Download Obsessive Compulsive Disorder handout

Obsessive-Compulsive Disorder
Stephanie C. Eken, MD, FAAP
Regional Medical Director
Rogers Behavioral Health
October 2015
Obsessive-Compulsive Disorder
• Either obsessions and/or compulsions.
• Obsessions are:
– Recurrent and intrusive thoughts, images and impulses.
– They are NOT excessive worries about real life problems.
– Because obsessions are unwanted and distressing, people try to
resist them, get rid of them, or reduce their distress in some way:
• Avoidance of triggers.
• Distraction.
• Compulsive behaviors or thoughts.
Examples of Obsessions
• Contamination (1).
• Repeated doubt (2).
• Harming (3).
• Need for exactness or
symmetry.
• Need to tell, ask, or
confess.
• Sexual imagery.
• Religious.
• Fear of Loss.
• Need for Perfection.
OCD: What is a compulsion?
• A compulsion is a behavior or mental act that a
person feels driven to perform over and over again
– to prevent or reduce anxiety, discomfort or distress.
– to “prevent” something bad from happening.
• Often performed in response to an obsession
• Often performed according to rigid rules or until it
feels “just right.”
Examples of Compulsions
• Checking (1).
• Washing or cleaning (2).
• Counting (3).
• Ordering/Arranging.
• Repeating.
• Praying.
• Requesting reassurance.
Commonly Asked Questions
• How common is OCD?
– 2.5% of population life-time prevalence.
• 1 in 100 adults diagnosed with OCD
• 1 in 200 children diagnosed with OCD
– 4th most common psychiatric condition in U.S.
• Sex differences?
– No (males do seem to develop earlier, however).
Commonly Asked Questions
• Onset?
– Onset can be as young as age three although the
average age of first symptoms is closer to age ten.
– Generally two ages when OCD first appears
• Between 8 and 12 years
• Between late teen years and early adulthood
– Roughly half by 18 years of age.
– Rarely after 50 years of age.
Associated Features
• Secondary depressed mood (85%).
• Academic and occupational impairment.
• Low self-esteem.
• Social withdrawal.
• Family discord.
• Fear of embarrassment (hide symptoms).
• Avoidance.
What is not OCD?
• Pathological gambling, kleptomania, substance
abuse disorders, certain sexual behaviors.
– Thoughts are not unwanted and may derive pleasure
from “compulsive” act.
– Typically, only want to stop because of negative
consequences of acts.
• Just because you do something over and over
again does not mean you have OCD.
Assessment of OCD
Children’s Yale-Brown Obsessive-Compulsive Scale
(CY-BOCS)
• 60 symptom checklist (past and current).
– 10 item severity rating scale (0-4).
– 5 questions regarding obsessions.
– 5 questions regarding compulsions.
– Mean score for OCD = 24.
CY-BOCS Scores
0 - 7 = subclinical.
8 - 15 = mild.
16 - 23 = moderate.
24 - 31 = severe.
32 - 40 = extreme.
Etiology of OCD
• Uncertain.
• Most believe that biology plays a role.
– Genetics?
• 20% of first-degree relatives will have OCD.
• Additional 15% will have “subclinical” symptoms.
• Does not appear to be learned (phenotypes different).
– Serotonin – chemical messenger in the brain
• Medications that reduce OCD symptoms increase available
levels of serotonin.
PANDAS
• Pediatric Autoimmune Neuropsychiatric
Disorders Associated with Strep.
– Acute (very sudden) onset of OCD-like symptoms
occurring during illness.
– May respond to antibiotic medications and reduce
symptoms.
– Accounts for small percentage of cases.
PANDAS (continued)
• May also exhibit:
–
–
–
–
–
–
Challenges with eating.
Sensory issues.
Handwriting deterioration.
Urinary frequency or bedwetting
Tics.
Separation anxiety and other fears.
• Typically, needs “traditional” treatment as well.
First-line Treatments of OCD
• Exposure and Response Prevention (ERP).
• Medications.
• Combination of medications and ERP.
Exposure and Response Prevention (ERP)
• A specific behavior therapy technique.
• Victor Meyer published first study in 1966.
• Based on the principle of habituation.
– Habituation is the decrease in anxiety experienced
with the passage of time.
• Examples: Wool sweater, cold pool
Exposure
• Placing an individual in feared situations (targets
the obsessions).
– Needs to be prolonged enough to lead to habituation
during an exposure to the feared situation (at least 50%
reduction in anxiety).
• Door knob example
– Needs to be repetitive enough to lead to habituation in
between exposures (until causes minimal to no anxiety).
– Needs to be graduated (increases compliance).
Response Prevention
• Blocking the typical response (compulsion)
before, during, and after exposure so habituation
can take place (targets compulsions).
– Replace the response with habituation as way of
controlling anxiety.
– Example, hand washing after touch a public door
knob
Typical OCD Scenario
High
Trigger
(Anxiety)
Low
60 sec
(Time)
Typical OCD Scenario
High
Response/Ritual/Compulsion
(Anxiety)
Low
60 sec
(Time)
Exposure and Response Prevention (ERP)
High
Exposure
(Anxiety)
Low
60 sec
(Time)
Exposure and Response Prevention (ERP)
High
Exposure
Response Prevention
(Anxiety)
Habituation
Low
60 sec
20 min
(Time)
Exposure and Response Prevention (ERP)
High
Exposure
Response Prevention
(Anxiety)
Low
20 min
60 sec
(Time)
ERP Treatment Steps
• Initial Evaluation (1-2 hours).
– Confirm diagnosis of OCD.
– Identify major problem areas (e.g., contamination,
doubting).
– Assess for common co-occurring illnesses.
– Educate patient and family about OCD and treatment
options.
ERP Treatment Steps (continued)
• Detailed Assessment Phase.
– CY-BOCS checklist and severity rating scale.
– Generate specific exposure exercises.
– Patient rates each exercise on scale of perceived
difficulty (i.e, 1-10 rating scale).
– Create exposure hierarchy/fear ladder.
ERP Treatment Steps (continued)
• Treatment Phase (conducting the hierarchy).
– Mild to moderate cases.
• Most cases can be treated in weekly outpatient .
– Moderate to severe cases.
• Typically need more intensive treatment (need more therapistaided exposure).
• Multiple visits per week, multiple hours per visit, for a 4-8 week
period of time.
• Dosage effect between severity of OCD and how much ERP
someone needs.
Thinking Errors
• Also known as Cognitive Restructuring
• Used as an addition to ERP.
• Attempts to identify and correct “errors” in thinking.
– Probability Overestimation Errors (e.g., contracting AIDS
from not washing hands).
– Catastrophizing Errors (e.g., my mom is late to pick me
up so I worry she was in a car accident).
– Intolerance of Uncertainty (increasing rituals or
reassurance reduces this).
Effectiveness of ERP
• Produces roughly 60% symptom reduction.
• Produces on average an 11.8 point reduction in
YBOCS scores.
• Low relapse rates.
• Key to medication discontinuation.
When to Consider Medication
• Child unable to participate in therapy due to severity of
symptoms or developmental delay
• Child has another mental health diagnosis
– May reduce their ability to participate in ERP
• Symptoms that do not respond to an adequate trial of
ERP
• No access to CBT with ERP
• Functional impairment is moderate to severe
• Poor insight into irrational nature of OCD
SSRIs
• First-line medication for OCD
– Make serotonin more available in the brain
– Safer side effect profile
• Typically require higher doses as compared to patients with
mood disorders or other anxiety disorders
• May take 8-12 weeks to determine if medication works
– SSRIs typically take 4-6 weeks to determine effectiveness in depression
• Monitor more closely for side effects due to higher doses
• No evidence that one SSRI is superior to another
– No comparative trials
FDA Approved SSRI’s for OCD
• FDA approved for adults with OCD:
– Fluoxetine, Fluvoxamine, Paroxetine, Sertraline
• FDA approved SSRIs for childhood OCD:
– Sertraline (Zoloft) – age 6 and over
– Fluoxetine (Prozac) – age 7 and over
– Fluvoxamine (Luvox) – age 8 and over
• Research has demonstrated effectiveness of SSRI’s vs.
placebo including sertraline, fluvoxamine, fluoxetine and
paroxetine in children and adolescents
Dosing Guidelines
Starting Dose (mg)
Pre-Adolescent
Starting Dose (mg)
Adolescent
Typical Dose Range
(mg)
Clomipramine
6.25-25
25
50-200
Fluoxetine
2.5-10
10-20
10-80
Sertraline
12.5-25
25-50
50-200
Fluvoxamine
12.5-25
25-50
50-300
Paroxetine
2.5-10
10
10-60
Citalopram
2.5-10
10-20
10-60
5
10
10-40
Drug
Escitalopram
American Academy of Child & Adolescent Psychiatry. Practice parameter for the assessment
and treatment of children and adolescents with obsessive-compulsive disorder. Journal of Am
Acad of Child & Adolescent Psychiatry; 51 (1): 107.
Clomipramine (Anafranil)
• Only FDA approved tricyclic antidepressant in pediatric
OCD (10 years and older)
• Can be used as single agent or additional medication with
SSRIs
• Typically used after at least two SSRI failures
• Requires physical exam and lab work prior to starting
– Typically get baseline pulse, blood pressure, and EKG
– Get family history of heart disease
Strategies for Treatment Resistant OCD
• May try a different medication that effects serotonin
– SSRIs – failing one SSRI does not predict failure for another
– Clomipramine (Anafranil)
– Antidepressants that affect multiple chemical messengers
(neurotransmitters) including serotonin
• May use other medications to increase effectiveness of SSRI’s
– Atypical anti-psychotics
– Mood stabilizers
– Medications that affect glutamate
• Gabapentin
• Memantine
Discontinuing Medication
• Consider after patient has been optimally treated and
stable for 12-18 months
• Done gradually with 25% reduction in dose as initial step
– Re-evaluate after each step in discontinuation
• CBT/ERP should be part of treatment plan
Multi-Center Research (continued)
• Pediatric OCD Treatment Study (POTS)
– N=112 (children 7-17).
– Randomized, placebo controlled study.
•
•
•
•
12 weeks of ERP.
Sertraline.
12 weeks of ERP + sertraline (combined).
Placebo.
– Looked at Clinical Remission rates (CY-BOCS <10).
POTS Team (2004)
Combining Treatments
• CBT superior in multiple studies to medication in mild and
moderate OCD
• Evidence demonstrates superiority of combined treatment
in moderate to severe cases of OCD
• May be a “synergistic” effect
– Both interventions effect serotonin in the brain
Addressing Family Accommodation in
OCD
What is Family Accommodation?
Specific behaviors of family members to:
• Provide reassurance to the child
• Yield to the child’s demands
• Assist in rituals
• Assist with or complete tasks for the child
• Decrease the child’s responsibility because anxiety or OCD
symptoms interfere with daily life
Examples of Family Accommodation
• Providing reassurance
• Physically assisting the child to hand wash or complete
shower rituals
• Opening doors or turning on light switches
• Not entering child’s room or touching child’s objects
• Participating in bedtime rituals, such as saying certain
prayers
• Changing your routine to be available to answer your
child’s calls or texts from school
You are in Good Company!
AT LEAST
90%
of families accommodate!
Why some families accommodate:
• It’s easier in the beginning
• It seems helpful
• It worked with your other children
• It’s hard to tolerate your child’s anxiety/distress
• You feel guilty or “mean” if you don’t accommodate
• You fear your child will feel unloved if you do not
accommodate
• You are scared of your child’s behavioral response
What’s the problem with accommodating?
• Accommodation conflicts with goals of CBT
– Limits opportunities for child to learn that feared consequences
do not happen
– Reduces child’s motivation to change
– Prevents habituation
• Associated with poorer treatment outcomes in children
and adults with OCD
– Reduces effectiveness of CBT and long-term outcomes
Treatment Outcomes
• Family accommodation is a major predictor of treatment
response and outcomes in children (Storch et al., 2008)
and adults (Ferrao et al., 2006)
• Numerous studies have demonstrated smaller reductions in
CY-BOCS scores and worse functioning for children when
families accommodate
• Family conflict typically increases with accommodation
which also worsens outcomes (Peris et al., 2008)
• Family accommodation contributes to OCD severity
(Noppen and Steketee, 2009)
Tolerating Your Child’s Anxiety
• You can be empathetic without being accommodating
• Have age-appropriate expectations
• Be aware of your body language and tone of voice when
your child is anxious
• Thought challenge: Anxiety is NOT dangerous.
• This is harder when you struggle with anxiety
– Seek help if you feel the need to rescue your child every time
Reducing Accommodations
• Needs to be in conjunction with the treatment team and the CBT
goals
– Important that your child knows parents and therapist are working
together and are in agreement
• Typically, accommodation reduction occurs gradually
• You should prepare your child for accommodation reduction
through good communication
– Discuss working as a team to fight anxiety and OCD
– Separate anxiety and OCD driven behaviors from child
– Accommodation is allowing anxiety/OCD monster to “win”
Reducing Accommodations
• Practice accommodation reduction in therapy sessions
• Ask your child to rate his/her anxiety
– If anxiety is elevated this is a cue that it may be difficult to communicate
effectively
– Do NOT over talk when your child is going into meltdown mode
– Reduce avoidance by “shaping” desired behaviors
• Help track ban/stop behaviors (ritual prevention)
– Remind your child to record ban behaviors (in calm manner)
• Do NOT provide mixed messages
– For example, having them hand wash before meals if they have a
handwashing protocol.
Summary
• OCD is a common, debilitating condition.
• Cause is unknown, however biology appears to
play a role.
• OCD is a treatable disorder to treat when treated
properly.
– Proper type.
– Proper dose.
About OCD Awareness Week
OCD Awareness Week is coordinated by the
International OCD Foundation as a vehicle for
support, advocacy and education to help end the
stigma surrounding OCD and to encourage
people who have OCD to find treatment.
OCD Awareness Week
October 7 – 11, 2015
Resources
International Obsessive Compulsive Disorder Foundation
OCFoundation.org
Anxiety and Depression Association of America
ADAA.org
Rogers Memorial Hospital
rogershospital.org
Thank you
Stephanie C. Eken, MD, FAAP
Regional Medical Director
Rogers Memorial Hospital is a national leader in the treatment of
OCD and other anxiety disorders in children, teens and adults.
800-767-4411 | rogershospital.org