The obsessive-compulsive spectrum

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CHAPTER 9 The obsessive-compulsive spectrum

David J. Castle, Darryl Bassett

Obsessive-compulsive spectrum disorders are characterised by the presence of:

image obsessional thoughts, which are recognised by the individual as their own, and are intrusive, anxiety-provoking and distressing, and
image compulsions, which are ritualised acts or mental processes responsive to the obsession and which reduce (at least in the short term) the anxiety associated with the obsession.

These phenomena can also be seen in other psychiatric disorders and occur in psychiatrically healthy people. They thus lack specificity. Indeed, obsessions and some degree of compulsive behaviour are quite normal, and arguably a degree of ‘carefulness’ in terms of, for example, checking behaviours, is both adaptive and useful in everyday life.

Obsessive-compulsive disorder (OCD)

When obsessional thoughts become excessively intrusive, and the obsessions and compulsions become time-consuming (over an hour a day) and interfere with daily functioning, the individual can be considered to have obsessive-compulsive disorder (OCD), as long as other psychiatric and medical (organic) causes have been excluded.

OCD symptoms can co-occur with other psychiatric symptoms, and the determination of which is ‘primary’ has important potential therapeutic implications, as demonstrated in the case studies in this chapter.

OCD itself can manifest in a number of ways. The most robust subtypes of OCD are shown in Box 9.1. There is overlap between these subtypes, and some patients present with symptoms from a number of them at the same time or at different time-points on their illness trajectory.

BOX 9.1 Subtypes of obsessive-compulsive disorder (OCD)

Subtypes include:

• cleanliness obsessions and washing rituals
• uncertainty and checking rituals
• angry/religious/sexual obsessions without overt rituals
• primary obsessional slowness, and
• hoarding.

Hoarding is a behaviour (or set of behaviours) that does not sit well within the obsessive-compulsive rubric. It clearly delineates from the other subtypes of OCD clinically, and does not respond well to the classic OCD treatments, such as exposure/response prevention (EX/RP) and serotonergic antidepressants. Furthermore, it can manifest in a number of other disorders, including senile squalor (‘Diogenes’) syndrome, schizophrenia and dementia.

There has been a lack of consensus about how common OCD really is. A number of early studies probably underenumerated it, while more recent large population-based studies such as the Epidemiological Catchment Area (ECA) study in the US, which relied on lay-interviewer diagnoses (based on a structured interview, the Diagnostic Interview Schedule (DIS), but open to interpretation), almost certainly led to overestimates. Application of DSM–IV criteria to an Australian general population sample resulted in a rate estimate of 0.6%, and this seems a reasonable take-home figure.

There is less debate about gender differences, with most studies suggesting an equal lifetime risk for males and females, but with males having an overall earlier onset of illness (late teens versus early 20s for females). The longitudinal course of illness is variable, and symptoms often wax and wane, usually worsening at times of personal stress.

Management

The management of OCD encompasses psychological and pharmacological domains.

Psychological domain

Psychological treatments generally include elements of EX/RP, with the patient helped to ‘face their fears’ in a structured, supported and hierarchical way. For example, the patient with contamination fears is encouraged to become progressively ‘contaminated’ (the exposure) and not immediately wash (the response prevention). Family members can be usefully included in the treatment plan to ensure they support the patient, but do not give in to reassurance-seeking behaviours that would undermine the exposure exercise (e.g. the checker of electrical appliances asking a family member to check that the appliance has been switched off).

Psychological treatment in patients without overt rituals is rather more complex, but various strategies can be used. These include distraction

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