IDD-MH Prescriber Guidelines
Funded by the WITH Foundation
Obsessive Compulsive and Related Disorders
L. Jarrett Barnhill, MD, DFAPA, FAACAP
Contents
Fundamentals of Psychopharmacology
The Lived Experience Perspective
- Communicating with Patients with IDD and Their Family Members
- Considerations for Waiting Rooms
- Sensory Considerations for Medical Providers
- Cultural Competency and Prescribing
Psychiatric Assessment Considerations
Medical Assessment Considerations for Patients with IDD/MH
Best Practices in MH Diagnosis and Treatment
- Trauma and Stressor Related Disorders
- Anxiety Disorders
- Obsessive Compulsive and Related Disorders
- Depressive Disorders
- Bipolar Disorders
- Grief and Loss
- Schizophrenia and Other Psychotic Disorders
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
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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