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Clinical Psych Chapter 6.5 - OCD - Coggle Diagram
Clinical Psych Chapter 6.5 - OCD
Diagnostic Criteria
OCD
is characterized as the presence of persistent obsessions, compulsions or/and both.
Obsessions
are
unwanted, repetitive
thoughts, urges, or images that are intrusive in nature and are commonly associated with anxiety
Compulsions
are
repetitive behaviors
that the individual feels that they must comply to.
In order to make a diagnosis, these symptoms must occur at least an
hour a day
and must lead to significant distress or change in their life
Examples of Obsessions
Fear of harming oneself
Fear of harming or killing other
Fear of Injuring oneself or others
Fear of an infection
Example of Compulsions
constantly checking
Putting things in order
Frequent handwashing
repeating or counting things
Example Study - Rapoport (1989)
Case study about a 14 year old boy named Charles who spent three or more hours washing himself and 2 hours of dressing himself.
He had specific rituals and order on how to wash himself. For example, by holding the soap in one hand, holding it under the water, etc. He was obsessed with the thought that there was something sticky on his body that he needed to wash off. In order to help him, his mother cleaned the room daily and had cleaned the surfaces that he touched with rubbing alcohol.
His behavior had been going on for 2 years and before that he was a good student in science. He only had one friend because his rituals were too long for him to step outside
He received standard treatment using psychotherapy, medication and behavioral therapies. For drug trial he was given
clomipramine
which is an anti-depressant which reduced his symptoms significantly but after a year he started to develop resistance to the medication, and symptoms re-emerged.
Measures
Maudsley Obsessive Compulsive Inventory (MOCI)
30 item
assessment tool
that is scored
"True"
or
"False"
. It assess the symptoms like
checking, washing, slowness and doubting
.
It takes 5 minutes to complete with scores produced from a range of 0-30.
For example,
I have to frequently check things like gas, doors and taps (Checking)
I am not unduly concerned about germs and diseases (Washing)
I do not take a long time to dress (Slowness)
Even when i do something carefully, I still feel like it is not right (Doubting)
Yale Brown Obsessive Compulsive Scale (Y-BOCS)
It is a test designed to measure the
nature and severity of the symptoms
There is a
semi- structured interview
that takes 30 minutes to conduct and also a
checklist
which contains a 10 items to assess the severity with the scale being from 0-4.
The scale checks how hard is it to resist the obsessions, how much distress do these obsession cause, etc and allows the researchers to plan the treatments accordingly. It can also allow the researchers to see whether the treatment is progressing or not
The score are from
0 to 40
, with 0 being no symptoms and 40 being severe
Both MOCI and YBOCS have
good concurrent validity
which means that individuals will score similar results on 2 scales. They also have
good test - retest reliability
which means that the individual repeats the test to check if they produce the same results (like
longitudinal studies)
. These 2 are important for checking to see consistent results
However, these 2 are self reports, which can reduce the validity of the test as the patient might fear being judged for their thoughts and this can be difficult to obtain a clear picture of OCD.
The MOCI and YBOCS are scales use a
nomothetic approach
which aims to create a tools that apply to everybody. This is useful because it allows the same criteria to be established, thus improving reliability
EXPLANATIONS
PSYCHOLOGICAL
Cognitive (thinking error)
It suggests that obsessions and compulsion are due to a faulty thinking /cognitive process (
Rachmann)
. For example, the thought that there are harmful germs that could kill you arises due to these errors in thinking. These conditions can worsen under stressful situations. Therefore, compulsive behaviors are a result of this faulty thinking.
Behavioral (Operant Conditioning)
Compulsive behaviors can be explained using the theory of operant conditioning. Engaging in compulsive behaviors might alleviate the behavior
For instance washing hands can act as a
negative reinforcer
as it have relieved them from an unpleasant situation. On the other hand, it can also be a
positive reinforcer
as they feel sense of achievement and reward
Thus, these negative and positive behaviors can shape obsessive - compulsive behaviors, making them
learned
behaviors
Psychodynamic
This theory is suggested by Freud as he claims that the symptoms of OCD are results due to internal conflicts between the id and the ego. This conflicts arises during the
anal stage
of the psychosexual stage of development.
Freud explains that there could be tension between the child and parents if child if unable to control when they defecate or urinate. Some parents might respond by punishing, ridiculing and embarrassing the child.
This can lead the child to be
anally expulsive
, which when the child soils themselves to regain control, causing more conflicts. This might end up with the child being rebellious in the future
On the other hand, it can lead the child to be
anally retentive
which is when the child fears harsh remarks or responses from the parent and retain their faeces.
Freud explains that these behaviors can lead to disturbances as they person might get "fixated" on that aspect. Therefore, the
obsessive thoughts that come from the id disturb the ego
BIOLOGICAL
Biochemical
Dopamine
is a chemical that is responsible for most of the disorder and is responsible for OCD as well. Research shows that people with OCD have
abnormally high levels of dopamine
.
Research by
Szechtman et al
shows that by increasing dopamine levels among rats, they show repetitive behaviors that resemble compulsive behavior with those who have OCD.
Serotonin
Research shows that people with OCD have
below normal levels of serotonin.
This research is supported by the evidence that antidepressants that work
specifically
by increasing serotonin levels are a more effective treatment to OCD than others.
Oxytocin
is commonly referred to as the "love hormone" as it enhances trust and attachment. However it has also shown to increase distrust and fear among stimuli. But there are a
lot of mixed results
For instance, research by
Leckman et al
shows that by analyzing the brain's
cerebral spinal fluid
, they found that there are some forms of OCD were related to oxytocin dysfunction
However, other research by
den boer and Westenberg
found no evidence relating the oxytocin to OCD. They conducted a double blind, placebo controlled study with 12 patients. In one group there was a
syntocinon
through a nasal spray and the other was a placebo. There was no reduction of obsessions nor compulsions in both groups, thus showing no link between oxytocin and OCD
Genetic
OCD might have a genetic basis. Research carried out by
Monzani et al
(2014) conducted a twin study between MZ and DZ twins. It showed that there was a
higher concordance rate
among MZ twins with
52%
than DZ twins with 21%. As MZ twins share a 100% genes than DZ twins, these findings show the
genetic heritability of OCD to be around 48%
Further research was conducted to see which genes are specifically responsible for OCD but there is no conclusive evidence. Since low serotonin levels are responsible for symptoms of OCD,
Ozaki et al
were investigating the SERT gene. They found a
mutation in the gene
leading to low serotonin levels among 6 members of 2 different families
Similarly,
Mattheisen et al
conducted a large scale study with 1406 patients with OCD and compared them to the general population to analyze and identify the genes that were linked to OCD. They found that PTPRD was implicated along with SLITRK3 which regulated particular synapses in the brain.
Overall, there is no definitive answer of what genes are responsible for OCD but it is known that the OCD that runs in families, is more concordant in MZ twins than DZ.
RESEARCH METHOD AND ISSUES AND DEBATES
The
biological explanation
has its strengths and weakness. The study on the genes responsible for OCD is objective as it is done is a lab and uses scientific analysis, making it highly replicable. However, it des not explain why some genes are implicated in individuals but does not show symptoms of OCD.
The
biochemical explanation
on oxytocin influencing symptoms of OCD is lab based . However, it does not establish a cause and effect relationship between the two.
Cognitive and behavioral explanations
suggests the experience of the symptoms but it mainly relies on self reports like MOCI and YBOCS. This could introduce a bias and could mislead the researchers. On the other hand, the
psychodynamic explanation
is an
empirical research
, which means that it is based off of observations rather than logic. This means that you cannot control the variables and so this does not establish a cause and effect relationship to see if harsh parenting style during toilet training could influence their obsessive and compulsive behavior.
Research method & Issues and Debates
Biological & cognitive explanation focuses on the
individual's
faulty thinking process and hormonal abnormalities. It can also be viewed as
reductionist
as they ignore other situational aspects. However, for the psychodynamic approach early relationships are considered
Genetic and biochemical explanations are biological explanations as they investigate physiological factors. Whereas, Psychodynamic approach and cognitive approach are psychological explanations as they focus on relationships and learned behaviors. This makes it
deterministic
we have no free will over our genetics, early relationships, hormones, etc.
TREATMENT AND MANAGEMENT
Biological
SSRIs
A range of drug therapies can be used to treat OCD. Anti-depressants and anti-anxiety medications can be given. The most common drug given is
SSRIs
which blocks the serotonin from being reabsorbed making the serotonin levels remain higher.
In a meta - analysis,
Soomro et al
reviewed 17 studies that compared the effectiveness of SSRIs with Placebos. All studies showed that SSRIs were more effective than placebos, showing an improvement in symptoms after 6-13 weakness treatment. It has also have shown to lessen the anxiety. Generally a higher dosage is given to people with OCD for effective treatment.
PSYCHOLOGICAL
Exposure and Response Prevention (ERP)
Its a form of CBT where the person is exposed to the stimuli which would triggers thoughts, images or urges but at the same time, patients are asked to consciously resist the urges to perform compulsive behavior.
For example, the person would be exposed to a door handle which would provoke their obsessive thinking of germs and might feel the urge to wash their hands
The individual is taught not to wash their hands and to tolerate the anxiety, which shows them that the uncomfortable feelings would go away and eventually become
habituated to it.
Example Study - Lehmkuhl et al
It was a
case study
of a 12 year old boy named Jason with high functioning Autism and OCD (not high func). Around 2 % of people with ASD have OCD. The symptoms are difficult to distinguish between the two; however cleaning, checking and counting was persistent
Jason experienced excessive handwashing, fear of contamination, counting and checking. He would spend several hours engaging in compulsive behavior and reported significant anxiety.
He attended ten
50 minutes CBT sessions over 16 weeks.
Jason first identified the feelings of distress and learned coping statements with a therapist. He did not do visualization techniques as it was too difficult for him to imagine pretend situations
After Jason identified the feelings, he was then
exposed
to the stimuli that he felt were "contaminated" and those that provoked anxiety or disgust.
For example, he was asked to repeatedly touch the door handle or elevator buttons until he became habituated to it. He also had to practice these tasks in a normal environment
After completing therapy,
Jason's score on the Y-BOCS dropped significantly lower
,
from 18-3
which was within the normal range. After a 3 month follow up his result were still low and participated in school and social activities.
KEY STUDY - LOVELL ET AL (2006) - CBT
Context
CBT is an effective treatment for OCD and it involves mostly fact to face conversations with a therapist for 45-60 mins. However, most of the time CBT is often and expensive and time consuming treatment
Since its time consuming, this could mean that however
long the waiting list is there would be a waiting time period
. Additionally, for people OCD a long waiting period could result in there symptoms to worsen. This would mean that might have to take a longer treatment, extending the waiting period for others
Thus, there have been attempts to ease the waiting periods by using
computerised CBT
and
Telephone CBT sessions
, both of which have shown to have been helpful
Main theories and Explanations
Firstly, telephonic CBT sessions
can reduce the waiting time
for patients than compared to traditional face to face CBT. It not only benefits the patients but also the practitioners as it can relieve them off some pressure
Secondly, telephonic CBT sessions
can be more accessible
to patients than face to face as some people might not have their own transports to arrive to the clinic. Some people might have some prior commitments which could prevent them from coming to traditional CBT sessions. Moreover, there is another factor were people with OCD might have difficulty in transportation and could feel anxious in a new setting.
There is some research that suggests that
telephone CBT be a more accessible support to those who cannot attend a clinic and might be more cheaper and effective
AIM
The aim of the study was to compare the effectiveness of telephone CBT sessions with traditional face to face CBT sessions. It is hypothesised that Telephone CBT condition would be more effective
Design
Randomized Control Trial
where p's both attended exposure therapy and response prevention but were put in 2 different groups. One was face to face CBT sessions (45-60 mins) and the other one was Telephone CBT sessions (30 mins).
Independent Measures Design
The sample consisted of
72 patients
who were diagnosed with OCD and had scored at least a 16 on their YBOCS scores. The age range was 16-65 year olds and all of them were from the UK. They all had to attend 1 of 2 outpatient clinics. They all did not suffer from substance abuse nor severe depressive disorder so we know that the symptoms are due to OCD.
Patients were randomly assigned to each group and there were
2 experienced therapist
who were put in either one of the groups. They conducted the CBT on the patients and the time kept was standardised. The
treatment consistency
was managed using
therapist manuals, fortnightly supervision and 4 month training days.
Pre - treatment, p's completed the
YBOCS and BDI
. They were assessed 2 times with
4 weeks apart.
After the treatment, they used the same tests at
4 time intervals
- right after the treatment, 1 month, 3 month and 6 month follow up. The patients also had to fill out
satisfaction questionnaire
Results finding and Conclusion
The mean YBOCS score before treatment was 25, however after the treatment, it had reduced significantly
The 4 points after the treatment showed that the
clinical outcome was equivalent in both conditions
. Therefore, the telephone CBT can be seen as
clinically relevant.
Scores on the
satisfaction questionnaire
showed that patients were
very satisfied
with the treatment. This was the same in both conditions
In conclusion, the clinical outcome both the CBT sessions are equivalent and patients reported high satisfaction of the treatments. This suggests that treatment for OCD can be delivered over phone.
Evaluation
Used independent measures design using a randomised control trial. This means researchers did not know which p's were in which condition. Face to face CBT was used as a control to measure effectiveness
The duration of therapy and the scales used in therapy were standardized which increases reliability and validity
There was a
relatively small sample
. All were from the UK and were from 1 of 2 outpatient clinics. Less generalisable and less representative
Self reports
used and could provide inaccurate information as p's give subjective answers. Might not give true account of feelings
This study shows a
more accessible and cheaper form of therapy
that would benefit the patients. Reduced waiting time, accessible and equally effective as traditional therapy
This study focuses more on the
psychological explanation
and it can be considered as a much more superior explanation than biological as it deals with the source of the problem