1. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS Dan J. Stein University of Cape Town

2. OCD OBSESSIONS: Recurrent and persistent thoughts COMPULSIONS: Repetitive behaviors or mental acts Distress/Dysfunction

3. OCD Contamination concerns  hand-washing Possible harm concerns  checking Symmetry concerns  symmetry behaviours

4. NOT OCD Obsessive-compulsive personality disorder Pathological or problem gambling, compulsive sexual disorder, problematic internet use Hoarding concerns  hoarding behaviors Being a meticulous professional or student

5. OCD 4 th most common psychiatric disorder in one USA study 10 th most disabling of all medical disorders in WHO BoD study Subclinical washing, checking, symmetry, symptoms are common (Ruscio et al, 2008)

6. OCD Spectrum Range of disorders with intrusive thoughts and repetitive behaviors - Tourette’s syndrome - Body Dysmorphic Disorder - Hypochondriasis - Hoarding Disorder - Trichotillomania - Skin Picking Disorder

7. Psychodynamic Approach Character  Neurosis  Psychosis Similarity in central unconscious conflicts Differences in certain psychodynamics

8. Cognitive-Behavioral Approach OCDS  OCD  OCDS Similarity in cognitive-behavioral function Differences in particular contents

9. Psychobiological Approach OCDS  OCD  OCDS Similarity in central psychobiol mechanisms Differences in certain psychobiol processes

11. Baseline After SSRI OCD Pre/Post SSRI

12. So: Range of Presentations Dermatologist:Dermatitis, Loss of Hair Neurologist: Tics Plastic Surgeon: Somatic concerns Internist: Hypochondriacal concerns Pediatrician: Early onset Obstetrician: Pregnancy

13. But: Overlapping Neurobiology OCD  OCD+Tics  Tics 5-HT genes  DA genes?? Good evidence that OCD and TS have a genetic relationship

14. And: Overlapping Pharmacology SRIs more effective than NRIs: OCD Body Dysmorphic Disorder, Hypochondriasis? Hoarding Disorder? Trichotillomania, Skin Picking Disorder? O-C symptoms in Tourette’s, in autism, in intellectual disability

15. Animal Stereotypy Pre-SSRI Post-SSRI

17. Animal Stereotypy

19. “From Bench to Bedside” (Harvey et al, 2008)

20. Somatic Preoccupations

21. OCD  BDD/ORS/HYP  anorexia (with or without insight) BDD is in DSM-5 OCRD section ORS likely in ICD-11 OCRD section HYP likely in ICD-11 OCRD section

22. Somatic Preoccupations OCD  BDD/ORS/HYP  anorexia (with or without insight) First line Rx of BDD/ORS/HYP is SSRI / CBT

24. Hoarding Behaviours

25. (Saxena et al, 2004)

26. Hoarding Behaviours OCD  Hoarding  OCPD hoarding Hoarding Disorder is in DSM-5 OCRD Criteria do not overlap with Collecting! Neuroanatomy slightly different from OCD

27. Hoarding Behaviours OCD  Hoarding  OCPD hoarding First line Rx of Hoarding Disorder is SSRI / CBT

28. Stereotypies/Grooming

30. “From Bench to Bedside”

31. Stereotypies/Grooming OCD  TTM/SPD  SMD/SIB TTM/SPD are in DSM-5 OCRD Partly due to consumer advocacy!

32. Stereotypies/Grooming OCD  TTM/SPD  SMD/SIB First line Rx of TTM/SPD is CBT Growing interest in N-acetylcysteine

33. Tics/Involuntary Movements

34. OCD/soft signs  OCD/tics  TS OCD has a tic specifier in DSM-5 TS likely in ICD-11 OCDR section Some evidence of overlapping neuroimmunology

35. PANDAS

36. “From Bench to Bedside”

37. (Harvey et al, 2008)

38. Tics/Involuntary Movements OCD/soft signs  OCD/tics  TS Rx options in Tourette’s Disorder include DA blockers / CBT

39. Treatment-Resistant OCD 27 short-term trials of Rx-resistant anxiety 19 investigated augmentation in OCD Similar design features eg low doses of antipsychotic agents in SRI non-responders Overall symptom severity reduced to a larger extent with these agents (Ipser et al, 2006)

40. OCD Treatment Principles Useful to screen for intrusive thoughts and repetitive behaviours Patients with one OCRD may well have another, or MDD / etc

41. OCD Treatment Principles Range of standardized OCS symptom severity measures available eg YBOCS Range of accurate information available on internet eg OCF, TLC

42. OCD Treatment Principles Exposure and response prevention is a highly effective form of Rx Many resources available eg OCF, www.stoppulling.com Important to involve partners and/or family

43. OCD Treatment Principles SSRIs are effective for OCD and for several OCRD Higher dose and longer duration than in MDD Consider referral after 2 different 12 week trials of SSRIs fail

44. Psychobiology: Pharmacotherapy * * * ** * * * * * * * p<0.05 vs PBO, ** p<0.01 vs PBO (Stein et al, 2007)

45. Treatment Resources MRC Unit Anxiety Disorders (cl2@sun.ac.za) GSH OCD Evaluations (dan.stein@uct.ac.za) Internet: –SADAG Support Groups –Obsessive-Compulsive Foundation (OCF) –Trichotillomania Learning Centre (TLC)

46. CONCLUSION OCRD are seen universally (and indeed DSM- 5 field surveys were from RSA) The psychobiology and treatment of OCD is increasingly understood

47. CONCLUSION Provides the basis for the DSM-5 / ICD-11 construct of OC and Related Disorders Aims to help recognize and Rx some key prevalent, overlooked, disabling conditions

48. CONCLUSION Initial Rx of these disorders should be initiated in primary care Referral resources are available in more refractory cases