Obsessive Compulsive +
Bipolar Disorders

Obsessive-Compulsive
Disorder

  • Under Obsessive-Compulsive and Related Disorders in the DSM-5
  • Requires the presence of obsessions, compulsions, or both

Obsessions are:

  • Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted and cause marked anxiety
  • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralise them (by performing a compulsion)
    • Thoughts, images, or impulsive
    • Repetitive, intrusive, uncontrollable, distressing
    • Not just excessive worries about real-life problems
    • Interpreted as strange or inappropriate
    • Compel the person to ignore or neutralise the obsessions in some way.
  • Repugnant: something the person finds morally reprehensible
  • Contamination: germs, cleaning/washing behaviours
  • Doubting: repeatedly checking locks, cords, outlets, etc.

Compulsions are:

  • Repetitive behaviours or mental acts that the individual performs in response to an obsession or according to rules
  • Aimed at reducing anxiety or preventing dreaded events; however, not connected in a realistic way with that they are designed to prevent or are clearly excessive.
  • Goals are usually to “undo” the obsession, to prevent harm associated with obsession, or to alleviate anxiety

epidemiology

  • Prevalence: 2-3% lifetime prevalence, equal between female and male
  • Onset: mean age is 17 years old, but significant portion have childhood onset
  • May be important differences in childhood-onset cases.

symptom dimensions

  • Heterogeneous disorder
  • 4 commonly replicable symptom dimensions
    • Obsessions about contamination and washing compulsions
    • Obsessions about responsibility for causing harm/making mistakes and checking compulsions
    • Obsessions about symmetry and ordering compulsions
    • Repugnant obsessional thoughts concerning sex, religion, and violence along with mental compulsions and other covert neutralising.
  • Hoarding is no longer considered OCD

biological model

  • Higher activity in the cortical-striatal-thalamic circuit (prefrontal cortex, thalamus, basal ganglia)
  • This is the area related to filtering out irrelevant information and perseveration of behaviour > also related to error detection

treatments

pharmacological

  • SSRIs (fluvoxamine, sertraline, fluoxetine, etc) found to be useful in OCD
  • Significant average symptom reduction of approximately 40% in 50-60% of subjects
  • Majority relapse after discontinuation of SSRIs > addition of behaviour therapy is important.

psychological

  • Exposure and response prevention (ERP)
  • Moderate symptom reduction between 55% and ⅔ of patients
    • Drop out rate of 19%
  • Through repeated exposure to feared situations and thoughts without performing compulsions, the person learns
    • Emotional response subsides (happens more quickly over trials)
    • The feared event does not happen
    • It is safe and moral to let the thought go without responding with a compulsion
  • Cognitive strategies
  • Rests on the cornerstone that 90%+ of people experience intrusive thoughts
  • Interpretation of the intrusive thought is typically threatening
  • It is the anxiety from the appraisal that promotes compulsive behaviour
  • OCD relevant beliefs:
    • Over-important of thoughts
    • Overestimation of threat
    • Perfectionism
    • Intolerance of uncertainty
  • Challenging meaning and importance of intrusive thoughts
  • Challenging thought-action fusion: thinking that because you’ve had a thought it’s more likely to happen (likelihood) and more immoral.

hoarding disorder

  • Former OCD dimension
  • About twice as common as OCD
  • Causes distress to more than just a single person, it creates living risk (fire, hygiene, etc)
  • Difficulties discarding items
  • Perceived need to save and distress when discarding
  • Clutter in active living areas
  • Can involve compulsive acquisition
  • Estimated prevalence of 2-5%
  • Onset early in life and tends to be chronic and worsen over time
  • Runs in families and may have a genetic component
  • Traumatic or stressful events may play a role
  • The current conceptualisation of hoarding: several factors place an individual at risk, including genetics, life events and executive dysfunction.
  • Was associated with poor treatment response to behavioural and medication treatment when it was still lumped with OCD
  • More encourage evidence for CBT based on Frost and Steketee’s model of hoarding.

Bipolar Disorders

key features

  • Periods of mania alternate with periods of depression
  • Emotional roller-coaster: elation to despair to elation to despair
  • Manic depression is an old name for bipolar disorders
  • Lithium is the usual bipolar disorder treatment, sometimes used with olanzapine (anti-psychotic)

manic episode

  • A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (any duration if hospitalisation is necessary)
  • 3 or more of the following (4 is mood is only irritable)
    • inflated self-esteem or grandiosity
    • decreased need for sleep
    • atypically talkative
    • flight of ideas
    • distractibility
    • increase in goal-directed activity
    • psychomotor agitation
    • excessive involvement of activity with a high potential for painful consequences
  • The mood disturbance is sufficiently severe to cause a marked impairment in social or occupational functioning OR necessitates hospitalisation to prevent harm to self or others OR there are psychotic features
  • Not substance induced

Hypomanic episodes

  • Only needs to last at least 4 consecutive days
  • Similar symptoms to manic episodes, but it is NOT severe enough to cause marked impairment and there are NO psychotic features.
  • The disturbance in mood or functioning is unequivocal and observed by others.
  • Distinction between hypomanic and manic used for categorising types of bipolar

3 main categories

Bipolar 2: hypomanic episodes alternate with major depressive episodes

  • Depressive episodes are necessary for diagnosis
  • Average length of mood episodes tend to be shorter > more likely to experience raid cycling
  • Approx 15% of B2 patients transition to B1.

Cyclothemia: hypomanic symptoms (not meeting criteria for hypomanic episode) alternate with hypodepressive symptoms (not meeting criteria for hypo-depressive episode)

  • Chronic low-level symptoms

bipolar 1: manic episodes (typically) alternate with major depressive episodes

  • Need at least one manic episode
  • Over 90% of B1 patients have recurring episodes
  • Manic episodes typically but not necessarily alternate with major depressive episodes
  • Manic symptoms can be psychotic, but typically not
  • Prevalence ~0.5-1%
  • The typical age of onset is late teens, or early 20s
  • The typical length of a mood episode is 2-6 months
    • Rapid cycling = 4 or more mood episodes in 12 months

causes

  • Heritability > highly heritable (among the highest of any mental disorder)
  • Genetics of bipolar: there is no one gene, rather small alterations in many genes across the genome can contribute to bipolar disorder.
  • Neurochemistry: bipolar depression > low levels of the serotonin transporter, mania > greater sensitivity to dopamine
    • Findings have been inconsistent

Why do bipolar disorders cycle?

  • Theory: bipolar disorder caused by abnormal circadian rhythms (colombo et al 2000)
  • Observations:
    • Manic individuals tend to sleep very little; bipolar depressed individuals tend to sleep a lot
    • Sleep deprivation can improve mood in bipolar depressed patients; sleep deprivation can trigger mania
  • In healthy people, circadian rhythms are set by zeitgebers (time-givers) such as light/dark cycles, meal times, etc. in bipolar patients, circadian rhythms become detached from these zeitgebers.
  • Key idea: bipolar patients have longer circadian rhythms (weeks rather than days)

Treatments

mood stabilisers

  • Suppress swings between mania and depression.
  • Primarily mania stabilisers; less effective against bipolar depression
  • Lithium: ‘gold standard’
    • Ancient treatment > alkali springs
    • The mechanism of action is unclear
  • Anticonvulsants, eg sodium valproate, blocks Na+ channels
  • Antipsychotics are also used > olanzapine: dopamine antagonist

cbt

  • Focus is on promoting stability and routine, and medication compliance
  • Helps patient identify warning signs for imminent mood shifts
    • Not sleeping, feeling full of energy, thoughts racing, starting to get irritable or frustrated with others.
  • CBT for bipolar depression; behavioural activation, scheduling pleasant events
  • CBT for mania; motivational interviewing > especially with regards to medication compliance
    • ‘Urge surfing’ > realising that they are just urges you don’t have to act on.

Bipolar disorder and creativity

  • The relationship between creativity and bipolar disorder is complex
    • Increased prevalence of bipolar disorder in artists (Johnson et al 2011)
    • Research into the relationship between creativity and bipolar disorder yields inconsistent results (Nascimento da Cruz, 2022)
    • Hypomania and milder symptoms of mania may be more associated with creativity than severe symptoms.