Download Obsessive Compulsive disorder for medical students

Obsessive
Compulsive
and related
disorder
Jacob Alexander
TAPPP
DSM V
• OCD
• Body dysmorphic
disorder
• Trichotillomania
• Excoriation (Skin
Picking)disorder
• Hoarding Disorder
Symptomatology
• Obsession- recurrent and intrusive thought,
feeling, idea or sensation
• Patient realises the irrationality of the
obsession
• Compulsion- a conscious, standardised,
recurrent behaviour geared towards reducing
the anxiety associated with an obsession
• Experiences both the O and C as being
egodystonic
• https://www.youtube.com/watch?v=KFVl2j9d
Epidemiology
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Lifetime prevalence of 2-3% amongst general population
Lifetime prevalence of OC symptoms estimated at 8.7%
Fairly consistent across cultures
Amongst outpatients in psychiatric clinics- 10%
Gender distribution: equal amongst adults, amongst
adolescents- boys more likely to be affected
• Onset of symptoms around 20 years of age- onset
slightly earlier for men, 2/3rds have onset of symptoms
before 25, less than 15% have symptoms originating
after the age of 35
• Single>married
Co-morbidity
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Depression 67%
Social phobia 25%
Alcohol use disorders
Specific phobias
Panic disorder
Eating disorders
Personality disorders
Tourette’s disorder (5-7%), tics (20-30%)
• Mood disorders, anxiety disorders, eating disorders and skin
picking were more prevalent in women and girls with OCD,
whereas tics, Tourette’s syndrome and alcohol dependence
were more common in men and boys with OCD
Differential diagnosis
• Overlap between OCD and apparently related
disorders, such as hoarding, trichotillomania,
skin picking, Tourette’s syndrome, body
dysmorphic disorder, hypochondriasis, is
frequently observed but poorly understood
• Some contend that hypochondriasis is a variant
of OCD but others do not
• Hoarding can function as an anxiety relieving
compulsion in OCD, but in the absence of other
OCD symptoms is marked by significantly less
distress, poorer response to treatment and
seems to be a clinically distinct syndrome
Etiology
• Biological factors
• Behavioural factors
• Psychosocial factors
Etiological Factors
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1.
2.
Biological factors
Neurotransmitters- serotonergic system > noradrenergic system
Neuro-immunology- Group A-beta haemolytic streptococcal
infection
3.
Brain Imaging studies- orbitofrontal cortex-caudate-thalamus,
basal ganglia and cingulum
4.
Genetics(i) Families of probands x 3-5 higher risk of having OCD
(ii) Increased risk of GAD, tics, BDD, hypochondriasis, eating dis. and
habits like nail biting
(iii) Twin studies suggest that OC symptoms in children are heritable,
with genetic influences ranging from 45 % - 65%
Etiology- Behavioural factors
• Learning theory- obsessions are
conditioned (respondent) stimuli
Neutral stimuli paired with a noxious or
anxiety provoking stimulus
• Compulsions established differently- learnt
by accidental encounter with activites
which reduce anxiety
Etiology-psychosocial factors
• Personality factors- 15-35% pre-morbidly
obsessional
• Vulnerability seems to be greater when family
history is marked by excessive responsibility
taking, rigid codes of conduct, equation of
thought and action, perfectionism, cognitive
inflexibility, or black and white perception that
tends to be intolerant of uncertainty and
ambiguity.
Origin and perpetuation
• During periods of stress, an individual who is
genetically vulnerable to OCD may experience
compelling intrusive thoughts (eg, possible loss
of control, possible HIV contamination) that are
hard to dismiss
• When this occurs the individual is likely to
increase efforts to neutralize such thoughts or to
seek reassurance repetitively , both of which,
over time, worsen anxiety and make the
intrusions more salient
Origin and Perpetuation
• A cycle of escalating intrusions,
hypervigilance, futile control of inherently
uncontrollable thoughts, reactive panic,
and powerfully reinforcing relief through
neutralizing rituals becomes selfperpetuating
Diagnostic criteria- ICD 10
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2.
Os/Cs/both present on most days for at least 2 weeks
Os/Cs have the following features:
Acknowledged as originating in the mind of the person
Repetitive and unpleasant, at least 1 recognized as
excessive or unreasonable
3. Tries to resist. At least 1 unsuccessfully resisted
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Experiencing the O or carrying out the C not inherently
pleasurable
Causes distress or interferes with social or individual
functioning
Not the result of another mental disorder
Types……..
• Predominantly obsessive thoughts or
ruminations
• Predominantly compulsive acts
• Mixed obsessional thoughts and acts
• Other obsessive-compulsive disorders
• Obsessive compulsive disorder
unspecified
Majority have both
Diagnostic criteria- DSM IV
• Os-recurrent or persistent thoughts, impulses or images
that are experienced as intrusive and inappropriatecontamination, repeated doubts, order, impulses, sexual
images
• Cs- repetitive behaviours or mental acts whose goal is to
prevent or to reduce anxiety or distress- hand washing,
ordering, checking, praying, counting, repeating words
• Recognition that the fear is excessive or unreasonable
• Os cause marked distress, are time consuming (>1hr/day)
• Significant impairment in social, occupational and daily
functioning
• Qualifier- With poor insight
Common Obsessional Themes
• The prevention of harm to self or others resulting
from contamination (eg., dirt, germs, bodily fluids
or faeces, dangerous chemicals)
• The prevention of harm resulting from making a
mistake ( eg., a door not being locked)
• Intrusive religious or blasphemous thoughts
• Intrusive sexual thoughts (eg., being a
paedophile)
• Intrusive thoughts of violence or aggression (eg.,
of stabbing one’s baby)
• The need for order or symmetry
Frequency of presenting
symptoms in descending order
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Contamination- washing or avoidance
Pathological doubt
Intrusive thoughts- sexual/ aggressive
Symmetry – compulsive slowing
Others- religious obsessions or
compulsive hoarding
Y-BOCS
• The standard assessment instrument for
OCD is the Yale-Brown Obsessive
Compulsive Scale
Course and prognosis
• >50% have a sudden onset following a
stressor
• Avg 5-10 years before psychiatric help
sought
• Course usually long and fluctuating
• 20-30% experience significant
improvement
• 40-50% have moderate improvement
• 20-40% remain ill or deteriorate
Prognostic Factors
Poor Prognostic Factors
• Yielding to symptoms
• Childhood onset
• Bizarre compulsions
• Need for
hospitalization
• Coexisting MDD
• Delusional beliefs/
overvalued ideas
• Presence of a
personality disorder
• Favourable
Prognostic factors
• Good social and
occupational
functioning
• Presence of a
precipitating event
• Episodic nature of the
symptoms
Treatment
• Pharmacological- SSRIs, clomipramine
Augmentation- NaValp/ Li/ Cbz
Other agents- venlafaxine, pindolol, MAOIs (phenelzine)
Non-responsive patients- buspirone, 5-HT, l-trytptohan,
clonazepam
Atypical Antipsychotic augmentation- Risperidone, Aripirazole
• BT- as effective as pharmacotherapies, beneficial effects
last longer- exposure and response prevention,
desensitization, thought stopping, flooding, implosion
therapy, ? Aversive conditioning
• Psychodynamic/ insight oriented psychotherapy- evidence
sparse
• ECT, Psychosurgery- singulotomy, capsulotomy
TREATMENT
• First line pharmacotherapy for OCD consists of
those drugs with potent serotonergic actions (ie.,
SSRI’s and, secondarily because of side effects,
clomipramine)
• OCD often requires higher eventual SSRI dosing
( 2 – 4 times the standard doses) compared with
other anxiety disorders
• The treatment for OCD is usually gradual and
partial, and many patients do not respond
adequately to first line treatment
OCD PEARLS
• SSRI’s are first line drug treatment for
OCD. Clomipramine and Venlafaxine may
be alternatives.
• Compared with other SSRI indications for
other disorders, drug treatment for OCD
will require higher doses.
• ERP is at least as effective as drug
treatment for OCD
Anankastic personality/OCPD
• It is not marked by the usually distressing obsessions and
compulsions of OCD
• OCPD is characterised by orderliness, control, rigidity, and
perfectionism that the individual sees as virtues even at the
cost of flexibility, efficiency, and relationships
• A pervasive pattern of preoccupation with orderliness,
perfectionism, and mental and interpersonal control, at the
expense of flexibility, openness, and efficiency, beginning by
early adulthood and present in a variety of contexts, as
indicated by 4 (or more) of the following:
OCPD Criteria
1. Is preoccupied with details, rules, lists,
order, organization, or schedules to the
extent that the major point of the activity
is lost
2. Shows perfectionism that interferes with
task completion (e.g., is unable to
complete a project because their own
overly strict standards are not met)
OCPD Criteria
3. Is excessively devoted to work and productivity
to the exclusion of leisure activities and
friendships (not accounted for by obvious
economic necessity)
4. Is overconscientious, scrupulous, and inflexible
about matters of morality, ethics, or values (not
accounted for by cultural or religious
identification)
5. Is unable to discard worn out or worthless
objects even when they have no sentimental
value
OCPD Criteria
6.Is reluctant to delegate tasks or to work with
others unless they submit to exactly his or her
way of doing things
7. Adopts a miserly spending style toward both self
and others; money is viewed as something to be
hoarded for future catastrophes
8. Shows rigidity and stubbornness
Body Dysmorphic disorder (BDD)
• https://www.youtube.com/watch?v=mHRuk4GbaM
0
• Preoccupation with an imagined defect in
appearance that causes clinically significant
distress or impairment in important areas of
functioning.
• If a slight physical anomaly is actually present, the
person’s concern is excessive and bothersome.
• Emil Kraeplin-dysmorphophobia
• Pierre Janet- obsession de la hontu du corps
BDD-commonest feature affected
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Hair
Nose
Skin
Eyes
Head/face
Overall body build/ bone
structure
7. Lips
8. Chin
9. Stomach, waist
10. teeth
Body Dysmorphic Disorder-etiology
• Serotonin pathways?
• Psychodynamic
explanations- repression,
dissociation, distortion,
symbolization and
projection, displacement
• Familial and cultural
concepts/ values around
beauty
• DD-OCD, delusional
disorder, Psychosis,
depression, anxiety
BDD-clinical symptoms
• Ideas or delusions of
reference
• Avoidance of social and
even occupational
exposure
• Excessive mirror checking
or avoidance of reflective
surfaces
• House bound
• Suicide in response to
distress
BDD-course, prognosis and
management
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Begins in adolescence
Gradual or abrupt onset
Long and undulating course
TCAs, MAOIs, SSRIs
Augmentation of antidepressant
Psychotherapy
Surgical intervention largely unsuccessful
Trichotillomania
• https://www.youtube.com/watch?v=rWmhmbbvLxs
• Chronic disorder characterized by:
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Repetitive hair pulling
Driven by escalating tension
Sense of relief or gratification after event
Causes variable hair loss, any body part can be involved
• Term coined by French Dermatologist Francois
Hallopeau in 1889
• Lifetime prevalence between 0.6%-3.4%
• An estimated 33-40% of patients with Trichotillomania
also chew or swallow their hair
• About 1/3rd of these will develop a trichobezoar
Aetiology
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Multifactorial
Onset is often stress related
Substance abuse
Depressive dynamics
Self stimulation – primary goal
Inappropriately released motor activity and
grooming behaviours
• Probands-Increased incidence of tics, other
impulse control disorders, OCD
Course, Prognosis and
Treatment
• Onset usually in early teens- good
prognosis
• Course poorly understood- chronic and
remitting forms
• Topical steroids
• Hydroxyzine hydrochloride
• Antidepressant- SSRIs
• Antipsychotic agents
CBT and Hypnotherapy
strategies
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Biofeedback
Self- monitoring
Covert desensitization
Habit reversal
Insight oriented psychotherapy
The End