OCD Spectrum Disorders

Overview of OCD Spectrum - Obsession's Cousins

• Group of disorders related to OCD, sharing features of repetitive thoughts or behaviors.
• Core features:
  • Preoccupations (intrusive thoughts) or repetitive behaviors (e.g., body-focused repetitive behaviors [BFRBs], rituals).
  • Cause significant distress or functional impairment.
• Distinction from classic OCD:
  • Focus often on perceived flaws (e.g., Body Dysmorphic Disorder), body-focused actions (e.g., Trichotillomania, Excoriation Disorder), or acquiring/saving items (e.g., Hoarding Disorder).
  • Not primarily driven by typical obsessions and compulsions seen in OCD.

⭐ Insight in OCD spectrum disorders can range from good to absent/delusional, significantly impacting treatment adherence and prognosis.

Body Dysmorphic Disorder (BDD) - Mirror, Mirror Misery

• Preoccupation: ≥1 perceived defects/flaws in physical appearance; not observable or slight to others.
• Repetitive Behaviors (compulsions) or mental acts:
  • Mirror checking, excessive grooming, skin picking, reassurance seeking.
  • Comparing appearance to others.
• Causes clinically significant distress or impairment.
• Insight specifiers: With good/fair insight, poor insight, or absent insight/delusional beliefs.
• Muscle dysmorphia: Subtype; preoccupation that body build is too small or insufficiently muscular.
• Common concerns: Skin (e.g., acne, scars), hair (e.g., thinning), nose (e.g., size, shape).

⭐ BDD is associated with high rates of suicidal ideation and attempts, often comparable to or exceeding those in major depressive disorder.

• Treatment: SSRIs (often higher doses), Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP).

Hoarding, TTM, & Excoriation - Clutter & Compulsions

• Hoarding Disorder:

  • Persistent difficulty discarding items, regardless of value → clutter.
  • Strong urge to save; distress with discarding.
  • Causes significant distress/impairment. Not due to other conditions.
  • Specifiers: w/ excessive acquisition; insight (good/fair, poor, absent/delusional).

• Body-Focused Repetitive Behaviors (BFRBs):

  • Trichotillomania (TTM): Recurrent hair pulling → hair loss (alopecia).
  • Excoriation Disorder: Recurrent skin picking → skin lesions/scars.
  • Common: Repeated attempts to stop; significant distress/impairment.
  • 📌 BFRBs: Recurrent, Unsuccessful attempts to stop, Body damage, Significant distress (RUBS).

  Feature	Trichotillomania (TTM)	Excoriation Disorder
  Primary Action	Hair pulling	Skin picking
  Common Sites	Scalp, eyebrows, eyelashes	Face, arms, hands
  Associated	Examining root, twirling, trichophagia	Squeezing, biting, examining skin

⭐ Hoarding disorder often has poor insight & is ego-syntonic, unlike typically ego-dystonic OCD, complicating treatment.

Shared Pathophysiology & Treatment - Brain Circuits & Fixes

• Core Pathophysiology:
  • Brain Circuits: Dysregulation in Cortico-Striato-Thalamo-Cortical (CSTC) pathways. Key areas: Orbitofrontal Cortex (OFC), Anterior Cingulate Cortex (ACC), Striatum.
  • Neurotransmitters: Primarily ↓ Serotonin (5-HT); Dopamine (DA) & Glutamate also implicated.
• Treatment Pillars:
  • Pharmacotherapy:
    • SSRIs: First-line (e.g., Fluoxetine, Sertraline). Often require higher doses (e.g., Fluoxetine up to 80mg/day) and 10-12 weeks for response.
    • Clomipramine: Potent TCA, effective alternative.
    • Augmentation: Low-dose antipsychotics (e.g., Risperidone) for treatment-resistant OCD.
  • Psychotherapy:
    • Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP).
    • Habit Reversal Training (HRT) for Body-Focused Repetitive Behaviors (BFRBs).

  ⭐ CBT with Exposure and Response Prevention (ERP) is the most effective psychotherapeutic modality for OCD.

  • Neuromodulation: Deep Brain Stimulation (DBS) for severe, refractory cases.

High‑Yield Points - ⚡ Biggest Takeaways

• OCD: Characterized by obsessions (intrusive thoughts) and/or compulsions (repetitive acts); often ego-dystonic.
• PANDAS: Sudden OCD/tic onset in children post-streptococcal infection.
• Hoarding Disorder: Persistent difficulty discarding items, leading to clutter.
• Body Dysmorphic Disorder (BDD): Preoccupation with perceived physical flaws.
• Trichotillomania (hair-pulling) & Excoriation (skin-picking) are body-focused repetitive behaviors.
• OCD Treatment: SSRIs (high doses), CBT (ERP). Clomipramine also effective.