Transcript Obsessiveâ**compulsive disorder (OCD)

Obsessive compulsive dis
order (OCD)
Dr. Safeyya Adeeb Alchalabi
OCD
Obsessive compulsive disorder (OC
D)
• A common, chronic condition, of
ten associated with marked anxiet
y and depression, characterised by
obsessions and compulsions .
Obsessive compulsive disorder (OC
D)
• Obsessions/compulsions must cause distress or
• interfere with the person's social or individual functioni
ng (usually by wasting time), and
• should not be the result of another psychiatric disorder.
• At some point in the disorder, the person recognizes the sy
mptoms to be excessive or unreasonable.
Clinical features
Obsessional symptom
Thoughts
Ruminations
Impulses
'Phobias'
Compulsive rituals
Abnormal slowness
Anxiety
Depression
Depersonalization
Obsessional thoughts
words, ideas, and beliefs
recognized by patients as their own,
intrude forcibly into the mind.
unpleasant, or shocking to the person, (may be obscene or blasphemous).
atempts are made to exclude them.
It is the combination of an inner sense of compulsion and of efforts at resistance
that characterizes obsessional symptoms,
Obsessional thoughts may take the form of single words, phrases, or rhymes,
Obsessional images are vividly imagined scenes, often of a violent or disgusting ki
nd (e.g. involving sexual practices that the person finds abhorrent.
Obsessional rumnations
are internal debates in which argum
ents for and against even the simples
t everyday actions are reviewed endle
ssly.
Obsessional impulses
are urges to perform acts, usually of a violen
t or embarrassing kind (e.g. leaping in front o
f a car, injuring a child, or shouting blasphem
ies at a religious ceremony).
Obsessional rituals
include both mental activities (e.g. counting repeat
edly in a special way, or repeating a certain form of
words) and repeated but senseless behaviours (e.g.
washing the hands 20 or more times a day).
Obsessional slowness
. Although obsessional thoughts and rituals l
ead to slow performance, a few obsessional p
atients are afflicted by extreme slowness that
is out of proportion to other symptoms.
Obsessional phobias
. Obsessional thoughts and compulsive rituals may
worsen in certain situations-for example, obsession
al thoughts about harming other people may incre
ase in a kitchen or other place where knives are ke
pt. The person may avoid such situations because t
hey cause distress.
Anxiety
This is a prominent component of obsessivecomp
ulsive disorders.
Some rituals are followed by a lessening of anxiety,
while others are followed by increased anxiety.
Depression
Obsessional patients are often depressed.
In some patients, depression is an understandable
reaction to the obsessional symptoms; in others, d
epression appears to vary independently.
Depersonalization
. Some obsessional patients complain of depersona
lization.
The relationship between this distressing symptom
and the other features of the disorder is unclear.
Differential diagnosis
Anxiety disorders •
Depressive disorder •
Schizophrenia •
Organic disorders •
Epidemiology
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Mean age: 20 yrs,
70% onset before age 25 yrs,
15% after age 35 yrs.
Sex distribution equal.
Prevalence: 0.5-3% of general population.
Aetiolo
gy
of OCD
Aetiology of OCD
• Neurochemical Dysregulation of the 5HT system, or 5HT/DA interaction.
• Immunological Cell-mediated autoimmune factors may be associated (e.g. aga
inst basal ganglia peptides_as in Sydenham’s chorea).
• Imaging CT and MRI: bilateral reduction in caudate size. PET/SPECT: hype
rmetabolism in orbitofrontal gyrus and basal ganglia (caudate nuclei) that normaliz
es following successful treatment (either pharmacological or psychological).
• Genetic Suggested by family and twin studies (3-7% of first-degree relatives affe
cted, MZ: 50-80% DZ: 25%.), no candidate genes as yet identified.
• Psychological Defective arousal system and/or inability to control unpleasant int
ernal states. Obsessions are conditioned (neutral) stimuli, associated with an anxiet
y-provoking event. Compulsions are learned (and reinforced) as they are a form of
anxiety-reducing avoidance.
• Psychoanalytical Regression from Oedipal stage to pre-genital anal-erotic stage o
f development as a defence against aggressive or sexual (unconscious) impulses. As
sociated defences:isolation, undoing, and reaction formation.
Associations
• Avoidant, dependent, histrionic traits (-40% of case
s),
• anankastic/obsessive-compulsive traits (5-15%) pri
or to disorder.
• In schizophrenia, 5-45% of patients may present wi
th symptoms of OCD (schizo-obsessive poorer pro
gnosis).
• Sydenham chorea (up to 70% of cases) and other b
asal ganglia disorders (e.g. Tourette’s Syndrome, p
ost-encephalitic parkinsonism).
Comorbidity
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Depressive disorder (50-70%),
alcohol- and drug-related disorders,
social phobia,
specific phobia,
panic disorder,
eating disorder,
PTSD,
tic disorder (up to 40% in juvenile OCD) or TS.
Management
Management
Psychological
Pharmacological
CBT
(behavioural)
SSRIs*
or SNRI(Venlafaxine)
Psychotherapy
(supportive,groups)
Clomipramine**
Psychoanalytical
(insight-oriented)
SNRI
Venlafaxine
Cognitive
(not proven effective)
Augmentation***
Behavioural
thought stopping
may help in
ruminations
Response prevention
useful in
ritualistic behaviour
exposure techniques
for obsessions
Buspiron
antipsychotic
Physical
ECT
(suicide,severe)
Psychosurgery****
Deep Brain Stimulation
DBS(severe refractory)
Management
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*Antidepressants SSRIs: fluoxetine, fluvoxamine, sertraline, or paroxetine shoul
d be considered first-line (no clear superiority of any one agent, high doses usu
ally needed (e.g. 40-60 mg fluoxetine, allow at least 12 wks for treatment respon
se, regard as long-term).
**Clomipramine (e.g. 250-300 mg) has specific anti-obsessional action
( second-line choice).
***Augmentative strategies:
– antipsychotic (risperidone, haloperidol, pimozide)
• if psychotic features,
• tics, or
• schizotypal traits;
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•
buspirone/short term clonazepam if marked anxiety
****psychosurgery may be considered for severe, incapacitating intractable cas
es, i.e treatment resistance:
– 2 antidepressants,
– 3 combination treatment,
– ECT, and
– behavioural therapy)
•
where the patient can given informed consent e.g. stereotactic cingulotomy (re
ported up to 65% success). In theory, disrupts the neuronal loop between the or
bitofrontal cortex and the basal ganglia.
Course
Course
• Often sudden onset (e.g. after stressful loss e
vent,e.g loss, pregnancy, sexual problem),
• symptom intensity may fluctuate (contact-re
lated/phasic) or be chronic.
Differential diagnosis
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Normal (but recurrent) thoughts, worries, or habits;
anankastic PD/OCD,
schizophrenia;
phobias;
depressive disorder;
hypochondriasis;
body dysmorphic disorder;
trichotillomania.
Outcome
Outcome
• 20-30% significantly improve,
• 40-50% show moderate improvement,
• but 20-40% have chronic or worsening symp
toms.
• Relapse rates are high for stopping medicati
on.
• Suicide rate increased esp. if there is second
ary depression.
Prognosis
Prognostic factors
• Poor prognosis:
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Giving in to compulsions,
longer duration,
early onset,
male,
presence of tics,
bizarre compulsions,
hoarding,
symmetry,
comorbid depression,
delusional beliefs or overvalued i
deas,
• personality disorder (esp. schiz
otypal PD).
• Better prognosis:
• Good premorbid social an
d occupational adjustment,
• a precipitating event,
• episodic symptoms,
• less avoidance.
Thank you