Mental Disorders >> Obsessive Compulsive Disorder

Mental Disorders >> Obsessive Compulsive Disorder
Psychology Super-Notes PsychoTech Services Psychology Learners Version 1.0 Anxiety Disorders Obsessive Compulsive Disorder M. S. Ahluwalia
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Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders - Obsessive Compulsive Disorder >> Contents Contents 1. Introduction to Anxiety Disorders 2. Obsessive Compulsive Disorder 3. Case Study 4. Aetiology (Causes) 5. Treatment 10
Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Introduction to Anxiety Disorders 1. Introduction to Anxiety Disorders (1/2) 11 Anxiety is normal… • Anxiety is a common reaction to stress. It prevents humans from being careless. • Examples: • Anxiety about your examination makes you study. • Anxiety over her baby’s health makes a mother care for her baby. …however, in same situations anxiety can be abnormal • If anxiety crosses a reasonable limit, it might become a disorder • Examples: • when one is so anxious that he/she has a breakdown in the exam hall, forgetting everything • when a mother is so anxious about her baby’s health, that she spends day and night praying to God Nature of Anxiety Fear • Fear is a basic emotion of human beings associated with the perception of a real threatening situation and involves the ‘fight or flight’ response activated by the sympathetic nervous system. • Example: If a street thug attacks you, you would feel intense fear. Then, you would either run for dear life, or hit him back. • Thus fear involves: • cognition of the threatening object, • subjective cognition of being in danger, • physiological components like increased heart rate, • behavioural components like running or hitting. Anxiety • Anxiety also involves subjective perception of threat, physiological changes and some behavioural reaction. • However, there is no immediate threat - you are projecting the threatening situation in future and reacting to it as if it is imminent. If you cannot go out of your home because of apprehensions of an attack by a hoodlum, it is anxiety. • Anxiety serves an adaptive function - it prepares a person for fight or flight if the danger really comes. But if the person avoids the situation that in her perception may cause the danger, and if such imagined situations are unrealistic, then the effect becomes debilitating.
Psychology Super-Notes PsychoTech Services Psychology Learners PsychoTech Services Psychology Super-Notes Psychology Learners 12 One may distinguish between adaptive anxiety and pathological anxiety by assessing the realistic probability of the occurrence of the object of anxiety and by assessing how dysfunctional it makes the person.
Psychology Super-Notes PsychoTech Services Psychology Learners Focus of this document Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Introduction to Anxiety Disorders 1. Introduction to Anxiety Disorders (2/2) 13 Common Characteristics/Nature of Anxiety Disorders • Cognition or subjective perception of danger – may be accompanied by vivid, occasionally morbid, images of the difficulties encountered. • Physiological Responses - through activation of sympathetic nervous system. Usually includes dilated pupils, increased heart rate, trembling, breathing discomfort, nausea etc. • Behavioural Responses - usually a tendency to avoid the dreaded situation. Except in OCD and sometimes PTSD, where repetitive behaviour is observed. Anxiety Disorder Anxiety Disorder is a blanket term that covers a group of disorders characterized by irrational fear of some thing or situation. The person is usually aware of the irrationality. 1 Panic Disorder (with or without agoraphobia) 2 Phobic Disorders (specific or social) 3 Generalised Anxiety Disorder (GAD) 4 Obsessive Compulsive Disorder (OCD) 5 Post Traumatic Stress Disorder (PTSD) Types of Anxiety Disorders (DSM IV TR)
Psychology Super-Notes PsychoTech Services Psychology Learners Obsession • Obsession refers to intrusive thoughts, images and impulses often of a negative or unacceptable kind, despite one’s desire to get rid of it. • According to DSM IV- TR, obsessions are recurrent and persistent thoughts, impulses or images that are experienced as intrusive and generate considerable anxiety. • These thoughts do not concern current real life problems, and are often irrelevant to present reality. • The person has insight and tries to remove these thoughts, but is often unsuccessful. Particularly when aggressive and sexual thoughts predominate, the person considers herself ‘bad’. Yet the thoughts continue to haunt her. Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Diagnosis and Epidemiology 2. Obsessive Compulsive Disorder (1/3) 15 Compulsion • Compulsion refers to being compelled from within to perform certain ritualistic acts, because you are afraid that if you don’t, you might end up being harmed. • Compulsions are repetitive overt behaviours like washing or checking or mental acts like counting or praying in response to an obsessive thought. • Compulsions are to be done following rigid rules to prevent or reduce the impact of some dreaded thing or action. • After a compulsion is performed the person temporarily feels relieved, but again succumbs to the same cycle. Obsessive Compulsive Disorder A psychiatric disorder characterised by intrusive thoughts or images of some negative event, impulse or thing (obsession) and ritualistic acts to undo or prevent these obsessive thoughts (compulsion).
Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Diagnosis and Epidemiology 2. Obsessive Compulsive Disorder (2/3) 16 Content of Obsessive Thoughts • Unusual fear of contamination • Fear of harming oneself or one’s own loved ones • Religious themes • Sexual themes - specially the unacceptable forms • Wishing ill for others: example - wishing one’s mother dead • Doubt about whether one has done things properly. Primary Kinds of Compulsive Acts • Cleaning: like repeated washing • Checking: like repeatedly coming back home to check if the door has been locked properly • Counting: like the number of steps one takes before getting on the bed • Repeating: like coming back to the first word of the line as one is not sure if she has read it properly • Hoarding: like collecting things, not being able to dispose them off • Ordering: like arranging books on the table in a particular order each time one leaves the table Relation between Obsession and Compulsion Intrusive thoughts of negative things, impulses or events Repetitive behaviours (compulsions) that are believed to protect from the negative things Temporary relief from the intrusive thought, reinforcing the compulsion Distress due to inability to control intrusive thoughts
Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Diagnosis and Epidemiology 2. Obsessive Compulsive Disorder (3/3) 17 Epidemiology (Prevalence) • OCD seems to be present in about 2% to 3% of general population. • The onset is gradual beginning in adolescence or early adulthood. • Childhood onset is also possible. Usually the cases with childhood onset tend to be very severe. If it becomes severe, it usually turns chronic. • The risk is equal for both sexes. However, the content of obsession and compulsion may vary across age and sex. Co-morbidity OCD may occur concurrently with depression, phobia, panic disorder, GAD and also body dysmorphic disorder. • While in most cases, obsessions and compulsion are coexistent, there may be cases where only obsession or compulsion predominates. • The obsessions and compulsions take plenty of time from one’s daily routine and slow down the entire life process. For some, rituals take the whole day resulting in the sufferer’s inability to anything else at all. • Sometimes it results in health hazard: you may rub and clean your skin so much and with such material (like raw dettol) that there are wounds on your body. • For most people, there are multiple obsessions and compulsions. • The anxiety accompanying OCD is two fold: • Obsessive thoughts are unpleasant and anxiety provoking. • Compulsions reduce them to some extent, but the very insight that one is compelled to do such useless things causes lack of confidence and severe distress. • World Health Organization found obsessive compulsive disorder to be the world’s leading cause of disability. • It has also been associated with unemployment, marital problem and separation, and impaired social functioning.
Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Case Study 3. OCD Case Study • Client Background: John is a 25 year old man of considerable intelligence from an upper middle class family. He is presently employed at a private firm. • Incident: Once, during the late teens, when he was walking on the pavement he accidentally stepped on something which he did not bother about at the moment. Later, it came to his mind that it might have been a used condom. He felt very unclean and washed himself thoroughly. • Development of Obsession: He knew that his interpretation might have been wrong, but the thought continued to haunt him. Gradually, he became afraid of stepping over anything dirty on the street - condom, faeces, or sputum. He is particularly disturbed by vivid imagery of a person soiling the street. • Now he takes pains to look at the road very carefully before stepping and if ever he sees anything he avoids that particular street for a few days if possible. The city he lives in is not particularly clean and often there are dirty things on the street. If he sees anything like this Intrusive imagery of filthy sticky things haunts him till he is back home and washes himself following certain specific rituals. • Washing Ritual: He first washes his face ten times, then his arms, chest, back and legs a specific number of times. He has to take care of his feet particularly, and washes them twenty five times each. The washing ritual has to be completed irrespective of heat and cold, and irrespective of his health, even if he has fever. He also has to wash the surface of the soap he uses, as that too might be contaminated. • Impact on Life: Since he needs about three hours to wash himself, he takes dinner quite late and has difficulty waking up in the morning and coping with the stress of his job. As he has to avoid certain streets on certain days, he often reaches his office late. • His concentration is failing as he is always thinking if there are filthy things stuck in his feet. With repeated warnings and humiliations from his boss he is thinking about leaving this job and looking for another with less demanding conditions, even if salary is lower. 19
Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Aetiology 4. OCD Aetiology 21 Causes of OCD 1 Biological Factors 1.1 Genetic Factors 1.2 Evolutionary Perspective 1.3 Brain and Biochemical Abnormalities 2 Psychological Factors 2.1 Psychoanalytical Approach 2.2 Behavioural Approach 2.3 Cognitive Approach
Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Aetiology 4.1. Biological Factors 22 1. Genetic Factors • Moderate genetic inheritance has been observed in case of OCD. • There is a moderate concordance rate for monozygotic twins. • One strong evidence in favour of genetic basis is the connection of OCD and Tourette’s syndrome as it has a strong genetic basis. • A large number of first degree relatives of children with Tourette’s have been found to have OCD. • OCD has also been found to be associated with childhood autism, another disease with genetic causes. 2. Evolutionary Perspective • It suggests that as in the case of phobia, there is a preparedness factor in OCD. • For example, obsession about contamination is much more common than obsession about pencils. 3. Brain and Biochemical Abnormalities • Some parts of the brain, like caudate nucleus, orbital frontal cortex and the cingulated cortex show excessive metabolic activity in OCD patients. • Diseases like encephalitis and brain tumours have also been found to ritualistic behaviour, thus implicating certain parts of the brain abnormality for OCD. • There is also some evidence that increased activity of the neurotransmitter called serotonin and enhanced sensitivity of the stated brains structures to serotonin are also associated with OCD.
Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Aetiology 4.2. Psychological Factors 23 1. Psychoanalytical Approach • It attributes obsession to a fixation to the anal phase of life. • Too strict toilet training predisposes the child towards over- conscientiousness. • The unconscious impulse to soil and play with filth, natural in a child of anal phase is so strongly prohibited that the child takes recourse to defenses like reaction formation by being overly clean and undoing by rituals. • Paradoxically, obsession also provides a way of vicarious satisfaction of the prohibited impulse. If you are thinking for the whole day about how to stay away from dirt, you are, in a way, thinking of dirt only. 2. Behavioural Approach • Neutral stimuli may be associated through classical conditioning with frightening ideas and become capable of eliciting intense anxiety. • Example: John may have acquired the fear of dirty things on the street because he was thinking of something negative while walking on the street, and the object on the street became associated with it. Since the connection wasn’t logical, he couldn’t explain it. • Since compulsions reduce anxiety to a large extent, they become reinforced and continue in a cyclic manner. • So, if the person is exposed to the object of obsession, and the ritualistic compulsive behaviour is prevented, the reinforcement of the compulsion would stop. He would, gradually, understand that anxiety reduction is possible without compulsive acts. 3. Cognitive Approach • It suggests that there are negative automatic thoughts behind obsession. • Persons with OCD are often excessively responsible and perfectionistic. This may be due to childhood training. But, if they think of something obnoxious, which we all do occasionally, they cannot separate it from acting it out in reality. This is called thought-action fusion. • This fusion makes it easier for catastrophic thinking to take place. Of course, if you think that some harm may come to your friend, and you confuse it with your actually harming the friend, the results would be catastrophic. • Cognitive bias is apparent in obsession. Their attention easily goes to the concern of obsession in comparison to any other neutral stimulus. • They have information processing issues • Their memory seems to be selectively distorted as they cannot remember if they have done a thing properly or not, resulting in repetitive behaviour. • They also have difficulty in suppressing irrelevant information.
Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Treatment 5. OCD Treatment 25 Treatment of OCD 1 Pharmocology 2 Psychological Approaches • Clomipramine and Fluoxetine are used most frequently with OCD cases. • The improvement rate is moderate. Particularly when the medicine is discontinued there is chance of relapse unless behaviour therapy has been continued along with medicine. • Psychoanalytically oriented therapy or insight therapies are of little use for OCD patients. • Exposure and Response Prevention (ERP) works best for OCD. • In E&RP you need to encourage the person to expose themselves to their obsessions. • Then they must prevent themselves from the ritualistic acting out of the compulsions to get rid of the anxiety generated by the obsession. • As they are repeatedly faced with their fear and can reduce their anxiety without compulsion they get ‘habituated’ to the new experience. Behaviour therapy and medication are most popularly used modes of therapy. Behaviour therapy has higher percentage of completed treatment, compared to medication. OCD is one of the most difficult to cure diseases. However, even if the entire range of obsessive thoughts and compulsive acts cannot be cured, the severity can be considerably reduced to enable one to lead a successful life.
Psychology Super-Notes PsychoTech Services Psychology Learners Exposure and Response Prevention • A behavioural treatment of Obsessive Compulsive Disorder where the person is exposed to the feared thought and the compulsive act is prevented. • Gradually, the person becomes habituated to dealing with the obsessive anxiety without resorting to the compulsion. Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Treatment 5.1. ERP Definition and Example 26 Example Situation: You want to treat a lady who is bothered by the intrusive thought of possible harm to her husband, and then counts up to seven to protect him from the harm. Step 1 Exposure • You allow her to be subject to the thought Step 2 Response Prevention • You have to prevent her from counting. • You may distract her by discussing the possibility of the harm and after some talking she may feel the fear of harm a bit less. Step 3 Reinforcement • You reinforce this behaviour and ask her to practice it. • You can give her homework as well so that she may record the number of successful response prevention at home. • Gradually she becomes convinced that obsessive anxiety may go away even without the counting.
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