The obsessive-compulsive spectrum

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CHAPTER 9 The obsessive-compulsive spectrum

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

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.

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.

Disorders associated with bodily preoccupation

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