Download Obsessive Compulsive Disorder

Obsessive Compulsive
Disorder
Dr Rebecca Jacob
Consultant Psychiatrist
Fulbourn Hospital
Cambridge
• Obsessive-Compulsive Disorder, OCD, is an anxiety
disorder and is characterized by recurrent, unwanted
thoughts (obsessions) and/or repetitive behaviors.
• Excessive doubt, the need for completeness, shame,
and abnormal assessment of risk in the mind of the
patient are thought to underlie most obsessions.
• Repetitive behaviors (compulsive acts) such as hand
washing, counting, checking, or cleaning are often
performed with the hope of preventing obsessive
thoughts or making them go away.
• Performing these so-called "rituals," however, provides
only temporary relief, and not performing them markedly
increases anxiety
Most Common Symptoms
Obsessions
•
Fear of causing harm to someone
•
Fear of harm coming to self
•
Fear of contamination
•
Need for symmetry or exactness
•
Sexual and religious obsessions
•
Fear of behaving unacceptably / making a mistake
Compulsions
•
Cleaning
•
Hand-washing
•
Checking
•
Ordering and arranging
•
Hoarding
•
Asking for reassurance
Mental acts
•
Counting
•
Repeating words silently
•
Ruminations
•
“Neutralising” thoughts
The obsessive-compulsive disorder cycle.
Heyman I et al. BMJ 2006;333:424-429
©2006 by British Medical Journal Publishing Group
Helpful Screening Questions
• “Do you have repetitive thoughts that make
you anxious and that you cannot get rid of
regardless of how hard you try?”
• “Do you keep things extremely clean or wash
your hands frequently?”
• “Do you check things to excess?”
Jenike et al N Engl J Med 2004; 350:259-26
ICD 10 diagnosis
• Symptoms present for >2 weeks, most days
a) Obsessional symptoms recognized as
individuals own thoughts.
b) At least one thought that is still resisted
unsuccessfully.
c) Thought of carrying out acts not in itself
pleasurable.
d) Thoughts images or impulses
repetitive.
Epidemiology
• Onset usually in childhood or early adult life.
• M:F ratio 1:1
• Total prevalence 2.1% (pure form without comorbidity 1.2%)
• Community samples 60-70% obsessions
only, secondary care >70% suffer both
obsessions and compulsions.
Aetiology
• Genetics: twin studies > concordance in
monozygotic twins. Molecular studies,
associations OCD gene coding/ 5HT ID.
• Evidence of brain disorder:
1.Tourettes, Sydenham’s chorea, PANDAS
• 2. Brain Imaging: no structural
abnormalities but functional imaging
(PET) activity orbitofrontal cortex,
anterior cingulate gyrus, caudate
nucleus and thalamus (altered with Rx).
• Psychoanalytical- Freud suggested unconscious
impulses (aggressive/ sexual) with attendance
defence mechanism (repression, reaction
formation).
• Learning theory - abnormal learning with
avoidance response
• Cognitive Theory- deal with pts response rather
than focusing on intrusive thoughts.
• Abnormal Serotonergic function: Some studies
measuring serotonin transport (PET/SPECT)
suggestive but not conclusive.
• Early Experience- nature AND nurture, weak
link,stronger in non-specific neurosis.
Differential Diagnoses
• Anxiety Disorders
• Depressive disorders
• Schizophrenia-OCD thoughts may resemble
delusions
• Organic disorders: ecephalitis lethargica,
Tourettes.
Conditions that commonly occur with
obsessive-compulsive disorder
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•
•
•
•
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•
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Condition
Depression
Specific phobia
Social phobia
Eating disorder
Alcohol dependence
Panic disorder
Tourette's syndrome
Schizophrenia
Frequency (%)
50-60
22
18
17
14
12
7
14
Non-psychiatrists likely to see patients with
obsessive-compulsive disorder (OCD)
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•
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•
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Professional
General practitioner
Dermatologist
Cosmetic surgeon
disorder)
Oncologist
GU specialist
Neurologist
Obstetrician
Gynaecologist
Reason for consultation
Depression, anxiety
Chapped hands, eczema, trichotillomania
Concerns about appearance (body dysmorphic
Fear of cancer
Fear of HIV
OCD associated with Tourette's syndrome
OCD during pregnancy or puerperium
Vaginal discomfort from douching
Heyman et al BMJ 2006; 333 : 424
Management
• Psycho-eduction
• Investigation
• Treatments
(Assessments of severity and treatment
response with rating scales- best validated
Yale-Brown (Y-BOCS) scale.)
Treatment
• Medication- SSRI’s, Clomipramine SSRI’s plus
augmentation strategies (antipsychotics
/anixiolytics)
• Cognitive Therapy-remedying faulty reasoning
that may have developed with the disorder.
• CBT
• Neurosurgery
Cognitive Behavioural
Therapy
• The patient generates a hierarchy of feared
situations and then practices facing the fear
(exposure),
• During the exposure to the event he/she will
monitor the anxiety and note that it lessens without
the need to carry out a ritual (response prevention).
Neurosurgery
(limited RCT evidence)
•
Anterior cingulotomy, anterior capsulotomy, subcaudate tractotomy, and
limbic leucotomy. ( Blocks connections between dorsolateral and the
orbitomedial areas of the frontal lobes and limbic and thalamic structures).
•
Deep brain stimulation, surgically implanted electrodes that can be turned
on and off to stimulate or inhibit activity in surrounding brain tissue, has
been used for the treatment of Parkinson's disease and intractable pain;
•
Transcranial magnetic stimulation, whereby pulses of magnetic energy are
intermittently administered to surface regions of the brain through the skull,
appeared to be effective in one preliminary study.54
Treatment options for adults with obsessive-compulsive disorder (OCD).
Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. London:
NICE, 2005. (Clinical guideline 31.)06;333:424-429
©2006 by British Medical Journal Publishing Group
Unanswered Research Questions in obsessivecompulsive disorder (OCD)
Nosological status of OCD
Should OCD be classified as an anxiety disorder?
Do subtypes exist, each with different causes (for example, early
onset OCD, OCD with co-morbid tics, compulsive hoarding)?
Are hypochondriasis, body dysmorphic disorder, and other
“spectrum” disorders variants or completely separate disorders?
Causative Factors
What are the precise genetics of OCD?
Might environmental factors such as family
environment or streptococcal infection be risk factors?
Management Questions
What is the most effective cognitive behaviour therapy
package in terms of intensity and length of treatment and
training of therapist?
For how long should drugs be used?
What makes some cases treatment resistant? How
might treatments be best modified for these cases?
Lecture session 2
Clinical Encounter
• A 30 year old lady is referred to you by
her GP with symptoms of anxiety,
breathlessness and increasing social
isolation.
• How would you manage this case?
Anxiety Disorders
• Phobias (Specific/Social)
• Panic Disorder
• Generalized Anxiety Disorder
• OCD
• PTSD/ Acute stress, Adjustment disorders)
Generalized Anxiety Disorder
• Essential feature is anxiety, generalized and
not persistent but not restricted to any
particular environment ‘free floating’.
• In addition to cognitive anxiety, autonomic
symptoms must be evident.
ICD 10 Diagnosis
• Primary symptoms of anxiety for weeks and
usually several month:
a)Apprehension, worries, feeling on edge
b)Motor tension, fidgeting, headaches
c)Autonomic overactivity,sweating, dizziness
etc
Co-morbidities
• Major depression most common coexisting psychiatric illness
, occurring in almost two thirds of such patients.
• Panic disorder occurs in a quarter of patients with
generalized anxiety disorder, and alcohol abuse in more than
a third.
•
In prospective studies, anxiety almost always appears to be
the primary disorder and to increase the risk of depression.
Treatment
Non-pharmacological`:
• Counseling: absence of well conducted
controlled trials in other therapies
• Relaxation Training
• CBT
Pharmacological
Medication- : Short term (2-3 weeks)
anxiolytics e.g. long acting
benzodiazepines
• Diazepam
• Alprazolam
• Clonazepam
(BEWARE DEPENDANCE)
Longer term:
• other Anxiolytics- Buspirone
• Antidepressants SSRI’s
• Antipsychotics fluanxiol
• Beta-adrenoceptor anatogonists,
propranolol
References
• ICD 10
• NICE Guidelines Obsessive Compulsive and Body
Dysmorphic Disorders.
• Nice Guidelines Anxiety Disorders (GAD and Panic
Disorders) in Primary and Secondary Care
• Oxford Textbook of Psychiatry
• Hineman et al BMJ 2006; 333 : 424
• Jenike et al N Engl J Med 2004; 350:259-265