Obssessive-Compulsive Disorder: Clinical Features and Diagnosis Flavio Guzman, MD

Overview DSM V criteria for OCD Symptom clusters Diagnostic issues Epidemiology of OCD

Obsessions Compulsions

Obsessions - DSM V criteria Recurrent and persistent Intrusive and unwanted Cause marked anxiety and distress Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Arlington, VA: American Psychiatric Association, 2013.

Obsessions - DSM V criteria The patient attempts to: Ignore or suppress Neutralize with a compulsion Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Arlington, VA: American Psychiatric Association, 2013.

Compulsions – DSM V Criteria Repetitive behaviors Hand washing, ordering, checking Repetitive mental acts Praying, counting, repeating words silently Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Arlington, VA: American Psychiatric Association, 2013.

Compulsions – DSM V criteria Compulsions are aimed at: Preventing or reducing anxiety or distress Preventing an event or situation Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Arlington, VA: American Psychiatric Association, 2013.

Time and impact of OCD symptoms – DSM V Time consuming Cause significant distress or impairment in Social functioning Occupational functioning Other areas of functioning Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Arlington, VA: American Psychiatric Association, 2013.

Insight specifier DSM IV DSM V With poor insight With good or fair insight With absent insight / delusional belief Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Arlington, VA: American Psychiatric Association, 2013.

Tic specifier Specifier Description Tic related The individual has a current or past history of a tic disorder Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Arlington, VA: American Psychiatric Association, 2013.

Symptom clusters

Frequency of common obsessions and compulsions in a clinic sample of 560 patients with obsessive-compulsive disorder Obsessions % Compulsions Contamination 50 Checking 61 Pathological doubt 42 Washing Somatic 33 Counting 36 Need for symmetry 32 Need to ask or confess 34 Aggressive 31 Symmetry and precision 28 Sexual 24 Hoarding 18 Multiple obsessions 72 Multiple compulsions 58 Hales, R., Yudofsky, S. & Roberts, L. (2014). The American Psychiatric Publishing textbook of psychiatry. Washington, DC: American Psychiatric Publishing.

Contamination (obsession) / Washing (compulsion) Most prevalent obsession Dirt and/or germs Sources of contamination: door knobs, electric switches, newspapers Contamination obsession Hand washing, showering, cleaning Avoidance of sources of contamination Compulsions Nutt, D. & Ballenger, J. (2008). Anxiety Disorders. Oxford: John Wiley & Sons.

Doubt (obsession) / Checking (compulsion) Doubt is usually tinged with guilt Concern: if they do not check carefully enough they will harm others Doubt Often contributes to greater doubt Patients often enlist the help of family and friends Checking Nutt, D. & Ballenger, J. (2008). Anxiety Disorders. Oxford: John Wiley & Sons.

Doubt (obsession) / Checking (compulsion) Fear of causing a fire Fear of hurting someone while driving Doubt Checking the stove Repetitive driving back over the same spot Checking Nutt, D. & Ballenger, J. (2008). Anxiety Disorders. Oxford: John Wiley & Sons.

Pure obsessions Reprehensible to the thinker Themes: Somatic Aggressive Sexual Religious Obsessions Nutt, D. & Ballenger, J. (2008). Anxiety Disorders. Oxford: John Wiley & Sons.

Diagnostic issues

OCD prevalence can be underestimated OCD is egodystonic Patients are embarrassed of their symptoms Importance of screening Hudak, R. & Dougherty, D. (2011). Clinical obsessive-compulsive disorders in adults and children. Cambridge New York: Cambridge University Press.

Screening for obsessions and compulsions 5 useful questions: Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you would like to get rid of but you can’t? Do your daily activities take a lot of time to complete? Are you concerned about orderliness or symmetry? Hudak, R. & Dougherty, D. (2011). Clinical obsessive-compulsive disorders in adults and children. Cambridge New York: Cambridge University Press.

Differential diagnosis Depression Anxiety disorders GAD Specific phobia Psychotic disorders Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Arlington, VA: American Psychiatric Association, 2013.

Epidemiology Was once thought to be a rare condition Epidemiological Catchment Area (ECA) study: Large household sample of US residents Lifetime prevalence of OCD: 1.9% - 3.3% DSM V: 12-month prevalence is 1.2 % World Health Organization (WHO): OCD among the 10 medical and psychiatric conditions most likely to cause disability Hales, R., Yudofsky, S. & Roberts, L. (2014). The American Psychiatric Publishing textbook of psychiatry. Washington, DC: American Psychiatric Publishing. Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Arlington, VA: American Psychiatric Association, 2013.

OCD - Age of onset Average age of onset 21 Women: 19 years of age Men: 22 years of age 21% of patients report symptoms before puberty Late-onset OCD: 11% of patients will have onset of symptoms after the age of 30 years Hales, R., Yudofsky, S. & Roberts, L. (2014). The American Psychiatric Publishing textbook of psychiatry. Washington, DC: American Psychiatric Publishing.

Key Points Obsessions are thoughts, images or urges that are recurrent, persistent, intrusive and unwanted Obsessions are egodystonic They cause significant anxiety and distress Common themes include doubt and contamination

Key Points Compulsions include not only repetitive behaviors but mental acts DSM V has three possible insight specifiers Average age of onset is 21 years old Childhood onset: Late-onset OCD: 21%