Obsessive-Compulsive-

Related Disorders
DSM-IV-TR vs. DSM-5
• In DSM-IV-TR, Obsessive-Compulsive and Related Disorders
and Trauma-Related Disorders were included with Anxiety
Disorders
• Some common symptoms, risk factors, and treatments with
anxiety disorders
• DSM-5 creates new chapters for Obsessive-Compulsive and
Related Disorders and Trauma-Related Disorders
Obsessive-Compulsive and Related
Disorders
1. Obsessive -Compulsive Disorder (OCD)
• Repetitive thoughts and urges (obsessions)
• Repetitive behaviors and mental acts (compulsions)
2. Body Dysmorphic Disorder
• Repetitive thoughts and urges about personal appearance
3. Hoarding Disorder
• Repetitive thoughts about possessions
4. Trichotillomania
• Hair-Pulling Disorder
5. Excoriation
• Skin-Picking Disorder
Obsessive-Compulsive Disorders
Obsessions
• Intrusive, persistent, and uncontrollable thoughts or urges
• Interfere with normal activities
• Often experienced as irrational
• Most common:
• Contamination, sexual and aggressive impulses, body problems,
religious, symmetry and/or order
Obsessive-Compulsive Disorders

Compulsions
• Impulse to repeat certain behaviors or mental
acts to avoid distress
• e.g., cleaning, counting, touching,
checking
• Extremely difficult to resist the impulse
• May involve elaborate behavioral rituals
• Compulsive gambling, eating, etc. NOT
considered compulsions, because they are
pleasurable
• Compulsions only server reduce anxiety,
not give pleasure
ETIOLOGY
• Biomedical Explanations for OCD
• Genetic causes: OCD runs in families and can be considered a
"familial disorder." The disease may span generations with
close relatives of people with OCD significantly more likely to
develop OCD themselves.
• Biochemical Causes:
• Leckmanet al, 1994, found that some forms of OCD were
related to oxytocin dysfunction. This could mean that OCD
type behaviors may be at extreme end of a normal range of
behaviors moderated by the hormone.
ETIOLOGY
• Neurological Causes:
• Brain imaging techniques lead to the discovery that some
parts of the brain are different in people with OCD when
compared to those without.
• Brain scans have shown abnormal activity in people with OCD.
• Despite this finding, it is not known exactly how these
differences relate to the development of OCD.
• Imbalances in the brain chemicals serotonin and glutamate
may play a part in OCD.
ETIOLOGY
• Behavioral causes:
• The behavioral theory suggests that people with OCD
associate certain objects or situations with fear.
• They learn to avoid those things or learn to perform "rituals"
to help reduce the fear.
• This fear and avoidance or ritual cycle may begin during a
period of intense stress, such as when starting a new job or
just after an important relationship comes to an end.
• Once the connection between an object and the feeling of fear
becomes established, people with OCD begin to avoid that
object and the fear it generates, rather than confronting or
tolerating the fear.
ETIOLOGY
• Cognitive causes:
• The cognitive theory, focuses on how people with OCD
misinterpret their thoughts.
• Most people have unwelcome or intrusive thoughts at
certain times, but for individuals with OCD, the importance
of those thoughts are exaggerated.
• For example, a person who is caring for an infant and who is under
intense pressure may have an intrusive thought of harming the infant
either deliberately or accidentally.
• Most people can shrug off and disregard the thought, but a
person with OCD may exaggerate the importance of the thought
and respond as though it signifies a threat.
• As long as the individual with OCD interprets these intrusive
thoughts as catastrophic and true, they will continue the
avoidance and ritual behaviors
ETIOLOGY

The Psychodynamic Perspective;

ETIOLOGY

The Psychodynamic Perspective;

 DSM-5 Diagnostic Criteria: Obsessive-Compulsive
Disorder 300.3 (F42)
A. Presence of obsessions, compulsions, or both:
• Obsessions are defined by (1) and (2):
1. recurrent, persistent, intrusive, unwanted thoughts, urges, or images.\ that are
experienced, at some time during the disturbance, as intrusive and unwanted,
and that in most individuals
2. The individual attempts to ignore or suppress such thoughts, urges, or images,
or to neutralize them with some other thought or action (i.e., by performing a
compulsion).
• Compulsions are 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 individual 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 anxiety or
distress, or preventing some dreaded event or situation; however, these
behaviors or mental acts are not connected in a realistic way with what they are
designed to neutralize or prevent, or are clearly excessive.
• Note: Young children may not be able to articulate the aims of these
behaviors or mental acts.
 DSM-5 Diagnostic Criteria: Obsessive-Compulsive
Disorder 300.3 (F42)
B. The obsessions or compulsions are time-consuming (e.g., take
more than 1 hour per day) or cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
C. The obsessive-compulsive symptoms are not attributable to the
physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another
mental disorder.
Specify if:
• With good or fair insight, with poor insight or with absent
insight/delusional beliefs:
• Specify if:
• Tic-related: The individual has a current or past history of a tic
disorder.
Obsessive-Compulsive Disorder (OCD)
• Develops either before age 10 or during late
adolescence/early adulthood
• More common in women
• 1.5 times more common than in men
• OCD often chronic
• Pattern of symptoms is similar across cultures
 Body Dysmorphic Disorder
• Preoccupied with an imagined or exaggerated defect
in appearance
• Perceive themselves to be ugly or “monstrous”
• Women focus on: skin, hips, breasts, legs
• Men focus on: height, body hair, muscularity
• Body part of focus can differ by culture
DSM-5 Criteria for
Body Dysmorphic Disorder 300.7 (F45.22)
A. Preoccupation with one or more perceived defects or flaws in
physical appearance that are not observable or appear slight to
others.
B. At some point during the course of the disorder, the individual
has performed repetitive behaviors (e.g., mirror checking,
excessive grooming, skin picking, reassurance seeking) or mental
acts (e.g., comparing his or her appearance with that of others) in
response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns
with body fat or weight in an individual whose symptoms meet
diagnostic criteria for an eating disorder.
DSM-5 Criteria for
Body Dysmorphic Disorder 300.7 (F45.22)
Specify if:
• With muscle dysmorphic: The individual is preoccupied with the
idea that his or her body build is too small or insufficiently muscular.
This specifier is used even if the individual is preoccupied with other
body areas, which is often the case.
Specify if:
• Indicate degree of insight regarding body dysmorphic disorder
beliefs (e.g., “I look ugly” or “I look deformed”).
• With good or fair insight
• With poor insight
• With absent insight/delusional beliefs
Hoarding Disorder
DSM-5 criteria of Hoarding Disorder 300.3
(F42)
A. Persistent difficulty discarding or parting with possessions,
regardless of their actual value.
B. This difficulty is due to a perceived need to save the items and to
distress associated with discarding them.
C. The difficulty discarding possessions results in the accumulation of
possessions that congest and clutter active living areas and
substantially compromises their intended use. If living areas are
uncluttered, it is only because of the interventions of third parties
(e.g., family members, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning
(including maintaining a safe environment for self and others).
 DSM-5 criteria Hoarding Disorder
E. The hoarding is not attributable to another medical condition (e.g., brain
injury, cerebrovascular disease).
F. The hoarding is not better explained by the symptoms of another mental
disorder
Specify if:
• With excessive acquisition: If difficulty discarding possessions is
accompanied by excessive acquisition of items that are not needed or for which
there is no available space.
• Specify if:
• With good or fair insight:
• With poor insight:
• With absent insight/delusional beliefs:
Prevalence and Comorbidity
• Lifetime prevalence
• 2% OCD (more common in women)
• 2% BDD (more common in women)
• 1.5% Hoarding disorder (no gender differences)
• Comorbidity
• High rates of comorbidity among all three syndromes
• Also comorbid with depression and anxiety
• OCD and BDD often comorbid with substance use
disorders
Trichotillomania (Hair-Pulling Disorder)
Diagnostic Criteria 312.39 (F63.2)
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The hair pulling or hair loss is not attributable to another medical condition
(e.g., a dermatological condition).
E. The hair pulling is not better explained by the symptoms of another mental
disorder (e.g., attempts to improve a perceived defect or flaw in appearance
in body dysmorphic disorder).
Prevalence
• Adult and adolescents: l%-2%.
• More in females than males i.e. 10:1.
Comorbidity
• With MDD and excoriation (skin-picking) disorder.
• An additional diagnosis of other specified obsessive-
compulsive and related disorder (i.e., body-focused
repetitive behavior disorder) is often expected.
Excoriation (Skin-Picking) Disorder
698.4 (L98.1)
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
D. The skin picking is not attributable to the physiological effects of a
substance (e.g., cocaine) or another medical condition (e.g.,
scabies).
E. The skin picking is not better explained by symptoms of another
mental disorder (e.g., delusions or tactile hallucinations in a
psychotic disorder, attempts to improve a perceived defect or flaw
in appearance in body dysmorphic disorder, stereotypies in
stereotypic movement disorder, or intention to harm oneself in
non-suicidal self-injury).
Prevalence
• In adults is 1.4%
• Three-quarters or more of individuals with the disorder are
female.
Comorbidity
• With OCD and trichotillomania (hair-pulling disorder), MDD
• may deserve an additional diagnosis of other specified
obsessive-compulsive and related disorder (i.e., body-focused
repetitive behavior disorder).
Differential Diagnosis
• Anxiety disorders.
• the recurrent thoughts that are present in GAD (i.e., worries) are
usually about real-life concerns, whereas the obsessions of OCD
usually do not involve real-life concerns and can include content
that is odd, irrational, or of a seemingly magical nature
• moreover, compulsions are often present and usually linked to
the obsessions.
• Like individuals with OCD, individuals with specific phobia can
have a fear reaction to specific objects or situations; however, in
specific phobia the feared object is usually much more
restricted, and rituals are not present.
• In social anxiety disorder (social phobia), the feared objects or
situations are limited to social interactions, and avoidance or
reassurance seeking is focused on reducing this social fear.
Major depressive disorder. In MDD thoughts are usually mood-
congruent and not necessarily experienced as intrusive or distressing;
• moreover, ruminations are not linked to compulsions, as is typical in
OCD.
Other obsessive-compulsive and related disorders.
• In body dysmorphic disorder, the obsessions and compulsions are
limited to concerns about physical appearance; and in
trichotillomania (hair-pulling disorder), the compulsive behavior
is limited to hair pulling in the absence of obsessions.
Hoarding disorder symptoms focus exclusively on the persistent
difficulty discarding or parting with possessions, marked distress
associated with discarding items, and excessive accumulation of
objects. However, if an individual has obsessions that are typical of
OCD (e.g., concerns about incompleteness or harm), and these
obsessions lead to compulsive hoarding behaviors (e.g., acquiring all
objects in a set to attain a sense of completeness or not discarding old
newspapers because they may contain information that could prevent
harm), a diagnosis of OCD should be given instead.
• Eating disorders. In OCD the obsessions and compulsions are
not limited to concerns about weight and food.

• Tics (in tic disorder) and stereotyped movements. Tics and

stereotyped movements are typically less complex than
compulsions and are not aimed at neutralizing obsessions.

• Obsessive-compulsive personality disorder. It is not characterized

by intrusive thoughts, images, or urges or by repetitive behaviors that
are performed in response to these intrusions; instead, it involves an
enduring and pervasive maladaptive pattern of excessive
perfectionism and rigid control.
Treatment of the Obsessive-Compulsive
and Related Disorders
• Medications
• SSRIs (serotonin reuptake inhibitors)
• Tricyclic antidepressants: Anafranil (clomipramine)
• Exposure plus response prevention (ERP)
• Not performing the ritual exposes the person to the full
force of the anxiety provoked by the stimulus
• The exposure results in the extinction of the conditioned
response (the anxiety)
• Cognitive therapy
• Challenge beliefs about anticipated consequences of
not engaging in compulsions
• Usually also involves exposure
 CBT for OCD & related disorders
• Research has shown that 75 percent of people with OCD
are significantly helped by cognitive behavioral therapy.
• Treatment techniques include exposure and response
prevention (ERP), this involves the following:
• Exposure: This involves exposure to situations and
objects that trigger fear and anxiety. Over time, the
anxiety generated by these obsessional cues decreases
and, eventually, the obsessional cues cause little or no
anxiety. This is called habituation.
• Response: Response prevention refers to the ritual
behaviors that people with OCD engage in to reduce
anxiety. This treatment helps people learn to resist the
compulsion to perform these rituals.
 A CASE STUDY
• A thirty-year old school teacher without previous treatment. She
described having a book collection that she dusted daily and would
not let anyone else, including her husband, touch. She insisted that
her husband get into bed at night before her so that she could
make sure that nothing in the house had been moved after she
went to bed. If they were late for an engagement, she was unable
to modify her routine of getting ready. Both at work and at home,
she refused to allow others to do any tasks that might be helpful to
her, as she felt that only she could perform these tasks correctly.
When leaving the house, she insisted on driving or walking a
predetermined route despite any obstacles, such as traffic, that
presented themselves along the way. She was critical and
outspoken about "shortcuts" that she thought other teachers took
in their work. These patterns of behavior and attitudes caused
major marital conflict and conflict with other teachers.
 TASK
• Video link
• https://www.youtube.com/watch?v=VnvUkWwuW_g

• Go through the differential diagnosis of OCD and related

disorders.