maintaining factors (such as family accommodation) and comorbid problems. Next, education about the causes (biological and psychological) of OCD is presented, and misattributions about causes are corrected, and patients are asked to keep track of all possible O/C symptoms over the course of a week, as this allows for construction of a fear hierarchy to begin. Different O/C symptoms are often interwoven in hierarchy, as most people will present with two or more symptom clusters (e.g., symmetry and contamination, or hoarding and forbidden thoughts). The therapist and patient work on hierarchy construction together, based on self-report, other-report (e.g. parents), and behavioral observations. Once the hierarchy is constructed, items on it begin to be addressed in therapy, starting with moderately difficult situations, as ones below will show decreases naturally with treatment of higher problems. During the treatment phase, the clinician makes use of EX/RP techniques, including both imaginal and in vivo exposures. Imaginal exposures are often used in the beginning to demonstrate that anxiety will decrease across time, or when the person has abstract worries and fears that are difficult to perform real-life exposures for.

This also allows for practicing coping skills (e.g., cognitive restructuring and thought challenging) before confronting the real situation or stimuli. In vivo exposures follow and are similar to those conducted for persons with phobias, with the incorporation of cognitive challenges, modeling, reinforcement, and education into each exposure. Between sessions, homework is critical to the success of CBT for OCD, with the therapist helping the client to plan exposures to perform throughout the week, usually variations on what was accomplished during therapy. Ideal exposures are prolonged, repeated, prevent the use of distraction behaviors and show a SUDs decrease of at least 50% (with more being better). There may need to be shaping up to the more difficult situations, in terms of both time and use of distracters. For example, a person may need to move from just standing in a public restroom, to touching the door, then the door handle, then the floor, then the top of the toilet, to the toilet handle, the toilet seat, and finally into the bowl.

Proposed DSM-5 Revisions

Several changes have been proposed to the diagnosis of OCD, primarily just wording changes such as clarifying that the O/C are time consuming and impairing. The largest change is in the specifiers, which will move from the dichotomous “with poor insight” to a more continuum-based assessment rated from “good or fair” to “poor” to “absent” insight. In addition, the specifer of “tic-related OCD“will be used if the patient has a lifetime history of a chronic tic disorder or Tourette’s Syndrome. This has been proposed because this appears to be a distinct subtype of OCD and may account for up to 40% of pediatric cases. This category is often male-dominated, with a high incidence of symmetry/exactness/ordering and lower cleaning/contamination symptoms than seen in the general OCD population. In terms of comorbidity, there are very high rates of trichotillomania and disruptive behavior disorders seen in this subtype.

Key References

Abramowitz, J.S., Taylor, S., & McKay, D. (2009). Obsessive-compulsive disorder. Lancet, 374, 491-499.

Abramowitz, J.S., Whiteside, S.P., & Deacon, B.J. (2005). The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 36, 55-63.

Lack, C.W., Storch, E.A., Keely, M., Geffken, G.R., Ricketts, E., et al. (2009). Quality of life in children and adolescents with Obsessive-Compulsive Disorder. Social Psychiatry and Psychiatric Epidemiology, 44, 935-942.

Leckman, J.F., Denys, D., Simpson, H.B., Mataix-Cols, D., Hollander, E. et al. (2010). Obsessive-compulsive disorder: A review of the diagnostic criteria and possible subtypes and dimensional specifiers for DSM-V. Depression and Anxiety, 27, 507-527.

Storch, E.A., Lewin, A.B., Farrell, L., Aldea, M.A., Reid, J.A. et al. (2010). Does cognitive-behavioral therapy response among adults with obsessive–compulsive disorder differ as a function of certain comorbidities? Journal of Anxiety Disorders, 24, 547-554.