Fundamentals of Psychological Disorders - 3rd edition Part III Mental Disorders - Block 2 Module 9 Obsessive-Compulsive and Related

Fundamentals Disorders Module and Related Disorders edition as of July 2023 Module Overview In Module , we will discuss matters related to and related disorders to include their clinical presentation , epidemiology , etiology , and treatment options . Our discussion will include obsessive compulsive disorder ( OCD ) body disorder ( and hoarding . Be sure you refer Modules for explanations of key terms ( Module ) an overview of the various models to explain psychopathology ( Module ) and descriptions of the therapies ( Module ) Module Outline . Clinical Presentation . Epidemiology . Etiology . Treatment Module Learning Outcomes Describe how disorders present . Describe the epidemiology of disorders . Describe in relation to disorders . Describe the etiology of disorders . Describe treatment options for disorders . Clinical Presentation Section Learning Objectives Describe how obsessive compulsive disorder presents . Describe how body disorder presents . 188

Fundamentals Disorders Describe how hoarding disorder presents . Disorder disorder , more commonly known as OCD , requires the presence of obsessions , compulsions , or both . Obsessions are defined as repetitive and persistent thoughts , urges , or images . These obsessions are intrusive , take more than an hour a day ) and unwanted , often causing significant distress or impairment in an individual daily functioning . Common obsessions are contamination ( dirt on self or objects ) errors of uncertainty regarding daily behaviors ( locking the door , turning off appliances ) thoughts of physical harm or violence , and orderliness , to name a few ( Adams , et , 2011 Foa , 2009 ) Often the individual will try to ignore these thoughts , urges , or images . When they are unable to ignore them , the individual will engage in compulsory behaviors to gain temporary relief from the distress or anxiety . Compulsions are , repetitive behaviors or mental acts that an individual performs in response to an obsession . Common examples of compulsions are checking ( repeatedly checking if the stove is turned off even though the first they checked it was ) counting ( the lights off and on exactly five times ) hand washing , symmetry , fears of harm to self or others , or repeating words ( APA , 2022 ) These compulsive behaviors essentially alleviate the anxiety associated with the obsessive thoughts . For example , an individual may feel as though their hands are dirty after using utensils at a restaurant . They may obsess over this thought for some time , impacting their ability to interact with others or complete a specific task . This obsession will ultimately lead to the individual performing a compulsion where they will wash their hands with extremely hot water to rid all the germs , or even wash their hands a specified number of times if they also have a counting compulsion . At this point , the individual anxiety should be temporarily relieved . These obsessions and compulsions are more excessive than the typical cleanliness as they consume a large part of the individual day . Additionally , they cause significant impairment in one daily functioning . Given the example above , an individual with a fear of contamination may refuse to eat at restaurants , or they may bring their utensils from home . The frequency and severity of the obsessions and compulsions varies by patient , with some having mild to moderate symptoms and only spending hours a day obsessing or engaging in compulsive behaviors , while other patients present with severe symptoms and have nearly constant intrusive thoughts or compulsions that can become incapacitating ( APA , 2022 ) Body Disorder Body disorder is another obsessive disorder however , the focus of the obsessions is with perceived defects or flaws in one physical appearance . A key feature of these obsessions is that they are not observable or appear slight to others . An individual who has a congenital facial defect or a burn victim who is concerned about their scars are not examples of an individual with body disorder . The obsessions related to ones appearance can run the spectrum from feeling unattractive to looking While any part of the body can be a concern for an individual with body disorder , the most commonly reported areas are skin ( acne , wrinkles , skin color ) hair ( particularly thinning or excessive body hair ) and nose ( size or shape APA , 2022 ) Interestingly , the 189

Fundamentals Disorders disorder can occur by proxy meaning the individual is not concerned with their own defects but those of another person , often a spouse or partner but at times , a parent , child , sibling , or stranger . Due to the distressing nature of the obsessions regarding one body , individuals with body disorder also engage in compulsive behaviors that take up a considerable amount of time in their day . For example , they may repeatedly compare their body to other people bodies in the general public frequently look at themselves in the mirror engage in excessive grooming , which includes using up to modify their appearance . Some individuals with body disorder will go as far as having numerous plastic surgeries in attempts to obtain their perfect appearance . While most of us are guilty of engaging in some of these behaviors , to meet criteria for body disorder , one must spend a considerable amount of time preoccupied with their appearance ( on average hours a day ) as well as display significant impairment in social , occupational , or other areas of functioning . Some individuals excessively tan , change their clothes repeatedly , or compulsively shop such as for beauty products . perceived defects is a common behavior and could involve applying makeup , adjusting a hat or one clothes , or covering the forehead or eyes with one hair , all to hide or cover the perceived defect or problem area ( APA , 2022 ) As the notes , body disorder has been associated with , abnormalities in emotion recognition , attention , and executive function , as well as biases and inaccuracies in interpretation of information and social situations ( APA , 2022 , 273 ) These individuals tend to express a bias for negative and threatening interpretations of facial expressions and situations that would be classified as ambiguous , for instance . Muscle . While muscle is not a formal diagnosis , it is a common type of , particularly within the male population . Muscle refers to the belief that one body is too small or lacks the appropriate amount of muscle definition ( Ahmed , Cook , Schwartz , 2014 ) While the severity of between individuals with and without muscle appears to be the same , some studies have found higher use of substance abuse ( steroid use ) poorer quality of life , and increased reports of suicide attempts in those with muscle ( Pope , Pope , Fay , Philips , 2005 ) The instructs to specify if body disorder occurs with muscle . Insight . Those diagnosed with body disorder vary in the degree of insight they have about the accuracy of their body disorder beliefs , ranging from good to . On average , insight is poor and at least of those diagnosed with the disorder display insight . Mental health professionals would indicate the degree of insight regarding body disorder beliefs using with good or fair insight , with poor insight , or with absent beliefs . See page 272 of the for more information . Note that the insight specifier is used with OCD and hoarding disorders as well . Hoarding Disorder In hoarding disorder , the key feature is the persistent of possessions ( APA , 2022 ) While we all obtain items throughout life , individuals with hoarding disorder continue to accumulate items without discarding possessions , regardless of their value or sentiment . This lack of discarding occurs over a long period and is not explained by a recent significant stressor ( lost house in fire , so 190

Fundamentals Disorders now keeps everything ) For example , last week newspaper would likely have no relevance to you or possibly any historical value , but those with hoarding disorder would keep this newspaper despite the lack of value or sentiment . The most commonly hoarded items are newspapers , magazines , clothes , bags , books , mail , and paperwork ( APA , 2022 ) While these items may be stored in attics and garages , individuals with a hoarding disorder also have these items cluttering their living space , sometimes to the extent that they are unable to utilize their furniture because it is covered in stuff . Cognitive factors contributing to the need to hold onto these items are fear of losing valuable information and fear of being wasteful . When asked to clean out their house or get rid of these items , individuals with hoarding disorder experience significant distress . Individuals with hoarding disorder display indecisiveness , avoidance , procrastination , perfectionism , difficulty planning and organizing tasks , and are easily distractible . One hoarding behaviors also impacts their daily functioning and causes impairment in social and occupational functioning . It can lead to low quality of life and in extreme cases , place the individual at risk for figure , falling , poor sanitation , and other health risks . Family relationships are often strained and with neighbors and local authorities is common ( APA , 2022 ) Key Takeaways You should have learned the following in this section As part of OCD , obsessions are repetitive and persistent thoughts , urges , or images while compulsions are repetitive behaviors or mental acts that an individual performs in response to an obsession . Body disorder is characterized by obsessions over perceived defects or in ones physical appearance . Muscle refers to the belief that one body is too small or lacks the appropriate amount of muscle definition and is a type of body disorder common to men . Hoarding disorder is characterized by accumulating items without discarding possessions , regardless of their value or sentiment . Section Review Questions . Define obsessions and compulsions . Provide a list of examples of each . What is body disorder ?

Give examples of characteristics that would not be consistent with a body disorder diagnosis . Many of us save items throughout our lifetime that remind us of specific events . How is this different from hoarding ?

191 Fundamentals Disorders . Epidemiology Section Learning Objectives Describe the epidemiology of OCD . Describe the epidemiology of body disorder . Describe the epidemiology of hoarding disorder . OCD The prevalence rate for OCD is approximately both in the and worldwide ( APA , 2022 ) Women are diagnosed with OCD more often than males however , in childhood , boys are diagnosed more frequently than girls ( APA , 2022 ) With respect to gender and symptoms , females are more likely to be diagnosed with cleaning related obsessions and compulsions . In contrast , males are more likely to display symptoms related to forbidden thoughts and symmetry ( APA , 2022 ) The reports that the mean age of onset of OCD is years with a quarter of cases starting by 14 years of age . Additionally , males have an earlier age of onset ( yrs . compared to females ( yrs . 1990 ) Body Disorder The point prevalence rate for body disorder among adults is while outside the , the point prevalence is to . prevalence rates indicate that women are more likely to be diagnosed with body disorder than men , though muscle is diagnosed more frequently in men . Additionally , women are more likely to be preoccupied with weight , breasts , buttocks , legs , hips , and excessive body or facial hair while men have preoccupations with their genitals , body build , and thinning hair ( APA , 2022 ) Hoarding Disorder While national studies on the prevalence rate of hoarding within the and internationally are not available , community surveys estimate clinically significant hoarding as occurring in to of the population ( APA , 2022 , 2010 ) Clinical samples are more highly represented by females than males and older individuals ( over the age of 65 years ) are three times more likely to be diagnosed with hoarding disorder than younger adults . 192

Fundamentals Disorders Key Takeaways You should have learned the following in this section The prevalence rate for OCD is about while body disorder is and hoarding is estimated at to . In terms of gender , females are more likely to be diagnosed with the three disorders , though in terms of body disorder , males receive the muscle specifier more than females . Gender differences are also present for symptom presentation in OCD and the area of the body focused on in body disorder . Section Review Questions . What are the key gender differences related to OCD and body disorder ?

How do the prevalence rate of the three disorders compare ?

Section Learning Objectives Describe the of OCD . Describe the of body disorder . Describe the of hoarding disorder . OCD There is a high between OCD and other anxiety disorders . Nearly 76 of individuals with OCD will be diagnosed with another anxiety disorder , most commonly panic disorder , social anxiety disorder , generalized anxiety disorder , or a specific phobia . Additionally , due to the nature of OCD and its symptoms , nearly 41 of those with OCD will also be diagnosed with a depressive or bipolar disorder ( APA , 2022 ) There is a high between OCD and tic disorder , particularly in males with an onset of OCD in childhood . Children presenting with OCD typically have a different presentation of symptoms than traditional OCD . Research has also indicated a strong triad of OCD , tic disorder , and in children . Due to this psychological disorder triad , it is believed there is a neurobiological mechanism at fault for the development and maintenance of the disorders . 193

Fundamentals Disorders It should be noted that there are several , bipolar disorder , eating disorders , body disorder , and Tourette disorder that OCD is much more common in . Therefore , who have a patient diagnosed with one of the disorders should also routinely assess patients for OCD ( APA , 2022 ) Finally , OCD has a mean rate of lifetime suicide attempts of , a mean rate of lifetime suicidal ideation of , and a mean rate of current suicidal ideation of . Severity of OCD , the symptom dimension of unacceptable thoughts , a history of , and severity of depressive and anxiety symptoms are of greater suicide risk ( APA , 2022 ) Body Disorder Major depressive disorder is the most common psychological disorder with body disorder and typically occurs after the onset of body disorder . Additionally , there are some reports of social anxiety disorder , OCD , and disorders ( likely related to muscle enhancement APA , 2022 ) Those with body disorder are four times more likely to have experienced suicidal thoughts and times more likely to have made suicide attempts compared to healthy control subjects and those diagnosed with eating disorders , OCD , or any anxiety disorder . Hoarding Disorder Of those diagnosed with hoarding disorder , about 75 have a mood or anxiety disorder with major depressive disorder , social anxiety disorder , and generalized anxiety disorder being the most common conditions . Additionally , nearly 20 also meet the criteria for OCD ( APA , 2022 ) Key Takeaways You should have learned the following in this section OCD is shown to have a high with anxiety and depressive disorders as well as tic disorder and in children . Body disorder has a high with major depressive disorder . Hoarding disorder has a high with mood and anxiety disorders . Section Review Questions . What are the most common for OCD ?

Be specific . This section discussed the OCD triad in children . What two other disorders complete this triad ?

Which disorder is body disorder most with ?

What can we say about with hoarding disorder ?

194 Fundamentals Disorders . Etiology Section Learning Objectives Describe the biological causes of disorders . Describe the cognitive causes of disorders . Describe the behavioral causes of disorders . Biological There are a few biological explanations for related disorders , including hereditary transmission , neurotransmitter deficits , and abnormal functioning in brain structures . Hereditary transmission . With regards to heritability studies , twin studies routinely support the role of genetics in the development of behaviors , as monozygotic twins have a substantially greater concordance rate ( than dizygotic twins ( Carey , 1981 van , Cath , 2005 ) Additionally , first degree relatives of patients diagnosed with OCD are at a increase to develop OCD at some point throughout their lifespan ( et , 2000 ) Interestingly , a study conducted by and colleagues ( 2000 ) exploring the familial role in the development of disorder found that family members of individuals with OCD had higher rates of both obsessions and compulsions than control families however , the familial relationship with regards to obsessions were stronger than that of compulsions suggesting that there is a stronger heritability association for obsessions than compulsions . This study also found a relationship between age of onset of OCD symptoms and family heritability . Individuals who experienced an earlier age of onset , particularly before age 17 , were found to have more relatives diagnosed with OCD . In fact , after the age of 17 , there was no relationship between family diagnoses , suggesting those who develop OCD at an older age may have a different diagnostic origin ( et , 2000 ) Initial studies exploring genetic factors for and hoarding also indicate a hereditary however , environmental factors appear to play a more significant role in the development of these disorders than that of OCD ( Ahmed , et , 2014 et , 2009 ) Neurotransmitters . Neurotransmitters , particularly serotonin , have been identified as a contributing factor to obsessive and compulsive behaviors . This discovery was made accidentally , when individuals with depression and OCD were given antidepressant medications 195

Fundamentals Disorders and of which increase levels of mediate symptoms of depression . Not only did these patients report a significant reduction in their depressive symptoms , but also a substantial improvement in their OCD symptoms ( Anderson , 2014 ) Antidepressant medications that do not affect serotonin levels are not effective in managing obsessive and compulsive symptoms , thus offering additional support for deficits of serotonin levels as an explanation of obsessive and compulsive behaviors ( Burton , Arnold , 2017 Anderson , 2014 ) More recently , there has been some research implicating the involvement of additional , and the development and maintenance of OCD , although future studies are still needed to draw definitive conclusions ( 2017 ) Brain structures . Seeing as neurotransmitters have direct involvement in the development of behaviors , it only logical that brain structures that house these neurotransmitters also likely play a role in symptom development . studies implicate the brain structures and circuits in the frontal lobe , more specifically , the orbitofrontal cortex , which is located just above each eye ( Marsh et , 2014 ) This brain region is responsible for mediating strong emotional responses and converts them into behavioral responses . Once the orbitofrontal cortex receives information via sensory inputs , it transmits this information through impulses . These impulses are then passed on to the caudate nuclei , which filters through the many impulses received , passing along only the strongest impulses to the thalamus . Once the impulses reach the thalamus , the individual essentially the emotional response and decides whether to act ( et , 2013 ) It is believed that individuals with obsessive compulsive behaviors experience overactivity of the orbitofrontal cortex and a lack of filtering in the caudate nuclei , thus causing too many impulses to transfer to the thalamus ( et , 2011 ) Further support for this theory has been shown when individuals with OCD experience brain damage to the orbitofrontal cortex or caudate nuclei and experience remission of OCD symptoms ( et , 2013 ) Cognitive Cognitive theorists believe that OCD behaviors occur due to an individual distorted thinking and negative cognitive biases . More specifically , individuals with OCD are more likely to overestimate the probability of harm , loss of control , or uncertainty in their life , thus leading them to potential negative outcomes of events . Additionally , some research has indicated that those with OCD also experience bias , which causes the individual to seek out evidence of their failure to perform the ritual or compensatory behavior correctly ( Sue , Sue , Sue , Sue , 2017 ) Finally , individuals with OCD often report the inability to trust themselves and their instincts , and therefore , feel the need to repeat the compulsive behavior multiple times to ensure it is done correctly . These cognitive biases are supported throughout research studies that repeatedly find individuals with OCD experience more intrusive thoughts than those without OCD ( Jacob , Larson , 2014 ) We have shown that individuals with OCD experience cognitive biases and that these biases contribute to the obsessive and compulsive behaviors , but why do these cognitive biases occur so often ?

Everyone has times when they have repetitive or intrusive thoughts such as Did I shut the oven off after cooking dinner ?

or Did I remember to lock the door before I left home ?

Fortunately , most individuals are able to either concede to their thoughts once , or even forgo acknowledging their thoughts after they talk themselves through their actions , ensuring that the behavior in question was or was not 196 Fundamentals Disorders completed . Unfortunately , individuals with OCD are unable to neutralize these thoughts without performing a ritual as a way to put themselves at ease . As you will see in more detail in the behavioral section below , the behaviors ( compulsions ) used to neutralize the thoughts ( obsessions ) provide temporary relief to the individual . As the individual is continually exposed to the obsession and repeatedly engages in the compulsive behaviors to neutralize their anxiety , the behavior is repeatedly reinforced , thus becoming a compulsion . This theory is supported by studies where individuals with OCD report using more neutralizing strategies and report significant reductions in anxiety after employing these neutralizing techniques ( Larson , 2014 et , 2003 ) Behavioral The behavioral explanation of obsessive disorders focuses on compulsions rather than obsessions . believe that these compulsions begin with and are maintained through operant conditioning . How so ?

Well , an individual with OCD may experience negative thoughts or anxieties related to an unpleasant event ( obsession the event is a stimulus ) These cause significant distress to the individual , and therefore , they seek out some behavior ( compulsion the response ) to alleviate these threats ( escape behavior associated with negative reinforcement ) This provides temporary relief to the individual , thus reinforcing the compulsive behaviors used to lessen the threat . Over time , the compulsive behaviors are reinforced due to the repeated exposure of the obsession and the temporary relief that comes with engaging in these compulsive behaviors ( escape behavior ) Strong support for this theory is the fact that the behavioral treatment option for exposure and response prevention , is among the most effective treatments for these disorders . As you will read below , this treatment essentially breaks the patient operant conditioning associated with the obsessions and compulsions by preventing the individual from engaging in the compulsive behavior until anxiety is reduced . Key Takeaways You should have learned the following in this section Biological causes of disorders include hereditary transmission , neurotransmitter deficits particularly in relation to serotonin , and abnormal functioning in brain structures . Cognitive causes of disorders include distorted thinking such as overestimating the probability of harm , loss of control , or uncertainty in their life , and negative cognitive biases such as bias . Behavioral causes of disorders include operant conditioning . Section Review Questions 197

Fundamentals Disorders . What are the biological implications regarding the etiology of OCD and related disorders ?

What brain structures have been linked to these disorders ?

Discuss identified cognitive biases that are related to the development and maintenance of OCD and related disorders ?

The behavioral model discusses how respondent conditioning may explain the development and maintenance of these disorders . What type of reinforcement is at work and how ?

Treatment Section Learning Objectives Describe treatment options for OCD . Describe treatment options for body disorder . Describe treatment options for hoarding disorder . OCD . Exposure and Response Prevention ( Treatment of OCD has come a long way in recent years . Among the most effective treatment options is exposure and response prevention ( March , Frances , Carpenter , 1997 ) First developed by psychiatrist Victor Meyer ( 1966 ) as you might infer from the name , individuals are repeatedly exposed to their obsession , thus causing , while simultaneously prevented from engaging in their compulsive behaviors . Exposure sessions are often done in vivo ( in real life ) via videos , or even imaginary , depending on the type of obsession . For example , a fear that one house would burn down if their compulsion was not carried out would obviously be done via imaginary exposure , as it would not be ethical to have a person burn their house down . Prior to beginning the exposure and response prevention exercises , the clinician must teach the patient relaxation techniques for them to engage in during the distress of being exposed to the obsession . Once relaxation techniques are taught , the clinician and patient will develop a hierarchy of obsessions . Treatment will start at those with the lowest amount of distress to ensure the patient has success with treatment , as well as preventing withdrawal of treatment . Within the hierarchy of obsessions , the individual is also gradually exposed to their obsession . For example , an individual obsessed with germs , may first watch a person sneeze on the computer in session . Once anxiety is managed and compulsions refrain at this level of exposure , the individual would move on to being present in the same room as a sick individual , to eventually shaking hands with 198

Fundamentals Disorders someone obviously sick , each time preventing them from engaging in their compulsive behavior . Once this level of their hierarchy was managed , they would move on to the next obsession and so forth until the entire list was complete . Treatment outcome for exposure and response prevention is very effective in treating individuals with OCD . In fact , some studies suggest up to an 86 response rate when treatment is completed ( Foa et , 2005 ) Combination treatments such as with family counseling ( utilizing techniques ) may increase this response rate even higher ( 2011 , 2015 ) Like most OCD related treatments , the largest barrier to treatment is getting patients to commit to treatment , as the repeated exposures and prevention of compulsive behaviors can be extremely distressing to patients . There has been minimal support for the treatment of OCD with medication alone . This is likely due to the temporary resolution of symptoms during medication use . Among the most effective medications are those that inhibit the reuptake of serotonin , and . Reportedly , up to 60 of patients show improvement in symptoms while taking these medications however , symptoms are quick to return when medications are discontinued ( 2002 ) While there has been some promise in a combined treatment option of exposure and response prevention and , these findings were not superior to exposure and response prevention alone , suggesting that the inclusion of medication in treatment does not provide an added benefit ( Foa et , 2005 ) Body Disorder Seeing as though there are strong similarities between OCD and body disorder , it should not come as a surprise that the only two effective treatments for body disorder are those that are effective in OCD . Exposure and response prevention has been successful in treating symptoms of body disorder , as patients are repeatedly exposed to their body and prevented from engaging in compulsions used to reduce their anxiety . et , 1996 Wilhelm , Otto , 1999 ) The other treatment option , has also been shown to reduce symptoms in patients with body disorder . Similar to OCD , medications such as and are generally prescribed . While these are effective in reducing body disorder symptoms , once medication is discontinued , symptoms resume nearly immediately suggesting this is not an effective treatment option for those with body disorder . Treatment of body disorder appears to be difficult , with one study finding that only of participants had full remission at a , and 21 reported partial remission ( Phillips , Stout , 2006 ) A more recent finding reported more promising findings , with 76 of participants reporting full remission over years ( et , 2011 ) Plastic surgery and medical treatments . Many individuals with body disorder seek out plastic surgery to attempt to correct their deficits . Phillips and colleagues ( 2001 ) evaluated treatments of patients with body disorder and found that of the patients reported some form of plastic surgery or medical treatment , with dermatology treatment the most reported ( 45 ) followed by plastic surgery ( 23 ) The problem with this type of treatment is that the individual is rarely satisfied with the outcome of the procedure , thus leading them to seek out additional surgeries on the same defect ( Phillips et , 2001 ) Therefore , it is important that medical professionals 199

Fundamentals Disorders thoroughly screen patients for psychological distress before completing any medical treatment . Hoarding Disorder Recent research has concluded that unlike OCD , many individuals with hoarding disorder do not experience intrusive thoughts , nor do they experience urges to perform rituals . Because of this difference , treatment for hoarding disorder has moved away from exposure and response prevention , and more toward a traditional approach . Frost and ( 1996 ) believed that individuals with hoarding disorder engage in complex making processes , overanalyzing the value and worth of possessions , thus leading to hoarding the object as opposed to discarding it . Therefore , in addition to having the individual engage in exposure treatment , an added component of cognitive restructuring and motivational interviewing are added to address the making that is involved in maintaining unnecessary possessions . By discussing motives for keeping items , as well as fears that may be associated with discarding items , can assist patients in their cognitive processes to ultimately determine the item actual worth ( Williams , 2016 ) Unfortunately , due to the distressing nature of having to discard their possessions , many individuals in treatment for hoarding disorder prematurely end treatment , thus never reaching remission of symptoms ( 2011 ) Key Takeaways You should have learned the following in this section Treatment options for OCD include exposure and response prevention , as well as though the drug does not provide an added benefit in treatment . Treatment options for body disorder include exposure and response prevention and drugs and . Treatment options for hoarding disorder include exposure treatment , cognitive restructuring , and motivational interviewing . Section Review Questions . Discuss the various types of treatments for OCD . Which treatment option has the best outcome ?

What are the different components of Exposure and Response Prevention ?

How do they work together to reduce OCD symptoms ?

What are the most effective treatment approaches for body disorder ?

According to Frost and ( 1996 ) what are the main components that contribute to the maintenance of hoarding disorder ?

200 Fundamentals Disorders Module Recap As in all modules past , we have discussed the clinical presentation , epidemiology , etiology , and treatment options for a specific class of disorders obsessive compulsive and related disorders . edition 201