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Obsessive-Compulsive Disorder - Coggle Diagram
Obsessive-Compulsive
Disorder
What is OCD?
obsessive-compulsive disorder is characterised by intrusive thoughts called
obsessions
.
sometimes the intrusive thoughts can be disturbing, and most people can brush them off.
people with ocd can't just brush off their intrusive thoughts. some people with ocd feel like thinking the thoughts is equivalent to doing the actions >
thought-action fusion
for some people, if you fight hard to push the intrusive thoughts out of your mind, the harder they stick around.
sometimes, the intrusive thoughts can be alleviated by performing some form of repetitive, ritualistic behaviour, known as
compulsions
.
quite often, the compulsions have little to do with the obsession. other times, the obsession and the compulsion are related.
for a person with ocd, they will perform the behaviour to an extremely excessive degree
four categories
certain types of obsessions usually result in certain types of compulsions
symmetry or exactness:
most common form of the disorder.
the compulsions are usually performed to alleviate obsessions relating to organising things, placing them "just so", or repeating certain actions like walking up and down stairs until the person feels like they've done it "right."
forbidden acts:
the person may be traumatised by unrelenting sexualised thoughts, thoughts of harming themselves, thoughts of harming others, or about offending god.
the compulsions that go with this category can be varied > related or unrelated to the disorder.
contamination (physical or mental):
person may engage in hand-washing rituals to remove imagined contamination, person may wear gloves, person may engage in elaborate cleaning rituals.
hoarding:
a strong desire to collect and an inability to get rid of meaningless and sometimes unsanitary items
subtypes
any of the four categories can be seen with any subtype of ocd
up to 30% of people with ocd also present with a tic disorder, a specific form of compulsion where the person feels compelled to perform sudden, repetitive body movements.
seems to be so common that
ocd with comorbid tic disorder
has become its own subtype.
another subtype is
early-onset ocd
, where the disorder develops in childhood. the average age of onset is 11 years old.
much more common in males, there is a very strong family history, and it tends to have a poorer response to treatment than other types.
hoarding disorder
been recognised as its own disorder because, when a large-scale investigation was performed,
less than 20% who met the diagnostic criteria that were being proposed for hoarding disorder actually met the dsm-5 criteria for ocd.
ocd, anxiety, depression and schizophrenia show hoarding symptoms
**ocd symptoms tend to wax and wane and periods of worsening illness seem to be triggered by stress. hoarding disorder is progressive and gets worse as people age.
hoarding is much more common that other oc disorders:
2-6% of the adult population and about 2% of children.
tends to start in childhood or adolescence and shows a progressive, chronic course.
by the time the person is in their 20s-30s their lives are significantly negatively impacted > they progressively become more isolated as the symptoms worsen.
important not to pathologise people who just happen to fall outside of statistical or cultural norms:
around a third of the neurotypical adult population collects things and about 70% of neurotypical children collect things.
in general, adult collectors tend to be male, free from psychiatric illness, and their homes are usually uncluttered. the items in their collections are carefully selected, organised, and traded if they no longer meet the owner's intentions or goals.
hoarders end to collect and keep items with no goal or discretion
. there is no order to their actions, and, by definition, the clutter created interferes with their ability to use the space in the way that the room of their house was intended.
the cognitive driver behind hoarding can be to minimise waste rather than maximise acquisition.
there is a subtype of hoarding where the person has excessive acquisition. common with another subgroup, those who hoard animals
.
tend to be serious cases, as the person feels deeply responsibly for the animal's welfare, but the animals are almost always severely neglected.
people with ocd have a high level of insight into their own disorder. they often known that their obsessions and compulsions are irrational, but to not perform the compulsion would just be too distressing.
this aspect can seem bizarre to onlookers, especially when the person reports that they neither want to perform the compulsions, nor enjoy doing them. they just feel like they have to.
the disconnect between a person's goals and their behaviours has sometimes been referred to as "egodystonia".
Causes
ocd
alongside genetic influences, there has been a
lot of research linking ocd symptoms to abnormalities in neurochemical and neurotransmitter systems
. the most well-studied is a proposed dysfunction with the serotonergic system.
people with strong ocd symptoms tend to have hypersensitive serotonin receptors.
SSRIs have been found to work really well in reducing ocd symptoms, but this doesn't seem to be due to the drug making people happier or less anxious > long-term SSRI treatment down-regulates the serotonergic system
social factors
more accurate to think of them as "contributing triggers" rather than "causes".
it has been noted in children with ocd that, when asked why they're performing their rituals, the children often report that they don't know why they're doing them, just that they need to.
in nearly half of all children with ocd, it seems that the obsessions only develop after repeated interrogation.
suggests that, at least in some paediatric ocd cases, the compulsions do not develop in order to relieve the anxiety of obsessions. in some cases, the obsessions develop as a kind of rationalisation to pacify the social scrunity and interrogation in relation to their compulsions.
some mental health professionals have questioned whether these cases would be better described as "cod" to reflect the directionality.
studies have shown that
individuals diagnosed with ocd are more likely to have a first-degree relative with the same disorder than controls
. studies in children report that genetic factors may account for up to 45-65% of the variance on ocd measures.
across all age cohorts, ocd seems to have a stronger biological influence than specific phobias or social anxiety do.
the tic-related and early-onset subtypes in particular appear to have a very strong genetic component.
the exact genes responsible for ocd and its subtypes are still a topic of research, but the most likely genetic candidates relate to serotonin, GABA, glutamate, and genes relating to a brain circuit called the cortico-striatal loops.
hoarding disorder
what's driving and maintaining hoarding behaviour?
from an evolutionary perspective, it would have been useful for our ancestors to stockpile certain resources to use at later times > it's possible that hoarding represents a disruption to this evolutionary tendency and a breakdown in the cognitive processes necessary to distinguish between items with and without value.
the person feels extreme distress at decision-making related to discarding objects because they can't work out if they're valuable or not, so to avoid making the decision to keep them instead.
people with hoarding disorder have no intrusive thoughts. they also have little to no insight into the problems
with their living conditions or sanitation problems, even if they're obvious > contrasted with ocd, where people understand how illogical their thoughts and behaviours are.
very strong genetic component to hoarding disorder
12% having a first degree relative diagnosed with the disorder, and around half of their first-degree relatives showing some symptoms.
genetics seems to contribute to about 50% of a person's risk with environment making up the other half
some early genetic studies suggest that one of the genes of chromosome 14 seems to be related to hoarding and ocd with hoarding symptoms.
Models of
OCD
the habit hypothesis
operant conditioning > the law of effect > animals and humans will often string together long chains of reinforced behaviours until they can be performed effortlessly as a long behavioural sequence.
behavioural scientists call highly practiced behavioural chains 'habits'.
sometimes our mindless habits and our conscious goals are in opposition to each other. to change from a well-practised habit, your prefrontal cortex needs to kick in and take control of your behaviour.
the actual reason why freudian slips happen.
in 2000, ann graybiel and her colleagues proposed that ocd was the result of dysfunctional habits and an inability of the prefrontal cortex to take control of the person's behaviour
ocd compulsions often run in opposition to the person's actual goals.
the prefrontal cortex kicking in doesn't happen in people with ocd, and also disorders where compulsions play a big role (addiction, eating disorders, gambling).
one key part of habitual behavioural chains is what's known as a cut-off point or end signal
> the brain recognises that the environmental stimuli match the way they're supposed to look when the behavioural chain has finished.
a brain region known as the
striatum
plays a crucial role in signalling these cut-off points. another part of the brain, the
orbitofrontal cortex (OFC)
plays a role in recognising that the environmental stimuli look the way they should when the task has been completed correctly.
fMRI studies have repeatedly demonstrated that the connections between the striatum and the orbitofrontal cortex are altered in people with ocd.
the neurons in the striatum don't fire when they're supposed to (don't signal the cut-off point when they should).
in symmetry or exactness ocd, this could explain why people repeat rituals over and over again, but can't explain why it hasn't been done "right."
when doing a ritual and you've done something incorrectly, the brainwaves that form a part of the brain called the anterior cingulate cortex dip slightly > error-related negativity
the error-related negativity dip is bigger in ocd rituals that don't feel right. the ocd dips are bigger than those seen in repetitive behaviours in other mental illnesses like schizophrenia, depression, anxiety, compulsive drug seeking, or autism.
might make a useful early diagnosis and treatment tool
Treatments
ocd
up until the release of the dsm-5, ocd used to be classified as an anxiety disorder > it was thought that ocd rituals were functioning in the same way as other anxiety safety behaviours.
xanax (benzodiazepine) works to treat anxiety disorders, but does nothing for ocd symptoms > suggests that the heart of ocd is not anxiety, which is why it was moved to its own category.
SSRIs
are effective in treating ocd but only if they're taken for a long time, long enough for the drug to make structural differences in the brain.
exposure and ritual prevention therapy > treatment works in similar ways to exposure therapy:
the compulsions are prevented and the client is gradually and systematically exposed to the feared situation.
high effectiveness, superior to SSRIs.
deep brain stimulation
inserting a very, very fine microelectrode deep into the brain (into the striatum).
was shown to work in people with parkinson's disease > regain control of their bodies and get some functionality back.
success for approx 1/3 of people with ocd who are resistant to conventional treatments.
more than half the people who undergo dbs treatment for ocd experience a 25% reduction and full remission of their symptoms.
remains strictly experimental and only available to a very select group of ocd patients who have failed to respond to multiple rounds of treatment.
its not entirely clear how dbs actually workds. it does seem to change the rate that the neurons are firing in certain parts of the brain and this seems to calm the tics associated with some types of ocd as well as tourette syndrome and parkinsons disease.
comes with substantial risks includeing brain haemorrhage and infection.
hoarding disorder
many people with hoarding disorder go unnoticed and untreated unless the authorities are called due to the unsanitary living conditions on their properties.
people with hoarding disorder don't usually seek out treatment because there is a lot of shame surrounding hoarding disorder and the person can feel a distinct lack of empathy from the people who want them to part with their items.
compliance is usually low for treatment programs like
cbt
. cbt is used to help teach the person how to decide which items are valuable and which are not.
ideally done at the person's house.
talking therapies like cbt are conducted in a very strict and particular way because they actually change the structure of the brain.
medication has mixed success.
some studies report good improvements and others report little to no improvement.
both SSRIs and SNRIs have shown promise.
early research has had some success with the psychostimulants that are used to treat ADHD > people with hoarding disorder struggle with decision-making and ADHD drugs increase the availability of dopamine in the frontal lobe, allowing it to work.