1 OBSESSIVE COMPULSIVE DISORDER (OCD) 3/2/16 GERRY BROPHY OBSESSIVE COMPULSIVE DISORDER (OCD)

2 3/2/16 Group activity In small groups identify what you already know about OCD

3 3/2/16 Statistics The illness affects as many as 12 in every 1000 people (1.2% of the population) from young children to adults, regardless of gender or social or cultural background. In fact, it can be so debilitating and disabling that the World Health Organisation (WHO) has actually ranked OCD in the top ten of the most disabling illnesses of any kind, in terms of lost earnings and diminished quality of life. Based on current estimates for the UK population, there are potentially around 741,504 people living with OCD at any one time.   But it is worth noting that a disproportionately high number, 50% of all these cases, will fall into the severe category, with less than a quarter being classed as mild cases.

4 3/2/16 The History of OCD The incidence of Obsessive-Compulsive Disorder (OCD), or  Obsessive Compulsive Neurosis as it was once known, is a relatively common disorder and can be traced historically, cross-culturally and across a broad social spectrum and does not appear to restrict itself to any specific group of individuals.

5 3/2/16 Past sufferers Martin Luther ( ), the first and most important leader of the Protestant Reformation in Europe suffered from OCD.

6 3/2/16 John Bunyan ( ) is also believed to have suffered with OCD. The writer and preacher, famous for writing Pilgrim's Progress, suffered unwanted intrusive thoughts of a blasphemous nature.

7 3/2/16 Charles Darwin ( ) is now also widely accepted to have suffered from OCD.  Darwin wrote about various obsessional thoughts and how he could not get away from them.

8 3/2/16 , Howard Hughes ( ) whose story was told in the 2004 film, ‘The Aviator’, he spent his final days both mentally and physically incarcerated by his own contamination terrors and elaborate cleaning rituals.

9 3/2/16 What is OCD Obsessive–Compulsive Disorder (OCD) is a serious anxiety-related condition where a person experiences frequent intrusive and unwelcome obsessional thoughts, often followed by repetitive compulsions, impulses or urges.

10 3/2/16 continued In general, OCD sufferers experience obsessions which take the form of persistent and uncontrollable thoughts, images, impulses, worries, fears or doubts. They are often intrusive, unwanted, disturbing, significantly interfere with the ability to function on a day-to-day basis as they are incredibly difficult to ignore. People with OCD often realise that their obsessional thoughts are irrational, but they believe the only way to relieve the anxiety caused by them is to perform compulsive behaviours, often to prevent perceived harm happening to themselves or, more often than not, to a loved one.

11 3/2/16 Obsessions In general, the obsessions that a person with OCD will experience generally fall into the category of persistent and uncontrollable thoughts, images, impulses, worries, fears and doubts (or a combination of these). Additionally they are intrusive, unwanted, disturbing and significantly interfere with normal life, making them incredibly difficult to ignore.

12 3/2/16 GROUP ACTIVITY commonly occurring obsessions that affect people with OCD:

13 commonly occurring obsessions that affect people with OCD: 3/2/16 commonly occurring obsessions that affect people with OCD: Worrying that you or something/someone/somewhere is contaminated. Worrying about catching HIV/AIDS or other media publicised illnesses such as Bird Flu or Swine Flu. Worrying that everything needs to be arranged symmetrically or at perpendicular angles so everything is ‘just right’. Worrying about causing physical or sexual harm to yourself or others.

14 3/2/16 continued Unwanted or unpleasant sexual thoughts and feelings, including those about sexuality or fear of acting inappropriately towards children. Intrusive violent thoughts. Worrying that something terrible will happen unless you check repeatedly. Worrying that you have caused an accident whilst driving. Having the unpleasant feeling that you are about to shout out obscenities in public.

15 3/2/16 Compulsions Compulsions are the repetitive physical behaviours and actions, or mental thought rituals that are performed over and over again, in an attempt to relieve the anxiety caused by the obsessional thoughts.  But unfortunately, any relief that the compulsive behaviours provide is only temporary and short lived, and often reinforces the original obsession, creating a gradual worsening cycle of the OCD.

16 compulsion A compulsion can either be 3/2/16 compulsion A compulsion can either be overt (i.e. observable by others), such as checking that a door is locked or covert (an unobservable mental act), such as repeating a specific phrase in the mind.

17 Compulsion examples Excessive washing of one’s hands or body 3/2/16 Compulsion examples Excessive washing of one’s hands or body Excessive cleaning of clothes or rooms in the house Checking that items are arranged ‘just right’ and constantly adjusting inconsequential items, such as pens on a table, until they are aligned to feel ‘just right’ as opposed to looking aligned Mental rituals or thought patterns such as saying a particular phrase, or counting to a certain number, to ‘neutralise’ an obsessional thought.

18 3/2/16 Compulsion examples Avoiding particular places, people or situations to avoid an OCD thought Repeatedly opening and sealing letters / greetings cards that one has just written, maybe hundreds of times (fear of writing something offensive by mistake within the letter/card). Constant checking of light switches, handles, taps, locks etc to prevent perceived danger from flooding, break in, gas leak or fire. Saying out loud (or quietly) specific words in response to other words (to prevent disaster happening). Avoidance of kitchen knives and other such instruments, (for example locking them in a drawer) to prevent coming into contact with them

19 3/2/16 OCD people without the illness will wash their hands when they are dirty and ‘see’ that they are dirty.  In contrast someone with OCD will ‘feel’ their hands are dirty, and therefore keep washing until they ‘feel’ clean, and by doing so will be keeping their loved ones safe by not contaminating them.

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21 3/2/16 Categories It has traditionally been considered that there are four main categories of OCD. Although there are numerous forms of the illness within each category, typically a person’s OCD will fall into one of the four main categories: Checking Contamination / Mental Contamination Hoarding Ruminations / Intrusive Thoughts

22 Diagnoses OCD is diagnosed when the obsessions and compulsions: 3/2/16 Diagnoses OCD is diagnosed when the obsessions and compulsions: Consume excessive amounts of time (approximately an hour or more) Cause significant distress and anguish  Interfere with daily functioning at home, school or work, including social activities and family life and relationships.

23 3/2/16 continued Sufferers often go undiagnosed for many years, partly because of a lack of understanding of the condition by the individual themself and amongst health professionals, and partly because of the intense feelings of embarrassment, guilt and sometimes even shame associated with what is often called the ‘secret illness’. This often leads to delays in diagnosis of the illness and delays in treatment, with a person often waiting an average of 10–15 years between symptoms developing and seeking treatment.

24 3/2/16 What causes OCD? In spite of a range of theories and considerable research, scientists so far have not been able to identify a definitive cause for a person developing Obsessive-Compulsive Disorder (OCD). However, whilst this may be the case, it is believed that OCD is likely to be the result of a combination of either neurobiological, genetic, behavioural, cognitive, or environmental factors that trigger the disorder in a specific individual at a particular point in time.

25 3/2/16 Biological factors However, despite the recognition that certain parts of the brain are different in OCD sufferers, when compared with non-sufferers, it is still not known how these differences relate to the precise mechanisms of OCD.

26 3/2/16 Biological factors focuses on a circuit in the brain which regulates primitive aspects of our behaviour such as aggression, sexuality, and bodily excretions. This circuit relays information from the orbito-frontal cortex (front part of the brain), to the striatum, and the thalamus (deeper parts of the brain). When this circuit is activated, these impulses are brought to your attention and cause you to perform a particular behaviour that appropriately addresses the impulse.

27 3/2/16 example after a visit to the bathroom, you may begin to wash your hands to remove any harmful germs you may have encountered. Once you have performed the appropriate behaviour — in this case, washing your hands — the impulse from this brain circuit diminishes and you stop washing your hands and go about your day. It has been suggested that if you have OCD, your brain has difficulty turning off or ignoring impulses from this circuit.

28 3/2/16 Serotonin Abnormalities, or an imbalance in the neurotransmitter, serotonin, could also be to blame. Serotonin is the chemical that sends messages between brain cells and it is thought to be involved in regulating everything from anxiety, to memory, to sleep. Medications known as Selective Serotonin Re-uptake Inhibitors (SSRIs) are often used to treat OCD, although it is not fully known why the SSRI medications seem to help some people with OCD.

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30 3/2/16 Causes Other research has revealed that there may be a number of other factors that could play a role in the onset of OCD, including behavioural, cognitive, and environmental factors.  Research has revealed a great deal about the psychological factors that maintain OCD, which in turn has led to effective psychological treatment in the form of Cognitive Behavioural Therapy (CBT).

31 3/2/16 causes Some children begin to exhibit symptoms after a severe infection such as strep throat.  It is thought that the body's natural response to infection, the production of certain antibodies, when directed to parts of the brain might be linked in some way to Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS).

32 3/2/16 Causes Another interesting line of research is in the area of genetics.  Some research points to the likelihood that OCD sufferers will have a family member with the OCD or with one of the other disorders in the OCD ‘Spectrum’.  However, the theory is not conclusive - for example,  identical twins will not necessarily both have OCD.  So although the genetics may play a part, they aren’t the whole story and learned or environment factors may play a part. 

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34 3/2/16 Accessing Treatment It can be a very isolating experience to have Obsessive Compulsive Disorder (OCD). Statistically it takes the average person with the condition 12 years before they will seek help. You may feel you have OCD but you aren’t sure or your symptoms may be getting unbearable and you think it is time you did something. Perhaps loved ones are getting concerned and are encouraging you to seek help.

35 3/2/16 Stepped Care Approach The National Institute for Health and Clinical Excellence (NICE) has produced Guidelines for NHS staff when working with and treating people with OCD. Treatment for your OCD should be in line with their recommended stepped care approach. You can be referred to any level of Stepped Care depending on your symptoms.

36 3/2/16 GP Cognitive Behavioural Therapy (CBT) up to ten hours of therapy which can include Exposure Response Prevention The use of self help materials. CBT by phone or group CBT.

37 3/2/16 next step referred by your GP to the Community Mental Health Team (CMHT). The team can all offer psychological support, encouragement and practical help. In terms of treatments offered at this stage, NICE recommends the choice of either a course of an SSRI, alternative SSRI or Clomipramine or more intensive CBT which would include ERP and more than 10 hours of therapist time, perhaps with a more experienced OCD therapist.

38 3/2/16 Specialist Services These services may be out of your local area and your Community Mental Health Team may have to get funding for your assessment and subsequent treatment agreed by your Local Primary Health Care Trust (PCT) in England and Local Health Board ( LHB) in Wales and Scotland. You will need to be referred by your CMHT

39 3/2/16 Specialist Services Units will provide outpatient treatment and some will offer inpatient facilities. At this stage in your treatment, NICE recommends SSRI or clomipramine, CBT (including ERP), or a combination of SSRI or clomipramine and CBT (including ERP).

40 3/2/16 Specialist Services If you have found no improvement in your symptoms after accessing specialist services, you may need more intensive treatment at one of the specialist units (mentioned above) for an extended period of time. The category of people who access these services have OCD or BDD which carries a risk to their life. They may be severely self-neglecting and be severely distressed or disabled by their condition.

41 3/2/16 Funding The Department of Health provides an extra centrally funded (as opposed to locally funded) service for people with this form of OCD. This resource is called the National Commissioning Group Service (NCG). To be referred via this route you will have accessed your local Community Mental Health Team (CMHT) and they will have to make your referral. Very specific criteria have to be met before you can access this referral route.

42 3/2/16 Associated Disorders

43 OCD and Compulsive Hoarding 3/2/16 OCD and Compulsive Hoarding Hoarding is not currently considered a illness in its own right.  Traditionally compulsive hoarding has been treated as symptom or subtype of Obsessive Compulsive Disorder (OCD), rather than a condition in itself.   The DSM-IV (The Diagnostic and Statistical Manual of Mental Disorders) which was published in 1994 (text amendment in 2000) lists Compulsive Hoarding only as a symptom of OCD. The DSM-IV does not list hoarding behaviour in the diagnostic criterion of OCD. However this is all due to change with DSM-V where hoarding disorder (compulsive hoarding) is expected to be defined as a discrete disorder rather than being a symptom of OCD. 

44 Why People who hoard keep things for the same reasons as anyone else: 3/2/16 Why People who hoard keep things for the same reasons as anyone else: For sentimental value - emotional attachment or to remember an important life event. For utility value - the item is, or could be, useful. For aesthetic value - the item is considered to be attractive or beautiful.

45 3/2/16 WHY A hoarder will also be very concerned about maintaining control over their possessions. Well-meaning family members who try to help by sorting and purging the clutter on the hoarder's behalf are likely to find their good deed has an unanticipated result: an increased effort on the part of the hoarder to protect their stuff from "unauthorized touching".

46 3/2/16 Recent studies The most recent studies have identified two separate situations; OCD plus hoarding and compulsive hoarding on its own.  Other researchers are beginning to think that compulsive hoarding is almost always an independent condition but that it is often found in conjunction (co-morbidity) with other psychological disorders.

47 3/2/16 Studies It also seems that hoarders with OCD tend to behave differently to clinical compulsive hoarders.   The perfectionist OCD hoarder arranges neatly ordered stacks, the piles are sorted, organised and perfectly aligned.  They more likely to hoard  'bizarre' items and feel a need to perform compulsions related to the items they hoard, such as checking or rituals.

48 3/2/16 types of hoarding The term 'hoarding' is used generically to describe a very wide range of medical conditions.  Clinical compulsive hoarding which is the most common type. OCD or 'perfectionist' hoarding. Animal hoarding.  This is very rare, although these are the cases that reach the newspapers.  Diogenes syndrome, also known as senile squalor syndrome is exceedingly rare disorder of self-neglect in association with severe personality disorders usually in the elderly.

49 The Medical Definition 3/2/16 The Medical Definition In 1996 Randy O Frost and Tamara L Hartl defined compulsive hoarding with the following: The acquisition of, and failure to discard, possessions that appear to be of useless or of limited value. Living spaces so cluttered that using the room as intended is impossible Significant distress or impairment to function.

50 3/2/16 Demographics Education.  It is suspected that those who have a higher level of education, may be more likely to hoard things. Age.  It seems that hoarding behaviour begins in childhood or adolescence, however it often doesn't become a problem until the later years of life.  The problem has always been there it is just that no-one has noticed. Marital status. People with this problem tend to be single. Those who get married, tend to get divorced and live alone. Hoarders are often very isolated people.

51 3/2/16 'Prevention of harm' hoarding – Prevention of bad things happening, common to other forms of OCD, where a person will fear that harm will occur if they throw things away.  For example dustmen will be injured by sharp edges of discarded cans or glass objects, or that someone may be contaminated from a discarded item.

52 3/2/16 'Deprivation hoarding' – Where a person feels that they may need the object later, sometimes because of previous experience of deprivation.  For example just after the Second World War many people across Europe had nothing, and so everything became valuable and reusable.

53 3/2/16 'Emotional' Hoarding  – For some people hoarding becomes emotional, where perhaps, because of past traumatic experiences with people, they believe objects hold a special emotional significance.  For example where a loved teddy bear can be trusted more than people, a person will develop relationships with objects rather than people.

54 3/2/16 Hoarder Part of the problem for hoarders is that they find it hard to make decisions about what to do with their possessions - e.g. whether to keep something or throw it away. A hoarder may feel that something bad will happen if they discard an item or it may feel like a part of their identity will be lost. If a hoarder has a past experience of throwing something out and regretting it later, this is likely to increase their distress (Warren, Ostrom, and Rosenfeld, 1988).

55 Insight May be A Barrier to Hoarding Treatment 3/2/16 Insight May be A Barrier to Hoarding Treatment Research has shown that people who hoard often have worse insight into their symptoms than people with OCD who do not hoard. This lack of insight often causes people to avoid seeking treatment, withdraw early from treatment, and/or fail to complete homework assignments. Often, people who hoard only agree to enter treatment after being threatened with eviction or some other negative consequence that is secondary to those caused by their hoarding. In these cases, the person may carry out treatment simply to avoid negative consequences, rather than out of a belief that change is necessary.

56 Body Dysmorphic Disorder (BDD) 3/2/16 Body Dysmorphic Disorder (BDD)

57 Body Dysmorphic Disorder (BDD) 3/2/16 Body Dysmorphic Disorder (BDD) Body Dysmorphic Disorder (BDD) is often called the 'imagined ugliness' disorder. It was formerly known as Dysmorphophobia and is an anxiety disorder whereby a person is abnormally preoccupied with an imagined or slight defect in their physical appearance. They may compare their looks with other people’s, worry that they are physically flawed and spend a lot of time in front of a mirror concealing what they believe is a defect.

58 3/2/16 Statistics Here in the United Kingdom current estimates suggest that 0.5% of the population will have BDD, from children and young people to older adults, which equates to 5 out of every 1000 people.  That is some people based on the 2009 population estimate.

59 3/2/16 Onset The onset of BDD usually begins in adolescence up to the early twenties, a time when people are generally most sensitive about their appearance. While not unique to women, the condition is more predominant amongst females, although clinical samples tend to suggests it affects bith sexes equally. It has been noted that BDD has features that are quite similar to those of OCD. Some studies have shown that many of those people with BDD also have OCD.

60 3/2/16 Behaviours Although the two disorders are quite different, there are also many similarities. For example, a person with BDD may have to repeat certain acts such as: Checking how they look Seeking reassurance about their looks Picking their skin to make it ‘feel’ smooth or just right Repeatedly grooming of hair, eyebrows or make-up to ‘feel’ just right Avoiding mirrors to avoid being triggered by their reflection

61 3/2/16 Behaviours Checking the appearance of the specific body part in mirrors. Camouflaging the perceived defect with clothing or makeup. Excessive grooming, by combing, shaving, removing or cutting hair, applying makeup. Picking their skin to make it smooth. Picking the skin around the perceived defect. Comparing the appearance of the perceived defect with that of others. Dieting and excessive exercise or weight lifting. Avoiding social situations in which the perceived defect might be exposed. Possibly seeking surgery or dermatological treatment despite being told that surgery is not required.

62 3/2/16 Finally There is still not a single clear cause for Body Dysmorphic Disorder, but experts believe that biological, psychological and socio-cultural factors have contributed to its emergence. Neurochemical factors, such as abnormalities in the brain chemical serotonin, may make some people more likely to express the symptoms of BDD than others. However, psychological factors such as teasing about one's appearance during childhood, families' or peers' emphasis on appearance and trauma or sexual abuse might also be risk stimuli for the expression of symptoms