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Obsessive Compulsive + Bipolar Disorders - Coggle Diagram
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.