Obsessive Compulsive and Related Disorders

L. Jarrett Barnhill, MD, DFAPA, FAACAP

Obsessive Compulsive Disorder (OCD) was once considered to be a rare disorder. The current combined prevalence rates for community and clinic-based sampling remain around 1-3%1 of the general population. The prevalence rates have not changed dramatically since nomenclature and inclusion criteria were clarified with the adoption of the DSM-52 or DM-ID-23. Only a minority of affected people seek treatment unless there are co-occurring mood, anxiety, OC related behaviors, or comorbid neurodevelopmental disorders (including ADHD and tic disorders).

Assessment

Diagnostic criteria involve the presence of at least one obsessive and one compulsive inclusion behavior, active involvement in these events for 1 hr./day, sufficient functional impairment, and an extensive list of rule outs and co-occurring disorders. Specifiers in level of insight and co-occurring tic disorders are principal signifiers. Factor analytic studies focused on limiting heterogeneity in Obsessive Compulsive and Related Disorders (OC-RD) suggest four subtypes: 1) primary obsessives; 2) hoarding; 3) classical contamination, doubting and associated passive avoidance behaviors along with a cluster of intrusive violent/sexual images; 4) counting, arranging, touching symmetries and some asocial behaviors. Classic OCD appears related to high harm avoidance/low novelty seeking temperament that may underlie the obsessions, and a relatively narrow range of compulsions that permit a transitory respite from the distressing obsessions. Hoarding associated with OCD seems the most closely linked to Autism Spectrum Disorder (ASD) but this is still under study. Touching, need for symmetry, and counting tend to co-occur with tic disorders. Primary obsessions include intrusive images, or sensory urges (overlapping sensory and premonitory tics) that lack a significant cognitive component. Several related disorders seem to share features with other forms of OC-like disorders, and impulse control disorders (internet shopping addiction for example).

Among individuals with intellectual and developmental disabilities (IDD), including ASD, prevalence rates are biased by a limited capacity to attain self-reported symptoms, diagnostic overshadowing by other related disorders, and difficulty distinguishing OC behaviors from the core features of ASD (stereotypic, restrictive and repetitive behaviors) or ritualistic behaviors in individuals with severe ID. Referrals for people with IDD involve high levels of co-occurring disruptive stereotypies and complex ritualistic behaviors, self-injury and aggression. The presence of comorbid ADHD, tic disorders, or specific behavioral phenotypes often lead to referral, and diagnosis of OC-RD emerges during these assessments. In many clinical settings, OC-RD is over-diagnosed based on overshadowing by repetitive or ritualistic behaviors.

Treatment Strategies

OC-RD is a heterogeneous group of repetitive behaviors with multiple etiologies and comorbidities. For many individuals, treatments begin with generalized strategies, which may be effective in two-thirds of patients. Each decision step beyond this point requires a careful assessment and thoughtful intervention strategies. In cases with significant comorbidity, step one is to focus on combined interventions for the most problematic conditions. For example, in individuals with ASD and ID, ADHD and externalizing behaviors, OC-related symptoms and tic disorders are common co-occurring conditions. Combined therapies are common, but it is important to avoid unnecessary polypharmacy and apply ecological interventions and psychotherapies in each subsequent treatment tier.

Generalized Strategies for OC-RD:

  • Cognitive Behavioral Therapy (CBT)
  • Exposure Cognitive Behavioral Therapy (ECBT)
  • Exposure Response Prevention (ERP)
  • Habit Reversal Training (HRT)

Common psychopharmacological treatment strategies for OC-RD:

  • SSRIs/Clomipramine

Four Approaches to Treatment 

Tier 1: Uncomplicated OCD

Treatment of uncomplicated OCD usually begins with CBT/ERP with modifications for ASD and ID. If ineffective or significant residual symptoms occur, then HRT is tried. This may accompany SSRI monotherapy. Perhaps the best predictor of SSRI response is high harm avoidance temperament, suggesting behavioral inhibition, increased sensitivity to negative contingencies, internalizing symptoms, intolerance of uncertainty, and high threshold for risk taking.

There are several caveats to declaring a Tier 1 treatment approach ineffective:

  1. Patients with OC-RD generally require a prolonged latency of response, longer duration of treatment, and higher doses of SSRI/SNRIs.
  2. Most treatment strategies contribute to improvement but fewer remissions, and rarely complete recovery from OC-RDs.
  3. The symptoms may wax and wane, intensify during periods of distress, loss, or trauma, and on occasion intensify after medical illnesses (Beta-Hemolytic Strep, auto-immune, inflammatory-infectious disease s).
  4. Many individuals with chronic medical or neurological illness may also develop obsessions and rituals surrounding health care. These may require additional focus on the impact of the primary disorder and on the impact of chronic illnesses on psychological adaptation.
  5. OC and other repetitive behaviors can occur in several forms of neurodegenerative disorders. They are generally differentiated based on the co-occurrence of positive neurodiagnostic or genetic studies, and present with perseveration, difficulties with set shifting and declining neurocognitive and executive functions.

Tier 2: OC-RD with Co-Occurring Tics

If standard Tier 1 treatment is ineffective or OC-RD co-occurs with tic disorders, the following should be considered:

  1. ERP/CBT/HRT, SSRI’s augmented with alpha-agonists, SGAs and in exceptional cases clonazepam.
  2. Treating OC symptoms and tics first means overcoming concerns about the adverse effects of treating psychiatric co-morbidities that can increase irritability, SIB and aggression; and increase repetitive behaviors associated with OC-RD. For example, stimulants used to treat ADHD might, in some cases, increase repetitive behaviors. Current evidence suggests that this is unlikely but there are exceptions.
  3. Remain aware of drug-drug interactions when using augmentation strategies. Reassess the need for combined treatments at frequent intervals. Remember the waxing nature of both OCD and tic disorders as well as the special ecological adaptations needed for ASD and ID.
  4. Clinical judgment and consultation or referral to peers and experts may be useful. These complex co-occurring conditions suggest more neuropharmacological heterogeneity. In reality, OCRD is not a single neuro-transmitter condition and NE, DA, GABA, glutamate, and neuropeptide/opioid are players in its pathophysiology.
  5. Consider the presence of genetic disorders associated with SIB (e.g. Lesch-Nyhan syndrome), neurodegenerative disorders, and cerebrovascular and TBI. Both ASD and ID are associated with behavioral phenotypes and a large array of genetic and metabolic disorders.

Tier 3: OC-RD with Psychiatric Comorbidities

Co-morbidities might include: ADHD, mood disorders, anxiety, TBI, impulse control disorders, trauma/PTSD, schizophrenia, substance use, and fronto-temporal dementias. In this situation, treat the primary condition first. See other sections of this guide for treatment recommendations for these conditions.

Tier 4: OC-RD, ID and ASD

Research on alternative biological treatments have excluded individuals with ID/ASD in controlled studies of TMS, Direct Electrical Current, treatment for PANS or PANDAS, deep brain stimulation, or capsulotomy. 

Summary

In general, 60% respond to treatment, fewer go into remission, and some are treatment resistant. Most individuals with IDD and OCD require augmentation, or in combination with pharmacotherapy/manualized psychotherapies. This group may also require an extensive review of previous diagnoses and treatment, especially reassessment, including associated neurological or degenerative disorders.

Case Vignette

RB is a 26-year-old male with ASD, borderline ID, Tourette’s disorder, and compulsive handwashing. He failed to sustain improvement on standard treatments for OC-RD and Tourette’s Disorder. As expected, the characteristic waxing and waning of his tic disorder complicated treatment, especially when changes in OC-RD symptoms were in synchrony with the severity of his tic disorder.

His primary compulsion of hand washing arose amid contamination fears associated with agoraphobia and social avoidance. Anxieties about touching contaminated surfaces fed his compulsive handwashing rituals.

A combination of increased structured activities outside the home and a very slow successive program of exposure and limiting time he could wash (decreasing from three hrs. to under 30 minutes/day) was more effective than standard ERP and HRT techniques. Even with modified ERP/HRT intervention, RB continues active avoidance strategies such as keeping his hand in his pockets and not touching any objects except with his shoulder. He was reaching a point where Transcranial Magnetic Stimulation (TMS), Direct Current Stimulation and more invasive somatic procedures were under investigation.

Conclusion

OC-RD is a heterogeneous group of repetitive behaviors with multiple etiologies and comorbidities. For many indi­viduals, treatment begins with generalized strategies (CBT/ERP/HRT and SSRIs/clomipramine). These may be effective in two-thirds or patients. Each decision step beyond this point requires a careful assessment and thoughtful interven­tion strategies. Combined therapies are common, but we must do our best to avoid unnecessary polypharmacy and apply ecological interventions and psychotherapies in each subsequent treatment tier.

1 National Institute of Mental Health. Obsessive compulsive disorder (OCD). https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml. Updated October 2019. Accessed August 27, 2020.

2 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association, 2013.

3 Fletcher RJ, Barnhill J, Cooper S-A (Eds). Diagnostic Manual-Intellectual Disability 2: A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability. Kingston, NY: NADD Press; 2017.

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