Obsessive-Compulsive Disorder. Subtypes and Spectrum Conditions

316 Pages·2007·21.12 MB·English

by  Jonathan S. Abramowitz, Dean McKay and Steven Taylor (Eds.)

CONTRIBUTORS
Numbers in parentheses indicate the pages on which the authors' contributions
begin.
Jonathan S. Abramowitz, PhD, ABPP (127, 271, 287) Associate Professor,
Department of Psychology, University of North Carolina ta Chapel Hill,
Chapel Hill, North Carolina, USA
Andrea R. Ashbaugh, AB (19) Department of Psychology, Concordia ,ytisrevinU
Montreal, Quebec, Canada
Theo K. Bouman, PhD (196) Department of Clinical dna Developmental
Psychology, University of Groningen, Groningen, ehT Netherlands
David .A Clark, PhD (53) Professor, Department of Psychology, University of
weN Brunswick, Fredricton, weN Brunswick, Canada
Meredith E. Coles, PhD (36) Assistant Professor, Department of Psychology,
Binghamton University (SUNY), Binghamton, weN York, USA
Kristen M. Culbert, AB (230) Department of Psychology, Michigan State
,ytisrevinU East Lansing, Michigan, USA
Thilo Deckersbach, PhD (94) Assistant Professor, Department of Psychiatry,
Massachusetts General Hospital dna Harvard Medical School, Boston,
Massachusetts, USA
Gretchen J. Diefenbach, PhD (139) Postdoctoral Fellow, ehT Institute of Living,
Hartford, Connecticut, USA
Michel J. Dugas, PhD (19) Associate Professor, Department of Psychology,
Concordia University, Montreal, Quebec, Canada
Heather Durdle, MA (160) Department of Psychology, University of ,rosdniW
,rosdniW Ontario, Canada
Jane L. Eisen, MD (246) Associate Professor, Department of Psychiatry dna
Human Behavior, Butler Hospital dna Brown Medical School, Providence,
Rhode Island, USA
Martin E. Franklin, PhD (139) Associate Professor, Department of Psychiatry,
University of Pennsylvania, Philadelphia, Pennsylvania, USA
Randy O. Frost, PhD (76) Professor, Department of Psychology, Smith College,
Northampton, Massachusetts, USA
Xl I CONTRIBUTORS
Laurie A. Gelfand, AB (19) Department of Psychology, Concordia University,
Montreal, Quebec, Canada
Jennifer .T Gosselin, AB (177) Department of Fordham Psychology, ,ytisrevinU
Bronx, weN York, SU A
Sapna Gupta, AB (177) Department of Bronx, Fordham University, Psychology,
weN York, USA
Brendan .D Guyitt, AB (53) Department of Psychology, University of weN
Brunswick, Fredricton, weN Brunswick, Canada
Kelly L. Klump, PhD (230) Assistant Professor, Department of Psychology,
Michigan State East Lansing, Michigan, University, USA
Julie Leclerc, PhD (212) Fernand-Seguin Research Centre, University of
Montreal, Montreal, Quebec, Canada
Han-Joo Lee, AB (107) Department of ,ygolohcysP University of Austin, at Texas
USA Texas, Austin,
Maria C. Mancebo, PhD (246) Department Instructor, of Psychiatry dna Human
Behavior, Butler Hospital dna Brown Medical School, Providence, Rhode
Island, USA
Dean McKay, PhD, ABPP (127, 177, 287) Associate Professor, Department of
Bronx, Psychology, Fordham University, weN York, USA
Suzanne A. Meunier, PhD )3( Postdoctoral fellow, Anxiety Disorders Center,
The Institute of Living, Hartford, Connecticut, USA
Kieron O'Connor, PhD (212) Fernand-Seguin Research Centre, University of
Montreal, Montreal, Quebec, Canada
Bunmi O. Olatunji, PhD (94) Assistant Professor, Department of Psychology,
tlibrednaV Nashville, Tennessee, University, USA
Ashley .S Pietrefesa, AB (36) Department of University Binghamton Psychology,
Binghamton, (SUNY), weN ,kroY USA
Anthony Pinto, PhD (246) Assistant Professor, Department of Psychiatry dna
Human Behavior, Butler Hospital dna Brown Medical School, Providence,
Rhode Island, USA
Adam .S Radomsky, PhD (19) Associate Professor, Department of Psychology,
Concordia University, Montreal, Quebec, Canada
Steven A. Rasmussen, PhD (246) Associate Department Professor, of Psychiatry
Hospital Butler Behavior, Human and dna Brown Providence, Medical School,
Rhode Island, USA
Gall Steketee, PhD (76) Professor, School of Social Work, Boston University,
Boston, Massachusetts, USA
Sherry H. Stewart, PhD (160) Professor, Departments of Psychiatry and
Psychology, Dalhousie University, Halifax, Nova Scotia, Canada
CONTRIBUTORS XlII
Steven Taylor, PhD, ABPP (127, 287) Professor, Department of Psychiatry,
University of British Columbia, Vancouver, British Columbia, Canada
Michael J. Telch, PhD (107) Professor, Department of Psychology, University of
Texas at Austin, Austin, Texas, USA
David .F Tolin, PhD ,3( 139) Director, Anxiety Disorders Center, The Institute of
Living, Hartford, Connecticut, USA
Sabine Wilhelm, PhD (94) Associate Professor, Department of Psychiatry,
Massachusetts General Hospital and Harvard Medical School, Boston,
Massachusetts, USA
PREFACE: WHY SUBTYPES?
WHY SPECTRUM
DISORDERS?
OCD ACCORDING TO THE DSM-IV
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV-TR; American Psychiatric Association, 2000), obsessive-compulsive disorder
(OCD) is an anxiety disorder defined by the presence of obsessions or compulsions
that produce significant distress and cause noticeable interference with functioning
in domains such as work and school, social and leisure activities, and family set-
tings. Table 1 shows a summary of the DSM-IV-TR criteria for OCD. Obsessions
are defined as intrusive thoughts, ideas, images, impulses, or doubts that the person
experiences in some way as senseless and that evoke affective distress (typically in
the form of anxiety). Classic examples include preoccupation with germs and con-
tamination, doubts about having caused harm, and unwanted sexual, blasphemous,
and violent impulses. Compulsions era urges to perform behavioral rituals (e.g.,
washing, checking) or mental rituals (e.g., praying) that are senseless, excessive,
and often conforming to strict idiosyncratic rules imposed by the individual (e.g.,
washing according to a specified routine, checking 51 times).
LIMITATIONS OF THE DSM DEFINITION
Research on the phenomenology of OCD, however, suggests that the DSM-IV-TR
definition of OCD has several limitations. First, the definition implies that obses-
sions and compulsions are independent phenomena - that one or the other is neces-
sary and sufficient for a diagnosis of OCD. Prior to deciding upon the diagnostic
criteria for OCD during the drafting of the DSM-IV (the diagnostic criteria in
DSM-IV-TR 2000 are unchanged from DSM-IV1994), some experts argued that
OCD ought to be defined by the presence of obsessions and compulsions. In fact,
data from a large multi-site field trial that was conducted during the early 1990s (in
conjunction with the preparation of the DSM-IV; Foa et al., 1995) revealed that 96%
of 411 OCD patients exhibited both obsessions and compulsions. Only 2.1% evi-
denced obsessions in the absence of compulsive rituals; and only 1.7% evidenced
XV
XVl PREFACE
TAB LE | DSM-IV-TR diagnostic criteria for OCD
A. Either obsessions or compulsions.
Obsessions are defined by (1), (2), (3), and (4):
(1) repetitive and persistent thoughts, images or impulses that are experienced, at some point, as
intrusive and inappropriate and that cause marked anxiety or distress
(2) the thoughts, images or impulses are not worries about real-life problems
(3) the person tries to ignore or suppress the thoughts, images or impulses, or neutralize them
with some other thought or action
(4) the thoughts, images or impulses are recognized as a product of one's own mind and not
imposed from without
Compulsions are defined as (1) and (2):
(1) repetitive behaviors or mental acts that one feels driven to perform in response to an
obsession or according to certain rules
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing feared
consequences; however the behaviors or mental acts are clearly excessive or are not
connected in a realistic way with what they are designed to neutralize or prevent.
B. At some point during the disorder the person has recognized that the obsessions or compulsions
are excessive or unreasonable.
C. The obsessions or compulsions cause marked distress, are time-consuming (take more than 1
hour a day), or significantly interfere with usual daily functioning.
D. The content of the obsessions or compulsions is not better accounted for by another Axis I
disorder, if present. (e.g., concern with appearance in the presence of Body Dysmorphic
Disorder, or preoccupation with having a serious illness in the presence of hypochondriasis).
E. Symptoms are not due to the direct physiological effects of a substance or a general medical
condition.
Specify .'fi
With poor insight: if for most of the time the person does not recognize that their obsessions and
compulsions are excessive or unreasonable.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,
Text Revision, Copyright 2000. American Psychiatric Association.
compulsions without obsessions. Thus, the current diagnostic criteria appear to be
at odds with the fact that virtually everyone with OCD experiences both obsessions
and compulsions.
As we will see in the chapters of this volume, this discrepancy has had no small
effect on the tendency to draw parallels between OCD and other disorders involv-
ing obsession-like and compulsive-like behaviors. A number of disorders labeled
as 'obsessive-compulsive spectrum (OCS) disorders', e.g., conditions presumed
related to OCD primarily on the basis of symptom overlap, involve obsessions
without compulsions and compulsions without obsessions. As many of the
authors in Part II of this volume point out, the lack of both obsessions and com-
pulsions in these OCS disorders is a main reason for concluding that such disor-
ders are probably not related to OCD.
Along with their co-existence in virtually all OCD patients, obsessions and
compulsions demonstrate a sort of internal validity, even if irrational. For exam-
ple, patients with compulsive washing rituals are typically the same individuals
PREFACE XVII
with obsessions about germs. Similarly, those with checking rituals are the same
patients with obsessional doubts that they might be responsible for some sort of
harm. Thus, a second limitation of the DSM definition is that it portrays compul-
sive rituals as devoid of intent and does not include the clinically meaningful rela-
tionship discussed above. This relationship, however, has been demonstrated in
both experimental laboratory research (e.g., Rachman & Hodgson, 1980) and in
the DSM-IV field trial mentioned previously: 84% of patients indicated that they
performed compulsive rituals to reduce obsessional distress, often articulated in
terms of the probability of some specific feared consequence. Thus, contrary to
what the DSM definition implies, these data suggest that compulsive rituals are not
simply senseless, excessive, or rule-bound actions or movements. Rather, rituals
have a purpose for the person with OCD.
Further support for the ideas that obsessions and compulsions co-occur and are
closely related in a functional manner comes via a number of studies that have
identified symptom dimensions and 'subtypes' of OCD. These investigations con-
sistently find that specific obsessions and compulsions load together on the same
symptom-based factors and clusters (such as contamination obsessions with
washing rituals; e.g., Leckman et al., 1997) as well as on measures of symptom
severity (e.g., Deacon & Abramowitz, 2005). These symptom-based subtypes of
OCD comprise the focus of the chapters in Part I of this book. These chapters will
convince the reader that as much as the distinction between obsessions and com-
pulsions is intuitively appealing, OCD phenomenology does not distill neatly into
these two categories.
The DSM's emphasis on the repetitiveness and persistent nature of obsessions
and compulsions represents a third limitation of these diagnostic criteria. Whereas
these descriptions characterize some symptoms of OCD, the defining feature (as
we have mentioned previously) is the relationship between obsessions (which
evoke distress) and efforts to reduce this distress (e.g., compulsions). Few other
disorders in the DSM have symptoms characterized by such a relationship.
Moreover, as is revealed in the chapters of Part I, quintessential compulsive ritu-
als such as washing and checking represent only one class of tactics that patients
with OCD use in response to their distressing obsessional thoughts.
PURPOSE OF THIS BOOK
A scientific understanding of OCD and other psychological disorders entails an
attempt, in Plato's words, to 'carve nature at its joints' (Hackforth, 1952). As
research on the nature and treatment of OCD has accrued it has become increas-
ingly apparent that this disorder is heterogeneous, and possibly composed of many
different subtypes. Indeed, the specific themes of obsessions and compulsions rep-
resent an endless array of topics constrained only by the sufferer's idiosyncratic
personal concerns and experiences. Obsessions might relate to contamination,
harm, morality, exactness, sexual behavior, or religion. Compulsive behaviors typ-
ically take the form of washing, checking, arranging, or mentally neutralizing; as
XVIII PREFACE
well as avoidance of situations that provoke the obsessions. Although these sub-
types may share overlapping etiologic mechanisms and may respond to similar
treatments, there also appear to be some important differences. We feel that a clearer
understanding of the essential similarities and differences among these subtypes
will lead to advances in understanding and treating OCD.
Some authors have also noted that OCD appears to share characteristics with
other disorders. The OCS concept described earlier represents one manifestation
of this notion. As the reader will see later in this volume, the OCS is considered to
encompass between 10 and 20 conditions such as trichotillomania, body dysmor-
phic disorder, and Tourette syndrome. Such problems not only seem to have
symptoms similar to obsessions and compulsions, but many also seem to respond
to treatments similar to those used for OCD. Although the concept of an OCS
remains highly controversial, especially as work begins on the next iteration of the
DSM, it is our feeling that advances in understanding and treating these putative
(and understudied) OCS disorders can arise from a more critical examination of
how they are similar to, and different from OCD. Each chapter in Part II of this
book undertakes such an analysis.
It is with these points in mind that we developed the concept for the present
volume. The chapters within provide empirically based reviews of clinical obser-
vations, theoretical, and treatment data on proposed OCD subtypes and spectrum
disorders. Researchers and clinicians continue to disagree about the value of the
concepts of OCD subtypes and spectra. The chapters in this volume, however,
attempt to explore these controversies in order to arrive at a deeper understanding
of the causes and treatments for the many different clinical presentations covered
in the book.
This book also has implications for the classification of psychological disor-
ders in general. As the field of mental health begins to consider the next iteration
of the diagnostic manual (DSM-V is planned for release in 2012), an entire
research agenda is being implemented to elucidate issues such as how best to
understand and classify OCD. The questions of subtypes and spectrum disorders
are at the forefront of this issue and will guide how OCD is conceptualized in the
.V-MSD To 'weigh in' on this aspect of the field, the chapters in this book have
been contributed by scientist-practitioners who have the benefit of empirical data
and clinical observation.
The book is divided into two parts. Part I, which addresses the heterogeneity of
OCD, contains chapters addressing a variety of proposed OCD 'subtypes'. These
chapters critically review the literature and address the following aspects of each
presentation: (a) symptomatology, (b) empirically supported etiologic and con-
ceptual models, (c) support for the particular symptom presentation as a valid
OCD subtype, (d) a review of the subtype-specific treatment literature. A conclud-
ing chapter by the editors synthesizes and discusses conceptual issues raised in the
preceding chapters.
The chapters included in Part II address a number of proposed OCS disorders
and cover the following aspects of each condition: (a) clinical presentation and
PREFACE XlX
important features, (b) etiologic and conceptual models, (c) a review of the empir-
ical evidence pertaining to the disorder's standing as a possible OCS condition
(e.g., its similarity and relationship to OCD), and (d) treatment issues. As in Part I,
Part II concludes with our own discussion and critical review of the literature on the
OCS hypothesis, drawing on conclusions from the chapters within Part II.
The Editors
REFERENCES
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text rev.) (DSM-IV-TR). Washington, DC: APA.
Deacon, B. J., & Abramowitz, J. .S (2005). The Yale-Brown obsessive compulsive scale: Factor analy-
sis, construct validity, and suggestions for refinement. Journal of Anxiety Disorders, ,91 573-585.
Foa, E. B., Kozak, M. J., Goodman, .W K., Hollander, E., Jenike, M.A., & Rasmussen, .S (1995).
DSM-IV field trial: Obsessive compulsive disorder. American Journal of Psychiatry, 152, 90-96.
Hackforth, R. (1952). Plato's Phaedrus. Cambridge: Cambridge University Press.
Leckman, J. ,.F Grice, D. E., Boardman, J., Zhang, H., Vitale, A., Bondi, C., et al. (1997). Symptoms
of obsessive-compulsive disorder. American Journal of Psychiatry, 154, 911-917.
Rachman, ,.S & Hodgson, R. (1980). Obsessions and compulsions. New York: Prentice Hall.
1
C o NTAM I NATI O N AN D
DECONTAMINATION
DAVID F. TOLIN ,1 2 AND SUZANNE A. MEUNIER
t ehT Institute of Hospital; Living~Hartford
2University of Connecticut School of Medicine
PHENOMENOLOGY 1
Gretchen is a 22-year-old woman who came to the Anxiety Disorders Center for
treatment of her intense fears of contamination from HIV. She was afraid to come
into contact with anyone whom she perceived as being homosexual or sexually
promiscuous because she feared that these people had a high likelihood of being
HIV positive and spreading the virus to her. She also avoided certain stores and
restaurants that she worried were frequented by homosexual or promiscuous cus-
tomers because she was afraid to touch items that they had touched. During her
first therapy session, she found it difficult to sit in a chair or touch the doorknob
in the therapist's office because 'I don't know who's touched it.' She further
described a concern that someone else's semen or other bodily fluids might be on
the chair or doorknob, that these fluids would contain live HIV virus, and that the
virus would jump onto her or seep through her clothing and into bodily orifices
or microscopic cuts on her skin. When she felt contaminated, she was reluctant to
touch her car or house for fear of contaminating those previously 'clean' places.
Correspondence to: David F. Tolin, Anxiety Disorders Center, The Institute of Living, 200 Retreat
Avenue, Hartford, CT 06106.
JNames and other identifying information have been altered.
thgirypoC © 8002 reiveslE .dtL
evislupmoC-evissesbO redrosiD 3 llA sthgir fo noitcudorper ni yna mrof .devreser
4 SUBTYPES OF OBSESSIVE--COMPULSIVE DISORDER
Nicholas is a 43-year-old man who also presented with contamination-related
OCD. Unlike Gretchen, however, Nicholas did not fear contracting a disease.
Rather, he reported fears of being contaminated by his alma mater, the
University of Washington. He reported that, shortly after graduating and leav-
ing the campus, he began to think that the University and everything associ-
ated with it was contaminated in some way. He was unable to go to the
campus or even the state of Washington. If he saw someone wearing a t-shirt
from that University, or saw a bumper sticker on a car, he would immediately
have to go home to shower and change his clothes. When his therapist sug-
gested experimenting by looking at pictures of the University of Washington
on the Internet, Nicholas became visibly anxious and stated that this would
make him feel contaminated. When asked what he feared would happen if he
became contaminated by his former University, he replied, 'Nothing bad
would happen. I wouldn't get sick or anything. I'd just feel really contami-
nated and would have to wash or else I would go crazy.'
As is evident from the above examples, contamination-related obsessive-com-
pulsive disorder (OCD) can take many forms. Across all variants of this particular
symptom dimension, patients report an intense and often overwhelming fear that
they will become contaminated in some way or that they will accidentally spread
contamination to another person or place. In addition, across all variants of con-
tamination-related OCD, patients' fears of contamination are clearly in excess of
any actual risk. There are, however, a number of variations within the contamina-
tion symptom dimension. For example, some patients (such as Gretchen) fear con-
tamination from germs or other physical contaminants, whereas others (such as
Nicholas) fear contamination by unlikely sources that most people would not con-
sider to be contaminants. In addition, although many patients (such as Gretchen)
express an exaggerated belief that they will become ill if contaminated, others
(such as Nicholas) deny any illness-related fears but instead express a more vague
concern about feeling 'dirty' and a fear that their emotional reaction to contamina-
tion will be extreme or long-lasting. Contamination-related obsessions are typi-
cally (although not always) associated with washing and cleaning compulsions.
FEATURES OF CONTAMINATION-
RELATED OCD
The essential feature of contamination-related OCD is a fear of spreading conta-
gion. What is meant by 'contagion', however, may vary widely across individuals. In
many cases, such as the example of Gretchen above, there is a clear fear of contact
with physical contaminants such as viruses, bacteria, poisons, etc. In such instances,
the fear is typically related to the known effects of the contaminant- e.g., that one