Obsessive Compulsive Disorder OCD

1
Obsessive Compulsive Disorder(OCD)

• Dr. Bob Carey
• Regional Support Associates

2
As Good as It Gets
3
Monk
4
What is OCD?

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

5
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.

6
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.

7
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

8
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.

9
Most people with OCD have multiple OCD symptoms
10
Multiple Compulsions
11
Common Symptoms
12
OCD time spent thinking about the act and
performing the act
13
Ordering Compulsion
14
Most Common Symptoms

• Sets of common obsessions and compulsions are
  observed in developmentally disabled individuals
  with OCD. Typically, these sets are described
  best as just so behaviors, in which certain
  things have to be arranged or performed in a
  particular way to relieve the anxiety.
• The most clinically useful and detailed symptoms
  checklist is included in the Yale-Brown
  Obsessive-Compulsive Scale.

15
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.

16
Common Themes

• The most common theme of obsessions are
  contamination themes, and the related compulsive
  behavior is washing, usually compulsive
  handwashing. Along with contamination themes,
  problems with aggressive obsessions, sexual
  obsessions, the need for symmetry and order,
  obsessions about harm to oneself or others, and
  the need to confess exist. These excessive
  thoughts result in the common compulsive
  behaviors of washing, repeating, checking,
  touching, counting, arranging, hoarding, or
  praying.

17
Misdiagnosis is Common

• Because the behaviors observed in persons with
  OCD often are stereotypical and repetitive, 2
  other disorders, both in the developmental
  disability spectrum, commonly are confused with
  OCD.
• First, children with mild autism or Asperger
  disorder also may have repetitive thoughts and
  specific stereotypic compulsive behaviors. While
  disorders in the autistic spectrum are considered
  to be pervasive developmental disorders (PPD) and
  quite different than OCD, at times the
  differential diagnosis between the 2 sets of
  disorders is somewhat difficult to make.

18
How to Tell the Difference

• Remember - Social difficulties and communication
  problems are key intrinsic features of Asperger
  disorder on the PDD spectrum.

19
Co-Morbid Disorders Differential Diagnosis
20
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.

21
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 (10-12).
• 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.

22
(No Transcript)
23
Epidemiology of OCD

• The majority of patients with obsessive-compulsive
  disorder have both obsessions and compulsions,
  some have only one or the other.
• Most patients realize the irrational nature of
  their thoughts and rituals but feel helpless and
  hopeless about controlling them.
• In one epidemiologic survey, 18 children were
  found to have OCD, and only 4 were receiving any
  professional mental health care. Not one of these
  4 was diagnosed properly.

24
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.

25
Prevalence of OCD

• The World Health Organization lists
  obsessive-compulsive 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.

26
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.

27
Prevalence with Intellectual Disability

• In the general population, the prevalence is
  estimated to be around 1
• In populations with intellectual disability, the
  prevalence has been estimated to be between 1 and
  3.5

28
What Causes OCD?

• The probable biologic explanations of
  obsessive-compulsive 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).

29
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)
30
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).

31
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

32
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.

33
OCD Cause Summary

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

34
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.

35
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

36
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)

37
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.

38
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.

39
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.

40
More Treatment Considerations

• The impact of obsessive-compulsive disorder on
  interpersonal relationships, employment,
  marriage, and academic performance needs to be
  evaluated early in the diagnostic process.
• Coexisting psychiatric conditions (eg, major
  depression, panic disorder, phobias, eating
  disorders) should be treated along with
  obsessive-compulsive disorder. Similarly,
  obsessive-compulsive patients with ongoing
  alcohol or drug abuse problems should be treated
  for these before medication is considered.
• Although obsessive symptoms can be reduced with
  medications, the interpersonal relationships,
  social skills, work habits, and ability to resist
  compulsions require a comprehensive treatment
  plan that involves several aspects of each
  patient's life.

41
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.

42
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.

43
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.

44
Medications First-line drug treatment

• In a primary care setting with appropriate
  psychiatric consultation, pharmacotherapy for
  obsessive-compulsive disorder and comorbid
  psychiatric conditions can be quite successful.
  Between 50 and 70 of patients respond well to
  medication.
• The tricyclic antidepressant clomipramine
  hydrochloride (Anafranil) and various selective
  serotonin reuptake inhibitors (SSRIs) have been
  approved by the US Food and Drug Administration
  (FDA) for treatment of obsessive-compulsive
  disorder.
• The approved SSRIs include fluvoxamine maleate
  (Luvox), paroxetine hydrochloride (Paxil),
  sertraline hydrochloride (Zoloft), and fluoxetine
  hydrochloride (Prozac).

45
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

46
Side Effects to Watch for

• Teratogenetic concerns avoid all medications
  during pregnancy unless symptoms are disabling .
  All SSRIs are excreted in breast milk and
  therefore should not be used by nursing mothers.
• Hepatic disease and hepatic metabolism SSRIs
  should be used cautiously in patients with
  chronic hepatic diseases. Clinical monitoring and
  dose reductions are recommended to prevent drug
  interactions and undesirable side effects.
• Sexual dysfunction Although most side effects
  associated with SSRIs are well tolerated over
  time, sexual dysfunction is perhaps the most
  troubling adverse effect and can lead to
  discontinuation of or noncompliance with drug
  therapy.
• Cessation of therapy Abrupt discontinuation of
  SSRIs can lead to development of the
  "interruption-discontinuation syndrome." This is
  manifested by emergence of adverse effects and
  worsening of obsessive-compulsive symptoms.
  Therefore, gradual tapering of doses or shifting
  among various SSRIs is recommended (17).

47
Adjunctive drug therapy

• Buspirone hydrochloride (BuSpar), a specific
  nonbenzodiazepine anxiolytic medication, has been
  shown to benefit some obsessive-compulsive
  patients with comorbid anxiety.
• Mood stabilizers (eg, lithium, carbamazepine,
  valproic acid Depakene, Depakote) can be used
  to augment the efficacy of SSRIs or to treat
  obsessive-compulsive patients with comorbid
  bipolar disorder .

48
Med. Treatment Issues

• Clomipramine and SSRIs as anti-compulsive agents
  have the potential to precipitate hypomania and
  mania
• Risperidone is useful as an acute hypomanic
  agent, has mood stabilizing properties.

49
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

50
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.

51
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

52
Relaxation Techniques

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

53
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

54
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

55
Best Treatment Approach

• Multi-Modal that considers the
  Bio-Psycho-Social 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.

56
Difficulties in Producing Change
57
Case History

• Story of Alaa Severe OCD

58
Alaa

• Diagnostic uncertainty English is not first
  language possible High Functioning Autism or
  Aspergers syndrome

59
Ritualistic Behaviours

• Will perform ritualistic behaviours all day long
  cleaning, repetitive questions, routine and
  ordering
• Will become agitated during performance of
  rituals can become very aggressive at these
  times

60
Case Alaa

• Severe Aggression led to placement in
  Institutional setting where he was given 31
  staffing ratio (Alaa 3 staff)
• He was not allowed out

61
Alaa environment

• He was kept in a locked room most of day (TV room
  with locked half door)
• He was moved (e.g. to bathroom) with 3 staff
  encircling him and having him keep his hands in
  pockets

62
Case Alaa

• CTO was used for extreme aggression
• He would also engage in SIB hundreds of times
  per day
• He would also engage in Property Destruction
  holes in walls, broken toilets, etc

63
Case Alaa Treatment Plan

• Use of DRO Contingency Management Token
  Economy absence of target behaviours
• Greatly improving the quality of his time and
  interactions with staff doing fun activities
• Eliminate locked areas in house but reserving use
  of CTO for extreme aggression
• Develop prompting strategy so as not to
  inadvertently reinforce repetitive questions (one
  reminder prompt and withdraw attention)

64
Alaa Treatment

• Expose him to many other reinforcing activities
  to lessen his obsessions around specific video
  movies, food, cleaning
• New Psychiatrist new medications with use of
  SSRIs .
• Propranolol Nozinan seem to be helping

65
Ontario OCD Resources

• The Ontario OCD Network.Contact Details for
  Resource DirectoryCorinna de Beer120 Lombard
  St., Suite 301, Toronto, Ontario, M5C 3H5Ph
  416-970-2611Fax [phone]eMail
  cdebeer_at_rogers.com

66
OCD Network

• Ontario Obsessive Compulsive Disorder NetworkPO
  Box 151Markham, OntL3P 3J7tel
  416-410-4772fax [phone]web site    
  http//home.interhop.net/oocdnEmail is
  oocdn_at_interhop.net