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, with the patient taught to bring pleasant or neutral thoughts into their mind to counter the obsession; thought stop, where a stop sign or some such image is used; aversive conditioning, such as snapping an elastic band on the wrist when obsessions arise; and exposure to a script or recording of their own thoughts. There is some debate as to how much a cognitive addition to EX/RP helps patients with OCD, as most patients readily admit that their fears are unreasonable. However, some patients do gain benefit from direct cognitive challenge. For example, a patient who believed every time she had sex that she had become pregnant, despite the use of a condom and being on a contraceptive pill, was tasked with establishing the objective risks of pregnancy in the setting of each of these precautionary measures, and shown how the risk of conception while using both was mathematically extraordinarily unlikely.

Pharmacological domain

The most effective and well-established pharmacotherapy for OCD is serotonergic antidepressants, including the selective serotonin reuptake inhibitors (SSRIs) and clomipramine (see Ch 13). Doses required are often higher than those usually needed for depression and it can take some months of treatment to see the full benefit. Many patients are left with residual symptoms, and some of these benefit from the adjunctive use of other agents such as antipsychotics. There is some evidence that patients with concomitant motor tics or schizotypal personality disorder benefit particularly from this latter approach.

Obsessive-compulsive spectrum disorders

Obsessions and/or compulsions can also occur in a number of other disorders, as shown in Figure 9.1. These are sometimes grouped together into a so-called obsessive-compulsive spectrum of disorders (OCS). While the veracity of this approach is open to criticism, and some members of the spectrum fit much more snugly than do others, we use this overall structure here to address these groups of disorders in turn.

image

FIGURE 9.1 Obsessive-compulsive spectrum disorders

Disorders associated with bodily preoccupation

Body dysmorphic disorder (BDD)

Body dysmorphic disorder (BDD) is characterised by a preoccupation with a perceived imperfection or abnormality in physical appearance. It usually onsets in the teens and affects males and females roughly equally. Any aspect of appearance may be affected, but if the preoccupation is solely with weight and shape, then the diagnosis is of an eating disorder (actually there is a high rate of ‘comorbid’ BDD in people with eating disorders). The disorder has many similarities with OCD, but the intrusive thoughts are technically ego-syntonic, and are much more likely (about 50%) to be held with delusional conviction. Rituals such as excessive and prolonged grooming can be very time-consuming; mirror checking can be either excessive or avoided as far as possible. There is also significant comorbidity with social anxiety disorder and depression.

Treatment includes various psychological techniques, notably cognitive behaviour therapy (CBT) and EX/RP, and serotonergic antidepressants: as with OCD, high doses and prolonged treatment trials are required. Adjunctive antipsychotics can be helpful in some patients, but are not effective as sole agents, even if the patient has the delusion form of BDD.

Eating disorders

These are covered in Chapter 10.

Hypochondriasis

This is a somewhat old-fashioned term which refers to a preoccupation with physical health, a belief one has a physical illness, and the seeking of help for this perceived problem from health professionals. Numerous medical tests and reassurance from health professionals are to no avail. It is one manifestation of somatisation, and is classed with the somatoform disorders in DSM–IVTR (see Ch 11). Hypochondriacal preoccupations can be seen in a number of other disorders, including depression (where they can reach delusional intensity: see Ch 6), generalised anxiety disorder (see Ch 8), and monosymptomatic hypochondriacal delusions (in DSM–IVTR, delusional disorder, somatic subtype: see Ch 5).

Neurological disorders

Obsessions and compulsions can manifest in response to a number of brain insults, including head injury and encephalitis lethargica. Of particular interest are children who have an abrupt onset of OCS after throat infection with streptococcus type A. This idiosyncratic autoimmune reaction has been grouped within the pervasive autoimmune neuropsychiatric disorders associated with streptococcus A (PANDAS). Treatments can include plasmapheresis.

A number of other neuropsychiatric disorders can manifest OCS. These include autism, Huntington’s disease and Tourette’s syndrome.

Impulse control (‘habit’) disorders

This is a group of disorders characterised by impulsive behaviours which become ‘habits’ that are very difficult to resist. The archetypal member of this group is trichotillomania (TTM), where sufferers repeatedly pull out their hair. Usually, hair pulling occurs in bouts, commencing with a feeling of being ‘pent up’, and ‘needing’ to pull to relieve this unpleasant affect. Some patients have a ritualised way of dealing with the plucked hair, including mouthing it and even ingestion: gastrointestinal obstruction can occur because of hair balls.

Treatment is difficult, with the most established mode being behaviour modification, where a competing action (e.g. fist clenching) is encouraged to break the pulling cycle. Serotonergic antidepressants help some patients, but not very consistently.

CASE EXAMPLES: obsessive-compulsive spectrum disorders

Depression with secondary hypochondriasis

A 45-year-old man presented with severe depression. He had become obsessed with his physical health, thinking he had bowel cancer (he was constipated) and kept seeking reassurance from medical doctors and requesting further investigations for his bowel problem. Treatment was primarily of the depressive process.

Obsessive-compulsive disorder

A 20-year-old nurse who had always been fastidious about personal cleanliness presented with intense anxiety revolving around the belief she had contracted hepatitis C following being inadvertently splashed by the urine of a patient with this condition. She was taking excessive precautions to avoid contact with any bodily fluids, including wearing safety goggles and three layers of gloves at all times at work. When she arrived home from work, she would strip off all her work clothes, place them in the washing machine, and don an ‘uncontaminated’ set of clothes for indoor use. She could no longer invite work colleagues to her home in case they contaminated it. Treatment was with a combination of EX/RP and a serotonergic antidepressant.

Obsessive-compulsive syndrome secondary to an atypical antipsychotic

A 40-year-old man with schizophrenia developed, after commencing the antipsychotic clozapine, ritualised checking and cleaning behaviours, which themselves became distressing and very time-consuming. The beliefs were quite independent of any psychotic beliefs, which had actually abated with the clozapine. Treatment was to continue the clozapine and treat the OCS with the established psychological and pharmacological techniques (note that the antidepressant fluvoxamine should be avoided as it interacts with clozapine).

Body dysmorphic disorder

An 18-year-old woman was referred by a plastic surgeon. She had had two rhinoplasties by other surgeons, but was still unhappy with the outcome and was seeking a further procedure. She had been ‘obsessed’ by her ‘hideous’ nose since childhood, thought about it incessantly, constantly compared her nose with others and with models in magazines, and spent hours a day looking at her nose from different angles in the mirror. As soon as she was 16 she had persuaded her parents to pay for the initial cosmetic procedure. She was at first happy with the outcome, but soon began to think it even worse than before, and resorted to covering it up with a plaster before she would even venture out of the house. She was avoidant of social situations and had become significantly depressed. Treatment was with a combination of CBT and high-dose serotonergic antidepressants.

References and further reading

Castle D., Groves A. The internal and external boundaries of obsessive compulsive disorder. Australian and New Zealand Journal of Psychiatry. 2000;34:249-255.

Castle D., Phillips K.A. The obsessive-compulsive spectrum of disorders: a defensible construct? Australian and New Zealand Journal of Psychiatry. 2006;40:114-120.

Crino R., Slade T., Andrews G. The changing prevalence of obsessive-compulsive disorder criteria from DSM–III to DSM–IV. American Journal of Psychiatry. 2005;162:876-882.

Hollander E. Obsessive-compulsive disorder and spectrum across the lifespan. International Review of Psychiatry in Clinical Practice. 2005;9:79-86.

Stein D.J., editor. Obsessive-compulsive spectrum disorders. Psychiatric Clinics of North America. 2006;29:343-613.

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