Obsessive Compulsive Disorder OCD The Secret Problem

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• Obsessive Compulsive Disorder (OCD)The Secret
  Problem
• Identification and Treatment
• Dr James Woolley
• Consultant Psychiatrist
• St Anthonys Hospital Priory Hospital
• Visiting Lecturer Institute of Psychiatry,
  Kings College London

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Obsessive-Compulsive Disorder

• Affects almost 3 of worlds population
• Start anytime from preschool to adulthood
• Typically between 20-24
• Many different forms of OCD differ from person
  to person
• Checking / contamination / doubting / hoarding
  etc
• Cause unknown
• Better outcome when diagnosed treated early

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Obsessive-Compulsive Disorder

• Average time between onset and diagnosis is on
  average 7.5 years (Yaryura-Tobias Neziroglu
  1997)
• 60 of OCD sufferers go on to develop depression
• Listed amongst the top ten most debilitating
  illnesses by the World Health Organisation in
  terms of loss of income, and reduction in the
  quality of life
• Limited NHS provision

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Definition

• Specific criteria to be clinically diagnosed
• Anxiety disorder with presence of obsessions or
  compulsions
• egodystonic realise thoughts and actions are
  irrational or excessive
• Must take up more than 1 hour a day
• Must disrupt daily routine
• Symptoms cant result from effects of other
  medical conditions or substances

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• OCD often takes classic forms including
• pure obsessive thoughts
• obsessive thoughts
• compulsions

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Obsessions

• Repetitive and constants thoughts, images, or
  impulses that cause anxiety or distress
• Thoughts, images, or impulses not about real-life
  problems
• Try to ignore or counteract thoughts, images, or
  impulses
• Thoughts, images, or impulses recognized as a
  product of ones own mind and not imposed from
  without

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Pure obsessions

• Pure obsessions intrusive thoughts but do not
  lead to compulsive routines or rituals
• thought about pushing someone in front of a
  moving vehicle
• driving you car into the central reservation
• harming a child
• Do not carry out the thought!
• Not a form of psychosis or command hallucination

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Obsessive thoughts

• Bee in your bonnet triggering anxiety and
  fears.
• excessive and exaggerated. These obsessions
  lead to routines and rituals.
• Thoughts of being contaminated or being the cause
  of contamination to others.
• Such thoughts cause the sufferer to avoid certain
  places or situations, or lead to checking
  behaviour.
• eg Urge to throw out all their furniture in case
  it had been contaminated, change clothes
  throughout the day, or insist that others change
  before entering the house.
• Anxiety around household chemicals, blood,
  Hepatitis and HIV
• includes regularly demanding that a partners have
  blood screens for HIV etc

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Compulsions

• Repetitive behaviours or mental acts person does
  in reaction to obsessions
• Behaviours or mental acts done to avoid or
  decrease distress
• Behaviours or mental acts are clearly excessive
  or not realistic (and patients know this
  rationally)

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Aetiology Historic

• 14th 15th century thought people were possessed
  by the devil and treated by exorcism
• 17th century thought people were cleansing their
  guilt
• 18th century finally considered medical issue
• 20th century began treating with behavioral
  techniques

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Aetiology Recent history

• Early-mid 20th century
• psychodynamic issues of unconscious
  inner-conflicts from childhood.
• attempt to put life in order
• protect ego emotionally
• make sense of the world
• seek attention
• Late 20th century / 21st.....
• Neuro biological brain abnormality
• thalamus / caudate nucleus / orbital cortex /
  cingulate gyrus

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Biological Aetiology

• Serotonin is involved in regulating anxiety
• Abnormality in serotonin response, especially
  basal ganglia - thalamus - orbitofrontal cortex
  circuits
• Possible genetic mutation - human serotonin
  transporter gene?

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OCD and the brain

• PET scans show different brain activity from
  controls and recovered patients
• Not a single area neural network / feedback
  loop involving
• orbital frontal cortex
• caudate nucleus
• thalamus
• Caudate nucleus causes thalamus to become
  hyperactive and sends never-ending worry
  signals between OFC and thalamus ? OFC responds
  by increasing anxiety

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PET scans indicate differences in brain activity
of OCD patients versus normal
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Hoarding OCD as a separate entity?
An SK, Mataix-Cols D, Lawrence NS, Wooderson S,
Giampietro V, Speckens A, Brammer MJ, Phillips ML
(2008). To discard or not to discard the neural
basis of hoarding symptoms in obsessive-compulsive
disorder. Molecular Psychiatry
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Paediatric Autoimmune Neuropsychiatric Disorders
Associated with Streptococcal Infection (PANDAS)

• Anti-basal ganglia autoantibodies
• In children, post Strep throat infection
• Pre-pubertal symptoms onset
• Sudden onset or episodic course of symptoms
• Temporal association between streptococcal
  infections and neuropsychiatric symptoms
  exacerbation
• Associated neurological abnormalities including
  anti-neural antibodies and neuroimmune
  dysfunction
• Experimental therapy - plasmapharesis

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Comorbidity

• Comorbidity is common
• Depression, Schizophrenia, Tourettes Syndrome
• Depression is the most common
• Many people with OCD suffered from depression
  first
• 2/3 of OCD patients develop depression ? makes
  OCD symptoms worse and more difficult to treat
• Sometimes difficult to distinguish from
  schizophrenia

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Assessment

• Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
• 1 1/2 hours
• maps out symptoms
• duration impairment
• level of control
• identify target symptoms for treatment

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Y-BOCS sample questions - first 3 sections

• AGGRESSIVE OBSESSIONS
• Fear might harm self
• Fear might harm others
• Violent or horrific images
• Fear of blurting out obscenities or insults
• Fear of doing something else embarrassing
• Fear will act on unwanted impulses (e.g. to stab
  friend)
• Fear will steal things
• Fear will harm others because not careful enough
  (e.g. hit/run RTA)
• Fear will be responsible for something else
  terrible happening (e.g. fire/burglary)

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• CONTAMINATION OBSESSIONS
• Concerns or disgust with bodily waste or
  secretions (e.g. urine, faeces, saliva)
• Concern with dirt or germs
• Excessive concern with environmental contaminants
  (asbestos, radiation, toxic waste)
• Excessive concern with household items (e.g.
  solvents, cleansers)
• Excessive concern with animals (eg. Insects)
• Bothered by sticky substances or residues
• Concerned will get ill because of contaminant
• Concerned will get others ill by spreading
  contaminant (Aggressive)
• No concern with consequences of contamination
  other than how it might feel
• SEXUAL OBSESSIONS
• Forbidden or perverse sexual thoughts, images or
  impulses
• Content involves children or incest
• Content involves homosexuality
• Sexual behaviour towards others (Aggressive)

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Treatment

• Most have symptom relief with treatment
• Treatment choices depend on the problem and
  patient preference
• Behavioural Therapy / Cognitive Therapy
• Medication
• Psychodynamic Therapy, Transactional Analysis,
  and hypnotherapy have yet to evidence any
  effectiveness in treating OCD in robust treatment
  trials

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Medication

• Anxiolytic benzodiazepine ? temporary relief from
  anxiety but not really effective on obsessions
  and compulsions
• Selective Serotonin Re-uptake Inhibitors (SSRIs)
  / clomipramine because of common depression, plus
  specific effects in OCD
• regulates anxiety
• reduces frequency and intrusiveness of obsessive
  thoughts
• easier engagement with psychological approach
• Allow adequate duration (often 3 months ), and
  higher dose than commonly used on depression (eg
  fluoxetine 60mg)
• Specialist augmentation strategies eg
  antipsychotics

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Cognitive-Behaviour Therapy

• Cognitive Challenge distorted thinking and
  beliefs
• Behavioural Change reaction to
  anxiety-provoking situations
• Exposure and Response Prevention
• Slowly learning to tolerate anxiety associated
  with not performing ritual behavior
• Keep measures / graphs
• Practical, tailored, collaborative, supportive
• Systematic Desensitisation
• Learning cognitive strategies to deal with
  anxiety then gradual exposure to feared object

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Cognitive-Behaviour Therapy

• Patient needs to be ready
• Must be customized for each persons specific
  form of OCD and their needs
• Side effect increased anxiety with exposure to
  fear
• Often lasts about 12 weeks
• Positive effects of CBT may last longer than
  those of medication
• If OCD returns can successfully treat again with
  same therapy
• Best treatment approach for most is CBT combined
  with medication

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19 years old. Male OCD around relationships
checking re safety of partner with Sense of
responsibility fear of harm Significant
functional impairment
Dropping off girlfriend Considering
university Holidays
Phone calls Texts Avoidance (travel)
Tremor Sweating Nausea
I am responsible for preventing harm If bad
things happen it is my fault (by commission
or omission)
Anxiety Panic Fear
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Conclusion

• OCD is complicated, chronic and associated with
  significant comorbidity.
• In the WHO top 10 most impairing conditions
  worldwide
• Symptoms are often lifelong and fluctuate
• Most patients improve with CBT in combination
  with medication, though often incompletely
• Reducing delay to effective treatment reduces
  disability

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• Thank you.
• Questions?
• Dr James Woolley
• Consultant Psychiatrist
• contact_at_drwoolley.info
• www.drwoolley.info