Theoretical Analysis of Obsessive Compulsive

¶ … theoretical analysis of Obsessive Compulsive Disorder: How it affects those stricken in their personal and public lives, the etiology of the disorder, and possible treatments.

OCD: The symptoms

Obsessive-compulsive disorder (OCD) is a disease that is experienced by approximately 2.5% individuals in the U.S., although due to shame regarding symptoms, it is plausible that the number may be far higher (Rappaport, 1990).

OCD is characterized by intrusive and unwanted thoughts, ideas; images (obsessions) that result in repetitious, perfectionist rituals (compulsions) intended to decrease behavior and images and to neutralize anxiety. These symptoms are "egodystonic" i.e. atypical to character and distressing. Absorption with this behavior and obsessions take up much of the person's daily life and effect his or her significant impairment in occupational and social activity as well as in his habitual life functioning. Similarly, too, the disease has an overwhelming impact on the caregiver and immediate family who may spend much of their time caring for the patient and preventing him from harming himself (Hollander & Wong 1998). Predictably, OCD symptoms wax and wane through the disorder, which may make it so hard to measure and may be particularly challenging for studies that involve longitudinal research on the disease (American Psychiatric Association, 1994; Foa & Goldstein, 1978). This, indeed, is the case, with many of the study examples illustrated in the following essay.

Unique and in a class of its own, OCD is, nonetheless, disquietingly similar to body dysmorphic disorder (BDD). Researchers had, in fact, emphasized dissimilarities but Phillips et al. (2007) were uncertain. To that end, Phillips et al. (2007) compared characteristics of subjects with OCD (n = 210), BDD (n = 45), and comorbid BDD/OCD (n = 40) in order to discover whether differences could be delineated between the two. OCD and BDD did not significantly differ in terms of demographic features, age of OCD or BDD onset, illness duration, and many other variables. However, subjects with BDD were more likely to be delusional. Subjects with BDD were also significantly more likely than those with OCD to have lifetime suicidal ideation, as well as lifetime major depressive disorder and a lifetime substance use disorder. The researchers concluded that "OCD and BDD did not significantly differ on many variables but did have some clinically important differences" (p.1).

Phillips et al.'s (2007) study devolved around two longitudinal studies one involving a OCD sample, the other involving a BDD sample. Both were conducted over a similar time period, were conducted at the same site, and used nearly identical methodology and measures. The only exclusion criterion was the presence of a mental disorder.

I see several problems with their study: The OCD sample was more broadly inclusive and larger than the BDD (2010 to 45); longitudinal studies always present problems with history, maturation and experimental attrition. Finally, there is the selection component where the groups are functionally non-equivalent. Although OCD is certainly different from BDD, support for that statement can be more reliably derived form studies other than that of Phillips et al. (2007)

Treatments

If untreated, OCD generally persists. On a more optimistic note, effective and reliable psychological and biological treatments are available.

The National Institute for Health and Clinical Excellence (NICE) recommends a progressive mode of treatment (i.e. A "stepped care" model according to clinical need and severity) (Fineberg, & Gale, 2005).

Treatments of OCD can be divided into psychological and pharmacological approaches. Psychological approaches include exposure-based procedures and cognitive-based approaches, whereas pharmacology has been dominated by the use of depressants, more specifically serontonin reuptake inhibitors. Medication has to be retained on a long-tem level, since if dropped, or replaced by a placebo, studies have shown that large number of patients (particularly those with severe comorbodities) relapse.

In a test of cognitive behavioral therapy vs. rational emotive therapy (where cognition alone was employed), Freeman et al. (2008) found Cognitive behavioral therapy to be successful in reducing the symptoms particularly in children of a young age for whom there is a paucity of effective treatments. CBT was used to addressed cognitive, emotional, and behavioral aspects of the child and getting him or her to access her fears and restructure obsessional thoughts by using CBT-based techniques. Parents were involved in order to support and assist children.

Freeman et al.'s (2008) method was to employ family-based CBT to a sample of 42 young children and evaluate the results. Children ranged in age from 4 to 8 years Assessment and treatment occurred in a child disorder specialty clinic and children were tested to ascertain that they fulfilled criteria of DSM-IV diagnosis of OCD (primary) by a semi-structured interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version [KSADS-PL]) that was jointly administered to parent and child before session. The child had to evidence OCD symptoms at least 3 months before being approached. Exclusion criteria included an abundance of conditions such as primary or secondary diagnosis; receiving of medications or treatments; that child had received CBT treatment in the past; and was receiving concurrent psychotherapy.

The population sample was primarily white and middle class, consistent with other OCD reports but inconsistent with the larger demographics, the families were primarily married and living together. The sample had moderately severe OCD symptoms; most (54.8%) had comorbid-internalizing diagnosis, whilst a second amount (35.7%) had comorbid-internalizing diagnosis. 16% of the children had previous treatment. The children were randomized to receive 12 session of CBT or family-based Rational therapy delivered over the course of 14 weeks. Assessments were conducted before and after treatment by independent raters blind to treatment assignment. Primary outcomes included scores on the Children's Yale-Brown Obsessive Compulsive Scale and Clinical Global Impressions- Improvement. All raters and therapists were fully trained, and sessions videotapes and monitored.

Internal validity seems strong. The only two problems I see here are skewed population (primarily white even though this is at odds to general population and predominantly middle class). The fact that sessions spanned 12 separate classes over 14 weeks could also produce problems in maturation and attrition. In fact, only 31 of the 42 patients completed treatment to the end. Furthermore, even though participants were closely examined for history effects prior to study, history effects could readily have occurred in the interval between each study. Otherwise, the instruments are reliable; groups were closely matched in inclusion and exclusion conditions. The researchers concluded that CBT is an effective approach for treating young children with OCD, and found it preferable to RET. This is interesting, since social scientists are still divided over whether cogntive aspects alone are effective in treating OCD.

In another experiment, Abramowitz (1997) showed that CBT-based approaches were at least as effective as exposure approaches (where the OCD patient was exposed to the item causing anxiety), and that both were equally effective in reducing OCD symptoms. This makes sense so since both involve similar methodologies and overlapping mechanisms of treatment. it, therefore, makes sense that a behavioral-cognitive program applying both would show high levels of success in reducing symptoms. Abramowitz (1997) further showed that serotenergic medication, particularly, although not necessarily, clomipramine, also substantially reduced OCD symptoms. In effect, therefore, a combination of psychotherapy (particularly CBT approach) and medication seem to be the most effective and efficient approach in treating OCD.

Onset of OCD

Consistent findings show the average age of patient to be in the early twenties (Minichiello et al., 1990) although children as young as 6 or 7 can start to evidence symptoms, whilst, at the other end of the range, symptoms may first appear in old age (Piggott et al., 1994). Most adults with the disorder report onset in childhood or adolescence, and one of the recurring questions is whether OCD symptoms do, indeed, occur at a certain moment in life, or whether they are only evident at a certain moment in life and are manifest much later. Mancebo et al. (2008) examined clinical correlates of juvenile-onset OCD across the lifespan by collecting intake data from 257 consecutive participants with a juvenile-onset of OCD (20 children, 44 adolescents, and 193 adults) in a naturalistic study of the clinical course of OCD. Their objective was dual: firstly to describe the intake characteristics of the 64 juvenile participants (20 children (aged 6-12) and 44 adolescents (aged 13-18), and, secondly, to compare current OCD symptoms and lifetime correlates of juveniles (n=64) with a subgroup of adults (n=163) who also reported juvenile onset of OCD. Their larger intent was to know which OCD symptoms are consistent across the lifespan and which develop with age. Inclusion criteria were: 1) a primary DSMIV diagnosis of OCD defined as the disorder that participants considered their most major problem symptomatic of their disease; 2) age at least 6 years; 3) treatment-seeking within the past five years. The sole exclusionary criterion was secondary comorbidity of organic mental disorder and mental retardation.

Participants and parents of juvenile participants completed a structured diagnostic interview, rater-administered severity measures, and self-report questionnaires.

Researchers reported that children and adolescents shared similar features with the exception of age at onset and OCD symptom expression. Clinically meaningful differences between juvenile and adult participants were also found. Compared to adults, juveniles were more likely to be male, recall an earlier age at OCD onset, and have different lifetime comorbidity patterns. Significant outcomes were that children were less likely than either adolescent or adults to report aggressive obsessions and mental rituals.

The glaring - and possibly only -- distractions that I see with this study are that groups are ill matched. There is a large range of ages even amongst each group (children ranged between 6-12 whilst adolescents ranged between 13-18); they were ill-matched in OCD symptoms too; there were far less children than adolescents; and adults more than doubled the size of the juvenile and children group combined. Self-reported OCD symptom could have been produced by an alternate factor (another determinant) that was not taken into account. What could have been taken then as start of symptom could have been, in reality, commencement of something else, or symptom could have been instigated by some element peculiar to the individual's background, situation, personality, or other confounding influence. More so, the reverse could as equally be true in that overt manifestation of symptom appeared only later, whilst covert had been in existence much earlier.

In short, there are observed differences between the groups, with groups being drastically top-heavy and non-equivalent to one another in number; the observed effect may be due to these differences rather than as the result of the experimental study.

Effect of OCD on caregivers

The disorder has an overwhelming impact on the caregiver and immediate family and friends who may spend much of their time caring for the patient and preventing him from harming himself (Hollander & Wong 1998). In severe cases, ritualizing can take the entire day and the individual may suffer, for instance, extensive skin damage from excessive hand washing or hand-rubbing.

To assess the effect on the caregiver, Tolin et al. (2008) conducted an Internet survey amongst participants who reported hoarding behavior. Self-identified hoarding participants (N =864, 94% female, 65% of these met research criteria for clinically relevant compulsive hoarding) and a sample of family members of those who hoarded (N = 655, 58% described a relative who appeared to meet research criteria for compulsive hoarding), completed an Internet survey. Questions were partially derived from the National Comorbidity Survey (NCS), and participants were compared to NCS participants. According to researchers, results suggested that compulsive hoarding represents a "profound public health burden in terms of occupational impairment, poor physical health, and social service involvement" (p.1). Problems included the fact that the sample was conducted from over 8,000 individuals who had contacted researchers during the last 3 years for information about compulsive hoarding. Other factors might have influenced the diagnosis. Particularly considering the fact that participants were self-reported hoarders, it is by no means certain that they reliably met the criteria of OCD even though reliable instrumentation was used. Secondly, a second group -- family members - was approached regarding hoarding behavior of a family member who hoarded. The individual in question (the family member himself) was not approached in this case. It is difficult, therefore, without direct contact with the specific individual, to know whether family members were accurate in their diagnosis despite internal consistency of the measure. Although instrumentation - the Hoarding Rate Scale Interview is recorded to have high internal validity -- self-report is nonetheless questionable. Moreover, the selection method itself could have interacted with maturation and history (several participants had approached researched at least 3 years earlier) thus biasing the study.

A more egregious concern is that data was matched against the NCS, a stratified, multistage area probability sample of mental disorders in persons aged 15 to 54 years in the United States from 1990 -- 1992. Yet, the NCS was conducted more than 15 years ago on a different population (this population, for instance, consisted of primarily females), in a different environment, using different recruitment methods and methodology. The online atmosphere may have introduced confounding elements and distractions. To compare results, as researchers did, to the results obtained from the NCS survey is, consequently, erroneous.

Another problem with the questionnaires -- and one that is relevant to certain other studies mentioned here aside from the one above - is that recognition of OCD may require direct questions, as the patient is often embarrassed to divulge symptoms, and may not always be aware of their fullest extent. Moreover, people with hoarding symptoms may not see their hoarding as a problem (Tolin, 2008). The current best-validated instrument is the Yale-Brown obsessive-compulsive scale (Y-BOCS), which exists in both an adult and a child version (Goodman et al., 1984).

OCD and quality of life

It is inevitable that OCD affects the quality of life not only of the individual but also of involved caretakers. Absorption with ritualizing and obsessions take up much of the person's daily life and effect significant impairment in occupational and social activity as well as in his habitual life functioning. Moreover, children can drop out of education, and several patients do, in fact, become virtually housebound. The World Health Organization (*), in fact, reports OCD as ranking amongst the 20 most disabling diseases. The egodystronic quality of the obsessions and ritual, too, interrupts individuals from completing even mundane acts.

In 2009, Huppert et al. administered multiple measures that assessed quality of life (QOL) and functional impairment to 66 OCD patients who had previously consented for a clinical trial, and to 36 age and sex matched individuals who denied any psychiatric history in order to discover whether OCD is conclusively associated with interference in QOL and functional impairment. Results confirm that OCD was associated with significantly lower QOL and functional impairment compared to healthy controls.