The characteristics of unacceptable/taboo thoughts in obsessive-compulsive disorder

BACKGROUND

In the quest to unravel the heterogeneity of obsessive-compulsive disorder (OCD), an increasing number of factor analytic studies are recognising unacceptable/taboo thoughts as one of the symptom dimensions of OCD.

AIMS

This study aims to examine the characteristics associated with unacceptable/taboo thoughts.

METHODS

Using the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC) with 154 individuals with OCD, obsessive-compulsive symptoms were subjected to principal components analysis. The characteristics associated with the resulting symptom dimensions were then assessed using logistic and linear regression techniques.

RESULTS

Unacceptable/taboo thoughts comprised of sexual, religious and impulsive aggressive obsessions, and mental rituals. Higher scores on an unacceptable/taboo thoughts symptom dimension were predicted by higher Y-BOCS obsession subscores, Y-BOCS time preoccupied by obsessions scores, Y-BOCS distress due to obsessions scores, importance of control of thought ratings, male gender, and having had treatment prior to entering into the study. Unacceptable/taboo thoughts were also predicted by greater levels of hostility, and a past history of non-alcohol substance dependence.

CONCLUSIONS

An unacceptable/taboo thought symptom dimension of OCD is supported by a unique set of associated characteristics that should be considered in the assessment and treatment of individuals with these symptoms.

Psychiatrists and GPs: diagnostic decision making, personality profiles and attitudes toward depression and anxiety

OBJECTIVES

The objective of this article is to explore diagnostic decision making around psychological symptoms presenting to general practitioners (GPs) and psychiatrists, identify attitudinal and personality factors of possible relevance in these decisions, and compare GPs and psychiatrists to help identify potential educational targets.

METHODS

GPs and psychiatrists attended separate peer-facilitated workshops in which two case presentations were discussed. Decision making was explored by structured questions embedded in the workshop, with responses recorded by electronic keypad technology. Participants completed demographic questionnaires and measures of personality and attitudes to depression.

RESULTS

GPs and psychiatrists accorded emphasis to different elements of the history, and assigned different diagnoses based on the same set of symptoms. Both groups relied on non-pharmacological management for milder psychological symptoms; GPs were less likely to make a diagnosis of bipolar disorder. Traits of Extraversion and Agreeableness were associated with greater ease in treating depression.

CONCLUSIONS

Differences in diagnostic decision making likely reflect the different contexts of specialist and generalist practice. Educational targets may include information about key symptoms to assist in diagnostic precision, but further information is needed to determine the best match between diagnostic processes, context and outcome. An awareness of the role of personality factors may help when designing education and support programs.

The use of psychotropic agents for the symptoms of obsessive-compulsive disorder

OBJECTIVE

To describe the use of psychotropic agents in a sample of subjects with obsessive-compulsive disorder (OCD), and in particular the differences associated with different OCD symptoms.

METHOD

A total of 154 subjects participated in a study assessing OCD symptom subtypes, called the Nepean OCD Study. In addition to a comprehensive evaluation of the subjects' OCD symptoms using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Vancouver Obsessive-Compulsive Inventory (VOCI), and the Sheehan Disability Scale (SDS), the subjects' medication history was recorded. The association between symptom severity, disability, OCD symptom subtypes and the use of psychotropic agents was examined.

RESULTS

Psychotropic medication was taken by 93 (60.4%) participants. In the majority of cases (n=55, 59.1%), selective serotonin reuptake inhibitors (SSRIs) were taken, and of the SSRIs, the most commonly used agent was escitalopram (n=21, 22.6%). Psychotropic agents were more likely to be taken by subjects with higher Y-BOCS and SDS scores. Hoarding was associated with a lower likelihood of psychotropic use, whereas unacceptable/taboo thoughts were associated with an increased likelihood of psychotropic and antipsychotic use.

CONCLUSION

Patients with OCD are more likely to be taking psychotropic agents if they have a more severe illness, greater disability and more prominent unacceptable/taboo thoughts.

Obsessive-compulsive personality disorder co-occurring with obsessive-compulsive disorder: Conceptual and clinical implications

OBJECTIVES

There are ongoing uncertainties in the relationship between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). This study aimed to test the proposition that OCPD may be a marker of severity of OCD by comparing groups of OCD individuals with and without OCPD on a number of variables.

METHOD

A total of 148 adults with a principal diagnosis of OCD were administered the Mini International Neuropsychiatric Interview, Yale-Brown Obsessive-Compulsive Scale, Sheehan Disability Scale, Vancouver Obsessional Compulsive Inventory and Symptom Checklist 90-Revised. Participants with a DSM-IV diagnosis of OCPD were compared with those without OCPD.

RESULTS

Some 70 (47.3%) participants were diagnosed with OCPD. The groups of participants with and without OCPD did not differ significantly with respect to any of the demographic variables, clinician-rated severity of OCD, levels of disability and mean age of onset of OCD. All self-rated OCD symptom dimensions except for contamination and checking were significantly more prominent in participants with OCPD, as were all self-rated dimensions of psychopathology. Participants with OCPD had significantly more frequent hoarding compulsions and obsessions involving a need to collect and keep objects. Of Axis I disorders, only panic disorder was significantly more frequent in participants with OCPD than in those without OCPD.

CONCLUSIONS

A high frequency of OCPD among individuals with OCD suggests a strong, although not necessarily a unique, relationship between the two conditions. This finding may also be a consequence of the blurring of the boundary between OCD and OCPD by postulating that hoarding and hoarding-like behaviours characterise both disorders. Results of this study do not support the notion that OCD with OCPD is a marker of clinician-rated severity of OCD. However, individuals with OCPD had more prominent OCD symptoms, they were more distressed and exhibited various other psychopathological phenomena more intensely, which is likely to complicate their treatment.

Interpersonal reassurance seeking in obsessive-compulsive disorder and its relationship with checking compulsions

This study aimed to examine interpersonal reassurance seeking (IRS) in obsessive-compulsive disorder (OCD) and the relationship between IRS and checking compulsions. One hundred and forty adults with OCD underwent a comprehensive assessment, which included obtaining information on seeking reassurance from others because of their obsessions. Sixty-seven (47.9%) participants reported IRS. They exhibited more psychopathology than participants without IRS, tended to have a greater overall severity of OCD and were far more likely to have checking compulsions. Participants with IRS also had more severe obsessions, suggesting that IRS plays a role as an additional coping strategy when obsessions are more prominent. The severity of obsessions and the absence of obsessions about a need to collect and keep objects were independent predictors of IRS, whereas the presence of obsessions about unintentional harm and not being married or in a de facto relationship independently predicted checking compulsions. Although a close relationship exists between IRS and checking compulsions, these results suggest important differences, with implications for understanding the factors that contribute to IRS and checking compulsions.

Diagnostic processes in mental health: GPs and psychiatrists reading from the same book but on a different page

OBJECTIVE

To explore the clinical reasoning processes underpinning diagnostic and management decision-making in treating patients presenting with psychological distress in general practice.

METHOD

Practising GPs were invited to attend small-group workshops in which two case histories were presented. Discussion was GP-facilitated and recorded for thematic analysis. GPs provided demographic data, completed personality and attitudinal questionnaires, and answered a series of multiple-choice questions embedded in the cases.

RESULTS

GPs recognize the possibility of psychiatric disorders early in the clinical reasoning process, but are cautious about applying definitive diagnoses. GPs perceive that patients may be resistant to a psychiatric diagnosis and instead emphasize the need to build rapport and explore and exclude physical comorbidities. GPs see patients with a broad spectrum of distress, illness and impairment, in whom the initial presentation of psychological symptoms is often poorly differentiated and somatically focused, requiring elucidation over time. GPs therefore adopt a longitudinal strategy for diagnosis rather than investing heavily in cross-sectional assessment.

CONCLUSION

GPs appear cognizant of possible psychiatric disorders and management strategies, but employ diagnostic strategies and decision-making processes that, in addition to experience and expertise, likely reflect key differences between the primary care and specialist practice settings.

Patterns of hypnotic medication use for sleep disturbance amongst hospital inpatients

OBJECTIVE

The objective of this article is to examine patterns of temazepam prescribing amongst inpatients at a Sydney teaching hospital.

METHOD

The study involved a retrospective file audit of 98.8% (n=410) of patients discharged from psychiatry, medical, surgical and obstetric and gynaecology wards of Nepean Hospital during a one-week period. Data was collected on patient demographics, temazepam and other sedative-hypnotic use, falls risk and analgesia use.

RESULTS

Sixteen per cent (n=64) of patients were prescribed temazepam during their stay. All patients from the psychiatry wards had been prescribed temazepam. Fifteen per cent (n=6) of falls risk patients had been prescribed temazepam. Temazepam prescription was associated with an increased length of stay, psychiatry and surgical wards, and higher use of analgesia.

CONCLUSIONS

Temazepam continues to be a frequently prescribed medication in the acute psychiatry setting. Its frequent prescription to patients in surgical wards and to those prescribed analgesic agents indicates that it still has a role in settling patients to sleep in the hospital setting.

Disgust propensity in obsessive-compulsive disorder: cross-sectional and prospective relationships

BACKGROUND AND OBJECTIVES

Findings from non-clinical samples suggest that disgust propensity is associated with contamination concerns in obsessive-compulsive disorder (OCD). However, studies of clinical samples have yielded conflicting results. We investigated the relationship between disgust propensity and OCD symptoms in a clinical sample and examined whether changes in disgust propensity are associated with changes in OCD symptoms.

METHODS

One hundred and nine OCD participants completed measures of disgust propensity and OCD symptoms. Sixty of these underwent a six-month follow-up assessment.

RESULTS

At the baseline assessment, disgust propensity was associated with all OCD symptom dimensions except hoarding. Changes in overall disgust propensity between baseline and the six-month follow-up assessment were associated with changes in overall self-reported OCD symptoms but not with changes in contamination-based OCD symptoms or changes in interviewer-assessed OCD symptoms.

LIMITATIONS

There was substantial participant attrition between the baseline and follow-up assessments.

CONCLUSIONS

Our study is the first to investigate prospective relationships between disgust propensity and OCD across a six-month interval. Our findings suggest that if there is an association between changes in disgust propensity and changes in contamination-based OCD symptoms its magnitude is likely to be small.

Hospital admissions for obsessive-compulsive disorder in NSW, 1997 to 2010

OBJECTIVES

To assess the characteristics of admissions to NSW hospitals with a diagnosis of obsessive-compulsive disorder (OCD).

METHOD

Assessment of administrative data from all NSW hospital admissions from 1997 to 2010.

RESULTS

The average admission rate for a primary diagnosis of OCD was 1.5 per 100,000 population. This rate increased over the period assessed. OCD was much more common as a secondary diagnosis (6.1 per 100,000 population), often occurring with affective disorders in adults and other anxiety disorders in children. Adults admitted with OCD had an average length of stay of 24 days.

CONCLUSIONS

Although hospital admissions of patients with OCD are uncommon, the high rates of comorbidity and increasing rates of admission alert us to the significance of screening patients for OCD and being able to offer outpatient treatment.

The nature and correlates of avoidance in obsessive-compulsive disorder

OBJECTIVES

Avoidance in obsessive-compulsive disorder (OCD) has been neglected by research. This study aimed (i) to collect information on the nature and frequency of avoidance in people with OCD and ascertain the types of obsessions related to avoidance; (ii) compare OCD individuals with and without avoidance, and (iii) determine predictors of avoidance in people with OCD.

METHOD

A total of 124 OCD adults underwent a comprehensive assessment. Participants were asked whether they engaged in any avoidance behaviour because of their OCD, and the nature and number of instances of such avoidance were recorded. The instances of avoidance were grouped according to the type of obsession and compulsion that they were related to.

RESULTS

A total of 74 (59.7%) participants reported OCD-related avoidance. Avoidance was most commonly related to contamination obsessions. Almost 80% of all contamination obsessions and more than 50% of all aggressive obsessions were associated with avoidance, and contamination obsessions were significantly more common among the participants with avoidance. In contrast, very few obsessions about a need to collect and keep objects and obsessions about a need for ordering, arranging and doing things right or in an exact way were associated with avoidance; these types of obsessions were also significantly more common among the participants without avoidance. The strongest predictor of avoidance was the presence of contamination obsessions. Participants with avoidance had a significantly more severe OCD than those without avoidance.

CONCLUSIONS

Avoidance is common in OCD, and it is particularly frequently associated with contamination obsessions. There is a weak link between avoidance and hoarding and between avoidance and ordering/arranging/symmetry obsessions and compulsions. These results, along with the finding that OCD with avoidance is a more severe illness, have implications for the future diagnostic criteria, description, subtyping and treatment of OCD and for its relationship with other anxiety disorders.

The characterization of beliefs in obsessive-compulsive disorder

Beliefs are associated with most obsessions and compulsions in obsessive-compulsive disorder (OCD). The characteristics of these beliefs can vary considerably, which has led to some of them being regarded as overvalued ideas or delusions and has contributed to confusion regarding the conceptualization and classification of OCD. This article proposes that beliefs arising in the context of OCD be assessed along the following, well-defined characteristics: conviction, fixity, fluctuation, resistance (to beliefs), insight pertaining to an awareness of the inaccuracy of one's belief, and insight referring to the ability to attribute the belief to an illness. This approach to the assessment of OCD-related beliefs may allow a clearer distinction between non-delusional beliefs, overvalued ideas, and delusions. Although the characteristics of non-delusional beliefs may vary, especially on the dimension of awareness of the inaccuracy of belief, these beliefs can generally be distinguished from overvalued ideas and delusions in terms of lower levels of conviction and fixity and greater fluctuation, resistance and ability to attribute the belief to OCD. The development of an assessment tool using these well-defined characteristics will test the proposed model, which may lead to a more objective evaluation of OCD-related beliefs. This is likely to have implications for diagnostic conceptualization and subtyping of OCD.

Functions of compulsions in obsessive-compulsive disorder

OBJECTIVES

The key function of compulsions in obsessive-compulsive disorder (OCD) is to alleviate anxiety or distress caused by the obsessions, but compulsions may also have other functions. The main aim of this study was to systematically ascertain what motivates individuals with OCD to perform compulsions.

METHOD

A total of 108 adults with OCD were assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Functions of Compulsions Interview. The latter instrument elicits the functions of identified compulsions.

RESULTS

The functions of 218 compulsions were identified. The mean number of functions per compulsion in the whole sample was 2.94 and the vast majority of compulsions (85.3%) were performed for more than one reason. The total number of functions of compulsions endorsed for the three main compulsions correlated with Y-BOCS total scores (r = 0.37, p < 0.001). Compulsions were most frequently performed automatically and to decrease distress or anxiety, but there was substantial variation, depending on the type of compulsion. Hoarding was often performed for reasons not related to any other compulsion (involving a perceived need for collected objects), whereas ordering/symmetry/repeating compulsions were frequently performed to achieve a 'just right' feeling. Checking was frequently performed because of the belief that something bad or unpleasant would happen if one failed to check; washing/cleaning compulsions were most frequently performed to decrease distress or anxiety and automatically, and mental compulsions were performed automatically far more often than for other reasons.

CONCLUSIONS

The majority of compulsions have more than one function and they are often performed automatically. The finding of different functions of compulsions in different types of compulsions provides some support to the subtyping of OCD on the basis of obsessions and compulsions. Identifying functions of compulsions allows better understanding of the functional relationship between obsessions and compulsions, which may have implications for cognitive-behavioural therapy of OCD.

Obsessive-compulsive spectrum disorders: a comorbidity and family history perspective

OBJECTIVE

The concept of obsessive-compulsive spectrum disorders (OCSDs) has become so influential that there are proposals to introduce it into new diagnostic classificatory systems. The aim of this paper was to assess whether rates of comorbidity and family history of OCSDs in patients with obsessive-compulsive disorder (OCD) supported this concept.

METHOD

Comorbidity and family history were assessed in a group of participants with a primary diagnosis of OCD, using structured clinical interviews. Rates of OCSDs and other anxiety disorders (OADs), excluding OCD, were compared.

RESULTS

Of the 77 OCD participants assessed, the most prevalent comorbid conditions were OADs: generalized anxiety disorder (34.6%), specific phobia (26.9%), social phobia (21.8%) and panic disorder (19.2%). The proposed OCSDs were less frequently comorbid: tic disorder (12.8%), trichotillomania (5.1%), hypochondriasis (3.8%) and body dysmorphic disorder (BDD) (3.8%). Similar trends were observed for a family history of these disorders. No participant reported a family history of an OCSD without a family history of an OAD.

CONCLUSIONS

Although the concept of OCSDs has invigorated thinking in this complex diagnostic field, these results support the current association of OCD with OADs rather than with OCSDs.

Characteristics of admissions to a recently opened Psychiatric Emergency Care Centre

OBJECTIVE

The Psychiatric Emergency Care Centre (PECC) is a relatively recent service development that aims to improve emergency care of psychiatric patients. The goal of this paper was to report on the characteristics of admissions to a recently established PECC.

METHOD

Several key characteristics of admissions to the PECC were documented for each of 376 patients in the first 6 months of its operation. These characteristics were then compared to the characteristics of admissions of 299 patients in the 'virtual' PECC (a PECC within the general emergency department) in the 6 months prior to the opening of the PECC.

RESULTS

The most common presenting symptom in the PECC was suicidal ideation (47.6%, n = 179) and the most frequent diagnosis made in the PECC was adjustment disorder (35.9%, n = 135). When comparing admissions to the 'virtual' PECC, PECC admissions were characterized by a significantly less frequent use of physical restraint and haloperidol and midazolam as pro re nata (prn) medications.

CONCLUSIONS

Although further study is needed, one possible advantage of the PECC may be a less frequent use of physical restraint and certain prn medications (i.e. haloperidol and midazolam) for agitated and aggressive patients.

An evaluation of monitoring practices in patients on second generation antipsychotics

OBJECTIVE

Treatment with second generation antipsychotics (SGAs) can increase the risk of patients with schizophrenia developing obesity, hyperlipidaemia and diabetes. Routine monitoring is recommended, but clinical practice suggests monitoring is not conducted at a rate necessary for these comorbidities. The aim was to audit what proportion of patients were having their weight, height, girth, body mass index, lipids and blood sugar levels monitored and recorded.

METHOD

An audit of patients with schizophrenia, discharged from three psychiatric wards, was conducted. Two data sheets were recorded for every patient and inter-rater reliability was calculated. Data were then entered into SPSS and statistical significance calculated.

RESULTS

The sample consisted of 93 patients; SGAs were taken by 31% of admitted and 88% of discharged patients. Of these, 65% had their weight recorded, 61% height, 31% random blood sugar levels, 3% postprandial blood sugar levels, 2% glycosylated haemoglobin, and 7.5% cholesterol and triglycerides. Girth and BMI were not recorded. Abnormalities were detected in 29% of recorded BSL and 2% of recorded cholesterol.

CONCLUSIONS

Patients with schizophrenia on antipsychotics have an alarmingly low rate of monitoring of these common adverse effects and comorbidities. Clinicians need to be aware of this, so that they can improve their practice.

Symptom subtypes of obsessive-compulsive disorder: are they relevant for treatment?

Several symptom subtypes of obsessive-compulsive disorder (OCD) have been identified on the basis of the predominant obsessions and compulsions. The objectives of the present article were to review the literature on the relationship between OCD symptom subtypes and treatment response and to suggest strategies that might assist with the choice of treatment and improve treatment outcome in patients with various subtypes. An extensive literature search was performed, relevant studies were identified, and their results reported. Overt compulsions were generally associated with a relatively good response to the behaviour therapy technique of exposure and response prevention (ERP) and with poorer response to serotonin re-uptake inhibitors (SRIs). Washing/cleaning and checking compulsions tend to respond well to ERP, whereas the majority of studies show that washing/cleaning compulsions are associated with a poorer response to SRIs. Most studies suggest that patients with the symmetry, ordering and arranging subtype do not fare worse with ERP and SRIs than patients with other symptom subtypes. Some studies suggested that obsessions might respond to SRIs somewhat better than to ERP. In the majority of the studies, hoarding and the subtype characterized by sexual or religious obsessions and absence of overt compulsions ('pure obsessions') have been associated with poor response to ERP and SRIs. It was concluded that treatment strategies cannot be precisely tailored to OCD symptom subtypes. Many other factors influence the outcome of treatment and need to be considered along with the symptom subtypes when making decisions about treatment. While ERP and SRIs remain the mainstay of treatment regardless of the symptom subtype, the addition of cognitive therapy techniques and/or antipsychotic medications may enhance treatment response in the presence of certain features discussed in the article.

A cross-sectional survey of the frequency and characteristics of delusions in acute psychiatric wards

OBJECTIVE

The aim of this paper was to ascertain the frequency and characteristics of delusions across several acute psychiatric wards.

METHOD

A survey of the files of all 160 acute psychiatric inpatients aged 18-65 years within Western Sydney was conducted. Patients recorded as currently delusional were compared to non-delusional psychotic patients on demographic data, diagnoses, reason for admission, mode of admission, length of hospital stay, legal status, and treatments.

RESULTS

More than one-half of all patients in the acute psychiatric wards were recorded as being delusional. Persecutory delusions were found in 80% of delusional patients, and multiple delusions were common. Most delusions were steady in course, and 40% lasted longer than 6 months. Patients with delusions received a diagnosis of schizophrenia in 67% of the cases, while 72% of patients with schizophrenia were recorded as having delusions. Almost 90% of delusional patients were detained involuntarily. Antipsychotic medications were the mainstay of treatment for delusional patients, and 30% were treated with more than one antipsychotic. Non-pharmacological strategies for managing delusions were not used.

CONCLUSIONS

Delusions are commonly seen in acute psychiatric wards. There may be a relationship between the presence of delusions, severity of illness and treatment resistance. This highlights the need for a broad and more effective approach to management.