OCD

Definition - Obsessive-compulsive disorder (OCD) is represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and
compulsions
- The obsessions or compulsions are time-consuming and interfere significantly with the person's normal routine, occupational functioning, usual social
activities, or relationships.
Epid Lifetime prevalence: 1-1.8%
Mean age of onset: 20 years old
M:F
Rate of OCD in first-degree relatives is higher than in the general population
Risk • Neurochemical: dysregulation of the 5-HT system (possibly involving 5-HT1B, or 5-HT/DA interaction.
Factors/ • Immunological: cell-mediated autoimmune factors may be associated e.g. against basal ganglia peptides—as in Sydenham’s chorea.
Etiology • Imaging: CT and MRI: bilateral reduction in caudate size. PET/SPECT: hypermetabolism in orbitofrontal gyrus, basal ganglia (caudate nuclei), and cingulum
that ‘normalizes’ following successful treatment (either pharmacological or psychological).
• Genetic: suggested by family and twin studies (3–7% of first-degree relatives affected, MZ: 50–80% DZ: 25%), no candidate genes as yet
identified, but polymorphisms of 5-HT1BB have been replicated.
• Psychological: defective arousal system and/or inability to control unpleasant internal states. Obsessions are conditioned (neutral) stimuli, associated with
an anxiety-provoking event. Compulsions are learned (and reinforced) as they are a form of anxiety-reducing avoidance.
• Psychoanalytical: Freud coined the term ‘obsessional neurosis’, thought to be the result of regression from oedipal stage to pre-genital anal–erotic stage of
development as a defence against aggressive or sexual (unconscious) impulses. Associated defences: isolation, undoing, and reaction formation. Symptoms
occur when these defences fail to contain the anxiety.
DSM V SIMPLIFIED

1 & 2. Presence of obsessions and/or compulsions that are time consuming (>1 hr /day) or cause clinically significant distress or dysfunctioning :

Obsessions : Recurrent and persistent thoughts, urges, or images that cause anxiety/stress, and such that the individual attempts to ignore/ suppress with
some other thought / action (i.e. Perform a Compulsion)

Compulsions : are defined by (i) and (ii):

i. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven
to perform in response to an obsession / according to rules that must be applied rigidly. It aimed to reduce anxiety or prevent dreaded situation (But, not
realistically linked to what they prevent / excessive)

Otherwise :

MD ZAKI MEDICAL NOTES

3. Not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) / another medical condition.
4. Not better explained by the symptoms of another mental disorder (See beside)

FULL

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in
most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing
a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels
driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these
behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical
condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder;
preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in
trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized
eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with
having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct
disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other
psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive disorder
beliefs are definitely or probably not true or that they may or may not be true.
 With poor insight: The individual thinks obsessive-compulsive disorder beliefs are
probably true.
With absent insight/delusional belief: The individual is completely convinced that
obsessive-compulsive disorder beliefs are true.

Specify if:
Tic-related: The individual has a current or past history of a tic disorder.
CF
I) Obsessive thoughts / Ruminations : Contaminated with virus, Violence (Self harm), religious, superstition, endless question (Eg. About God)
II) Obsessive Compulsive Behaviours : Repeated checking, Repeated washing , counting, orderly / arranging thing, doubt (Eg. Prayer) , hoarding (Not able to
dispose “junk”)
 5 THEME OF OCD
1. Doubt -> Checking
2. Contamination -> Washing
3. Aggression -> Variable
4. Blesphamy -> Variable
5. Sexual -> Variable
Versus

Ix - TFT (Anxiety symptoms)

- RP, LFT (Baseline)
- Neuroimaging (If needed) – Especially if late onset
Mx PHARMACOTHERAPY + BEHAVIOURAL THERAPY

• Pharmacotherapy:
- SSRIs : FLUOXETINE (Prozac) – 20-80mg , fluvoxamine (Luvox), paroxetine (Paxil), SERTRALINE (Zoloft) – 200mg, citalopram (Celexa). Side effects : sleep
disturbance, nausea and diarrhea, headache, anxiety, and restlessness. Potential of relapse.
- Cloromipiramine/Clomipramine (TCA) -> GOLD STANDARD . Must be titrated upward over 2 to 3 weeks to avoid gastrointestinal adverse effects and
orthostatic hypotension, and as with other tricyclic drugs, it causes significant sedation and anticholinergic effects, including dry mouth and constipation.
- If failed SSRI or Clomipramine, augment with valproate/lithium/carbamazepine (Mood stabilizers)
- Antipsychotics (risperidone), if :
✓ Presence of Delusion
 ✓ To potentiate/augment (Resistant cases)

•Behavioral Therapy :
- EXPOSURE WITH RESPONSE PREVENTION (ERP) : Special type of CBT – involves exposure to feared situations with the addition of preventing the compulsive
behaviours; cognitive strategies include challenging underlying beliefs
- Psychodynamic psychotherapy can be used if patient resistant to treatment
- Others : Thought/compulsive diary, Thought stopping (Say “STOP” when sudden thought) , Gradual exposure, Aversive conditioning
Last resort: In treatment-resistant, severely debilitating cases, can use psychosurgery (cingulotomy) or electroconvulsive therapy (ECT) (especially if comorbid
depression is present).

•Others:
- Supportive psychotherapy (Includes Psychoeducation, Ventilate feelings) , Family therapy, Group therapy

Psychological
1. Supportive psychotherapy
- communication between Dr and patient
- Psycho-education: Explanation ,clarification
and reassurance, guidance, suggestion,
- helps with the problem solving
- boost patient self esteem
2. Cognitive behavioural therapy
- to modify the OCD related ideas/belief
Behavioural
- Thought or compulsive diary
- Thought stopping (initially to shout the word
stop overtly, later to say it quietly)
- ERP : Response prevention , involve
exposure and prevention of ritual to reduce
anxiety
- Gradual exposure (from mildest to the severe
most anxiety provoking stimuli)

Prognosis - Chronic and Relapsing symptoms

- Suicidal ideation in 50%, attempts in 25% of patients with OCD
- High comorbidity with other anxiety disorders (> 75%), depressive or bipolar disorder (> 60%), obsessive-compulsive personality disorder (up to 32%), and tic
disorder/ History of tics (up to 30%)
Diff Dx - OCD Related disorder (Eg. Body dysmorphic disorder, Hoarding disorder)
- Anxiety disorders
- Phobias
- Depressive disorder
- Schizophrenia/ Delusional Disorder
 - Organic cerebral disorders
OCD
Related Disorder Intro/Concept Simplified DSM V Management
Disorder Body Preoccupied with - Preoccupation with one or more perceived defects or flaws in physical SSRIs and/or CBT may reduce the
Dysmorphic body parts appearance that are not observable by or appear slight to others obsessive and compulsive symptoms
Disorder that they - Repetitive behaviors (e.g., skin picking, excessive grooming) or mental acts in many patients.
perceive as (e.g., comparing appearance to others) are performed in response to the
flawed or appearance concerns
defective -> - Preoccupation causes significant distress or impairment in functioning
Excessive time to - Appearance preoccupation is not better accounted for by concerns with
correct flaws body fat/weight in an eating disorder
Hoarding Difficulty to let - Persistent difficulty discarding possessions, regardless of value. - Very difficult to treat.
Disorder go of possessions - Difficulty is due to need to save the items and distress associated with - Specialized CBT for hoarding.
because need to discarding them. - SSRIs can be used, but not as
save them -> - Results in accumulation of possessions that congest/clutter living areas and beneficial unless OCD symptoms are
Accumulation compromise use. present.
- Hoarding causes clinically significant distress or impairment in social,
occupational, or other areas of functioning.
- Hoarding is not attributable to another medical condition or another mental
disorder.
Tricho- Recurrent pulling - Recurrent pulling out of one’s hair, resulting in hair loss. - Treatment includes medications
tillomania of hair with - Repeated attempts to decrease or stop hair pulling. such as SSRIs, second-generation
(Hair failure in - Causes significant distress or impairment in daily functioning. antipsychotics, N-acetylcysteine, or
pulling stopping it - Hair pulling or hair loss is not due to another medical condition or psychiatric lithium.
Disorder) disorder. - Forms of cognitive-behavior
- Usually involves the scalp, eyebrows, or eyelashes, but may include facial, therapy (e.g., habit reversal training)
axillary, and pubic hair. are the best-evidenced
psychotherapy.
Excoriation Recurrent skin - Recurrent skin picking resulting in lesions. - Treatment is similar to that for
(Skin- picking, failure to - Repeated attempts to decrease or stop skin picking. trichotillomania.
picking) stop -> skin - Causes significant distress or impairment in daily functioning. - Specialized types of cognitive-
Disorder lesions - Skin picking is not due to a substance, another medical condition, or another behavior therapy (e.g., habit reversal
psychiatric disorder. training).
- SSRIs have also shown some
 benefit.

"What would you attempt to do if you knew you would not fail?"