Obsessive-Compulsive and Impulse-Control Disorders: Key Concepts and Treatments

Obsessive-Compulsive and Impulse-Control Disorders

Overview

This chapter explores the nature, epidemiology, related disorders, and treatment approaches for Obsessive-Compulsive Disorder (OCD) and related conditions, including impulse-control disorders. These disorders are characterized by intrusive thoughts, repetitive behaviors, and difficulties with self-control, often resulting in significant distress and impairment.

Obsessive-Compulsive Disorder (OCD)

Definition and Features

• Obsessions: Recurrent, persistent, intrusive thoughts that are distressing and difficult to control.

• Compulsions: Repetitive behaviors or mental acts performed in response to obsessions, often aimed at reducing anxiety or preventing a feared event.

• Common Obsessions: Include concerns about dirt and germs, aggression, failure, sex, and religion.

• Negative Reinforcement: Compulsions are maintained because they temporarily relieve anxiety, reinforcing the behavior.

• Family Accommodation: Family members may participate in rituals, providing temporary relief but perpetuating symptoms.

Epidemiology and Comorbidity

• Chronicity: OCD is typically chronic and severe, rarely remitting without treatment.

• Prevalence: 1.6% to 2.7% in adults; 0.25% to 4% in children/adolescents.

• Comorbidity: At least half of individuals with OCD have additional psychiatric disorders.

• Cross-Cultural Similarity: Symptoms are similar across cultures, though spirituality may moderate presentation.

Developmental Factors

• Rituals in Children: Ritualistic behaviors are common in childhood and should be viewed developmentally.

• Onset: OCD typically begins in late adolescence.

• Gender: Prevalence is similar in adult men and women, though recent research suggests women may be more susceptible.

Obsessive-Compulsive Related Disorders (OCRDs)

Classification

OCRDs include several disorders with features similar to OCD, such as repetitive thoughts and behaviors.

• Body Dysmorphic Disorder (BDD)

• Hoarding Disorder

• Trichotillomania (Hair-Pulling Disorder)

• Excoriation (Skin-Picking) Disorder

Body Dysmorphic Disorder (BDD)

• Definition: Excessive preoccupation with perceived defects or flaws in physical appearance.

• Behaviors: Obsessive thoughts lead to repetitive, ritualistic behaviors (e.g., mirror checking).

• Gender Differences: Men focus on hair and muscularity; women focus on legs; both worry about skin.

• Prevalence: 2%; higher risk for hospitalization and suicide.

• Barriers to Treatment: Shame and embarrassment.

• Overrepresentation: Common in dermatology, orthodontic, and plastic surgery patients.

Hoarding Disorder

• Definition: Persistent difficulty discarding possessions, regardless of value.

• Impact: Impedes use of living spaces; often accompanied by excessive acquisition.

• Distinction from OCD: Acquisition thoughts are not intrusive and do not reduce anxiety.

• Prevalence: 2%, increasing in the elderly; symptoms begin in childhood/adolescence and worsen with age.

Trichotillomania (Hair-Pulling Disorder)

• Definition: Repetitive hair pulling resulting in hair loss, from various body sites.

• Complexity: Disorder is individualized; pulling may respond to different emotional states.

• Comorbidity: Depression, suicidal ideation, alcohol use disorder.

• Prevalence: 2% of adults; equal in men and women.

• Social Impact: Significant shame and avoidance of social activities.

Subtypes of Trichotillomania

Subtype	Features
Low Awareness Pullers	Automatic pulling, often in response to emotional triggers; higher impulsivity.
Sensory Sensitive Pullers	High sensory sensitivity; pulling is focused and mood-related; lower frequency.
Impulsive/Perfectionistic Pullers	Most severe symptoms; urge to resist is minimal; pulling used as a way to regulate negative feelings or perfectionistic thoughts.

Excoriation (Skin-Picking) Disorder

• Definition: Recurrent skin picking resulting in lesions (infections, ulcerations, scars).

• Sites: Face, scalp, arms, legs, chest.

• Prevalence: Up to 3%; more common in women; occurs across all racial/ethnic groups.

Impulse-Control Disorders

Definition and Features

• Definition: Disorders involving problems with self-control that violate the rights of others or societal norms.

• Examples: Pyromania (fire-setting), Kleptomania (stealing).

• Relation to OCD: Share features with OCD and OCRDs; considered addictive behaviors.

Pyromania

• Definition: Deliberate and intentional fire-setting for pleasure; considered addictive.

• Triggers: Stress, boredom, inadequacy, interpersonal conflict.

• Subgroups: Psychotic struggle, hopeless, dysregulated, fire interest.

• Prevalence: 1% of adults; more common in men; begins in adolescence.

• Associated Features: Aggression, antisocial behavior, shyness, peer rejection.

Kleptomania

• Definition: Failure to resist urges to steal items not needed for personal use or monetary value; addictive.

• Features: Stealing is preceded by tension and followed by pleasure or relief.

• Prevalence: 0.4% to 0.6%; more common in women (3:1 ratio); begins in adolescence/early adulthood.

• Comorbidity: Mood, anxiety, suicidality.

Treatment Approaches

OCD Treatments

• Biological:

  • Medication: Selective Serotonin Reuptake Inhibitors (SSRIs), neuroleptics.

• Behavioral/Cognitive Behavioral:

  • Exposure and Response Prevention (ERP)

  • Cognitive therapy

  • Acceptance and Commitment Therapy (ACT)

Treatment of OCRDs

• Medication:

  • SSRIs less effective for OCRDs than OCD.

  • BDD responds best to SSRIs (50%-70% positive response).

  • SSRIs beneficial for TTM; antipsychotic augmentation may help.

  • SNRIs can be used for hoarding.

  • SSRIs, SNRIs, and N-acetylcysteine help skin picking.

• Cognitive-Behavioral:

  • ERP and cognitive restructuring for hoarding.

  • Habit reversal training for TTM and skin picking.

  • Antidepressants, mood stabilizers, opioid agonists for pyromania and kleptomania.

  • Imaginal desensitization for pyromania and kleptomania.

Key Equations and Concepts

• Negative Reinforcement: $\text{Negative Reinforcement} = \text{Removal of aversive stimulus} \rightarrow \text{Increase in behavior}$

Summary Table: Disorders and Features

Disorder	Main Features	Prevalence	Gender Differences
OCD	Obsessions, compulsions	1.6%-2.7%	Equal in adults
BDD	Appearance preoccupation, rituals	2%	Men: hair/muscularity; Women: legs
Hoarding	Difficulty discarding, excessive acquisition	2% (higher in elderly)	Not specified
TTM	Hair pulling, shame, social avoidance	2%	Equal
Excoriation	Skin picking, lesions	Up to 3%	More common in women
Pyromania	Fire-setting, pleasure, subgroups	1%	More common in men
Kleptomania	Stealing, tension, relief	0.4%-0.6%	More common in women (3:1)

Additional info: These notes synthesize textbook slides and lecture content, expanding on definitions, epidemiology, and treatment modalities for exam preparation.