Abstract and Keywords
The Oxford Handbook of Obsessive Compulsive and Spectrum Disorders reviews current literature on obsessive compulsive disorder (OCD) and its associated spectrum conditions of body dysmorphic disorder (BDD), hoarding, trichotillomania and tic disorders. Authors who are leading researchers in their fields summarize and synthesize the current knowledge about these OC spectrum disorders to provide a road map for the field and open the door to new research and further study. This introduction previews the contents of the book and highlights some of the challenges in current research on epidemiology, features, and diagnosis, as well as biological and psychosocial theories and treatments for these conditions.
The task of developing a comprehensive and up-to-date reference book on obsessive compulsive disorder (OCD) and obsessive compulsive spectrum disorders (OCSDs) is challenging. Our goal in compiling the chapters for this volume was to summarize and synthesize the current knowledge about these mental health disorders in order to provide a road map for the field and open the door to new research and further study. This volume is part of the Oxford Library of Psychology, a landmark series of handbooks that will span the entire field of psychology, from the broad disciplinary level to the focused, in-depth topic level. This Oxford Handbook of Obsessive Compulsive and Spectrum Disorders reviews the major psychological disorders of OCD and its associated spectrum conditions with breadth, comprehensiveness, and excellent scholarship by authors who are leading researchers in their fields. This introduction highlights a few of the challenges in deciding what to include and what to place elsewhere in the Oxford handbook series, and how to cover the broad and sometimes uneven knowledge base for each of the spectrum conditions.
Among the first tasks was to determine what disorders would be included and which ones would not. Defined by the U.S.-based Diagnostic and Statistical Manual of Mental Disorders (the DSM-IV-TR, APA, 2000) or its World Health Organization (2007) counterpart, the International Classification of Diseases (ICD-10), the conditions described in this book reside in a somewhat informal category of OCSDs that groups together a handful of mental health problems thought to be related to OCD (see also Hollander, 2007). Along with OCD in its many forms or subtypes, we have included body dysmorphic disorder (BDD), hoarding, tic disorders and Tourette’s Syndrome, as well as trichotillomania and related habit disorders of skin picking and nail biting. These disorders have traditionally been included in prior writings on OCSD (e.g., Allen, King, & Hollander, 2003; Wetterneck, Teng, & Stanley, 2010). Not included in this book is (p. 4) hypochondriasis or health anxiety, a condition often associated with OC spectrum conditions by virtue of its obsession-like focus on health and bodily concerns and avoidant and compulsive behaviors, such as checking body parts and functions. The rationale for this decision was somewhat arbitrary and partly a function of arranging the coverage of the handbook series where hypochondriasis is covered (Martin Anthony and Murray Stein’s The Oxford Handbook of Anxiety and Related Disorders, among others). Also omitted were anorexia and bulimia, eating disorders that have been included in Stewart Agras’s The Oxford Handbook of Eating Disorders and James Lock’s The Oxford Handbook of Developmental Perspectives on Adolescent Eating Disorders. Other candidates for inclusion might have been the impulse control disorders, which bear some similarity to the habit disorders mentioned above and also to tic disorders. In addition to trichotillomania, which is included in this volume (see Chapters 5 and 23), these include intermittent explosive disorder, kleptomania, pyromania, and pathological gambling, which appear to more closely resemble addictions than OC spectrum conditions. These disorders have been included in Jon Grant’s and Marc Potenza’s The Oxford Handbook of Impulse Control Disorders.
As will be evident in the chapters contained here, these OCSD diagnoses bear some relationship to OCD with regard to nosology and phenomenology, although differences are clearly evident in onset, course, and biological features, as well as strategies for assessment and effective types of treatments. However, sometimes even the nosological relationship to OCD appears tenuous. For example, hoarding disorder appears to be driven by both positive and negative emotional states and to lack the characteristic ritualistic behaviors of OCD (see Chapter 4). The habit disorders often lack the hallmark obsessions of OCD (see Chapter 5). Even the requirement for impairment and distress may vary. DSM diagnoses in general, and OC spectrum conditions in particular, share the requirement of provoking significant distress and impairment in functioning to cross the line between mere subclinical symptoms and a DSM clinical disorder. Perhaps the sole exception to this is hoarding, which is in diagnostic flux at this time. Diagnostic criteria for hoarding have been proposed for the next revision of the DSM (DSM-V, expected in 2012), and these are detailed in Chapter 4. Interestingly, the almost legendary low-insight aspect of hoarding for many sufferers has led diagnosticians to develop criteria that do not require that hoarding sufferers themselves experience distress (as many do not report this), but that the distress might be experienced mainly by others living with and near them. This is a departure from the usual DSM requirement for both distress and impairment typically associated with OCD and other anxiety and mood disorders.
This volume begins with reviews of the diagnostic features, epidemiology, and phenomenology of OCD, BDD, hoarding, tic disorders, and trichotillomania, in Chapters 2 through 25. These chapters provide extensive literature reviews of the prevalence of these conditions, their association with anxiety, mood, and other comorbid disorders, and potential etiological factors. As Calamari, Chik, Pontarelli, and DeJong indicate in Chapter 2 on OCD, clarification of the heterogeneity within disorders like OCD can help advance theories about etiology, as well as research on treatments, and suggest where these and seemingly related conditions lie in our psychiatric disorder nomenclature. These reviews inevitably point to the ongoing debate about what features the OCSDs share, along what dimensions they differ, where each should be placed in the taxonomy of psychiatric disorders, and whether these conditions in fact belong in the broad category of OC spectrum conditions. Figure 1.1 presents a modified map of the dimensions along which several OCSD conditions might vary with regard to mood (euphoria to dysphoria) and behavioral propensities (harm avoidance to impulsivity; see also Lochner et al., 2005; Summerfeldt, Hood, Antony, Richter, & Swinson, 2004). On these dimensions, BDD falls on the most dysphoric and harm-avoidant end, with its frequent suicidal features and poor insight into the irrationality of the fears of imagined ugliness. OCD appears similar, with high rates of depression and avoidant behaviors. In contrast, impulse control disorders rest in the opposing end, with euphoric mood and impulsivity. In between are hoarding and habit disorders like trichotillomania. This figure does not contain reference to a third dimension of cognitive features (beliefs and cognitive processes) that might also help distinguish these conditions, as some chapters in this volume suggest (see Chapters 8, 12, and 18). How biological aspects (genetic, neurobiology) might be represented is yet another missing element.
Among the five chapters outlining symptoms and features of OCSDs, Calamari and colleagues (Chapter 2) point to OCD’s heterogeneity. While this may be less true of conditions like BDD and (p. 5) trichotillomania, heterogeneity certainly characterizes the larger category of OCSDs. These authors also note the potential value of studying both the subclinical and clinical levels of these conditions, an important point with regard to understanding the critical factors that affect their development and worsening. In Chapter 3, Kelly and Phillips highlight the very serious comorbidity that commonly characterizes BDD, including major depression, hypochondriasis, and psychotic disorders. This underresearched condition is perhaps one of the most severe within the OCSD grouping. Hoarding is the newest member of the spectrum conditions, as its departure from its former diagnostic role as a symptom of obsessive compulsive personality disorder and a subtype of OCD is based on research published within the past decade. Described in detail by Rasmussen and Frost in Chapter 4, it is perhaps one of the more confusing OC spectrum conditions from a nosological and phenomenological point of view. Chapter 5 by Ricketts and colleagues outlines the features of tic disorders and trichotillomania, a repetitive behaviors group sometimes referred to as habit disorders, in which symptoms rise and fall with changes in mood. As these authors note, information about crosscultural aspects of these conditions is limited, a statement that also applies to other OCSDs.
Next are three chapters that discuss various biological aspects of OCSDs. In Chapter 6, Samuels and colleagues review more than two decades of research on genetic aspects; findings indicate that specific genes for OCD and these spectrum conditions have not yet been identified, but there is little doubt that genetic linkages play a role. In Chapter 7, Mataix-Cols and van den Heuvel cover the neurobiological aspects of OCSDs and note that it remains unclear how they relate to one another from this perspective, a task complicated by the heterogeneity of OCD and related disorders, especially hoarding. In the third of these chapters on biology, Radomsky and Alcolado (Chapter 8) examine information-processing in OCD and spectrum disorders, describing a variety of experimental methodologies designed to elucidate the both the features and the mechanisms behind symptoms of these conditions. These three chapters do an excellent job of organizing the research findings to better understand OCSDs, just as they point to the great need for further research in these important areas.
Four chapters examine social, family, and personality features, as well as psychological models for understanding OCD and spectrum disorders. In Chapter 9, Renshaw, Caska, Rodrigues, and Blais point to serious patient impairments in social and family functioning, as well as problems among family members who also display distress and relationship problems with their afflicted relatives. Unfortunately, family accommodation and strong negative emotional reactions can contribute to (p. 6) treatment failure among those with OCD, but little is known about family responses in the spectrum conditions. Pinto and Eisen (Chapter 10) review the relationship of OCD to personality disorders, especially OCPD, a long studied but little understood association. They point to the need to examine dimensional personality traits rather than merely categorical groupings of personality disorders in order to inform theoretical models of OCSDs, noting that much remains to be done in this arena. Cassin and Rector (Chapter 11) review the largely untested psychodynamic models, and focus mainly on behavioral models with their 40 years of empirical support for explaining the symptoms of OCD and related disorders. However, as the authors note, these models only partly explain these disorders, and mainly the persistence of symptoms rather than their etiology. In Chapter 12, Taylor, Abramowitz, McKay and Cuttler detail the much more recent cognitive models for understanding OCD and the evidence supporting predictions derived from these models, as well as applications to related OCSDs. As noted for behavioral models in Chapter 11, these authors concur that cognitive theories only partly explain OCSDs. Their recommendations for improving upon the explanatory power of these models include examining special features like disgust, as well as developmental and cultural aspects, and tying dysfunctional beliefs to information-processing and neuroscience findings.
Two chapters focus on assessment methods. Chapter 13, by Dorfan and Woody, focuses mainly on assessing OCD symptoms, whereas Purdon’s Chapter 14 covers measurement of comorbidity, insight, family features, and functioning. Assessment methods for determining severity and features of BDD, hoarding, tics, and trichotillomania are not provided in a separate chapter but included within earlier chapters describing research on these conditions.
The largest portion of this volume focuses on treatment, with six chapters on treatments for OCD and three chapters on treatments for OC spectrum disorders. In the first group, Dougherty, Rauch and Jenike review pharmacological treatments in Chapter 15, mainly considering the substantial literature on selective serotonin reuptake inhibitors, or SSRIs, as major first-line treatments for OCD, with other monotherapies and augmentation strategies as second-line medication treatments. McLaughlin and Greenberg (Chapter 16) describe various nonmedication biological interventions, including neurosurgical methods such as cingulotomy, capsulotomy, leucotomy, and tractotomy, as well as deep brain stimulation. Not surprisingly, given the possibility of serious side effects, they point to the need for caution and careful review required before these methods can be applied. Chapter 17, by Abramowitz, Taylor, and McKay, reviews exposure treatments for OCD, noting that these are among the oldest and most effective methods available. They describe common variants and potential mechanisms of action, as well as comparative efficacy in relation to other methods, and predictors of outcome and strategies for improving outcomes. In Chapter 18, Whittal and Robichaud detail cognitive methods of therapy based on the empirically demonstrated assumption that intrusive thoughts are a universal phenomenon, but when interpreted negatively can become clinical obsessions. They point to the possible mechanisms of action of cognitive interventions that address various types of beliefs. Tolin (Chapter 19) reviews literature on the efficacy of combining medications and cognitive and behavioral therapy (CBT) for OCD, finding that combination therapies that include CBT have a small but significant advantage over single therapies. He points to new strategies for combining therapies to potentiate the mechanisms of CBT. The final chapter in this group by Muroff, Ross, and Rothfarb (Chapter 20) is on complementary and alternative approaches to treating OCD. These authors summarize research on such therapies as yoga, herbal remedies, motivational strategies, and bibliotherapy, as well as alternative methods more closely related to standard CBT, with a special focus on technology-supported treatments.
The next three chapters address treatments specifically developed for body dysmorphic disorder, hoarding, and tic and trichotillomania disorders. With regard to BDD, in Chapter 21, Greenberg Chosak, Fang, and Wilhelm point to the efficacy and limitations of separate and combined medications and cognitive-behavioral therapies. They also note that cosmetic procedures favored by patients are typically ineffective, and that early intervention is critical to limit the morbidity associated with BDD. In Chapter 22, Grisham, Norberg, and Certoma describe treatments for compulsive hoarding as an urgent public health priority. They comment on the poor response to standard pharmacological and psychological treatments, according to mainly retrospective research, and review the somewhat more positive outcomes to CBT that is derived from a model for understanding hoarding. Franklin, Antinoro, Ricketts, and Woods (Chapter 23) describe (p. 7) the methods and outcomes of treatments for tic disorders and trichotillomania. They indicate that cognitive therapy techniques are not typically included in psychosocial treatments, and that behavioral therapies including habit reversal training (HRT) are promising for both conditions.
Three final chapters cover OCD and spectrum conditions in older adults, children and adolescents, and across cultures. In Chapter 24, Carmin, Calamari, and Ownby focus on older adults, noting the need to study interventions for late life OCD that are designed to address possible medical and cognitive limitations, as well as beliefs about intrusive thoughts and compulsive behaviors. On the other end of the developmental spectrum, Storch et al. (Chapter 25) summarize the phenomenology, etiology, and treatment of OCSDs in children and adolescents. They propose novel CBT augmentation methods for OCD using D-cycloserine, as well as other modifications of CBT and medications, and point to the severely limited research on treatments for BDD and trichotillomania in children. Nedeljkovic, Moulding, Foroughi, and Kyrios discuss cultural aspects of OCD and OCSDs in Chapter 26. They consider the role of cultural and religious factors in how OCD symptoms are perceived, assessed, and diagnosed, as well as how patients present for help. Their review of the effects of treatments across countries, and within minority cultures from Western countries, indicates the extremely limited information available about cultural aspects of OC spectrum conditions.
Finally, we (Steketee & McCorkle, Chapter 27) close with a discussion of the topics of most compelling need for further research on obsessive compulsive and spectrum disorders. Here we review a number of the major issues raised in the research summarized across the chapters of this volume, especially as they pertain to the need to better understand the etiology of these conditions, their biological and social contexts, and the biological and psychosocial interventions that derive from these. It is our genuine hope that readers will benefit from the detailed research summaries contained in this book and use them to guide future research and clinical interventions.
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