Obsessive-Compulsive Disorder DSM-5 300.3 (F42)

Obsessive-Compulsive Disorder DSM-5 300.3 (F42)

DSM-5 Category: Obsessive-Compulsive and Related Disorders

Introduction

Obsessive-Compulsive Disorder (OCD) is a condition in which an individual experiences intrusive thoughts, images, or impulses which create a high degree of emotional distress. Although these emotions primarily involve anxious arousal; guilt and disgust may also be experienced. For example, a woman with OCD, may experience an obsession which involves the thought or image of killing her child by stabbing him or her. This intrusive thought causes her to feel anxious, disgusted with herself, as well as guilt-ridden. This emotional distress is triggered by not only the intrusive thought, but primarily because this thought is ego-dystonic (i.e., not a true representation of her true personality). As a result of this emotional distress, the person feels a need to perform some type of ritual (either overt or covert in nature). The ritual serves two functions: (1) to reduce the intensity of the anxiety, disgust, etc. and (2) to prevent or lessen the likelihood of acting on the thought/image. This is referred to as “thought-action fusion” (TAF).

The majority of individuals with OCD experience both obsessions and compulsions. Although individuals with OCD are aware that their rituals are senseless (unless they lack insight), they have great difficulty not engaging in their ritualistic behaviors, for the reasons mentioned above.

Symptoms of Obsessive-Compulsive Disorder under DSM-5

Under the DSM-5, Obsessive-Compulsive Disorder (OCD) is characterized by obsessions and/or compulsions. Those individuals who do not report engaging in compulsions (rituals) are often referred to as “Pure O’s”, or “Pure Obsessionals”.

As was discussed earlier, a person who evidences OCD experiences obsessions and/or compulsions (rituals) which result in emotional distress. Examples of obsessions may include themes related to cleanliness, aggression, harm, symmetry, etc. Examples of compulsions include cleaning, counting or arranging.

Obsessions are defined as:

  • Recurrent and persistent thoughts, impulses, or images that are intrusive and cause marked anxiety or distress; but are not excessive worries about real-life problems;
  • The person attempts to ignore, suppress or neutralize these thoughts, impulses, or images;
  • The person is aware that the obsessional thoughts, impulses, or images are a product of his or her own mind, as opposed to delusional in nature.

Compulsions are defined as:

  • Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession;
  • The behaviors or mental acts are directed at preventing or reducing distress or a dreaded event or situation;
  • These behaviors or mental acts may not always be associated with the content of the obsessional theme. For example, if the theme is Contamination, the ritual may involve mental rehearsal or counting;
  • The symptoms of OCD are not the result of another psychiatric disorder present or caused by a medical condition or substance abuse.

Obsessive-Compulsive Disorder Treatment and Therapy

Various treatments have been effective in reducing the symptoms of OCD. Evidenced-based treatments such as Cognitive-Behavior Therapy (CBT) techniques are typically the first-line course of treatment, which primarily consist of Exposure and Response (Ritual) Prevention methods. Psycho education plus relaxation training (PRT) may be used to treat severe functional impairment in children. Modifying family accommodation strategies has also been used with PRT (Piacentini et al., 2011).

Various forms of behavior therapy methods have helped to successfully reduce obsessive-compulsive symptomology. In one study, group cognitive-behavioral family-based therapy (CBFT) for childhood obsessive-compulsive disorder reduced OCD symptoms and depression, whereas individual CBT did not affect specific mood states, such as depression (O’Leary, Barrett, & Fjermestad, 2009).

Given the intrusive nature of obsessive-compulsive behavior on not only the individual but also family members, caregivers, teachers and others, therapy is often beneficial for these individuals as well. Family members may feel frustrated, angry and confused when certain OCD symptoms interfere with social-interpersonal relationships and daily functioning. Parent management training (PMT) together with CBT produced a much higher reduction in symptoms than CBT alone. Specifically, PMT helps lessen the parent-child conflict that can interfere with treatment outcomes (Sukhodolsky et al., 2013).

Anti-depressant medications, specifically several SSRI’s, have been used to treat OCD, along with the concurrent use of Cognitive-Behavior Therapy. One study administered cognitive behavioral therapy (exposure and ritual prevention) while another applied OCD-specific CBT (Franklin et al., 2011). In both studies, CBT together with SSRIs showed superior efficacy than SSRI’s alone (Simpson et al., 2013). In treatment-resistant OCD, deep brain stimulation has shown to improve global functioning, quality of life and depression, however improvement regarding symptoms of anxiety and OCD were not evident (Huff et al., 2010).

Living With Obsessive-Compulsive Disorder

Obsessive-compulsive behaviors can affect the quality of home, work and school life. They are often time consuming and impact daily functioning. For example, the repetitive act of cleaning in response to contamination obsessional themes can deplete both time and energy levels for other activities. Severe OCD may involve spending up to 7 hours each day engaging in various forms of ritualistic behaviors. An individual with OCD is often considered strange or eccentric and as a result may be subject to social stigma. Or they may hide their obsessions and compulsions by conducting them in private, thus limiting their social activities.

The self-awareness of the disorder, a key criteria under DSM-V, can act as a deterrent to receiving treatment. The individual may hide the behavior and perform their rituals in secret. There may be a socially unacceptable aspects concerning the nature of the person’s obsessions such as harm or sexually deviant behavior, making it increasingly difficult for the individual to disclose his or her symptoms to their doctor, or a family member, due to shame and embarrassment. The interference with daily functioning, shame and distress can all contribute to the depression that individuals with OCD often experience.

Obsessions and compulsions can frequently interfere with the lives of all family members who live with someone who evidences Obsessive-Compulsive Disorder. The attitude and reaction of family members toward an individual with OCD can have a significant impact (positive or negative) with respect to the course, severity and treatment effectiveness. Family-focused cognitive behavioral therapy (FCBT) has been shown to be quite successful in family environments that display cohesiveness, and are low in family conflict (Peris et al., 2012).

References

Franklin, M. E., Sapyta, J., Freeman, J. B., Khanna, M., Compton, S., Almirall, D., ... & March, J. S. (2011). Cognitive Behavior Therapy Augmentation of Pharmacotherapy in Pediatric Obsessive-Compulsive Disorder. JAMA: the journal of the American Medical Association, 306(11), 1224-1232.

Huff, W., Lenartz, D., Schormann, M., Lee, S. H., Kuhn, J., Koulousakis, A., ... & Sturm, V. (2010). Unilateral deep brain stimulation of the nucleus accumbens in patients with treatment-resistant obsessive-compulsive disorder: Outcomes after one year. Clinical neurology and neurosurgery, 112(2), 137-143.

O’Leary, E. M. M., Barrett, P., & Fjermestad, K. W. (2009). Cognitive-behavioral family treatment for childhood obsessive-compulsive disorder: a 7-year follow-up study. Journal of anxiety disorders, 23(7), 973-978.

Peris, T. S., Sugar, C. A., Bergman, R. L., Chang, S., Langley, A., & Piacentini, J. (2012). Family factors predict treatment outcome for pediatric obsessive-compulsive disorder. Journal of consulting and clinical psychology, 80(2), 255.

Piacentini, J., Bergman, R. L., Chang, S., Langley, A., Peris, T., Wood, J. J., & McCracken, J. (2011). Controlled comparison of family cognitive behavioral therapy and psychoeducation/relaxation training for child obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 50(11), 1149-1161.

Simpson, H. B., Foa, E. B., Liebowitz, M. R., Huppert, J. D., Cahill, S., Maher, M. J., ... & Campeas, R. (2013). Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry, 70(11), 1190-1199.

Sukhodolsky, D. G., Gorman, B. S., Scahill, L., Findley, D., & McGuire, J. (2013). Exposure and response prevention with or without parent management training for children with obsessive-compulsive disorder complicated by disruptive behavior: A multiple-baseline across-responses design study. Journal of anxiety disorders, 27(3), 298-305.

 


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