Obsessive Compulsive Disorder and OC Spectrum Disorders J. Hancey, MD Dept. of Psychiatry Oregon Health Sciences University

The many faces of OCD Dermatologist: Chapped hands, eczema, Trichotillomania Oncologist/Infectious disease: Hypochondriasis (Cancer, AIDS) Neurologist: OCD associated with Tourette’s or other neurologic disorders Obstetrician: OCD during pregnancy or postpartum Pediatrician: Compulsive behavior, OCD secondary to Sydenham’s chorea, difficulty in school Plastic surgeon: Body dysmorphic disorder Dentist: Gum lesions from excessive teeth bleeding Family practitioner: Report of family member washing or checking excessively, comorbid affective or anxiety disorders, all of the above.

Definitions of OCD An anxiety disorder characterized by: Obsessions Recurrent and persistent ideas, impulses, thoughts, images that are intrusive and sometimes senseless Compulsions Repetitive, seemingly purposeful behaviors performed in response to an obsession (e.g., ritualistic or stereotypic behavior) Anxiety arises around resistance to obsessions and/or compulsions Anxiety may or may not be the primary feature of OCD

Diagnostic Criteria for OCD Either obsessions or compulsions Recognized by patients as excessive or unreasonable Obsessions or compulsions cause marked distress, are time consuming, or significantly interfere with functioning DSM-IVtm 1994:417-423

Obsessive-Compulsive Spectrum Disorders Preoccupations with bodily sensations or appearance Body Dysmorphic Disorder Depersonalization Anorexia nervosa Hypochondriasis OCD Tourette’s syndrome Sydenham’s chorea Torticollis Autism ADHD Sexual compulsions Trichotillomania Pathological gambling Kleptomania Self-injurious behavior Neurologic disorders Impulsive disorders Hollander et al, J Clin Psychiatry, 1966

Epidemiology of OCD 6-month point prevalence: 1.6% Life-time prevalence: 2.5% An estimated 3.9 million Americans had OCD in 1990 4th most common psychiatric disorder Double that of panic disorder or schizophrenia

Biological Differences of OCD Anatomy decreased caudate nucleus volume Biochemistry increased CSF 5-HIAA Physiology increased frontal and pre-orbital glucose utilization

Precipitating Factors 25%--depression and/or anxiety accompanied the initial symptoms 50% - 60%--stressors around the time of onset of symptoms --pregnancy --childbirth --sexual problems --death in family Streptococcal pharyngitis

The Streptococcal Connection Increasing evidence for an autoimmune etiology Group A beta hemolytic streptococcus Antineuronal antibodies Genetic vulnerability D8/17 positivity as a marker

PANDAS Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections

Treatment Medications Cognitive Behavioral Therapy

COGNITIVE THERAPY

Cognitive Therapy Re-label Re-attribute Re-focus Re-evaluate Schwartz, J. Brain Lock Pearl: Use a “mental garbage can”.

BEHAVIOR THERAPY

Behavior Therapy Effective behavior therapy involves Exposure: facing feared or avoided object, thought, situation, or place, preferably in vivo Response or ritual prevention: delaying and diminishing anxiety-reducing compulsions

SUD’S List: (Subjective Units of Distress) List compulsive behaviors Assign SUD’s value to each (0-100) Rank order from top to bottom Begin at the bottom of the list Best source: Baer, Lee. Getting Control. Pearl: Break up complex rituals into various parts

Serotonin Reuptake Inhibitors in the Treatment of Obsessive Compulsive Disorder

Fluoxetine vs Clomipramine 20 week crossover No difference between Y~BOCS Delayed response to 2nd drug Relapse occurred during washout <ADR with fluoxetine ADR = adverse drug reaction Pigott et al. Arch Gen Psychiatry, 1990;47:926-932.

Factors Affecting Serum Drug Levels Absorption Protein binding Metabolism Elimination

Utilizing P450 Inhibition 1A2 2D6 CMI Desmethyl CMI inactive

The Role of Anxiolytics When, What, and When to Worry Initial stages of treatment, prn BZD’s - the long and short of it abuse, dependence and addiction

Benzodiazepine Issues Abuse Physical dependence Addiction

Treatment Strategies SSRI beginning at low doses, gradually increasing to maximum doses minimum 10 week trial switch SSRIs augmentation clonazepam atypicals opioid agonism/antagonism acamprosate cognitive-behavioral therapy surgery

Gamma Knife