Obsessive compulsive dis order (OCD) Dr. Safeyya Adeeb Alchalabi

OCD

Obsessive compulsive disorder (OC D) A common, chronic condition, of ten associated with marked anxiet y and depression, characterised by obsessions and compulsions.A common, chronic condition, of ten associated with marked anxiet y and depression, characterised by obsessions and compulsions.

Obsessive compulsive disorder (OC D) Obsessions/compulsions must cause distress orObsessions/compulsions must cause distress or interfere with the person's social or individual functioni ng (usually by wasting time), andinterfere with the person's social or individual functioni ng (usually by wasting time), and should not be the result of another psychiatric disorder.should not be the result of another psychiatric disorder. At some point in the disorder, the person recognizes the sy mptoms to be excessive or unreasonable.At some point in the disorder, the person recognizes the sy mptoms to be excessive or unreasonable.

Clinical features

Principal features of obsess ivecompulsive disorder Obsessional symptom ThoughtsRuminationsImpulses'Phobias' Compulsive rituals Abnormal slowness AnxietyDepressionDepersonalization

Obsessional thoughts words, ideas, and beliefs words, ideas, and beliefs recognized by patients as their own, recognized by patients as their own, intrude forcibly into the mind. intrude forcibly into the mind. unpleasant, or shocking to the person, (may be obscene or blasphemous). unpleasant, or shocking to the person, (may be obscene or blasphemous). atempts are made to exclude them. It is the combination of an inner sense of compulsion and of efforts at resistance that characterizes obsessional symptoms, Obsessional thoughts may take the form of single words, phrases, or rhymes, Obsessional images are vividly imagined scenes, often of a violent or disgusting ki nd (e.g. involving sexual practices that the person finds abhorrent.

Obsessional rumnations are internal debates in which argum ents for and against even the simples t everyday actions are reviewed endle ssly. are internal debates in which argum ents for and against even the simples t everyday actions are reviewed endle ssly.

Obsessional impulses are urges to perform acts, usually of a violen t or embarrassing kind (e.g. leaping in front o f a car, injuring a child, or shouting blasphem ies at a religious ceremony). are urges to perform acts, usually of a violen t or embarrassing kind (e.g. leaping in front o f a car, injuring a child, or shouting blasphem ies at a religious ceremony).

Obsessional rituals include both mental activities (e.g. counting repeat edly in a special way, or repeating a certain form of words) and repeated but senseless behaviours (e.g. washing the hands 20 or more times a day). include both mental activities (e.g. counting repeat edly in a special way, or repeating a certain form of words) and repeated but senseless behaviours (e.g. washing the hands 20 or more times a day).

Obsessional slowness. Although obsessional thoughts and rituals l ead to slow performance, a few obsessional p atients are afflicted by extreme slowness that is out of proportion to other symptoms.

Obsessional phobias. Obsessional thoughts and compulsive rituals may worsen in certain situations-for example, obsession al thoughts about harming other people may incre ase in a kitchen or other place where knives are ke pt. The person may avoid such situations because t hey cause distress.

Anxiety This is a prominent component of obsessivecomp ulsive disorders. Some rituals are followed by a lessening of anxiety, while others are followed by increased anxiety.

Depression Obsessional patients are often depressed. Obsessional patients are often depressed. In some patients, depression is an understandable reaction to the obsessional symptoms; in others, d epression appears to vary independently. In some patients, depression is an understandable reaction to the obsessional symptoms; in others, d epression appears to vary independently.

Depersonalization. Some obsessional patients complain of depersona lization. The relationship between this distressing symptom and the other features of the disorder is unclear.

Differential diagnosis Anxiety disordersAnxiety disorders Depressive disorderDepressive disorder SchizophreniaSchizophrenia Organic disordersOrganic disorders

Epidemiology Mean age: 20 yrs,Mean age: 20 yrs, 70% onset before age 25 yrs,70% onset before age 25 yrs, 15% after age 35 yrs.15% after age 35 yrs. Sex distribution equal.Sex distribution equal. Prevalence: 0.5-3% of general population.Prevalence: 0.5-3% of general population.

Aetiolo gy of OCD

Aetiology of OCD Neurochemical Dysregulation of the 5HT system, or 5HT/DA interaction.Neurochemical Dysregulation of the 5HT system, or 5HT/DA interaction. Immunological Cell-mediated autoimmune factors may be associated (e.g. aga inst basal ganglia peptides_as in Sydenham’s chorea).Immunological Cell-mediated autoimmune factors may be associated (e.g. aga inst basal ganglia peptides_as in Sydenham’s chorea). Imaging CT and MRI: bilateral reduction in caudate size. PET/SPECT: hype rmetabolism in orbitofrontal gyrus and basal ganglia (caudate nuclei) that normaliz es following successful treatment (either pharmacological or psychological).Imaging CT and MRI: bilateral reduction in caudate size. PET/SPECT: hype rmetabolism in orbitofrontal gyrus and basal ganglia (caudate nuclei) that normaliz es following successful treatment (either pharmacological or psychological). Genetic Suggested by family and twin studies (3-7% of first-degree relatives affe cted, MZ: 50-80% DZ: 25%.), no candidate genes as yet identified.Genetic Suggested by family and twin studies (3-7% of first-degree relatives affe cted, MZ: 50-80% DZ: 25%.), no candidate genes as yet identified. Psychological Defective arousal system and/or inability to control unpleasant int ernal states. Obsessions are conditioned (neutral) stimuli, associated with an anxiet y-provoking event. Compulsions are learned (and reinforced) as they are a form of anxiety-reducing avoidance.Psychological Defective arousal system and/or inability to control unpleasant int ernal states. Obsessions are conditioned (neutral) stimuli, associated with an anxiet y-provoking event. Compulsions are learned (and reinforced) as they are a form of anxiety-reducing avoidance. Psychoanalytical Regression from Oedipal stage to pre-genital anal-erotic stage o f development as a defence against aggressive or sexual (unconscious) impulses. As sociated defences:isolation, undoing, and reaction formation.Psychoanalytical Regression from Oedipal stage to pre-genital anal-erotic stage o f development as a defence against aggressive or sexual (unconscious) impulses. As sociated defences:isolation, undoing, and reaction formation.

Associations Avoidant, dependent, histrionic traits (-40% of case s),Avoidant, dependent, histrionic traits (-40% of case s), anankastic/obsessive-compulsive traits (5-15%) pri or to disorder.anankastic/obsessive-compulsive traits (5-15%) pri or to disorder. In schizophrenia, 5-45% of patients may present wi th symptoms of OCD (schizo-obsessive poorer pro gnosis).In schizophrenia, 5-45% of patients may present wi th symptoms of OCD (schizo-obsessive poorer pro gnosis). Sydenham chorea (up to 70% of cases) and other b asal ganglia disorders (e.g. Tourette’s Syndrome, p ost-encephalitic parkinsonism).Sydenham chorea (up to 70% of cases) and other b asal ganglia disorders (e.g. Tourette’s Syndrome, p ost-encephalitic parkinsonism).

Comorbidity Depressive disorder (50-70%),Depressive disorder (50-70%), alcohol- and drug-related disorders,alcohol- and drug-related disorders, social phobia,social phobia, specific phobia,specific phobia, panic disorder,panic disorder, eating disorder,eating disorder, PTSD,PTSD, tic disorder (up to 40% in juvenile OCD) or TS. tic disorder (up to 40% in juvenile OCD) or TS.

Management

Management PsychologicalPharmacologicalPhysical CBT(behavioural) Psychotherapy(supportive,groups) Psychoanalytical(insight-oriented) Cognitive (not proven effective) Behavioural SSRIs* or SNRI(Venlafaxine) Clomipramine** SNRIVenlafaxine Augmentation*** ECT(suicide,severe) Psychosurgery**** thought stopping may help in ruminations ruminations Response prevention useful in useful in ritualistic behaviour exposure techniques for obsessions for obsessions Buspironantipsychotic Deep Brain Stimulation DBS(severe refractory)

Management *Antidepressants SSRIs: fluoxetine, fluvoxamine, sertraline, or paroxetine shoul d be considered first-line (no clear superiority of any one agent, high doses usu ally needed (e.g mg fluoxetine, allow at least 12 wks for treatment respon se, regard as long-term).*Antidepressants SSRIs: fluoxetine, fluvoxamine, sertraline, or paroxetine shoul d be considered first-line (no clear superiority of any one agent, high doses usu ally needed (e.g mg fluoxetine, allow at least 12 wks for treatment respon se, regard as long-term). **Clomipramine (e.g mg) has specific anti-obsessional action**Clomipramine (e.g mg) has specific anti-obsessional action ( second-line choice). ( second-line choice). ***Augmentative strategies:***Augmentative strategies: –antipsychotic (risperidone, haloperidol, pimozide) if psychotic features,if psychotic features, tics, ortics, or schizotypal traits;schizotypal traits; – buspirone/short term clonazepam if marked anxiety ****psychosurgery may be considered for severe, incapacitating intractable cas es, i.e treatment resistance:****psychosurgery may be considered for severe, incapacitating intractable cas es, i.e treatment resistance: –2 antidepressants, –3 combination treatment, –ECT, and – behavioural therapy) where the patient can given informed consent e.g. stereotactic cingulotomy (re ported up to 65% success). In theory, disrupts the neuronal loop between the or bitofrontal cortex and the basal ganglia. where the patient can given informed consent e.g. stereotactic cingulotomy (re ported up to 65% success). In theory, disrupts the neuronal loop between the or bitofrontal cortex and the basal ganglia.

Course

Course Often sudden onset (e.g. after stressful loss e vent,e.g loss, pregnancy, sexual problem),Often sudden onset (e.g. after stressful loss e vent,e.g loss, pregnancy, sexual problem), symptom intensity may fluctuate (contact-re lated/phasic) or be chronic.symptom intensity may fluctuate (contact-re lated/phasic) or be chronic.

Differential diagnosis Normal (but recurrent) thoughts, worries, or habits;Normal (but recurrent) thoughts, worries, or habits; anankastic PD/OCD,anankastic PD/OCD, schizophrenia;schizophrenia; phobias;phobias; depressive disorder;depressive disorder; hypochondriasis;hypochondriasis; body dysmorphic disorder;body dysmorphic disorder; trichotillomania.trichotillomania.

Outcome

Outcome 20-30% significantly improve,20-30% significantly improve, 40-50% show moderate improvement,40-50% show moderate improvement, but 20-40% have chronic or worsening symp toms. but 20-40% have chronic or worsening symp toms. Relapse rates are high for stopping medicati on. Relapse rates are high for stopping medicati on. Suicide rate increased esp. if there is second ary depression.Suicide rate increased esp. if there is second ary depression.

Prognosis

Prognostic factors Poor prognosis:Poor prognosis: Giving in to compulsions, Giving in to compulsions, longer duration,longer duration, early onset,early onset, male,male, presence of tics,presence of tics, bizarre compulsions,bizarre compulsions, hoarding,hoarding, symmetry,symmetry, comorbid depression,comorbid depression, delusional beliefs or overvalued i deas,delusional beliefs or overvalued i deas, personality disorder (esp. schiz otypal PD). personality disorder (esp. schiz otypal PD). Better prognosis: Good premorbid social an d occupational adjustment, a precipitating event, episodic symptoms, less avoidance.

Thank you