Obsessive-Compulsive Disorder

Obsessions as defined by Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress The thoughts, impulses, or images are not simply exces­ sive worries about real-life problems The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Typical Obsessions Doubts (e.g. Did I turn off the stove? Did I lock the door? Did I hurt someone?) Fears that someone else has been hurt or killed Fears that one has done something criminal Fears that one may accidentally injure someone Worry that one has become dirty or contaminated Blasphemous or obscene thoughts

Compulsions as defined by Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

Typical Compulsions Checking Cleaning/washing Doing things a certain number of times in a row Doing and then undoing things Doing things in a certain order, with symmetry Mental acts such as praying, counting, etc.

Obsessive-Compulsive Disorder Either obsessions or compulsions The person has recognized that the obsessions or compulsions are excessive or unreasonable There is significant distress or an impairment in functioning due to the obsessions or compulsions The disturbance is not due to a GMC or substance

OCD Distribution 80% of normal people report obsessions; 54% report compulsions Lifetime prevalence 2 - 3% No gender difference Begins either before age 10 or 18-30 Less common among African Americans and Mexican Americans More common in divorced, separated, or unemployed people

Aetiology of OCD Psychoanalytical theories: attempt to suppress instinctual drives – sexual and aggressive – arising from the anal stage Biological theories: Brain injury/trauma/acute disease and/or neurochemical (serotonin); Genetic factors Behavioural and Cognitive theories: conditioning; modelling; memory deficits

OCD - Management Behaviour therapy CBT - less useful Pharmacotherapy Exposure and response prevention Paradoxical injunctions CBT - less useful Pharmacotherapy SSRIs, Clomipramine Augmentation with risperidone Clonazepam

OCD Psychosurgery - indicated rarely for severe intractable cases Outcome 60% respond to SSRIs but relapse is common on cessation of tx Predictors of poor outcome are male sex, early onset and obsessional slowness