User:Ongmianli/Portfolios/Obsessive-compulsive disorder

Obsessive-Compulsive and Related Disorders

The chapter on obsessive-compulsive and related disorders, which is new in DSM-5, reflects the increasing evidence that these disorders are related to one another in terms of a range of diagnostic validators, as well as the clinical utility of grouping these disorders in the same chapter. New disorders include hoarding disorder, excoriation (skin-picking) disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV diagnosis of trichotillomania is now termed trichotillomania (hair-pulling disorder) and has been moved from a DSM-IV classification of impulse-control disorders not elsewhere classified to obsessive-compulsive and related disorders in DSM-5.

Specifiers for Obsessive-Compulsive and Related Disorders

The “with poor insight” specifier for obsessive-compulsive disorder has been refined in DSM-5 to allow a distinction between individuals with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Analogous “insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. These specifiers are intended to improve differential diagnosis by emphasizing that individuals with these two disorders may present with a range of insight into their disorder-related beliefs, including absent insight/delusional symptoms. This change also emphasizes that the presence of absent insight/delusional beliefs warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder. The “tic-related” specifier for obsessive-compulsive disorder reflects a growing literature on the diagnostic validity and clinical utility of identifying individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications.

Demographic Information

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of Obsessive-Compulsive Disorder that they are likely to see in their clinical practice.

Setting (Reference)	Base Rate	Demography	Diagnostic Method
National Comorbidity Survey Replication (Ruscio et al., 2010)	2.3%	National (U.S.) adult sample (n=2073)	World Health Organization Composite International Diagnostic Interview (CIDI 3.0)
Epidemiological Catchment Area (ECA) Program (Karno et al., 1988)	1.9-3.3%	U.S. household sample (n=18572)	Diagnostic Interview Schedule (DIS)
Iranian population-based study Mohammadi et al., 2004	1.8%	Iranian adults (n=25180)	DIS
African-American and Caribbean Households (U.S.) (Himle et al., 2008)	1.6%	NSAL Adult Study (n=5191)	CIDI Short Form
Singapore Mental Health Study (Subramaniam et al., 2012)	3.0%	Epidemiological sample (n=6616)	CIDI 3.0

Search terms:

[obsessive compulsive disorder OR ocd] AND [prevalence OR incidence] in PsycInfo and PubMed

[obsessive compulsive disorder OR ocd] AND [epidemiology] in PsycInfo and PubMed

Diagnosis

DSM-5 Diagnostic Criteria

A. Presence of obsessions, compulsions, or both:

• Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

• Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Specify if:

• With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
• With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
• With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.

Specify if:

• Tic-related: The individual has a current or past history of a tic disorder.

Recommended Diagnostic Interviews

• Anxiety Disorders Interview Schedule (ADIS; Brown et al., 1994)
• Structured Clinical Interview for DSM-IV (SCID; First et al., 2002)
• Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989)
  • With Symptom Checklist (Y-BOCS-SC) or self-report (Y-BOCS-SR; Steketee et al., 1996)
• Brown Assessment of Beliefs Scale (BABS; Eisen et al., 1998)

Recommended Self-Report Questionnaires

• Dimensional Obsessive Compulsive Scale (DOCS; Abramowitz et al., 2010)
• Obsessive Compulsive Inventory – Revised (OCI-R; Foa et al., 2002)
• Interpretation of Intrusions Inventory (III; OCCWG, 2005)

Interpreting obsessive compulsive disorder screening measure scores

Overview

The purpose of this subsection is to use Baynesian probability theory in order to accurately predict the diagnosis of obsessive compulsive disorder, given base diagnosis rate in the region and diagnostic likelihood ratios.

Area Under Curve (AUC)

The area under the curve (AUC, or AUROC) is equal to the probability that a classifier will rank a randomly chosen positive diagnosis of obsessive compulsive disorder higher than a randomly chosen negative diagnosis of obsessive compulsive disorder.

Likelihood Ratios

Likelihood ratios (also known as likelihood ratios in diagnostic testing) are the proportion of cases with the diagnosis scoring in a given range divided by the proportion of the cases without the diagnosis scoring in the same range. The table below shows area under the curve (AUCs) and likelihood ratios in diagnostic testing for potential screening measures for obsessive compulsive disorder. It should be noted that all studies used some version of a K-SADS interview by a trained rater, combined with review by a clinician to establish consensus.

Likelihood Ratio	Comments
Larger than 10, smaller than 0.10	Frequently clinically decisive
Ranging from 5 to 10, 0.20	Helpful in clinical diagnosis
Between 2.0 and 0.5	Rarely result in clinically meaningful changes of formulation
Around 1.0	Test result did not change clinical impressions at all

"LR+" refers to the change in likelihood ratio associated with a positive test score, and "LR-" is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. On the other hand, likelihood ratios larger than 10 or smaller than 0.10 are frequently clinically decisive, 5 or 0.20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation.

Area under Curve (AUCs) and Likelihood Ratios for OCD Potential Screening Measures

Screening Measure	Area under curve (AUC) and Sample Size	LR+ (Score)	LR-	Citation	Clinical generalizability
Y-BOCS-SR (Steketee et al., 1996)	0.75 (N=162)	5.50 (7)	0.50	Lord et al., 2011	Moderate: OCD among pregnant and postpartum women
OCI-R Total (Foa et al., 2002)	0.81 (N=322)	3.66 (14)	0.44	Abramowitz & Deacon, 2005	High: OCD (n=167) versus other anxiety disorders (n=155) at outpatient anxiety clinic
OCI-R Total (Foa et al., 2002)	0.82 (N=458)	2.98 (18)	0.36	Foa et al., 2002	High: OCD (n=215) versus other anxiety disorders (n=243) at outpatient anxiety clinic
DOCS Total (Abramowitz et al., 2010)	0.77 (N=513)	2.33 (21)	0.43	Abramowitz et al., 2010	High: OCD (n=315) versus other anxiety disorders (n=198) at outpatient clinics across the U.S.

Treatment

Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention(ERP)

• Behavior therapy, specifically ERP, has been established as the treatment of choice for OCD (Whittal & McLean, 1998; Kozak & Foa, 1997).
• Therapy incorporates ERP and emphasizes cognitive change.
  • Therapist will help individual identify anxiety-provoking thoughts and situations.
  • Therapist will develop a treatment plan and idiographic “fear hierarchy.”
  • Individuals will learn to encounter situations that invoke anxiety without engaging in rituals used to dispel anxiety (ERP).
  • Exposures will be done gradually at a pace that is comfortable for the client.
  • Therapy will include homework assignments and is designed to offer lifelong skills.
• Therapy includes verbal techniques such as psychoeducation and cognitive restructuring.
• Manuals for reference:
  • Mastery of Obsessive-Compulsive Disorder: A Cognitive Behavioral Approach (Therapist Guide; Foa & Kozak)
  • Cognitive Therapy of Obsessive-Compulsive Disorder: A Guide for Professionals (Wilhelm & Steketee)
  • Obsessive Compulsive Disorder: Advances in Psychotherapy (Abramowitz)
• Treatment alliance is a predictor of subsequent change in OCD symptoms (Keeley et al., 2011). The therapist should provide a “validating and

encouraging” environment so that clients can tolerate the emotional arousal associated with exposures.

Medication

• Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat OCD.
• These antidepressants include:
  • • fluvoxamine
    • fluoxetine
    • sertraline
    • paroxetine
    • citalopram
    • clomipramine
    • escitalopram
    • venlafaxine
• High doses (relative to doses prescribed for depression) are needed for individuals with OCD.

Process and Outcome Measures

Clinically Significant Change Benchmarks with Common Instruments and Mood Rating Scales

Measure	Subscale	Cut-off scores			Critical Change (unstandardized scores)
Benchmarks Based on Published Norms
		A	B	C	95%	90%	SEdifference
Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR)	Total	10.6	14.4	12.6	4.7	3.9	2.4
	Obsessions	6.6	7.6	7.0	2.5	2.1	1.3
	Compulsions	3.5	8.2	6.1	3.6	3.0	1.8
Obsessive-Compulsive Inventory – Revised (OCI-R)	Total	1.0	41.0	23.0	14.8	12.5	7.6
	Washing	n/a	7.4	3.1	3.4	2.9	1.7
	Checking	n/a	8.0	3.7	3.0	2.5	1.5
	Ordering	n/a	10.5	4.6	3.1	2.6	1.6
	Obsessing	n/a	8.3	4.7	3.8	3.2	1.9
	Hoarding	n/a	9.8	4.1	2.8	2.4	1.4
	Neutralizing	n/a	6.2	2.3	3.0	2.5	1.5
Dimensional Obsessive Compulsive Scale (DOCS)	Total	n/a	31.7	19.0	10.3	8.7	5.3
	Contamination	n/a	7.8	3.4	2.4	2.0	1.2
	Responsibility for Harm	n/a	8.7	4.4	2.4	2.0	1.2
	Unacceptable Thoughts	n/a	9.6	5.4	2.5	2.1	1.3
	Symmetry	n/a	7.9	3.6	2.2	1.8	1.1

Note: “A” = Away from the clinical range – moving at least 2 standard deviations away from clinical mean; “B” = Back into the nonclinical range – moving within 2 standard deviations of the nonclinical mean; “C” = Closer to the nonclinical than clinical mean – crossing the weighted average of the two groups.

Process Measures

• Quality of Life
  • Sheehan Disability Scale (SDS; Sheehan, 1983)
  • Medical Outcomes Study (MOS) 36-Item Short Form (SF-36) Health Survey (Ware et al., 1993)
• Compulsions scale of YBOCS
• SUDS Ratings

Appendices

1. Anxiety Disorders Interview Schedule (ADIS; Brown et al., 1994)
2. Structured Clinical Interview for DSM-IV (SCID; First et al., 2002)
3. Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989)
4. Brown Assessment of Beliefs Scale (BABS; Eisen et al., 1998)
5. Dimensional Obsessive Compulsive Scale (DOCS; Abramowitz et al., 2010)
6. Obsessive Compulsive Inventory – Revised (OCI-R; Foa et al., 2002)
7. Interpretation of Intrusions Inventory (III; OCCWG, 2005)
8. Sheehan Disability Scale (SDS; Sheehan, 1983)
9. Medical Outcomes Study (MOS) 36-Item Short Form (SF-36) Health Survey (Ware et al., 1993)

See Also

• Hoarding
• Anxiety Disorders
• Trichotillomania
• DSM-IV
• DSM-5