Obsessions repetitive and constants thoughts, images, or impulses that cause anxiety or distress thoughts, images, or impulses not about real-life problems Try to ignore or counter act thoughts, images, or impulses thoughts, images, or impulses “recognized as a product of one’s own mind and not imposed from without”

Compulsions Repetitive behaviors or mental acts person does in reaction to obsessions behaviors or mental acts done to avoid or decrease distress behaviors or mental acts are clearly excessive or not realistic

ICD-10(F.42) DSM IV TR (300.3)

Obsessive-Compulsive Disorder Obsessions- repetitive unwanted ideas that the person recognizes are irrational Compulsions- repetitive, often ritualized behavior whose behavior serves to diminish anxiety caused by obsessions

EPIDEMIOLOGY Affects almost 3% of world ’ s population In India life time prevalence of OCD is 2-3% common in persons from upper social class and with high intelligence

Demographic characteristics Gender Distribution Women appear to develop OCD slightly more frequently than men (1.5:1) Males develop OCD at a younger age than do females

Marital status % of patients who had never married was significantly higher rate In India OCD is more common in unmarried males. (other countries are not reported)

Course and nature of history Age at onset Usually in childhood or early adult life The onset for males occurred earlier than for females (19.5±9.2 yrs Vs 22.0 ±9.8yrs)

Course of illness It is continuous and chronic in which patients rarely symptom free at follow up A long term follow up studies shows that about 25% remained unimproved overtime, 50% had moderate to marked improvement while 25% had recovered completely.

I.BIOLOGICAL THEORIES: Neurotransmitters  Brain Serotonin(5HT) function may contribute to anxiety symptoms

Noradrenalin Higher plasma free 3- methoxy 4-hydroxy phenyl glycol and plasma nor-epineherine levels

Genetics  Family history:- OCD is found in 5-7% of first degree relatives of patients with OCD  Strongest evidence comes from twin studies

Electro physiological studies  EEG abnormalities can lead to OCD ( temporal lobe spikes and increased theta waves in sleep EEG)

Neuropsychological studies Frontal deficit, although non dominant – parietal deficits also seen in patients with OCD

Brain imaging Cranial CT and MRI scans Non specific abnormalities are found in patients with OCD

PET scans indicate differences in brain activity of OCD patients versus normal

II. Behavioral theories  Learning theory suggest that obsession ritual are the equivalent of avoidance responses.  Ritual acts produce relief and thus through negative reinforcement increase the possibility of repetition of the phenomena

Psychodynamic theory Freud suggested that obsessional symptoms results from repressed impulses of an aggressive or sexual nature. Obsession symptom occur as a result of regression to the anal stage of development It is consistent with the obsessional patient’s frequent concerns over excretory functions and dirt

Anal sadistic phase Reaction formation Anxiety related to oedipal conflicts Obsessional Personality traits New defenses Isolation affect Regression Fixation in development In presence of fixation at anal sadistic phase undoingDisplacement Early Child hood Disturbed development in Normally disguised by Reinforcement of anal/aggressive impulses Obsessive thoughts compulsive acts phobias Needed as reaction formation is not enough At present

Clinical features Four clinical syndromes 1.Washers 2.Checkers 3.Pure obsessions 4. primary obsessive slowness

washers Obsession is with contamination with dirt, germs, body excretions etc. Compulsion is washing of hands or the whole body repeatedly many times a day ( clothes, bath room, door knobs, personal articles)

Checkers Person has multiple doubts ( door has not been locked, kitchen gas has been left open, counting of money was not exact) Compulsion of course is checking repeatedly to remove the doubts.

Pure obsessions Repetitive intrusive thoughts, impulses or images which are not associated with compulsive acts. The content is usually sexual or aggressive in nature. A variant is obsessive rumination, the person ruminates in his mind about pros and cons of the thoughts concerned, repetitively

Primary obsessive slowness Severe obsessive ideas or extensive compulsive rituals leads to marked slowness in daily activities.

Assessment of OCD  Maudsley obsessional compulsive inventory (MOCI) 30 items –true or false questionnaire  Yale Brown obsessive compulsive scale (Y-BOCS) Rating on time spent, interference, distress, resistance and control for obsessions and compulsions

Diagnosis-ICD-10(F.42) Either obsessions or compulsions (or both), present on most days for a period of at least two weeks. The obsessional symptoms should have the following characteristics: a.They must be recognized as the individuals own thoughts and impulses b.There must be at least one thought or act that is still resisted un successfully, even though others may be present which he sufferer no longer resists c.the thought of carrying out the act must not in itself be pleasurable d.the thoughts, images or impulses must be unpleasantly repetitive.

Differential diagnosis Generalized anxiety disorder Panic disorder Phobic disorder Depressive disorder Schizophrenia Organic cerebral disorders

Types F42.0 Predominantly obsessional thoughts and ruminations F42.1 Predominantly compulsive acts F42.2 Mixed obsessional thoughts and acts F42.8 Other obsessive-compulsive disorders F42.9 Obsessive-compulsive disorder, unspecified

Pharmacological management Benzodiazepines :-eg-alprazolam, clonazepam. Antidepressants:- SSRI:- eg- clomipramine mg/day Fluoxetine 20-80mg/day Sertraline Fluoxamine

Cont…. Antipsychotics:- Eg:- haloperidol, risperidone, olanzapine Buspirone (anxiolytic)

Psychotherapy Psychoanalytic therapy (patients) Supportive psychotherapy (patients and family)

Behavioral therapy Techniques  Thought stopping  Response prevention  Systematic desensitization  modeling

Electro convulsive therapy Indications:-  Severe depression with OCD  Risk of suicide  Poor response to other mode of treatment ECT is not the treatment of first choice in OCD

Psychosurgery Perform incase of not responding to other mode of treatment benefit is the marked reduction in associated distress and severe anxiety Procedures Stereotactic limbic leucotomy Stereotactic subcaodate tractotomy

Reference Mary c Townsend.psychiatric mental health nursing,3 rd edition Oxford text of psychiatry. 2 nd edition Judith Haber, Anila S. Comprehensive psychiatric nursing. 5 th edition ICD- 10 classification of mental and behavioural disorder

compulsive-disorder/DS compulsive-disorder