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• Shanghai Arch Psychiatry
• v.29(5); 2017 Oct 25

Language: English | Chinese

Multidimensional Approaches for A Case of Severe Adult Obsessive - Compulsive Disorder

一例多维整合治疗成人重度强迫症的案例, zhongyong shi.

1 Department of Psychiatry, Tenth People’s Hospital of Tongji University, Shanghai, P. R. China

Xinchun MEI

2 Department of Psychiatry, Tongji Hospital of Tongji University, Shanghai, P. R. China

Yupeng CHEN

3 School of Medicine, Tongji University, Shanghai, P. R. China

Obsessive-compulsive disorder (OCD) is a chronic, distressing and substantially impairing neuropsychiatric disorder, characterized by obsessions or compulsions. The current case describes a 44-year-old adult female diagnosed with OCD. The patient had an incomplete response to several SSRIs alone during her past treatment, and led a poor-quality life for at least three years. Current multidimensional approaches, including combined cognitive behavioral therapy (CBT) and the Selective Serotonin Reuptake Inhibitor (SSRI, Sertraline) with a small dose of antipsychotics (Aripiprazole) for augmentation, as well as familial support and resources from the internet were provided for the patient for six months. Standardized assessments with Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) every two months indicated significant reductions in obsessive and compulsive symptoms, with significant improvements in her social functioning and quality of life. A case such as this one provides preliminary support to multidimensional approaches for OCD treatment in order to achieve an optimal response, though further rigorous clinical trials are needed to provide more evidence.

概述

强迫症(OCD) 是一种慢性、痛苦和进行性损害 的神经精神疾病，其特点是存在强迫意念或强迫动作。 本文报道的一名44 岁成年女性强迫症的病例。之前3 年治疗中，患者对数个选择性5 - 羟色胺再摄取抑制剂 (SSRIs) 疗效不佳，生活质量受到严重影响。经过6 个 月的多维整合治疗，包括认知行为治疗(CBT)、舍曲林 和低剂量抗精神病药物 (阿立哌唑)，以及家庭支持和 网络支持。每两个月Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) 标准化量表评估显示，强迫意念或强迫 动作明显减少，其社会功能和生活质量得到明显改善。 本病例初步显示OCD 多维整合治疗有助于达到最佳治 疗疗效较好治疗效果，期待今后更严格的临床试验验 证。

1. Case History

1.1 presentation.

Mrs. L. was a 44-year-old female with a college education. Her primary symptoms were strong fear of contamination and an uncontrollable desire to wash her hands or scrub “everything” (e.g., furniture and floor) where she worked (the Public Security Bureau) for the previous three years. However, without any obvious triggers, Mrs. L. began to worry about being infected by bacteria or HIV from reports about pornography. She was unable to control her hand washing and constantly disinfected with alcohol anything that had been touched. She becam sensitive to specific words in the newspaper or on television, such as “letter”, “express” or “postal”. These words would immediately cause her to associate thoughts of “bacteria” or “HIV”. These obsessions made it difficult for Mrs. L. to work, as well as causing severe anxiety and insomnia. Consequently, she quit her job and spent most of her time in bed. She rarely did any housework or had dinner with her family. In general, she isolated herself from society. Moreover she compelled her husband and daughter to perform the same ritual behaviors. Once her family members refused to engage in these behaviors she became depressed and irritable. Mrs. L. had a relatively strong personality and some characteristics of perfectionism. There was no personal or familial history of physical illness or psychosis.

Mrs. L. had seen several psychiatrists and had a consistent diagnosis of OCD. Drug regimens included Clomipramine and several SSRIs (e.g., Fluoxetine and Fluvoxamine), however, they were repeatedly discontinued due to the lack of efficacy or because of adverse side effects. It was necessary to rule out specific phobias because of Mrs. L.’s fear of letters, express packages or postal deliveries. The core reasons for her fears were rooted in her uncontrolled obsessions and compulsions rather than a certain object or situation-specific phobia. Moreover, she exhibited excellent insight into the nature of her excessive and unreasonable symptoms during the whole course of this disorder. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) [ 1 ] was used to assess her symptoms every two months and baseline scores were 28 points, indicating severe OCD. Mrs. L. met the diagnostic criteria for OCD according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). [ 2 ]

1.2 Treatment

1.2.1 cognitive behavioral therapy.

During the first interview, individual CBT including two aspects was discussed: (1) Cognitive Therapy (CT), focusing on disputing irrational beliefs, teaching patients to identify and correct their dysfunctional beliefs about feared situations and developing cognitive restructuring skills; (2) Exposure-and-Response-Prevention therapy (ERP), involving repeated and prolonged exposures to fear-eliciting stimuli, combined with instructions for strict abstinence from compulsive behaviors.

30 minutes of CBT content was scheduled into each session. During the Cognitive Therapy section of the session, the psychiatrist provided initial psychoeducation about CBT, helped Mrs. L. to realize the irrationality of her obsessive thoughts, and introduced exposure therapy and how it would reduce anxiety when exposed to stimuli without ritual engagement. Afterwards, several behavioral experiments were conducted to challenge her illogical causality. For the ERP section, detailed procedures of behavior training were carefully made: (1) Have Mrs. L. list out situations that would cause her compulsive behaviors, and describe her feelings as well as the duration and frequency of rituals; (2) Establish a hierarchy of distressing situations, and ask Mrs. L. to progressively be exposed to the situations rated as moderately anxiety provoking without performing rituals; (3) As the anxiety habituated within those early exposures, further expose her to situations that were rated as highly anxiety provoking without engaging in behavioral rituals. Alternatively, she was encouraged to do her favorite things, such as playing with iPad to divert attention from obsessions and resist the desire to engage in compulsions. Mrs. L. was required to record all the symptom fluctuations and behavioral responses in a diary as homework, which would be discussed during the next interview.

1.2.2 OCD Medications

Sertraline was prescribed with an initial dose of 100 mg/d and titrated up to 150 mg/d within one week, while Aripiprazole at a flexible-dose of 5-10 mg/d was given as a synergistic agent. This was started at a lower dose of 5 mg/d, aiming to promote better and faster efficacy.

At the one-month follow-up, Sertraline was increased to 200mg/d in order to further strengthen the treatment effects. Unfortunately, after taking the higher dose of Sertraline for just for one week, Mrs. L. apparently became euphoric, overactive and more talkative than usual. Given this condition, the Sertraline was lowered back to 150 mg/d while Aripiprazole was increased to 10mg/d to consolidate the treatment effect. Soon afterwards, Mrs. L.’s hyperactivity went away. At the end of the fourth month, Mrs. L. had achieved significant improvements in both clinical symptoms and social functioning. At this point, Aripiprazole was decreased to 5mg/d and Sertraline was maintained at 150 mg/d. This medication plan was kept for maintenance treatment without a return of symptoms.

1.2.3 Family and Internet Supports

Most noteworthy was that, the psychiatrist set up a powerful therapeutic alliance with Mrs. L.’s family members. The family members were told not to assist with Mrs. L.’s rituals (e.g., agreeing to disinfect the floor for her, repeatedly washing hands at the her request), provide excessive reassurance regarding Mrs. L.’s obsessional anxiety (e.g., answering frequent questions about the probability of contamination), or aid Mrs. L. in avoiding obsessional stimuli (e.g., removing all “contaminated” clothes before entering her bedroom) because these compromising behaviors would have negative impacts on treatment outcomes. Instead, the family members were advised to supervise Mrs. L.’s responses and give timely feedback on progressive performances, thus to inspire her confidence and motivation in getting through bouts of high anxiety.

Furthermore, Mrs. L. was promised that she could communicate with the psychiatrist about her symptom fluctuations and uncomfortable feelings associated with taking medications through internet platforms, such as “We Doctor APP”. Such mobile medical services were not only beneficial in establishing a good doctor-patient rapport and improving the patient’s treatment compliance, but also convenient for the patient to make an online appointment or long-distance consultation even on non-working days.

1.3 Clinical efficacy

After two-month intensive treatments, Mrs. L. had significant improvement in OCD symptoms and social functioning. The total score of Y-BOCS showed a notable decline from 28 points to 17 points, indicating presence of moderate clinical symptoms. To our surprise, Mrs. L. intended to prepare for a new job. After another two months of consolidating treatment gains with the current treatment protocols, Mrs. L. started working and was willing to attend normal social activities. Although still performing some of her rituals, she was generally satisfied with her current condition and agreed to “Let it be, it is what it is.” The score on the Y-BOCS reduced to 12 points with the presence of mild OCD symptoms. Thereafter, monthly CBT and certain medications, as well as family and internet supports, were continued for maintenance treatment. Over six months of comprehensive treatments, Mrs. L. obtained marked improvements with a total Y-BOCS score of five points, demonstrating a good response ( Table 1 and Figure 1 ). The few residual obsessions and rituals had little influence on her daily life and social functioning.

Obsessive and compulsive symptoms measured by Y-BOCS at different phases of treatment with multidimensional approaches. Y-BOCS, Yale-Brown Obsessive-Compulsive Scale.

Changes in medication dosage and Y-BOCS scores at different phases of treatment

Note: Y-BOCS, Yale-Brown Obsessive-Compulsive Scale

Up to the latest follow-up, Mrs. L remained stable without a return of symptoms. No other apparent adverse effects were reported. No clinically significant changes in weight or laboratory values were seen from the Aripiprazole.

2. Discussion

The World Health Organization has identified OCD as a leading cause of nonfatal burden, accounting for 2.5% of total global years lived with disability (YLDs). [ 3 ] Currently, the established first-line treatments for OCD are cognitive behavioral therapy (CBT) and the Selective Serotonin Reuptake Inhibitors (SSRIs). [ 4 ] Unfortunately, these treatments usually take several weeks to achieve full effect, and almost half of patients with OCD don’t respond adequately and fail to experience complete remission of their symptoms. [ 5 ]

Mrs. L presented an extraordinary case of severe adult OCD. Given that CBT and SSRIs would take several weeks to achieve a full effect, additional augmented strategies, including second-generation antipsychotics and supports from family or internet resources, were administrated to achieve an optimal efficacy.

2.1 Psychotherapy

CBT is a well-documented intervention for adults with OCD. A systematic review of psychological treatments showed that psychotherapy derived from cognitive behavioral models, in specific for CT and ERP, was the most effective approach for adult patients with OCD. [ 6 ] With CT, patients directly confront unreasonable beliefs or an exaggerated sense of danger to develop insights into the real problem. With ERP, patients deliberately and voluntarily expose themselves to feared objects or ideas, either directly or by imagination (the exposure component). [ 7 ] Afterwards, they are discouraged or prevented with the patient’s permission from carrying out usual compulsive responses (the ritual prevention component). For example, a compulsive hand washer would be urged to touch something he/she had believed to be contaminated but be denied the opportunity to wash. The patient would be punished with a rubber band as aversion therapy when he/she didn’t control washing hands. If treatments worked well, the patient would gradually experience less anxiety (habituate) from the obsessive thoughts, and become able to get through without the compulsive actions for longer periods.

In addition, when administrating CBT, the following learning experiences drawn from this case should be taken into consideration: (1) Establishing a good rapport with the patient to improve their motivation to engage in therapy; (2) In addition to regular visits, it is important to require the patient to carefully complete “homework assignments”, which not only serve as a record of the course of OCD symptoms but also their personal progress.

2.2 Medications

CBT has been shown to be an efficient psychotherapy for OCD. However, some patients drop out of therapy because of the unbearable anxiety from ERP or having an unsatisfactory partial response. Studies comparing pharmacological and psychotherapeutic treatment strategies for adults with severe OCD indicate that, combined interventions achieve a greater reduction in Y-BOCS score and superior efficacy in improving insight, functioning and quality of life. [ 8 ]

SSRIs are the first-line pharmacotherapy (over Clomipramine) owing to their potent effects on brain’s serotonergic system and better adverse-event profile. [ 9 ] SSRIs tend to take longer to be effective (between 4 and 12 weeks) and higher doses are often required for OCD patients, as compared with depression or generalized anxiety. [ 10 ] Although all SSRIs appear to be equally efficacious in treating OCD, Fluoxetine, Fluvoxamine and Sertraline are more commonly used in clinical practice because of higher patient compliance. Regarding the current case study, the patient showed a poor response to Clomipramine, Fluoxetine and Fluvoxamine during previous treatments, thus Sertraline was a considerable alternative. However, the response rate (40%-60%) and the probability of full remission (11%) with monotherapy SSRIs for patients with OCD is still less than satisfactory. How to achieve sufficient efficacy remains to be seen.

Among pharmacological augmentation strategies, one very frequently administrated strategy was using adjunctive low-dose antipsychotic drugs with SSRI medications, which showed obvious efficacy and safety for treatment-refractory OCD patients.

Recently, Markus et al meta-analyzed 14 double-blind randomized controlled trials, and confirmed antipsychotic augmentation of SSRIs in treatment-resistant OCD patients. [ 12 ] Specifically, this systematic review indicated that Aripiprazole was significantly superior to placebo in reducing Y-BOCS total score, as well as treating obsessions and compulsions. [ 12 ] Aripiprazole was regarded as the augmenting drug of first choice, and may have particular merits in such difficult-to-treat OCD cases by virtue of its dual impacts on serotonergic and dopaminergic mechanisms. [ 13 ] Therefore, augmentation of SSRIs with antipsychotic drugs can be considered as an evidence-based treatment option, with great advantages such as faster efficacy and better compliance. Further studies in larger samples are warranted to validate this point, and to evaluate the optimum antipsychotic dose, the optimum duration of the adjunctive treatment, as well as the long-term tolerability.

2.3 Synergetic strategies

For optimal response, besides CBT and medications, we also gained some positive experiences from the current case which may be beneficial to achieving more sufficient and longer-lasting efficacy for OCD patients.

One is taking advantage of family resources. Recently, family accommodation of OCD symptoms in adults has received great attention. Most family members often engage in assisting patients with their rituals in order to alleviate anxiety, prevent conflicts or “help out” with time consuming compulsive behaviors (e.g., agreeing to check locks for the patient; washing hands frequently at the patient’s request). Previous research has shown that higher levels of family accommodation at baseline predicted poorer treatment response and was associated with more severe OCD symptoms. [ 14 , 15 ] Therefore, interventions for OCD patients including the efforts from their family and uncovering the maladaptive accommodation may improve treatment outcomes. In Mrs. L.’s case, her family members were asked to reduce accommodation behaviors, cooperate with the psychiatrist to supervise completing of “homework assignments”, and give timely feedback instead of following every request. Such a constant support system provided additional emotional encouragement which increased the patient’s willingness to perform exposures, as well as removing roadblocks to preventing ritualistic compulsive behaviors.

Other resources were also drawn from the internet. Although CBT remains the most effective psychological intervention for OCD, there still exist many barriers to initiating and completing therapy in clinical practice, such as financial costs, difficulty in accessing long-term treatments and limited professional therapists, particular for individuals in rural and remote settings. [ 16 ] Large treatment effect sizes and similar rates of clinical significance in the treatment of OCD have been reported for internet-delivered CBT (iCBT), combining specific internet programs with clinician’s support. [ 17 ] In this case, Mrs. L was able to communicate with her psychiatrist through “We Doctor APP”, which improved her compliance with the on-going psychotherapy. Compared with standard in-office CBT, technological innovations are promising to transform care for the most remote and marginalized patients, which could provide a platform for supervising and encouraging patients to complete homework or communicate about fluctuations in their condition.

3. Conclusions

This case study provided preliminary support for the feasibility and utility of multidimensional approaches for patients with severe OCD, including routine CBT and SSRIs (Sertraline) with a small dose of antipsychotics (Aripiprazole) for augmentation, as well as drawing support from family and internet-based resources.

Zhongyong Shi graduated with a master’s degree in Psychiatry and Mental Health from Tongji University in 2016. She is currently pursuing her PhD and working as a resident in the Department of Psychology at the Shanghai Tenth People’s Hospital. Her main research interest is biomarkers of cognitive impairment.

Funding statement

No funding support was obtained for preparing this case report.

Conflict of interest statements

The authors declare that they have no conflict of interest related to this manuscript.

Informed consents

The patient signed an informed consent form and agreed to the publication of this case report.

Authors’ contributions

Shi participated in patient interview and drafted the manuscript. Mei, Zhu, Shuai and Chen helped with data collection. Wu and Shen carried out the clinical diagnosis and treatments. Shen critically reviewed the manuscript. All authors read and approved the final manuscript.

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Chapter 11: Psychological Disorders

Obsessive-Compulsive and Related Disorders

Learning objectives.

• Describe the main features, development, and prevalence of obsessive-compulsive disorder, body dysmorphic disorder, and hoarding disorder

Obsessive-compulsive and related disorders are a group of overlapping disorders that generally involve intrusive, unpleasant thoughts and repetitive behaviors. Many of us experience unwanted thoughts from time to time (e.g., craving double cheeseburgers when dieting), and many of us engage in repetitive behaviors on occasion (e.g., pacing when nervous). However, obsessive-compulsive and related disorders elevate the unwanted thoughts and repetitive behaviors to a status so intense that these cognitions and activities disrupt daily life. Included in this category are obsessive-compulsive disorder (OCD), body dysmorphic disorder, and hoarding disorder.

Obsessive-Compulsive Disorders

People with obsessive-compulsive disorder (OCD) experience thoughts and urges that are intrusive and unwanted (obsessions) and/or the need to engage in repetitive behaviors or mental acts (compulsions). A person with this disorder might, for example, spend hours each day washing his hands or constantly checking and rechecking to make sure that a stove, faucet, or light has been turned off.

Obsessions are more than just unwanted thoughts that seem to randomly jump into our head from time to time, such as recalling an insensitive remark a coworker made recently, and they are more significant than day-to-day worries we might have, such as justifiable concerns about being laid off from a job. Rather, obsessions are characterized as persistent, unintentional, and unwanted thoughts and urges that are highly intrusive, unpleasant, and distressing (APA, 2013). Common obsessions include concerns about germs and contamination, doubts (“Did I turn the water off?”), order and symmetry (“I need all the spoons in the tray to be arranged a certain way”), and urges that are aggressive or lustful. Usually, the person knows that such thoughts and urges are irrational and thus tries to suppress or ignore them, but has an extremely difficult time doing so. These obsessive symptoms sometimes overlap, such that someone might have both contamination and aggressive obsessions (Abramowitz & Siqueland, 2013).

Compulsions are repetitive and ritualistic acts that are typically carried out primarily as a means to minimize the distress that obsessions trigger or to reduce the likelihood of a feared event (APA, 2013). Compulsions often include such behaviors as repeated and extensive hand washing, cleaning, checking (e.g., that a door is locked), and ordering (e.g., lining up all the pencils in a particular way), and they also include such mental acts as counting, praying, or reciting something to oneself (Figure 1). Compulsions characteristic of OCD are not performed out of pleasure, nor are they connected in a realistic way to the source of the distress or feared event. Approximately 2.3% of the U.S. population will experience OCD in their lifetime (Ruscio, Stein, Chiu, & Kessler, 2010) and, if left untreated, OCD tends to be a chronic condition creating lifelong interpersonal and psychological problems (Norberg, Calamari, Cohen, & Riemann, 2008).

Watch this video to understand why people who are simply orderly or meticulous are probably not suffering from obsessive-compulsive disorder.

You can view the transcript for “Debunking the myths of OCD – Natasha M. Santos” here (opens in new window) .

Body Dysmorphic Disorder

An individual with body dysmorphic disorder is preoccupied with a perceived flaw in her physical appearance that is either nonexistent or barely noticeable to other people (APA, 2013). These perceived physical defects cause the person to think she is unattractive, ugly, hideous, or deformed. These preoccupations can focus on any bodily area, but they typically involve the skin, face, or hair. The preoccupation with imagined physical flaws drives the person to engage in repetitive and ritualistic behavioral and mental acts, such as constantly looking in the mirror, trying to hide the offending body part, comparisons with others, and, in some extreme cases, cosmetic surgery (Phillips, 2005). An estimated 2.4% of the adults in the United States meet the criteria for body dysmorphic disorder, with slightly higher rates in women than in men (APA, 2013).

Hoarding Disorder

Although hoarding was traditionally considered to be a symptom of OCD, considerable evidence suggests that hoarding represents an entirely different disorder (Mataix-Cols et al., 2010). People with hoarding disorder cannot bear to part with personal possessions, regardless of how valueless or useless these possessions are. As a result, these individuals accumulate excessive amounts of usually worthless items that clutter their living areas (Figure 2). Often, the quantity of cluttered items is so excessive that the person is unable use his kitchen, or sleep in his bed. People who suffer from this disorder have great difficulty parting with items because they believe the items might be of some later use, or because they form a sentimental attachment to the items (APA, 2013). Importantly, a diagnosis of hoarding disorder is made only if the hoarding is not caused by another medical condition and if the hoarding is not a symptom of another disorder (e.g., schizophrenia) (APA, 2013).

Causes of OCD

The results of family and twin studies suggest that OCD has a moderate genetic component. The disorder is five times more frequent in the first-degree relatives of people with OCD than in people without the disorder (Nestadt et al., 2000). Additionally, the concordance rate of OCD among identical twins is around 57%; however, the concordance rate for fraternal twins is 22% (Bolton, Rijsdijk, O’Connor, Perrin, & Eley, 2007). Studies have implicated about two dozen potential genes that may be involved in OCD; these genes regulate the function of three neurotransmitters: serotonin, dopamine, and glutamate (Pauls, 2010). Many of these studies included small sample sizes and have yet to be replicated. Thus, additional research needs to be done in this area.

A brain region that is believed to play a critical role in OCD is the orbitofrontal cortex (Kopell & Greenberg, 2008), an area of the frontal lobe involved in learning and decision-making (Rushworth, Noonan, Boorman, Walton, & Behrens, 2011) (Figure 3). In people with OCD, the orbitofrontal cortex becomes especially hyperactive when they are provoked with tasks in which, for example, they are asked to look at a photo of a toilet or of pictures hanging crookedly on a wall (Simon, Kaufmann, Müsch, Kischkel, & Kathmann, 2010). The orbitofrontal cortex is part of a series of brain regions that, collectively, is called the OCD circuit; this circuit consists of several interconnected regions that influence the perceived emotional value of stimuli and the selection of both behavioral and cognitive responses (Graybiel & Rauch, 2000). As with the orbitofrontal cortex, other regions of the OCD circuit show heightened activity during symptom provocation (Rotge et al., 2008), which suggests that abnormalities in these regions may produce the symptoms of OCD (Saxena, Bota, & Brody, 2001). Consistent with this explanation, people with OCD show a substantially higher degree of connectivity of the orbitofrontal cortex and other regions of the OCD circuit than do those without OCD (Beucke et al., 2013).

The findings discussed above were based on imaging studies, and they highlight the potential importance of brain dysfunction in OCD. However, one important limitation of these findings is the inability to explain differences in obsessions and compulsions. Another limitation is that the correlational relationship between neurological abnormalities and OCD symptoms cannot imply causation (Abramowitz & Siqueland, 2013).

Watch this CrashCourse psychology video to learn about the accurate definitions of phobias and OCD and how these contrast with common, incorrect descriptions of the terms.

You can view the transcript for “OCD and Anxiety Disorders: Crash Course Psychology #29” here (opens in new window) .

Connect the Concepts: Conditioning and OCD

The symptoms of OCD have been theorized to be learned responses, acquired and sustained as the result of a combination of two forms of learning: classical conditioning and operant conditioning (Mowrer, 1960; Steinmetz, Tracy, & Green, 2001). Specifically, the acquisition of OCD may occur first as the result of classical conditioning, whereby a neutral stimulus becomes associated with an unconditioned stimulus that provokes anxiety or distress. When an individual has acquired this association, subsequent encounters with the neutral stimulus trigger anxiety, including obsessive thoughts; the anxiety and obsessive thoughts (which are now a conditioned response) may persist until she identifies some strategy to relieve it. Relief may take the form of a ritualistic behavior or mental activity that, when enacted repeatedly, reduces the anxiety. Such efforts to relieve anxiety constitute an example of negative reinforcement (a form of operant conditioning). Recall from the chapter on learning that negative reinforcement involves the strengthening of behavior through its ability to remove something unpleasant or aversive. Hence, compulsive acts observed in OCD may be sustained because they are negatively reinforcing, in the sense that they reduce anxiety triggered by a conditioned stimulus.

Suppose an individual with OCD experiences obsessive thoughts about germs, contamination, and disease whenever she encounters a doorknob. What might have constituted a viable unconditioned stimulus? Also, what would constitute the conditioned stimulus, unconditioned response, and conditioned response? What kinds of compulsive behaviors might we expect, and how do they reinforce themselves? What is decreased? Additionally, and from the standpoint of learning theory, how might the symptoms of OCD be treated successfully?

group of overlapping disorders listed in the DSM-5 that involves intrusive, unpleasant thoughts and/or repetitive behaviors

characterized by the tendency to experience intrusive and unwanted thoughts and urges (obsession) and/or the need to engage in repetitive behaviors or mental acts (compulsions) in response to the unwanted thoughts and urges

involves excessive preoccupation with an imagined defect in physical appearance

area of the frontal lobe involved in learning and decision-making

General Psychology Copyright © by OpenStax and Lumen Learning is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Understanding Obsessive-Compulsive and Related Disorders

OCD is a common mental disorder, and is often disabling. The past few decades, however, have seen the emergence of many effective treatments, both pharmacological and psychotherapeutic. The challenges for the 21st century are two-fold: first, to make these effective treatments available to all sufferers; and, second, to unravel the biology of this disorder sufficiently so that we can cure its symptoms, and ultimately, prevent its occurrence. In order to tackle these challenges, it is essential that we understand the etiology of OCD.

Prevailing theories indicate that OCD is a biological disease. Functional brain imaging studies have produced a model for pathophysiology of OCD which involves hyperactivity in certain subcortical and cortical regions. On the basis of imaging studies, Insel has proposed that inappropriately increased activity in the head of the caudate nucleus inhibits globus pallidus fibers that ordinarily dampen thalamic activity. The resulting increase in thalamic activity produces increased activity in orbitofrontal cortex, which, via the cingulate gyrus, completes the circuit to the caudate and produces increased activity in the head of the caudate. Hypothetically, primitive cleaning and checking behaviors are "hard-wired" in the thalamus. Insel's hypothesis is supported by evidence from MRI (magnetic resonance imaging) studies, which have found an abnormally small caudate in some OCD patients, and by positron emission tomography (PET scan) studies, which have found increased metabolism in orbital frontal cortex, cingulate gyrus, and caudate, with decreases following successful treatment. The association of OCD with Tourette's syndrome and Sydenham's chorea, which are believed to involve basal ganglia pathology, is also consistent with this model.

In the section below, we have outlined a more detailed description of the various theories and hypotheses involved in the biological basis of OCD. As will be noted by many readers, the information provided here is more suited for clinicians, medical professionals, or others who are more familiar with medical terminalogy. For this reason, readers are encouraged to seek further information from their physicians/psychiatrists and/or other OCD resources.

Etiology: Biological Models

Functional Neuroanatomy

Many investigators have contributed to the hypothesis that OCD involves dysfunction in a neuronal loop running from the orbital frontal cortex to the cingulate gyrus, striatum (cuadate nucleus and putamen), globus pallidus, thalamus and back to the frontal cortex. Organic insult to these regions can produce obsessive and compulsive symptoms. The results of neurosurgical treatment of OCD strongly support this hypothesis. Surgical interruption of this loop by means of cingulotomy, anterior capsulotomy or subcaudate tractotomy brings about symptomatic improvement in a large proportion of patients unresponsive to all other treatments. Cingulotomy interrupts this loop at the anterior cingulate cortex, thereby disrupting frontal cortical input into the Papez circuit and limbic system, which are believed to mediate anxiety and other emotional symptoms. Anterior capsulotomy (lesions within the anterior limb of the internal capsules) and subcaudate tractotomy (lesions in the substantia innominata, just under the head of the caudate nucleus) interrupt fronto-thalamic fibers, which may mediate the obsessive and compulsive components of OCD. Baxter et al. in 1992 hypothesized that the hyperactivity observed in this neuronal loop arises because of imparied caudate nucleus function. The impariment allows "worry inputs" from the orbitofrontal cortex to inhibit excessively the inhibitory output from the globus pallidus to the thalamus. The resulting excess in thalamic output then impinges on various brain regions involved in the experience of OCD symptoms, including the orbital frontal region, thus reinforcing hyperactivity in the neuronal loop. However, Baxter et al. caution that the abnormal neurophysiology underlying OCD symptoms may involve structures as yet undetected. Decreased metabolic activity can be missed by current scanning techniques. Alternately, the metabolic hyperactivity of small neuronal fields can be missed when surrounding structures exhibit no change or mask the increase behind compensatory decreases.

Serotonin and Other Neurotransmitters

The hypothesis that an abnormality in serotonergic neurotransmission underlies OCD arose out of the observation that clomipramine, which inhibits both serotonin and norepinephrine reuptake, relieved symptoms, whereas noradrenergic reuptake inhibitors did not. The unique efficacy of clomipramine and the SSRIs remains the strongest support for this hypothesis. Studies of peripheral markers of serotonergic function in blood and cerebrospinal fluid have not conclusively demonstrated an abnormality. Pharmacological challenge studies with serotonergic agonists have suggested dysregulation within the serotonin system, with behavioral hypersensitivity and neuroendocrinological hyposensitivity to the activation of serotonin receptors, but numerous inconsistencies remain to be resolved. The beneficial effects of enhanced serotonergic neurotransmission do not prove that abnormalities in this system are the root cause of OCD symptoms. Serotonergic neurons modulate the function of many other systems, where the primary cause or causes may lie. In patients with comorbid Tourette's syndrome, tics and schizotypal personality disorder, treatment studies indicate a role for dopaminergic neurons.

Genetic Contributions

Twin studies and family studies strongly suggest that vulnerability to OCD can be inherited, but a positive family history is absent in many patients. Older studies of monozygotic twins show a 65% concordance for OCD, but no control groups were included. One study found an 87% concordance for "obsessional features" (OCD symptoms that may not have caused significant distress or social impairment) in monozygotic twins; the concordance of dizygotic twins was only half as large. On the other hand, none of eight monozygotic twin pairs in another study were concordant for OCD, according to Andrews et al. in 1990. A recent review notes that in Pauls' study in 1992, 10% of the parents of children and adolescents with OCD themselves had the disorder, and in another study, OCD was present in 25% of fathers and 9% of mothers. The symptoms of parents and children usually differed, arguing aginst social or cultural transmission. A study by Black et al. in 1992 however, found no increase in OCD prevalence in first degree relatives of OCD patients compared to those of control group. The recent finding, by Murphy et al. in 1997 and Swedo et al. in 1997, that an antigen which is a genetic marker for rheumatic fever susceptibility is also a marker for susceptibility to an autoimmune form of childhood onset OCD will undoubtedly spur progress in unraveling genetic contributions to the pathogenesis of OCD.

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Paraskevi Mavrogiorgou , Sarah Becker , Georg Juckel; Guilt and Shame in Patients with Obsessive-Compulsive Disorders. Psychopathology 2024; https://doi.org/10.1159/000537996

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Introduction: Obsessive-compulsive disorder (OCD) is a tremendous psychiatric illness with a variety of severe symptoms. Feelings of shame and guilt are universal social emotions that fundamentally shape the way people interact with each other. Mental illness is therefore often related to pronounced feelings of shame and guilt in a maladaptive form. Methods: A total of 62 participants (38 women and 24 men) were clinically and psychometrically investigated. Results: The OCD patients ( n = 31) showed a maladaptive guilt and shame profile, characterized by increased interpersonal feelings of guilt accompanied by a stronger tendency to self-criticism and increased punitive sense of guilt with a simultaneous prevailing tendency to perfectionism, as well as an increased concern for the suffering of others. The proneness to profuse shame in OCD patients seems to be in the context of the violation of inner values and a negative self-image with persistent self-criticism. Conclusion: Although there are limitations with a small sample size in this monocentric approach, our study underlines the importance of an individual consideration of the leading obsessive-compulsive symptomatology, especially in the context of very personal feelings of guilt and shame. Further multidimensional studies on guilt and shame could contribute to their implementation more strongly in individualized psychotherapy.

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Obsessive-Compulsive and Related Disorders

• First Online: 30 March 2024

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• Puja Chadha 5 &
• Shannon Suo 6  

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The Diagnostic and Statistical Manual of Mental Disorders -5th edition (DSM-5) took obsessive-compulsive disorder (OCD) and its related disorders out of anxiety disorders and created a new category to reflect evidence of their differences from anxiety disorders. Hoarding and excoriation disorders were new diagnoses added to DSM-5, having been recognized as separate disorders rather than symptoms of other anxiety or personality disorders since the publication of DSM-IV. OCD and hoarding disorder are among the more commonly recognized psychiatric problems by the public. Popular television shows now feature characters with these diseases, and reality shows like Hoarders center around the all-too shocking problems that such behaviors can create. While these disorders occur less frequently in geriatric patients, the impact these disorders can have on older adults can be more devastating than in younger adults. Older patients are more medically and physically vulnerable, more prone to social isolation, and problems such as hoarding can reach such devastating proportions as to result in the loss of house and home or severe medical consequences. This chapter focuses on five main diagnoses: OCD, body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation (skin-picking) disorder. We will discuss their diagnoses, disease course, and management. At the end of the chapter, we focus on two case studies intended to highlight how someone with the featured disorder may present along with important considerations in their workup and management.

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About this chapter

Chadha, P., Suo, S. (2024). Obsessive-Compulsive and Related Disorders. In: Hategan, A., Bourgeois, J.A., Hirsch, C.H., Giroux, C. (eds) Geriatric Psychiatry. Springer, Cham. https://doi.org/10.1007/978-3-031-47802-4_13

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DOI : https://doi.org/10.1007/978-3-031-47802-4_13

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The Oxford Handbook of Obsessive-Compulsive and Related Disorders (2nd edn)

David F. Tolin, Ph.D., The Institute of Living and Yale University School of Medicine

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Obsessive-compulsive and related disorders include obsessive-compulsive disorder, hoarding disorder, body dysmorphic disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder. This volume reviews the phenomenology and epidemiology of each of the disorders. Next, it reviews how the disorders are maintained, from biological (including genetic and neuroanatomical) and psychological (including information-processing, personality, behavioral, and cognitive) perspectives. Detailed instructions for the assessment and treatment of each disorder are provided, including somatic (such as pharmacotherapy, neurosurgery, and neuromodulation) and psychosocial (including exposure-based and cognitive) approaches as well as an exploration of the efficacy of combining pharmacotherapy and psychological approaches). The volume concludes with reviews of the obsessive-compulsive and related disorders in special populations including older adults, children and adolescents, and cross-cultural issues).

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Handbook on Obsessive-Compulsive and Related Disorders 1st Edition

This is the first book of its kind to reflect the new DSM-5 classification, which no longer identifies obsessive-compulsive disorder (OCD) as an anxiety disorder, but instead groups it with related conditions, which are now known as obsessive-compulsive and related disorders (OCRDs).

• ISBN-10 1585624896
• ISBN-13 978-1585624898
• Edition 1st
• Publisher American Psychiatric Association Publishing
• Publication date May 18, 2015
• Language English
• Dimensions 6 x 0.8 x 8.9 inches
• Print length 312 pages
• See all details

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Editorial Reviews

This Handbook has a story that has its roots in the text by Eric Hollander, Joseph Zohar, Paul J. Sirovatka & Darrel A. Regier, Obsessive-Compulsive Spectrum Disorders . Refining the Research Agenda for DSM-V (Washington, DC: American Psychiatric Publishing, 2011), and in the innovations that were introduced with the DSM-5: in particular, the inclusion of obsessive compulsive disorder in a separate sector compared to that in which it was previously placed, ie the area of anxiety disorders. This change, in the opinion of the authors, has a significant impact on improving the way in which clinicians diagnose and treat patients who present the broad spectrum of situations that revolve around obsessive and compulsive issues. But also, researchers can find in this new arrangement - which, it should be remembered, includes different configurations in addition to the classic obsessive-compulsive disorder - a different and more useful basic framework (see pp. 271-306 of the DSM-5. and statistics of mental disorders Milan: Raffaello Cortina, 2014). The eleven chapters of the text, written by twenty-two authors who have all been involved in the work of the Obsessive-Compulsive Spectrum Sub-Work Group for the development of the DSM-5, covers a wide range of clinical situations (from accumulation disorders to tic, trichotillomania and excoriation disorders), especially considering the fundamental aspects of diagnosis, differential diagnosis and treatment. About this second point the indication that runs through the entire text is that of cognitive-behavioral therapy (Cognitive-Bahavioral Therapy [CBT]), considered as the first-line treatment together with the latest generation drugs, selective inhibitors of the re-uptake of serotonin (known as SSRI, from the English Selective Serotonin Reuptake Inhibitors).

A modest space is then reserved for what is called "psychoeducation", while psychodynamic therapy is mentioned en passant only once and critically. The interest in the complex of obsessive-compulsive disorders also arises from the spread of these problems and from the frequent situation of comorbidity (especially anxiety, depressive and bipolar disorders). The age of onset is around nineteen years and if it is not treated this disorder tends to fluctuate, exacerbating, with a high possibility of becoming chronic. Several authors of the text emphasize the high cost (social and financial) paid by the company because of the impediments that force patients affected by this condition to fail to cope with normal life commitments: as stated in the DSM-5, we estimates that, at world level, the percentage of the affected population is between 1.1% and 1.8%, with a slight prevalence of females on males, observing that the onset in the male population is often precocious, ie placed in the childhood age. The text also includes three chapters dealing with topics strongly related to obsessive and compulsive disorders, but which have been placed in other areas of the Manual in the DSM-5: tic disorders, the new version of hypochondria (called "Anxiety Disorder" of disease ") and obsessive-compulsive personality disorder. On some topics related to the topic covered in the text it may be useful to consult Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors, signed by Jon E. Grant, Dan J. Stein, Douglas W. Woods & Nancy J. Keuthen (Washington, DC: American Psychiatric Publishing, 2012).

From the Inside Flap

Handbook on Obsessive-Compulsive and Related Disorders is the first book of its kind to reflect the new DSM-5 classification, which no longer identifies obsessive-compulsive disorder (OCD) as an anxiety disorder, but instead groups it with related conditions, which are now known as obsessive-compulsive and related disorders (OCRDs). This pivotal change recognizes the increasing evidence that these disorders are related to one another and distinct from other anxiety disorders, and is intended to help clinicians better identify and treat individuals with OCRDs. Many of the book's authors participated in the development of DSM-5, and the editors were chair the DSM-5 work group and chair of the sub-work group, respectively, that studied these disorders, ensuring that the text is utterly consistent with the classification and provides cutting-edge coverage, from body dysmorphic to tic disorders.

Key clinical points and case studies contribute to the book's hands-on usefulness, as do the many differential diagnosis tables and other charts. Handbook on Obsessive-Compulsive and Related Disorders is authoritative, but it is also written and structured to be accessible and should appeal to a broad range of readers.

From the Back Cover

About the author.

Katharine A. Phillips, M.D., is Professor of Psychiatry and Human Behavior at Alpert Medical School of Brown University; and Senior Research Scientist and Director of the Body Dysmorphic Disorder Program at Rhode Island Hospital in Providence, Rhode Island.

Dan J. Stein, M.D., Ph.D., is Professor and Chair of the Department of Psychiatry at the University of Cape Town in Cape Town, South Africa.

Product details

• Publisher ‏ : ‎ American Psychiatric Association Publishing; 1st edition (May 18, 2015)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 312 pages
• ISBN-10 ‏ : ‎ 1585624896
• ISBN-13 ‏ : ‎ 978-1585624898
• Item Weight ‏ : ‎ 15 ounces
• Dimensions ‏ : ‎ 6 x 0.8 x 8.9 inches
• #2,366 in Compulsive Behavior (Books)
• #2,806 in Psychopathology
• #3,813 in Psychiatry (Books)

About the authors

Katharine a. phillips.

Katharine A. Phillips, M.D., is internationally renowned for her clinical expertise and pioneering medical research studies on body dysmorphic disorder (BDD). BDD is a common, severe, and underrecognized condition in which people have distressing or impairing preoccupations with perceived defects in their physical appearance. She also has expertise in other body image conditions, obsessive-compulsive disorder, olfactory reference syndrome (preoccupation with emitting an unpleasant body odor), anxiety disorders, and other psychiatric disorders.

Dr. Phillips is Professor of Psychiatry at Weill Cornell Medical College, Cornell University, in New York City, where she has her clinical practice.

She is a physician and scientist who has spent her career caring for patients and conducting groundbreaking scientific research on BDD and other psychiatric disorders. Her research on BDD has identified many key aspects of this severe psychiatric disorder. Much of her work has focused on developing and testing effective treatments, both medication treatment and therapy, for BDD. Her scientific studies on BDD were continuously funded by the National Institute of Mental Health from 1995 to 2016.

When Dr. Phillips started seeing people with BDD and doing scientific research on BDD in the early 1990s, this debilitating condition was virtually unknown to professionals and the public alike. Because she saw the severe suffering that this condition so often causes, Dr. Phillips has been passionate about advancing knowledge and sharing findings from her research studies and those of other scientists. She has published many books on this condition, including the first book on BDD, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder, in 1996 (updated in 2005), and the first edited volume on BDD, Body Dysmorphic Disorder: Advances in Research and Clinical Practice, in 2017.

Dr. Phillips has received numerous honors and awards for her research studies, clinical work, and other academic accomplishments. She has more than 350 scientific publications, and she has given more than 600 presentations in the US and abroad and more than 500 media interviews. She has been interviewed by the New York Times, the London Times, the Los Angeles Times, the Wall Street Journal, the Washington Post, the Boston Globe, US News and World Report, Time Magazine, Newsweek, CNN, the BBC, National Public Radio, and many other media outlets. She has appeared on the Oprah Winfrey Show, 20/20, Dateline NBC, the Today Show, and Good Morning America.

Dr. Phillips has repeatedly been included in Who's Who in America, Best Doctors in America, Castle Connolly's America's Top Doctors, and Castle Connolly's Exceptional Women in Medicine. She has also been included in Marquis Who's Who in Science and Engineering, Who's Who in Medicine and Healthcare, Who's Who of American Women, and Who's Who in the World.

Dan J. Stein

Dan J Stein is Professor and Chair of the Dept of Psychiatry and Mental Health at the University of Cape Town and Director of the South African Medical Research Council (MRC) Unit on Risk & Resilience in Mental Disorders. He is interested in the psychobiology and management of the anxiety, obsessive-compulsive and related, and traumatic and stress disorders. He has also mentored work in other areas that are of particular relevance to South Africa and Africa, including neuroHIV/AIDS and substance use disorders.

Dan did his undergraduate and medical degrees at the University of Cape Town, and his doctorate (in the area of clinical neuroscience) at the University of Stellenbosch. He trained in psychiatry, and completed a post-doctoral fellowship (in the area of psychopharmacology) at Columbia University in New York. His training also includes a doctorate in philosophy. He is inspired by the way in which psychiatry integrates science and humanism, and contributes to addressing some of the big questions posed by life.

Dan's work ranges from basic neuroscience, through clinical investigations and trials, and on to epidemiological and cross-cultural studies. He is enthusiastic about the possibility of clinical practice and scientific research that integrates theoretical concepts and empirical data across these different levels. Having worked for many years in South Africa, he is also enthusiastic about establishing integrative approaches to services, training, and research in the context of a low and-middle-income country.

Dan has authored or edited over 40 volumes, including “Cognitive-Affective Neuroscience of Mood and Anxiety Disorders”, and “The Philosophy of Psychopharmacology: Smart Pills, Happy Pills, Pep Pills”. He has also contributed to many articles and chapters (http://scholar.google.co.za/citations?user= hSbjtvYAAAAJ&hl=en).

Dan's work has been continuously funded by extramural grants for more than 25 years. He is a recipient of CINP’s Max Hamilton Memorial Award for his contribution to psychopharmacology, and of CINP's Ethics and Psychopharmacology Award for his contribution to the philosophy of psychopharmacology.

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