Transcript OCD - Roger Peele

OCD
Questions and answers. Sources are
DSM-IV-TR, APA Practice Guideline,
or Sadock and Sadock, 10th edition
unless otherwise indicated. As of
1Sep08
OCD
• Q. DSM criteria?
OCD
• A. Has either compulsions or obsessions
• B. Person recognizes that the compulsions
or obsessions are unreasonable or
excessive (does not apply to children).
• C. Compulsions or obsessions are
distressing or disabling
• D. Compulsions or obsessions are not
within another disorder
• E. Not direct effect of substance
OCD – time requirements
• Q. Minimum time of
obsessions/compulsions to meet DSM-IV
criteria?
OCD - time
• Ans. > 60 minutes unless very disabling
and then can be shorter
OCD
• Q. What if the person doesn’t recognize
that the obsessions or compulsions are
excessive or unreasonable?
OCD
• Ans. add specifier, “With poor insight.”
OCD - gender
• Q. Gender prevalence?
OCD - gender
Ans. Boys more than girls, and equal in
adults.
OCD Prevalence
• Q. What is prevalence in US?
OCD - Prevalence
Ans.
Lifetime, 2.5%
One year: 0.5%, i.e., 1/200 have the
disorder in any given year.
OCD - Onset
• Q. What is usual age of onset?
OCD - Onset
Ans.
Males: 6 – 15 years old
Females: 20 -- 29.
OCD – Familial Pattern
• Q. What is familial pattern
OCD – familial pattern
Ans. Concordance rate:
• Monozygotic [70%] > dizygotic twins [50%]
• First degree relative higher (35%) than
normal population.
PANDAS
• Q. Stands for?
PANDAS
Ans. Stands for: pediatric autoimmune
neuroleptic disorder associated with
streptococcal infections.
Obsessions
• Q. Most common obsession?
Obsessions
Ans. Most common is fear of contamination.
Compulsions
• Q. Most common compulsion?
Compulsions
Ans. Checking.
Neuroanatomy
• Q. Neuroanatomy of OCD?
Neuroanatomy
Ans. While far short of being diagnostic,
there is a tendency for more gray matter
and less white matter than normals
Co-morbidity
• Q. What psychiatric disorders, other than
substance-related disorders, are most
commonly associated with OCD?
Co-morbidity
Ans.
• Most common is MDD, 2/3 (67%).
• Social phobia: 25%
• Tourette’s disorder: 5 - 7%
• Tics: 20 - 30%
OCD
• Differential Diagnosis, list medical and
psychiatric?
OCD - differential
Ans.
• Medical:
– Tourette’s disorder,
– other tic disorder,
– temporal lobe epilepsy
• Psychiatric:
–
–
–
–
Schizophrenia,
Obsessive-compulsive personality disorder,
phobias,
depressive disorders
Onset
• Q. Average number of years between
onset and treatment of OCD?
OCD
Ans. 17 years.
Outline of OCD treatment
• Q. What is basic treatment for OCD,
speaking generally?
Outline of treatment
Ans. Basically:
• SSRI/clomipramine and behavioral
therapy
FDA approved for OCD
• Q. FDA has approved?
FDA
Ans. FDA has approved:
• Clomipramine
• Fluoxetine
• Fluvoxamine
• Paroxetine
• Sertraline
Dosing
• Q. Typical doses of OCD with an SSRI?
OCD
Ans. Typically, dosing is higher than with
MDD.
OCD
• Q. Onset of effectiveness in OCD when
using an SSRI – when it is effective?
OCD
Ans. Should see improvement in 6 to 12
weeks.
OCD
• Q. If the SSRI is successful and then
discontinued, what is likely to happen?
OCD
Ans. Symptoms will return in two months.
Typical results
• Q. Typical results with an SSRI?
OCD
Ans. About ½ have 1/3 improvement
OCD augmentation
• If partial response to an SSRI, what meds
can you add that may make for further
improvement?
Augmentation
Ans.
• Atypical antipsychotic
• Buspirone
• Clomipramine
• Clonazepam
• Lithium
• Venlafaxine
• Valproate
Treatment of PANDAS
• Q. What is treatment?
PANDAS
• 1] plasmopheresis to clear antibodies
• AND
• 2] prophylactic antibiotics
Behavioral therapy for OCD
• Q. Behavioral therapies, three most
common?
Behavioral therapy
Ans. Three most common:
• 1. Exposure and response prevention
• 2. Imaginal flooding
• 3. Thought stopping
Exposure and response prevention
• Q. What is exposure and response
prevention?
OCD
Ans. Exposure and response prevention
consist of asking the pt to endure, in a
graduated manner, the anxiety of a
specific obsession the pt fears – and
refrain from the associated compulsion.
OCD
• Q. What is imaginal flooding?
OCD
Ans. Imaginal flooding consists of having the
pt provoked by the obsessions by
continually repeating the thought to where
the thought no longer provokes
fearfulness.
OCD
Q. What is thought stopping?
OCD
Ans. Thought stopping consists of having a
technique to stop the pt compulsive
thought, e.g., the pt keeps needing to
repeat a short prayer and one has the pt
shout when that happens, or make a loud
noise or snapping a rubber band on the
wrist to where it stings.
OCD
• Q. Behavioral therapy helps what % of
OCD pts?
OCD
Ans. 3/5
OCD
• Q. Usefulness of relaxation techniques in
OCD?
OCD
Ans. Relaxation techniques have not been
shown to be helpful
OCD
• Q. Pt only has obsessions, not
compulsions. In addition to techniques
already mentioned, what psychotherapy
technique might be tried?
OCD
Ans. The pt can try not resisting, “just let
them pass through.” Also can audio tape
and the pt can listen to the tape until no
loner upsetting.
OCD
• Q. Typical length of time of behavioral
therapy sessions?
OCD
• 90 minutes – and homework
OCD
• Q. Typically, how many sessions?
OCD
• 13 to 20 sessions
Families
• Q. What should you tell families of OCD
pts as to how they should relate to the pt?
OCD
Ans.
• Avoid condemnation
• And
• Avoid reassurance