1.5 Obsessive-compulsive disorder (OCD)

ICD-11 Characteristics and how to classify:

• Obsessive-compulsive disorder (OCD) is characterised by the presence of obsessions or compulsions, or most commonly both. Obsessions are unwanted, repetitive thoughts, images, or urges.

• Obsessions are most commonly due to anxiety. Compulsions are repetitive behaviours or mental acts that the individual feels the need to finish, as a response to obsession.

• For a diagnosis to be made the obsessions and compulsion must take up more than an hour per day and must result in significant distress, and impairment to important areas of functioning such as family, social, or occupational. 

Obsession: An obsession is a recurring and persistent thought that interferes with normal behaviour.

Obsession Examples: 1-Fear of infection or illness 2- Need for order/symmetry, 3- Fear of losing control, 5- Fear of harming others/self, 6- Fear of forgetting something important, 7-Fixation on certain numbers.

Compulsion: Compulsions or compulsive acts are repetitious, purposeful

physical or mental actions that the individual feels compelled to engage in

according to their own strict rules or in a stereotyped manner.

Compulsion Examples: 1-Cleaning (constantly cleaning up around you or showering etc), 2- Checking (Ensuring things are locked repeatedly), 3- Counting (Ordering and arranging possessions)

EXAMPLE CASE STUDY: RAPOPORT ET AL. (1989)

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Evaluation of Rapoport:

STRENGTHS

• Interview conducted. 

• Qualitative data collected.

• Charles explained his thoughts in his own words; For eg. 'maybe some sickness would come”

• Increased Validity as Charles was able to explain why he behaved as he did.

WEAKNESSES

• The case study focuses on only one individual - This case is a 14-year-old boy

• Not generalisable

• According to Rapoport, symptoms change.

• Younger children repeat behaviours whereas adults ruminate which is worry and overanalyzing thoughts

MEASURES

MOCI – Maudsley Obsessive Compulsive Inventory

• Developed by HODGSON AND RACHMAN (1977)

• Maudsley Obsessive-Compulsive Inventory (MOCI) is a short assessment tool with 30 simple yes or no questions. It assesses symptoms related to OCD such as washing, slowness, doubting, and checking. The MOCI was designed as a short assessment tool rather than a formal diagnostic tool. 

Frequently asked questions in the MOCI include:

• I frequently have to check things several times.

• I do not take a long time to dress in the morning.

• Even when I do something very carefully, I often feel that it's not quite right. 

Y-BOCS – Yale-Brown Obsessive Compulsive Scale

• Developed by GOODMAN ET AL. (1989) the Y-BOCS is a widely used test to measure the nature and severity of an individual’s symptoms.

• It is a semi-structured interview that takes 30 minutes, it also contains a checklist of different obsessions and compulsions with a 10-item severity scale.

• The checklist can be used to help plan treatment or to assess how treatment is progressing. Scores range from 0 (no symptoms) to 40 (severe symptoms) and Individuals with a score of 16 out of 40 are considered in the clinical range of OCD.

MEASURES EVALUATION: Strengths: 

• Both tests provide good concurrent validity which is a way to judge validity by comparing measures of the same phenomenon in different ways at the same time to show that they produce similar results in the same circumstances

• They also provide good test-retest reliability meaning those who repeat the measures at different times are likely to get the same results.

• MOCI provides Quantitative Data and the Y-BOCS produces Qualitative Data.

• Y-BOCS has high inter-rater reliability because it's an interview and around 4 researchers analyzed the data and came up with the same agreements of OCD for each person who did the test.

Weaknesses:

• The MOCI uses fixed questions so if a participant wants to express themselves beyond true or false they may not be able to explain it.

• Additionally, the MOCI has phrased their questions as difficult for eg. “I only use an average amount of soap” People with OCD may not know what defines average as their perception is distorted due to their disorder.

• Y-BOCS asks people to consider the severity of their symptoms in the last week, this is a problem because symptoms vary from person to person and they could experience it at different times.

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EXPLANATIONS FOR OCD:

BIOLOGICAL Biochemical:

• ALTEMUS ET AL. (1993) suggest that OCD is caused by low serotonin levels. HUMBLE ET AL. (2011) found high levels of oxytocin positively correlated with early onset OCD.

• Dopamine is abnormally high in OCD patients. (SZECHTMAN ET AL. 1998) shows if you increase dopamine levels in rats, they show repetitive behaviours that reflect the compulsivity of real OCD individuals. The DRD4 gene codes for dopamine receptors that then suggest an imbalance of dopamine is linked to OCD.

• OCD individuals have higher-than-normal levels of serotonin. MAO-A the enzyme that breaks down serotonin is linked to the vulnerability of OCD.

• Oxytocin dysfunction – increase in worries and fear of certain situations/stimuli with the belief that survival could be threatened. LECKMAN ET AL. (1994) found that some forms of OCD were related to oxytocin dysfunction.

• Neurological – abnormalities of brain structure and function. Basal ganglia are implicated in being related to obsessive thinking. Other neurological explanations involving abnormalities of brain structure and function such as abnormalities of basal ganglia being implicated in being related to obsessive thinking and related regions. These regions convert sensory input into thoughts and behaviours, and if these regions do not regulate activity (e.g. they become overstimulated) it could explain recurring thoughts and behaviour.

BIOLOGICAL Genetic:

• Recent research suggests OCD has a genetic basis.

• MONZANI ET AL. (2014) conducted a twin study:

  • Found higher concordance rate in identical twins (52%) compared to fraternal twins (21%).

  • Implies a heritability estimate of 48%.

• Specific genes for OCD remain unidentified.

• Low serotonin levels are linked to OCD.

• OZAKI ET AL. (2003) identified a mutation in the SERT gene:

  • Found in individuals from two unrelated families with OCD.

  • Leads to decreased serotonin levels.

• Genes cause OCD. (MATTHEISEN ET AL. 2015) large scale study of 1406 patients had found genes PTPRD and SLITRK3 were associated with OCD. TAJ ET AL. (2013) found gene DRD4 was related to uptake of dopamine. 

PSYCHOLOGICAL – Cognitive (Thinking Error): 

According to RACHMAN ET AL. (1977), cognitive obsessions stem from flawed reasoning, such as believing one's hands are contaminated with harmful germs. These cognitive errors can intensify during periods of stress. Behavioral compulsions are actions taken to relieve the distress caused by these intrusive thoughts.

PSYCHOLOGICAL – Behavioural (Operant Conditioning):

Compulsive behaviors in OCD are explained by operant conditioning. For instance, handwashing temporarily relieves obsessions about germs, serving as both a negative and positive reinforcer. This indicates that obsessive-compulsive behaviors are learned responses shaped by reinforcement.

PSYCHOLOGICAL – Psychodynamic:

The psychodynamic approach to OCD suggests that unconscious beliefs and desires contribute to the disorder. Freud proposed that OCD symptoms stem from conflicts between the id and ego, often rooted in the anal stage of development during toilet training. These conflicts may involve tension between children and parents over control of bodily functions. Children may respond by either soiling themselves (anally expulsive) or withholding waste (anally retentive). Psychodynamically, these behaviors can lead to later disturbances, as individuals become 'fixated' in this stage. The theory posits that obsessive thoughts disturb the rational ego, leading to compulsive cleaning rituals to cope with early childhood trauma

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TREATMENTS FOR OCD:

BIOLOGICAL – SSRIS:

OCD can be treated with anti-depressants and anti-anxiety medication. The most used medication for OCD though is SSRIs; they work by blocking the serotonin from being reabsorbed once a message has been passed from one neuron to another, meaning that serotonin levels remain higher.

SOOMRO ET AL. (2008) reviewed 17 studies involving 3097 participants, comparing SSRIs to placebos in treating OCD. SSRIs were consistently more effective than placebos in reducing OCD symptoms after 6-13 weeks.

PAMPALONI ET AL. (2009) found that higher doses of SSRIs are generally more effective in treating OCD compared to depressive disorder.

PSYCHOLOGICAL – Exposure and Response Prevention (ERP):

Exposure and response prevention (ERP) technique:

Exposure means facing or confronting the feared stimuli and/or situations repeatedly until the fear associated with them subsides, and response prevention means not carrying out the compulsive, avoidant, or escape behaviour. ERP targets he behavioural component of CBT.

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EXAMPLE CASE STUDY: LEHMKUHL ET AL. (2008)

• Case study of Jason, a 12-year-old boy had both autism and OCD. Had ten 50-minute sessions of CBT over 16 weeks. Used exposure response prevention.

• Jason could not identify specific obsessions and therefore not possible typical ERP. For Jason, cognitive component of treatment focused on identifying feelings of distress and learning coping statements to reduce anxiety, e.g. ‘I know that nothing bad will happen’ and ‘Doing the exposures will help me get better’.

• Between sessions Jason monitored thoughts using thought record to encourage identification of anxious thoughts. Jason learned to distinguish between normal worries and obsessive thoughts.

• 2nd session – Start with lowest level of hierarchy and move up. Jason was required to touch several common items in hospital such as elevator buttons, door handles) and exposures were repeated until Jason habituated to the anxiety.

• Sessions 3–8 – Gradually increased exposure to situations on hierarchy that Jason had obsessional thoughts about.

• Exposure – getting Jason to touch objects he has difficulties with such as elevator buttons, door handles, etc.

• Response prevention – reducing the anxious response to the objects by using coping statements. Jason does have high anxiety responses, but he learns as therapy progresses that these reduce quickly within a few minutes.

• After therapy score on Y-BOCS dropped from 18 to 3.

PSYCHOLOGICAL – COGNITIVE BEHAVIOURAL THERAPY (CBT):

KEY STUDY NAME: LOVELL ET AL. (2006)

Telephone administered CBT for treatment of OCD.

Aim: To compare the effectiveness of cognitive behaviour therapy delivered by telephone with the same therapy given face to face in the treatment of obsessive compulsive disorder.

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Main Theories Explained: Shorter telephone sessions for Cognitive Behavioural Therapy (CBT) can reduce waiting lists and offer more accessible treatment options for patients. It helps in alleviating pressure on resources, benefits individuals who struggle with transportation or scheduling conflicts, and is particularly beneficial for those with OCD. Research shows that telephone-delivered CBT is effective and less expensive than traditional face-to-face sessions.

Studies by Mohr et al. (2000) and Taylor et al. (2003) have shown that telephone-delivered CBT is effective and less expensive than face-to-face sessions, providing accessible support for those who cannot attend a clinic.

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Method (Research method & design): 

Independent Groups Design

Randomised Controlled Non inferiority trial.

Non inferiority trial is a study that tests whether a new treatment is not worse than an active treatment it is being compared to.

The procedure would be comparing exposure therapy and response prevention delivered via traditional 60-minute face-to-face sessions or shorter telephone sessions (up to 30 minutes each).

Sample

• 72 patients with obsessive compulsive disorder. (Scored at least 16 on the Y-BOCS)

• Opportunity Sample selected from two outpatient clinics in Manchester UK.

• Ages 16-65

Procedure

Treatment: Ten weekly sessions provided for each condition (conditions being: traditional 60-minute face-to-face sessions or shorter telephone sessions of up to 30 minutes each)

 conducted by two experienced therapists (one at each clinic) using therapist manuals, supervision sessions, and training days to ensure consistency.

Assessment: Participants were assessed twice before treatment using Y-BOCS and Beck Depression Inventory (BDI), then immediately after treatment, and at one-, three-, and six-month follow-ups using the same measures. A client satisfaction questionnaire was also administered.

Blinding: Researchers assessing participants before and after treatment were unaware of the participants' assigned condition to prevent bias.

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Results

• Mean Y-BOCS score before treatment was 25, indicating marked OCD severity. No significant difference existed in Y-BOCS or BDI scores between the two conditions initially.

• Clinical outcomes were similar across both conditions at all time points (immediately after treatment, one month, three months, and six months later).

• Mean Y-BOCS scores significantly decreased after treatment in both conditions. Treatment was considered clinically relevant if Y-BOCS scores dropped by two standard deviations or more, which occurred in 72% of patients overall (77% in telephone condition, 67% in face-to-face).

• Patient satisfaction scores were high and comparable across both conditions, indicating satisfaction with treatment.

• The study suggests that telephone-delivered CBT is as effective as face-to-face CBT for OCD treatment.

• Reduced contact time with telephone-delivered CBT did not compromise treatment effectiveness or patient satisfaction.

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Conclusions

• The clinical outcome of cognitive behaviour therapy delivered by telephone was equivalent to treatment delivered face to face and similar levels of satisfaction were reported.

• Patients with OCD may benefit equally from telephone-delivered CBT with reduced contact time as they would from traditional face-to-face CBT.

• These findings support the feasibility and effectiveness of telephone-delivered CBT as an alternative treatment approach for OCD, potentially increasing accessibility and reducing resource burden.

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1.5.2 Explanations of obsessive-compulsive disorder
(Biological - Genetic/Biochemical and Psychological - Cognitive/Behavioural/Psychodynamic