Chapter 6 The term obsessive-compulsive disorder (OCD) refers to unwanted and repeated mental rituals, including thoughts, feelings, ideas, sensations, or observable behaviors (i.e., obsessions) that make an individual feel driven to do something (i.e., compulsions; National Library of Medicine, 2013; Stein, 2002). Examples of obsessions include excessive counting, skin picking, ruminating about physical flaws, and hoarding (see Table 6.1). Rituals are very common among individuals diagnosed with OCD and may include frequent checking of doors or locks, recurrent hand washing, or avoidance of certain situations. An example would be a person who has persistent and uncontrollable thoughts that he is soiled, polluted, or otherwise unclean. To mitigate stress, he washes his hands numerous times throughout the day, gaining temporary relief from these thoughts. For his behavior to be considered an OCD, it must be disruptive to his everyday functioning, such as washing to the point of excessive irritation of his skin. Table 6.1 Common Obsessions and Compulsions Disorders listed in this chapter have the common feature of obsessive preoccupation and engagement in repetitive behaviors. These disorders are considered similar enough to be grouped in the same diagnostic classification but distinct enough to subsist as separate disorders. Some of the disorders in this chapter have historically been included as part of what was considered the “obsessive-compulsive spectrum.” OCD, previously classified in the DSM-IV-TR as an anxiety disorder, is now the first disorder listed in a stand-alone chapter in the DSM-5 titled Obsessive-Compulsive and Related Disorders. The fundamental features of obsession and compulsion, rather than anxiety, served as the driving force for moving OCD and other related disorders to a separate chapter (APA, 2013a). This also follows revisions within ICD-10-CM that classifies OCD separately from anxiety disorder. As with the ICD-10-CM, which keeps OCD and anxiety disorder in the same larger category, the sequential order of this chapter reflects the close relationship between OCD and anxiety disorder. Separating obsession and compulsion from anxiety received more support from psychiatrists than other mental health professionals, as only 40% to 45% of other mental health professionals supported the move (Mataix-Cols, Pertusa, & Leckman, 2007). Some counselors opposed the move because treatment protocols are similar for anxiety and obsessive-compulsive and related disorders and, just like anxiety and depression, comorbidity is more often the rule than the exception (Stein et al., 2010). New disorders in this chapter include hoarding disorder, excoriation (skin-picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV-TR diagnosis of trichotillomania is now termed trichotillomania (hair-pulling disorder) and has been moved from a DSM-IV-TR classification of impulse-control disorders to obsessive-compulsive and related disorders in DSM-5 (APA, 2013a). Aside from moving OCD out of the anxiety chapter and adding new diagnoses, most changes to this section are semantic. For example, the DSM-5 has modified the word impulse to the word urge. This change more accurately reflects the origin of obsessive disorders (i.e., behaviors that can be modified as opposed to an irresistible compulsion). The word impulse seems to have a strong biological component, thus insinuating that these disorders are involuntary. This modification is backed by numerous studies that demonstrated that obsessive-compulsive and related disorders can be treated and, in many cases, extinguished (Simpson et al., 2008; Tenneij, Van Megen, Denys, & Westenberg, 2005; Tolin, Maltby, Diefenbach, Hannan, & Worhunsky, 2004; Tundo, Salvati, Busto, Di Spigno, & Falcini, 2007). Other semantic changes include amending references to inappropriate behaviors or feelings to unwanted behaviors or feelings. The reason for this change is culturally based, because cultural norms regarding appropriate versus inappropriate behaviors are very different. Finally, the new diagnostic classifications of obsessive-compulsive and related disorders have removed the criterion that people must recognize their obsessions or compulsions as unreasonable or excessive. Although people must realize the obsessive thoughts, mental images, or urges are a product of their own minds, it is no longer required that they understand the behavior or mental rituals are excessive. As with anxiety disorders, the decision of APA (2013a) to cluster obsessive-compulsive and related disorders within one chapter, separate from anxiety and trauma and stressor-related disorders, influences differential diagnosis. Stein et al. (2011) posited that clinical attention should focus on the discernment of disorders enumerated within this chapter. One way to differentiate OCD is the common feature of obsessive preoccupation and repetitive behaviors. Once this has been established, counselors can then distinguish between the disorders in this chapter. Note To help differentiate between obsessive-compulsive and related disorders and anxiety disorders, counselors can ask clients, “Do you ever have thoughts or images that you can’t get out of your mind?” and “Are there things that you can’t resist doing over and over again?” Differential diagnosis of obsessive-compulsive and related disorders is challenging because of comorbidity with other diagnoses. It is not uncommon for individuals diagnosed with an obsessive-compulsive or related disorder to also exhibit symptoms of depressive and anxiety disorders; somatoform disorder; hypochondrias; eating disorder; impulse-control disorder, especially kleptomania; and ADHD (Pallanti, Grassi, Sarrecchia, Cantisani, & Pellegrini, 2011). There is also a significant amount of literature dedicated to comorbidity between OCD and Tourette’s syndrome. In a clinical population of children ages 7 to 18 years diagnosed with Tourette’s syndrome, approximately 30% also met diagnostic criteria for OCD (Sukhodolsky et al., 2003). In terms of commonality, counselors should look for mood disorders, specifically depression, social and simple phobias, eating disorders, panic disorder, and Tourette’s syndrome. Counselors should be aware that comorbidity with schizophrenia and other psychotic disorders is relatively uncommon; in cases in which a client is unable to recognize that the obsession is a product of his or her own mind, the obsession may be better classified as a delusion. In that case, a schizophrenia spectrum or other psychotic disorder may be a more appropriate diagnosis. Exact etiology for obsessive-compulsive and related disorders has not been determined. However, there is a considerable amount of research that suggests abnormalities in serotonin (5-HT) and dopamine neurotransmission are responsible for mental rituals and compulsive behaviors (Bloch et al., 2006; Greist, Jefferson, Kobak, Katzelnick, & Serlin, 1995; Kobak, Greist, Jefferson, Katzelnick, & Henk, 1998). Twin studies have suggested a strong genetic influence (van Grootheest, Cath, Beekman, & Boomsma, 2005), and a considerable amount of literature supports the idea that obsessive-compulsive and related disorders are stress responsive, meaning symptoms increase with stress. However, stress in and of itself is not seen as an etiologic factor (Abramowitz, Khandker, Nelson, Deacon, & Rygwall, 2006; Lin et al., 2007). The most commonly reported treatment for obsessive-compulsive and related disorders involves a combination of psychopharmacological treatments and psychotherapy (Simpson et al., 2008; Tenneij et al., 2005; Tolin et al., 2004). In some trials, CBT has been identified as more effective than drug treatment (Blatt, Zuroff, Bondi, & Sanislow, 2000; Melville, 2013) or as a suitable replacement once medication has reduced symptomatology (Tundo et al., 2007). The International Obsessive-Compulsive Disorder Foundation (IOCDF; 2012) specifically recommends exposure and response prevention (ERP), a type of CBT, citing that ERP may reduce symptoms by 60% to 80% if clients are active participants in treatment (Melville, 2013). ERP confronts thoughts, images, objects, and situations that make a person experience anxiety and uses “response prevention” to encourage clients to choose not to engage in a compulsive behavior. The ability for counselors to recognize obsessive-compulsive and related disorders is important because studies have indicated that nearly one in 100, approximately 2 to 3 million adults, currently have OCD (IOCDF, 2012; Kessler, Chiu, Demler, & Walters, 2005). Numbers for children are also alarming, with nearly 1 in 200, or 500,000 children and adolescents, diagnosed with OCD (Ruscio, Stein, Chiu, & Kessler, 2008). These numbers only apply to OCD and do not include other related disorders. Rates of BDD among community samples are between 0.7% and 1.1% of the general population (Phillips, 2004). Hoarding affects 4% of the general population (Samuels et al., 2008). Trichotillomania affects 2.5 million individuals within the United States (Diefenbach, Reitman, & Williamson, 2000), and 3.8% of college psychology students exhibited signs of excoriation (Misery et al., 2012). To help readers better understand changes from the DSM-IV-TR to the DSM-5, the rest of this chapter outlines each disorder within the Obsessive-Compulsive and Related Disorders chapter of the DSM-5. Readers should note that we have focused on major changes from the DSM-IV-TR to the DSM-5; however, this is not a stand-alone resource for diagnosis. Although a summary and special considerations for counselors are provided for each disorder, when diagnosing clients, counselors need to reference the DSM-5. It is essential that the diagnostic criteria and features, subtypes and specifiers (if applicable), prevalence, course, and risk and prognostic factors for each disorder are clearly understood prior to diagnosis. I couldn’t do anything without counting. It invaded every aspect of my life and really bogged me down. I would wash my hair three times as opposed to once because 3 was a good luck number and 1 wasn’t. It took me longer to read because I’d count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a “bad” number. —Cathey Obsessive-compulsive disorder is characterized by “recurrent, persistent, and intrusive anxiety-provoking thoughts or images (obsessions) and subsequent repetitive behaviors (compulsions)” (den Braber et al., 2008, p. 91). These thoughts, beliefs, ideas, or mental rituals dominate an individual’s life. Compulsions are the acts that relieve this distress and can be simple (e.g., thinking of a word) or extraordinarily complex (e.g., engaging in an elaborate washing routine that takes hours to complete). Most individuals have both obsessions and compulsions, although it is not unheard of for clients to report obsessions only. Once considered a rare and eccentric disorder, OCD has risen considerably in visibility since the NIMH conducted a study in 1988 that recognized a 2.5% lifetime prevalence of OCD in the U.S. population (Karno, Golding, Sorenson, & Burnam, 1988). There have been no major changes to this disorder in the DSM-5. The most common pattern of obsessions and compulsions is a fear of contamination, which causes excessive washing of an individual’s hands or body (Morrison, 2006). Also common are persistent doubts such as “Did I lock the door?” that lead a person to repetitively check the locks. There is also a strong need to have things in a particular order, which causes significant distress when objects are perceived as disorganized. These thoughts and behaviors significantly influence clients’ lives, sometimes to the point of interfering with work, school, family relationships, or social obligations. Individuals exhibiting symptoms of OCD often realize that these thoughts and behaviors are irrational and often have a strong desire to resist the obsessive thoughts and compulsive behaviors. Because of a lack of cognitive awareness, children have never been required to recognize obsessive-compulsive behaviors as unreasonable. Having some degree of obsessive thoughts or compulsive behaviors is not rare; in fact, 70% to 80% of the general population may experience some features of OCD (den Braber et al., 2008). A clinical diagnosis of OCD, however, requires substantial distress or impairment. Counselors should pay close attention to whether the symptoms significantly interfere with a person’s daily routine. For example, clients can have a fear of blurting out obscenities or insults, but until this fear prevents them from engaging in activities of daily living or from engaging in a regular routine at work, home, or school or in social situations, it cannot be diagnosed as OCD. Counselors should be aware that the level of insight among adults, and even children, varies considerably. There is a specifier with poor insight that can be applied to this diagnosis, but it is not unusual for adults to vary considerably in their ability to recognize a mental ritual or behavior as unreasonable. This is particularly common when the disorder coexists with another psychological disorder such as MDD or social anxiety disorder. Because avoidance of certain situations, such as one that might make an individual dirty, is common, evading objects or scenarios that provoke obsessions or compulsions may begin to seem ordinary as opposed to excessive (Morrison, 2006; National Library of Medicine, 2013). Counselors who work with individuals diagnosed with OCD must be on the lookout for situations that restrict functioning severely. OCD is more common among individuals with higher socioeconomic status and higher levels of intelligence. Culturally appropriate ritualistic behavior, such as rituals to ward off bad luck, may have distinct parallels to OCD but are not indicative of OCD unless the behavior exceeds cultural norms. Counselors must be sure they are familiar with the cultural context of the client before determining that a ritualistic behavior is obsessive-compulsive. OCD will typically manifest before the age of 25, with symptoms becoming more prevalent as the individual ages (Morrison, 2006). Many clients will report that obsessive hand washing, for example, began with a 3- to 4-minute wash routine using only soap. Gradually, however, clients may report that they began to use nail brushes, surgical soap, and washing for 15 minutes per arm numerous times per day. Gender does not seem to be an indicator of prevalence. In children, however, OCD is more common in boys than in girls. Whereas the DSM-5 (APA, 2013a) states the age of onset is earlier for boys, research has indicated a wider age of onset, with symptoms appearing between ages 6 and 15, and women typically experience symptoms between the ages of 20 and 29 years (Mancebo et al., 2008). Familial patterns for OCD are higher in first-generation biological relatives than in the general population. Pathophysiologic findings provide evidence of a familial pattern with OCD; studies of monozygotic twins have revealed concordance rates as high as 87% and nearly half that for dizygotic twins (den Braber et al., 2008). Symptoms may fluctuate and increase with emotional stressors. For example, during flu season, a client may experience constant worry about becoming contaminated and exhibit persistent OCD symptoms, but these symptoms may decrease or even disappear during the summer months. Counselors must be sure to distinguish OCD from anxiety disorder due to another medical condition. For example, counselors working with children experiencing a sudden onset of obsessions, compulsions, or tics need to work with a medical professional to rule out pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections. If a substance is the source of the obsession or compulsion, counselors need to rule out substance/medication-induced anxiety disorder. Counselors should be aware that OCD could occur within the context of other psychological disorders. However, if content is distinctly related to another disorder, such as fixation with one’s appearance as in BDD or preoccupation with a fear-based object or situation as in specific phobia or social anxiety disorder, OCD cannot be diagnosed unless there are symptoms that are unrelated to the other disorder. In this case, both disorders would be diagnosed. Finally, an important criterion that distinguishes OCD from psychotic disorders is the ability of the individual to recognize, at some point, that the obsessions or compulsions are unreasonable. Although levels of insight occur on a continuum, counselors who detect a presence of psychotic features should consider assessing for schizophrenia spectrum and other psychotic disorder instead of or in addition to OCD. Note As many as half of individuals diagnosed with OCD have a comorbid psychiatric disorder. It is not uncommon for clients to display only OCD symptoms when they are experiencing a major depressive episode. Counselors should be careful to assess for accompanying disorders. There is only one diagnostic code for OCD: 300.3 (F42). However, there are two specifiers. The first specifier indicates the client’s current level of insight (with good or fair insight, with poor insight, or with absent insight/delusional beliefs). The second specifier, tic-related, denotes whether an individual has a current or past history of a tic disorder. These specifiers do not have specific codes associated with them. Note The same diagnostic code is used for both OCD and hoarding. Hoarding is a new disorder in the DSM-5 and is not listed specifically as a diagnosable disorder in the ICD. Therefore, the DSM-5 uses the same diagnostic code for OCD. Anuj is a 15-year-old Indian American boy who lives with his mother in a lower-middle-class neighborhood bordering a major metropolitan area. He is an only child and attends the 10th grade at a local public high school. Anuj recently had a full physical for school and the doctor reported no medical problems. His mother states that Anuj has a great deal of difficulty concentrating on and completing any of his schoolwork. Anuj reports he is constantly distracted by powerful and strange thoughts, such as counting how many times he blinks and how many steps it takes to get to the hallway. He feels compelled to avoid stepping on any floor tiles with dirt on them because he does not want to get germs on his feet. The possibility that germs could be on door handles or windows also forces him to avoid touching them unless he first uses a cloth (which he always carries with him) to clean them off. In fact, if he misplaces or forgets to bring a clean cloth with him, he feels a great deal of anxiety, feels paralyzed, and may get physically ill. Anuj realizes that his behavior does not make sense, and it frustrates him that he cannot overcome these powerful thoughts. His compulsive behaviors have become increasingly frequent over the past 2 years, although he has always had a lot of unusual fears and behaviors associated with cleanliness. Other classmates make fun of him and call him crazy.
Obsessive-Compulsive and Related Disorders
Obsessions
Commonly Associated Compulsions
Fear of contamination
Washing, cleaning
Need for symmetry, precise arranging
Ordering, arranging, balancing, straightening until “just right”
Unwanted sexual or aggressive thoughts or images
Checking, praying, “undoing” actions, asking for reassurance
Doubts (e.g., gas jets off, doors locked)
Repeated checking behaviors
Concerns about throwing away something valuable
Hoarding
Major Changes From DSM-IV-TR to DSM-5
Differential Diagnosis
Etiology and Treatment
Implications for Counselors
300.3 Obsessive-Compulsive Disorder (F42)
Essential Features
Special Considerations
Cultural Considerations
Differential Diagnosis
Coding, Recording, and Specifiers
Case Example
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