Obsessive Compulsive Disorder

(OCD)

Dr. Mahesh Kundagol

As Good as It Gets

What is OCD?

Disorder causing worries, doubts, and superstitious beliefs during everyday life. Described by some as mental hiccups that wont go away.

Obsessions? Compulsions?

Obsessions repetitive and unwelcome thoughts, images, or impulses that are difficult to dismiss or control. Compulsions repetitive behavioral responses can be resisted only with great difficulty. Recent studies have found lifetime prevalence of OCD in North America to be about 2.5/100 people.

Obsessions

Thoughts, images, or impulses that repetitively occur to become out of ones own control. Person suffering from these obsessions finds them intrusive and disturbing recognizes they dont make sense.

Obsessions - continued

Obsessions often accompanied by uncomfortable feelings such as fear, disgust, or doubt. For example, people with OCD may worry excessively about dirt and germs, and obsessed with the idea that they are contaminated or may contaminate others

Compulsions

These are acts that are continually performed to provide relief from discomfort caused by obsessions. OCD compulsions do not give the person pleasure (unlike drinking, gambling, etc.). For example, a person may repeatedly check to see if their stove was left on in fear of burning the house down.

Most people with OCD have multiple OCD symptoms

Multiple Compulsions

Common Symptoms
Common Obsessions
- Contamination fears of germs, dirt, etc.

Common Compulsions
- Washing.

- Imagining having harmed self or others.

- Imagining losing control of aggressive urges. - Intrusive sexual thoughts or urges. - Excessive religious or moral doubt. - Forbidden thoughts.
-

- Repeating.
- Checking. - Touching. - Counting. - Ordering/Arranging. - Hoarding or saving. - Praying.

A need to have things just so.

- A need to tell, ask, and confess.

OCD time spent thinking about the act and performing the act

Ordering Compulsion

Most Common Symptoms

The most clinically useful and detailed symptoms checklist is included in the YaleBrown Obsessive-Compulsive Scale.

OCD and Developmental Disability

may not to be able to identify obsessions may not recognize that obsessions dont make sense diagnosis often based on compulsions misdiagnosis is common both inaccurate diagnosis of OCD or misdiagnosis of another disorder.

Co-Morbid Disorders Differential Diagnosis

Phobias Hypochondriasis Impulse Control Disorder Tourettes Syndrome Obsessive Compulsive Personality

Panic Disorder Generalized Anxiety Disorder

Major Depression Delusional Disorder

Diagnostic Issues in DD

Difficult to distinguish with personality traits in persons with DH that engage in repetitive questions (repetitive speech, echolalia) that can occur in anxious individuals with limited verbal skills or in autistic spectrum disorders. Compulsive behaviours are common in adults with intellectual disability stereotyped behaviour and movement disorders from underlying brain damage.

When does OCD begin?

Begin anywhere from preschool age to adulthood (40 years). Obsessive-compulsive behavior affects both males and females equally but is more common among adolescent boys than adolescent girls. The mean age of onset is about 20 years (2,10), but cases have been reported in children as young as 2 years (1012). On average, people with OCD see 3-4 doctors and spend over 9 years seeking treatment before they receive a correct diagnosis. OCD tends to go under-diagnosed and under-treated because people with the illness often act secretive about their symptoms.

Gender & Culture

Boys are more likely to have a prepubertal onset and a family member with OCD or Tourette syndrome. Girls are more likely to have onset of OCD during adolescence. OCD is more common in whites than African American children in clinical samples. However, epidemiologic data suggest no differences in prevalence as a function of ethnic group or geographic region.

Prevalence of OCD

The World Health Organization lists obsessivecompulsive disorder as one of the five major causes of disability throughout the world. It is considered the fourth most common psychiatric condition, ranking after phobias, substance abuse disorders, and major depressive mood disorder.

Prevalence: Underestimated

Prevalence of OCD is underestimated why? 60% of all persons with a diagnosable anxiety disorder never see a mental health professional they may turn to their family physician, religious leader or another family member for help.

What Causes OCD?

The probable biologic explanations of obsessivecompulsive disorder include heredity, brain lesions, abnormal brain glucose metabolism, and serotonergic dysfunction. No specific gene associated with OCD however, when a parent has OCD there is an increased risk that the child will also develop the illness. Problems in the front part of brain (orbital cortex) and deeper structures (basal ganglia).

Brain Differences persons with OCD use different brain circuitry in performing a cognitive task than people without the disorder (Rauch et al. J. of Neuropsychiatry, 1997)

Genetic Link?

If one twin has OCD, the other twin is more likely to have OCD if the children are identical twins rather than fraternal twin pairs. OCD is increased among first-degree relatives of children with OCD, particularly among fathers (Lenane et al., 1990). It does not appear that the child is simply imitating the relatives behavior, because children who develop OCD tend to have symptoms different from those of relatives with the disease (Leonard et al., 1997).

Role of Serotonin

Studies showing that serotonin plays a role in the pathophysiology of obsessive-compulsive disorder have led to new and highly effective treatments

Infection Causes?

Recent research suggests that some children with OCD develop the condition after experiencing one type of streptococcal infection (Swedo et al., 1995). This condition is referred to by the acronym PANDAS, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Its hallmark is a sudden and abrupt exacerbation of OCD symptoms after a strep infection. The cause of this form of OCD appears to be antibodies directed against the infection mistakenly attacking a region of the brain and setting off an inflammatory reaction.

OCD Cause: Summary

Although a definitive cause of obsessivecompulsive disorder has not yet been found, it is considered the product of interactions between biologic predisposition and various developmental and psychosocial influences

OCD Assessment

For adults with intellectual disability: Compulsive Behavior Checklist (Gedye, 1996) This list uses 25 types of compulsions done by adults with developmental disabilities grouped into 5 categories ordering, completeness, cleaning, checking/touching, deviant grooming. Ratings are done by caregiver who has familiarity with person.

OCD Assessment

Also we can use the Obsessive Speech Checklist designed for use only with developmentally disabled people who talk in sentences and use meaningful speech This is used to help determine if they meet the criteria for OCD

Treatment

During last 20 years, two effective methods for treating OCD have been developed:
Cognitive-Behavioural Psychotherapy (CBT) Medication with a serotonin reuptake inhibitor (SRI)

Stages of Treatment

Acute Treatment Phase: Treatment is aimed at ending the current episode of OCD. Maintenance Treatment: Treatment is aimed at preventing future episodes of OCD.

Components of Treatment

Education: Educate family and patients on how to manage OCD and prevent complications. Psychotherapy: Cognitive-Behavioural Therapy (CBT) is the key element of treatment for most patients with OCD. Medication: Medication with a serotonin reuptake inhibitor is helpful for many OCD patients.

Treatment Considerations

Use of both medication and psychotherapy results in a better outcome than use of either alone. Many patients with obsessive-compulsive disorder are very secretive about their illness. Therefore, a detailed review of symptoms may be necessary. Many patients have somatic complaints (eg, fatigue, pain, hypochondriacal symptoms, excessive worrying, chronic sadness). Thus, a comprehensive medical evaluation is essential to rule out any preexisting medical and psychiatric condition.

Cognitive Behavioural Psychotherapy (CBT)

Exposure and response intervention. Exposure person remains in contact with something they usually fear until their anxiety is diminished. Response intervention persons rituals or avoidance behaviours are blocked (those afraid of germs are not only exposed to germs but refrained from ritualized washing). Exposure is usually more helpful in decreasing anxiety and obsessions, while response intervention is better at decreasing compulsive behaviours.

CBT (Contd)

Patients who complete CBT report a 50-80% reduction in OCD symptoms after 11-20 sessions. Using CBT on a weekly basis, can take 2 months or longer to show full effects. Practiced in the therapists office, and do daily E/RP homework. When the OCD is very severe, it is sometimes better to practice CBT in a hospital setting.

Treatment Effectiveness

Behavioural techniques are most effective for certain types of OCD symptoms particularly cleaning or checking rituals. Best approaches are: DRO in combination with in vivo exposure; Relaxation Training; Stimulus Control techniques.

Medication Efficacy Studies

Double Blind studies have shown the effectiveness of: - Clomipramine (may be the best but has the most adverse side effects) - Fluvoxamine - Fluoxetine - Sertraline They inhibit the reuptake of serotonin into synaptic nerve terminals

When insight is poor

Motivation is necessary for CBT to be effective OCD behaviour is of itself reinforcing When insight is poor, behavioural techniques may help If you block one compulsion, usually another is established

Behavioural Techniques

Behavioural techniques are most effective for certain types of OCD symptoms particularly cleaning or checking rituals. Best approaches are: Differential Reinforcement in combination with Relaxation Training and Stimulus Control techniques.

Differential Reinforcement

Very effective and efficient but difficult to do on a consistent basis Reinforce behaviours that are appropriate Ignore behaviours that are not appropriate Redirect

Relaxation Techniques

Identify anxiety behaviours Relaxation Deep breathing, muscle relaxation Guided Imagery Provide concrete visual cues Quiet place

Stimulus Control

Set up person for success Identify triggers /stimulus

Instigating conditions Vulnerability conditions Maintaining (reinforcing) conditions

Reduce the internal triggers - medication Modify environment Teach coping skills

Is this the hill you want to die on?

Restricting behaviour will escalate behaviour Compromise

Allow behaviour within defined limits E.g., defined space for hoarding

Best Treatment Approach

Multi-Modal that considers the Bio-PsychoSocial aspects of the person: OCD may improve with habilitative changes, person centred planning, specific behavioural intervention plans and appropriate medication treatment and ongoing monitoring of effectiveness.