OCD

1
OCD

• Dr A SHOKA
• Consultant Psychiatrist

2
The Task

• Introduction
• The Enigma of OCD
• Brief Historical Background
• Psychopathology,Related Disorders,DD
• Co-morbidity
• Treatment

3
An Over Looked Diagnosis?

• Why ?

4
Introduction

• Over the past decade we have witnessed a rapid
  growth in our understanding of the clinical
  features and pathophysiology of OCD.
• Despite that there are many patients with OCD who
  may continue to be characterized as difficultby
  the treating clinician.
• Until the early 1980s the only prevalence of OCD
  in general population was 0.05.

5
Still In The Introduction

• Data collected from the Epidemiology Catchment
  Area(ECA)survey has suggested that OCD is 50 to
  100 times more common than previously believed
  and twice as common as schizophrenia or panic
  disorder in the general population(RasmussenEisen
  1990)

6
Epidemiology

• 65 of patients onset lt 25
• 15 after age 35
• Mean age at onset 20 years
• Mean age of presenting to psychiatric services
  27.5 years
• Sex distributionequal

• 0.5-1 of general population
• Lifetime rates of 1.9-3.5 in ECA
• 1 of psychiatric out and inpatient .
• 4 of the neuroticgroup.

7
Enigmatic Phenomenon

• Secretive nature
• Diversity of clinical presentation
• Pathoplastic cultural effects
• Pathogenesis is at present not entirely
  understood
• F 42 in ICD 10 ?

8
Historical Background

• Hunter and MacAlpine(1963)have traced the
  literature on this syndrome back to the 16th
  century.
• In English early terms for OCD were
  scruples and religious melancholy.
• The French led by Esquirol took an early interest
  in folie du doute.
• By 1878 the German Carl Westphal coined the
  concept of obsessional thoughts

9
More History

• Obsession came from the Latin verb obsidere,means
  literally to besiege
• Compulsion comes ultimately from the verb
  compellere, to drive together
• Both terms suggest what we now recognize as the
  essence of OCDthe experience of an irritational
  or reprehensible thought besieging or driving up
  against the rational or respected self
  (Egodystonic)

10
Puzzling outlook !!

• It is one of the ironies of clinical psychiatry
  that,although the OCD illuminates the
  psychoanalytic concept of psychodynamic conflict
  perhaps better than any other psychoneurosis,its
  symptoms generally remain impervious to
  psychoanalytic treatment.
• Insight has little or no effect on the course of
  symptoms.

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Symptomatology

• Form of obsessions Thought
  Image Doubt
  Fear(phobia)
  Impulse Idea
  Ruminations

• Form of compulsions Yielding
  Controlling Mental
  Mechanical

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Symptomatology

• Content of obsessions Religious
  Blasphemous Sexual
  Dirtcontamination Germ
  Aggression
  Illness
  Indecisiveness

• Content of compulsions
  Cleaning,scrubbing, washing
  Checking/rechecking
  Counting/recounting Repeating
  Picking Fixed
  rituals Hoarding

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PhenomenologyRasmussenTsuang 1986

• Obsessional doubting 42
• Fears of contamination 45
• Bodily fears 36
• Insistence on symmetry 31
• Aggressive thoughts 28
• Checking compulsions 63
• Washing 50
• Counting 36

14
Remember

• Obsession increases anxiety level,compulsion
  reduces anxiety mainly the yielding type.Stern
  and Cobb(1978)suggest that resistance is not an
  essential component.

15
Remember

• Both obsessional thoughts and rituals inevitably
  lead to slow performance of everyday
  activities.However,a minority of patients are
  affected by extreme Obsessional Slowness
  (Rachman 1974)

16
Remember

• Obsessional thoughts and compulsive acts may
  worsen in certain situations e.g.harming others
  thoughts often increase in the kitchen where
  knives are kept leading to avoidance behaviour
  (Obsessional Phobia)

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OC symptoms may complicate

• Depressive illness(found in 20)-low rate of
  suicide in depressed OCD
• Schizophrenic disorder
• Early dementia and other organic brain
  syndrome(encephalitis lethargica epidemic in the
  1920s)
• Anorexia nervosa
• Generalized anxiety disorder

18
Related disorders

• Body dysmorphic disorder (BDD)
• Trichotillomania
• Religious scrupulousness
• Urinary obsessions
• Compulsive facial picking

19
Co-morbid diagnoses

• Schizotypal personality disorder
• Intrusive thoughts in PTSD
• Perfectionistic traits in OC personality disorder
• Underlying medical condition,Sydenhams chorea
• Tourette syndrome
• Drug induced,Clozapine and other atypicals

20
Anakastic Personality Disorder

• Resistance to change or novelty
• Risk aversion
• Ambivalance
• Excessive devotion to work
• Magical thinking
• Hypermorality
• Perfectionism

• Preoccupation with details,rules,lists,order
• Rigidty and stubborness
• PMP in 15-35
• Quantitative difference
• Egosyntonic

21
Mental State

• Evidence of compulsive behaviour(eg.raw hands
  from repeated washing)
• Affectanxious/depressed
• Thoughtsguilt,helplessness,low self esteem due
  to keeping the disease a secret
• Insight,presentpatient is very aware of the
  absurdity of the symptoms

22
Investigations

• Yale-Brown Obsessive-Compulsive Checklist ( Dr
  Wayne Goodman 1989)
• Maudsley OC inventory
• Blunted growth hormone response to IV clonidine
• Dexamethasone suppression test non-suppression

23
Investigations

• CT/MRI scanorbital-frontal cortex ,caudate and
  ventricular -brain ratio changes
• PET scanincreased activity bilaterally in the
  caudate nucleus and left orbital gyrus
  increased frontal and cigulate abnormaility
• SPECTincreased uptake in the frontal lobe which
  is reduced after treatment
• Neuropsychologyspatial perceptual deficits
  ,inappropriate synkinesias,tics.

24
Course of illness(Ingram)

• Constantstatic or worsening
• Fluctuatingperiods of worsening are interspersed
  with relative improvement
• Phasicone or more periods of complete freedom
  from symptoms since the onset of the disorder

25
Prognostic factors

• Disputed and unclear
• Longer the duration of illness,the worse the
  prognosis
• Early onset
• Bizarre compulsions,presence of obsessions about
  symmetry predict poor outcome
• Co-morbid diagnosis
• About 2/3 of cases improve by the end of a year

26
Treatment

• Biological/Pharmacological
  Clomipramine,tricyclic antidepressant with
  potent 5-HT uptake blocking effect.
  SSRIs,BNF listed Sertraline,Fluoxetine,
  Fluvoxamine ,Paroxetine,equipotent to
  clomipramine,but better tolerated in adults.
  Sertraline can also be used in children.
  Unlicensed with some efficacy,Citalopram at high
  doses

27
Treatment modalities

• Possible combinations
  Carbamazepineclomipramine
  Citalopramclomipramine
  PindololSSRIs
  RisperidoneSSRIsrisperidone
  
  augmentation of clomipramine-resistant
  OCD was effective in 50
  Olanzepine Fluoxetine
• NB ClozapineFluvoxamine should be avoided

28
Behaviour therapy

• Obsessional rituals usually improve with a
  combination of response prevention and exposure
  to any environmental cues that increase them
• About 2/3 of patients with moderately severe
  rituals can be expected to improve substanially
  but not completely
• Behavioural treatment is considerably less
  effective for obsessional thoughts

29
Psychotherapy

• Supportive interviews can benefit patients by
  providing continuing hope
• Joint interviews with the spouse are indicated
  where marital problems seem to be aggrevating the
  symptoms
• Exploratory and Interpretive psychotherapy seldom
  help

30
Psychosurgery

• The immediate results for severe OCD are often
  striking with marked reduction in tension and
  distress.However,it has not been proved that the
  long term prognosis is improved
• Cingulotomy,only 1/3 of patients improved
• Orbitomedial or cingulate lesions or both,
  again 1/3 of patients improved

31
Comment on treatment

• Innovations in behavioural treatment have
  profoundly improved the prognostic picture for
  OCD.However patients rarely find themselves
  entirely symptom free at the completion of this
  regimen.Maintenance of gains is problematic for
  about 20 of patients.

32
Summary

• The OCD patients are similar to persons with
  schizophrenia and mania in that they display an
  availability of primary process to consciousness,
  yet are also similar to the compulsive disorder
  in their ability to neutralize and contain this
  affective material and in their relatively
  accurate grasp of reality.Greenberg(1984)hypothesi
  zed that patients who develop OC symptoms have a
  pre-existing genotype.

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• Thank you

34
Introduction

• Define the subject matter
• State what the audience will learn in this
  session
• Find out any relevant background and interest of
  the audience

35
Agenda

• List the topics to be covered
• List the times allotted to each

36
Overview

• Give the big picture of the subject
• Explain how all the individual topics fit together

37
Vocabulary

• Glossary of terms
• Define the terms as used in this subject

38
Topic One

• Explain details
• Give an example
• Exercise to re-enforce learning

39
Topic Two

• Explain details
• Give an example
• Exercise to re-enforce learning

40
Summary

• State what has been learned
• Define ways to apply training
• Request feedback of training session

41
Where to get more information

• Other training sessions
• List books, articles, electronic sources
• Consulting services, other sources