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OBSESSIVE COMPULSIVE DISORDER (Dysfunctional Beliefs in OCD (Inflated…
OBSESSIVE COMPULSIVE DISORDER
Diagnostic Features
Obsessions:
recurrent, persistent thoughts, urges, or images that are
intrusive & unwanted
, which individual tries to ignore, suppress, or neutralize (these strategies are often ineffective)
Subtypes:
contamination
responsibility for harm/mistakes
incompleteness (symmetry/order)
unacceptable thoughts with immoral, sexual, or violent content
Ego-dystonic
- non-synchronistic with their values & personal beliefs
Compulsions:
repetitive behaviours or mental acts intended to
prevent/reduce anxiety/distress
or prevent dreaded events that person feels driven to do, either to neutralize an obsession or prevent an event, even though the behaviours or mental acts are not reasonably related to the obsession or are
excessive
decontamination
checking
repetitive routine activities
ordering & arranging
mental rituals
Repetition
- the debilitating part of OCD
repeat to prevent/reduce anxiety, neutralize obsessions with compulsions
often no relationship between obsessive thoughts & compulsion
doubt
can be very strong, distinguishing normal obsessive thoughts & OCD
continuum
- good/fair insight, poor insight, absent insight, delusional
Avoidance
intended to prevent obsessional fears & compulsive urges (e.g., avoid using knives as they evoke thoughts of impulsively stabbing children)
Poor Insight
"good/fair insight" / "poor insight" / "absent insight" denote degree to which person views his/her obsessional fear & compulsive behaviours as reasonable
4% convinced symptoms are realistic
Related Disorders
Obsessive-Compulsive Personality Disorder (OCPD)
Ego-syntonic (OCPD) vs. Ego-dystonic (OCD)
thoughts in OCPD tend to be ego-syntonic, thinking that being a perfectionist is a good thing, they are happy
Focus on everyday rules, functions, order (OCPD) vs. Not grounded in reality (OCD)
with OCPD, more grounded in reality (perfect at work, school, home), but not violent/sexual thoughts (not inappropriate)
Personality
traits
such as excessive perfectionism, inflexibility, & need for control, that
negatively impact relationships
& functioning
OCD more
distressing
than OCPD
Highly comorbid
Body Dysmorphic Disorder
- involve intrusive, distressing thoughts concerning appearance, but focus of BDD is limited to appearance
Hoarding
- separate problem; thoughts about acquiring & maintaining possessions, not particularly intrusive or unwanted; emotionally positive/neutral
OCD Epidemiology
Canadian prevalence:
1-2%
Onset:
early 20s
Course:
chronic
, unremitting, worse with life stress & fluctuation
Sex ratio:
~1:1
Females:
greater comorbidity with
depression
, higher
contamination/cleaning
Males
:
earlier age
of onset, greater comorbidity with
tic & substance abuse
, higher
sexual/religious
Not considered an anxiety disorder, rather grouped with body dystrophic, hair pulling, skin picking, hoarding disorder (OCRDs)
Tic-Related OCD
- history of tic disorders, such as Tourette's syndrome, appears to run in families, early onset & male predominance, concerning symmetry & exactness, ordering & arranging
Responses to Intrusive Thoughts
"Normal" Response
Stimulus → Intrusive Thought → Distraction
go on about normal day, don't attach special meaning to thoughts
Cognitive Model of OCD
hypervigilant to threat
thought action fusion
- thoughts take on power; if they thought it, they did it
compulsion to neutralize thoughts
rebound effect - serves to intensify the thoughts
see model
Stimulus
Hyper-vigilance/scanning of env't (e.g., scan for blood because scared of AIDS)
Intrusive thoughts (e.g., I am going to get AIDS) & thought itself is perceived as threatening (intolerance of uncertainty - what if I did tough the blood); thought-action fusion (think if I thought it, I did it); overestimation of threat (if I touch the blood, I 100% will get AIDS)
Neutralize compulsion - -ve reinforcement due to short-term anxiety reduction (e.g., washed my hands so I won't get AIDS, so should do it again)
Ends up being rebound effect, cycle restarts
Implies that successful treatment for OCD symptoms must accomplish two things:
correction of maladaptive beliefs & appraisals that lead to obsessional fear
termination of avoidance & compulsive rituals that prevent self-correction of maladaptive beliefs & extinction of anxiety
Dysfunctional Beliefs in OCD
Inflated responsibility:
belief that one has the power to cause &/or the duty to prevent negative outcomes
e.g., I have power to kill random children & I have power to prevent it, like by staying at home
Overestimation of threat:
belief that negative events are likely & unmanageable
catastrophizing of negative outcomes
Exaggeration of the importance of thoughts:
belief that the mere presence of a thought indicates that this thought has occurred (thought-action fusion)
thought-action fusion:
thought of something is the same as having done it
Need to control thoughts:
belief that complete control over thoughts is necessary & possible
complete control over thoughts is not always possible & not necessary to live a functional life
Perfectionism:
belief that mistakes & imperfection are bad & cannot tolerate this
Uncertainty:
belief that it's necessary & possible to be 100% certain that negative outcomes will not occur (
DOUBT
)
cannot stand even the slightest bit of uncertainty
Consequences of Neutralization/Compulsion
Paradoxical increase in thought frequency
strategies used to cope with obsessive thoughts are maladaptive & increase the obsessive thoughts, making things worse (paradoxical consequences to anxiety)
Hyper-vigilance to thought triggers (neutral stimuli included in attentional focus
generalizations, e.g., anything red is scary because it is associated with blood which can cause AIDS
Terminates exposure to thought (prevents new learning)
never learn that sitting with the thought will make it go away eventually
Negative mood → increased salience & accessibility of thought
with negative mood, it is easier to sit in the mood of obsessive thoughts
Exposure & Response Prevention (ERP)
Exposure to obsessive stimulus + prevention of compulsive response
habituation to obsessional distress
learn that feared outcomes are less likely or less severe than anticipated
eventual extinction of obsessional anxiety
Pharmaceutical Treatments:
SSRIs are the standard pharma treatment, and especially helpful in those with mild OCD
Low dose of antipsychotic meds for those with severe OCD
ERP is the most common & effective treatment for OCD
response prevention
makes it effective, encouraging not to carry out rituals
exposed to obsessive stimulus that prevents compulsive response (the response is the problem, not the obsessive thought because this is normal)
the hardest to treat are those with obsessive thoughts but no clear response
each time they are exposed, anxiety decreases as they learn that feared outcomes are less likely/severe than anticipated (
habituation of obsessional distress
)
#
high dropout rates because distressing
Example:
Blood contamination/washing
go out in world, encounter triggers, then once home, not allowed to wash
expose then neutralize by not letting the check & deal with uncertainty
gradually, intensity of thoughts dissipates
Efficacy of ERP by Patient Adherence
(a) quantity of homework exposures attempted *
(b) quality of attempted exposures *
(c) degree of success with response prevention **
found that degree of success with response prevention predicted best who will respond well to treatment
those that were able to not engage in rituals even at home alone are those that did best
C most strongly significant
50-70% clinically significant improvement
Interpersonal Aspects
frequently negatively impact interpersonal relationships
dysfunctional relationship patterns promote maintenance of OCD symptoms
symptom accommodation (e.g., washing/cleaning for them, assisting with rituals)