OBSESSIVE

COMPULSIVE DISORDER

Asim Masood
asimmm196@gmail.com
+923002626209
DIAGNOSTIC CRITERIA
 Obsessive-compulsive disorders (OCD) is characterized by the presence of
persistent obsessions or compulsions, or most commonly, both

 Obsessions are intrusive unwanted and repetitive thoughts or urges and

are commonly associated with anxiety

 Compulsions are repetitive behaviours or acts that an individual engages

in as a response to an obsession, and they feel this must be carried out
ritualistically

 For a diagnosis to be made, both obsessions must occur more than an hour
a day and must result in significant distress or impairment to one or more
areas of functioning such as family, social or occupational
Example study: Rapoport (1989)

 Rapoport reports a case study on a 14 year old boy named Charles with an
obsessive compulsive disorder

 The boy would spend three hours or more a day showering, with an additional
two hours getting dressed

 He was a good student with an interest in sciences, but it would be impossible

for him to attend school on time because of his repetitive routine

 An example of his repetitive behaviour would be to hold soap in one hand, put
it underwater, switch hands, and so on
 The boy’s mother contacted Rapoport when his behaviours had been
going on for two years

 The boy had been going in and out of hospital for his condition and had
been receiving standard treatments of medication, behavioural therapy,
and psychotherapy

 However, Charles still had an obsessive thought that he had something

sticky on his skin that he needed to wash off

 His mother helped him clean his room with rubbing alcohol to help him
reduce his obsessive thoughts and compulsive behaviours
 Charles underwent a drug trial for clomipramine which is an antidepressant
to help relieve him of his symptoms

 This proved to provide temporary relief as he was able to pour sticky

substances such as honey over himself, however, a year later he
developed tolerance to the medication

 He relapsed and returned to his ritualistic behaviour of washing and

dressing
Measures:
Maudsley Obsessive-Compulsive Inventory (MOCI)
 The Maudsley Obsessive Compulsive Inventory (MOCI) and the Yale-
Brown Obsessive Compulsive Scale (Y-BOCS) are two psychometric
tools that are used to assess obsessive compulsive disorders

 The MOCI has 30 items scored either ‘true’ or ‘false’

 It assesses symptoms relating to checking (9 items), washing (11

items), slowness (7 items), and doubting (7 items)

 The test can take around 5 minutes to complete with the scores
ranging from 0 to 30
 Examples of items from the scale include:
I frequently have to check things (gas or water taps, doors,
etc.) several times. (Checking)
I am not unduly concerned about germs and diseases.
(Washing)
I do not take a long time to dress in the morning. (Slowness)
 Even when I do something very carefully I often feel that it is
not quite right. (Doubting)
Measures:
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
 The Y-BOCS by Goodman (1989) was developed to assess both
compulsive and obsessive behaviours an individual may display

 It is useful in determining the severity and nature of the individual’s

symptoms

 It involves a semi-structured interview that can take up to 30 minutes

 It includes a ten-item severity scale that allows individuals to rate the

time they spend on obsessions, how hard they are to resist and how
much distress they cause
 Scores can range from 0 (no symptoms) to 40 (severe
symptoms)

 A score of 16 or above is considered in the clinical range for

OCD

 Obsessions include items of the following categories:

aggression, contamination, sexual, hoarding, religious,
symmetry, body focused.

 Compulsions include items of the following categories:

cleaning, washing, checking, repeating, counting,
ordering/arranging, hoarding etc.
 EXPLANATIONS
BIOLOGICAL
Biochemical:

 Research has shown that those with OCD tend to have abnormally high
levels of dopamine

 Research by Szechtman (1998) shows that if dopamine levels are

increased in rats, they will show repetitive movements that are reflective
of those seen in individuals with OCD
 Research has also shown that people with OCD have lower levels
of serotonin than normal, and this is supported by the fact that SSRIs
(a drug used to increase levels of serotonin) is effective at treating
symptoms of OCD

 Oxytocin is a chemical commonly referred to as the ‘love

hormone’ and it is involved in enhancing trust and attachment

 It can also cause distrust and fear towards certain stimuli

 Leckman (1994) found some forms of OCD were related to

oxytocin dysfunction
 However, den Boer and Westenberg (1992) found no evidence of
any link between oxytocin and OCD

 They conducted a double-blind, placebo-controlled study on 12

patients with OCD

 Half the participants were given syntocinon (synthetic oxytocin) via

a daily nasal spray, and the other half were given a placebo

 No reduction was reported in either group in their symptoms

Genetic:

 Monzani (2014) carried out a large-scale twin study and found a

significantly higher concordance rate for MZ twins (52%) compared
to DZ twins (21%), hence suggesting a genetic link, with an overall
heritability rate of 48%

 As low levels of serotonin are linked to OCD, it is important to

consider the role of genes responsible for serotonin levels, such as
the SERT gene

 Ozaki (2003) found a mutation of the SERT gene that led to lower
levels of serotonin in six members of two unrelated families who had
OCD
 Mattheisen (2015) conducted a study on 1406 patients with OCD
as well as other members of the general population to determine
and identify how genes may be linked to OCD symptoms

 According to his study, he showed that the two genes PTPRD and
SLITRK3 both had a role in the development of OCD in individuals
PSYCHOLOGICAL
Cognitive (thinking error):

 OCD consists of cognitive obsessions and behavioural compulsions

 According to Rachman (1977), obsessive thinking is caused by faulty reasoning

for instance the belief that one’s hands are covered in harmful germs that
could kill, could be the cause of irrational thinking

 He states that these mistakes in cognitions could worsen in stressful conditions

 In an attempt to reduce the anxiety and stress associated with or caused by

these obsessive thoughts, the individual can engage in compulsive behaviours
Behavioural (operant conditioning):

 Compulsive behaviours can be the result of operant conditioning

 Washing hands, for example, would mean the individual would feel they have
removed the germs which would bring them temporary relief

 This is a form of negative reinforcement as a negative or unpleasant stimulus

has been removed

 At the same time, the thought of having clean hands can act as a reward or
positive reinforce

 These positive and negative reinforcers can lead to obsessive-compulsive

behaviours, suggesting that these behaviours are learned
Psychodynamic (Freud):

 According to the psychodynamic theory, childhood experiences are

crucial in shaping adult personality

 It focuses on unconscious beliefs and desires, which at times we may

ourselves not be aware of, that can shape and explain our behaviour,
including OCD

 According to this theory, OCD symptoms occur as a result of a conflict

between the id and the ego

 According to Freud, this conflict emerges at the anal stage of

psychosexual development, which is when most children begin toilet
training
 Freud describes the ‘id’ as the instinctual part of the mind that contains
sexual and aggressive drives and hidden memories

 The ‘super-ego’ is the ethical component of the personality and

provides moral standards and it forms the person’s consciences based
on criticisms and prohibitions in the individual’s mind with regards to
certain behaviours

 The ‘ego’ is the realistic part of the mind that mediates between the id
and the super ego and helps us make sense of the world around us. In
other words, it helps to fulfil the desires of the id in a moral manner
(super-ego)
 According to the psychodynamic theory, during the stage where the child
learns to toilet train, the process may involve tension between the parents and
the child, as the parents may wish to control how and when the child uses the
toilet

 This may go against the child’s desires and wishes and in order to regain
control, the child may urinate or defecate without being on the toilet which
can lead to arguments between the child and parents

 Conversely, in order to regain control, the child may even retain their urine or
faeces as a result of fearing harsh responses from their parents

 Both these behaviours can lead to behavioural disturbances later on in life as

these obsessive thoughts from the id may disturb the ego to the extent that it
may lead to compulsive cleaning and tidying rituals later in life to deal with
early childhood trauma
 TREATMENT AND MANAGEMENT
BIOLOGICAL
SSRIs:

 The use of SSRIs has been discussed in the chapter on depression

 These drugs can also be useful in treating OCD symptoms

 These drugs work specifically on the neurotransmitter serotonin

 In a meta-analysis by Soomro (2008), he reviewed the findings of 17 studies that

compared the effectiveness of SSRIs to placebos on the reduction of OCD
symptoms
 All studies combined included a total of 3097 participants

 Overall results showed that SSRIs were more effective in reducing OCD
symptoms 6 – 13 weeks after treatment

 This was measured through the Y-BOCS

 SSRIs reduce the severity of obsessive compulsive symptoms as they

seem to lessen the anxiety associated with the disorder and have been
proven to work on patients with and without depression
PSYCHOLOGICAL
Exposure and Response Prevention (ERP):

 Lehmkuhl (2008) explored the effectiveness of exposure and response

prevention (ERP) as a form of CBT to treat patients with OCD

 He conducted a case study on a 12 year old boy named Jason with

OCD and autism

 Approximately 2% of children with autism spectrum disorder (ASD) are

also diagnosed with OCD and it can often be difficult to distinguish
between autistic repetitive behaviours and OCD repetitive behaviours

 Jason had high functioning autism (normal IQ score)

 He experienced contamination fear, excessive hand-washing, counting
and checking behaviours

 He would spend several hours in a day in these repetitive ritualistic

behaviours and would experience anxiety when he was prevented from
doing so

 ERP consists of i) gathering information about existing symptoms, ii)

therapist-initiated ERP, and iii) generalization and relapse training

 Jason attended ten 50 minute sessions of CBT over 16 weeks

 The treatment had to be modified to accommodate his autistic traits, for
example, he would not be asked to perform visualization exercises as he
would struggle with this

 Initially during treatment, Jason experienced distress, but learned coping

statements such as “I know nothing bad will happen”

 The next step involved exposing Jason to stimuli he felt were

contaminated and produced feelings of anxiety or disgust such as door
handles, elevator buttons etc.

 The exposure involved Jason having to touch these items repeatedly till
he became habituated (used to) them and his anxiety levels dropped
 He often practiced this exposure outside therapy, such as in his school or
home, by handling ‘contaminated’ items

 Upon completion of the therapy, Jason’s scores on the Y-BOCS

decreased from 18 to 3 which fell within the normal range

 At a 3 month follow-up, his score remained low and both he and his
parents reported improvements in his OCD symptoms as well as his
participation in school and social activities
Cognitive-Behavioural Therapy (CBT) (Lovell, 2006):

 Key study: Lovell (2006) used randomized control trials to compare the
effectiveness of CBT delivered by telephone, to CBT offered face to
face, in patients with OCD, as a form of cognitive therapy

 The sample comprised of 72 participants from two different outpatient

hospital departments in Manchester, UK, aged 16-65

 Each underwent ten weekly sessions of therapy that were delivered

either via telephone, or face-to-face
 There were a total of ten face to face sessions that lasted for one hour each,
and eight weekly telephone call sessions that lasted 30 minutes each

 The effectiveness in reducing or managing the symptoms was measured

through the Y-BOCS, Beck Depression Inventory, and a client satisfaction
questionnaire

 At a 6 month post-treatment follow-up, the Y-BOCS scale showed an

improvement in symptoms for both groups

 Participants appeared to be highly satisfied with both forms of therapy

 This suggests that patients with OCD can benefit equally via CBT administered
either face to face, or via a telephone call