Obsessive compulsive disorder (OCD) ا.د.الهام الجماس

OCD

Obsessive compulsive disorder (OCD) A common, chronic condition, often associated with marked anxiety and depression, characterised by obsessions and compulsions .

Obsessive compulsive disorder (OCD) Obsessions/compulsions must cause distress or interfere with the person's social or individual functioning (usually by wasting time), and should not be the result of another psychiatric disorder. At some point in the disorder, the person recognizes the symptoms to be excessive or unreasonable.

Clinical features

Principal features of obsessivecompulsive disorder Obsessional symptom Thoughts Ruminations Impulses 'Phobias' Compulsive rituals Abnormal slowness Anxiety Depression Depersonalization

Obsessional thoughts words, ideas, and beliefs recognized by patients as their own, intrude forcibly into the mind. 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 kind (e.g. involving sexual practices that the person finds abhorrent.

Obsessional rumnations are internal debates in which arguments for and against even the simplest everyday actions are reviewed endlessly.

Obsessional impulses are urges to perform acts, usually of a violent or embarrassing kind (e.g. leaping in front of a car, injuring a child, or shouting blasphemies at a religious ceremony).

Obsessional rituals include both mental activities (e.g. counting repeatedly 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 lead to slow performance, a few obsessional patients 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, obsessional thoughts about harming other people may increase in a kitchen or other place where knives are kept. The person may avoid such situations because they cause distress.

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

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

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

Differential diagnosis Anxiety disorders Depressive disorder Schizophrenia Organic disorders

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

Aetiology of OCD

Aetiology of OCD Neurochemical Dysregulation of the 5HT system, or 5HT/DA interaction. Immunological Cell-mediated autoimmune factors may be associated (e.g. against basal ganglia peptides_as in Sydenham’s chorea). Imaging CT and MRI: bilateral reduction in caudate size. PET/SPECT: hypermetabolism in orbitofrontal gyrus and basal ganglia (caudate nuclei) that normalizes following successful treatment (either pharmacological or psychological). Genetic Suggested by family and twin studies (3-7% of first-degree relatives affected, MZ: 50-80% DZ: 25%.), no candidate genes as yet identified. Psychological Defective arousal system and/or inability to control unpleasant internal states. Obsessions are conditioned (neutral) stimuli, associated with an anxiety-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 of development as a defence against aggressive or sexual (unconscious) impulses. Associated defences:isolation, undoing, and reaction formation.

Associations Avoidant, dependent, histrionic traits (-40% of cases), anankastic/obsessive-compulsive traits (5-15%) prior to disorder. In schizophrenia, 5-45% of patients may present with symptoms of OCD (schizo-obsessive poorer prognosis). Sydenham chorea (up to 70% of cases) and other basal ganglia disorders (e.g. Tourette’s Syndrome, post-encephalitic parkinsonism).

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

Management

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

Management *Antidepressants SSRIs: fluoxetine, fluvoxamine, sertraline, or paroxetine should be considered first-line (no clear superiority of any one agent, high doses usually needed (e.g. 40-60 mg fluoxetine, allow at least 12 wks for treatment response, regard as long-term). **Clomipramine (e.g. 250-300 mg) has specific anti-obsessional action ( second-line choice). ***Augmentative strategies: antipsychotic (risperidone, haloperidol, pimozide) if psychotic features, tics, or schizotypal traits; buspirone/short term clonazepam if marked anxiety ****psychosurgery may be considered for severe, incapacitating intractable cases, i.e treatment resistance: 2 antidepressants, 3 combination treatment, ECT, and behavioural therapy) where the patient can given informed consent e.g. stereotactic cingulotomy (reported up to 65% success). In theory, disrupts the neuronal loop between the orbitofrontal cortex and the basal ganglia.

Course

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

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

Outcome

Outcome 20-30% significantly improve, 40-50% show moderate improvement, but 20-40% have chronic or worsening symptoms. Relapse rates are high for stopping medication. Suicide rate increased esp. if there is secondary depression.

Prognosis

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

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