11: Obsessive Compulsive Disorder Flashcards
1
Q
List the obsessive compulsive spectrum disorders.
A
- Obsessive compulsive disorder
- Hoarding disorder
- Body dysmorphic disorder
- Trichotillomania (hair pulling disorder)
- Excoriation disorder (skin picking)
- OCD secondary to other medical condition
- Substance-induced OCD
2
Q
What are the DSM-5 criteria for obsessions?
A
- Recurrent thoughts, urges or images that are intrusive, unwanted, cause marked distress and are not simply worrying about life
- Types of obsessions:
- Taboo: aggressive, sexual, religious
- Harm to self/others
- Contamination
- Symmetry
- The individual attempts to ignore, suppress or neutralize the thoughts, urges or images
3
Q
What are the DSM-5 criteria for compulsions?
A
-
Repetitive
- Behaviors (handwashing, ordering, checking)
- Mental acts that the person is driven to perform (praying, counting, repeating words silently)
- Goal of compulsion
- Reduce distress (“to feel right”)
- Prevent a dreaded consequence
4
Q
What are the DSM-5 criteria for OCD?
A
- Presence of obsession, compulsions or both
- Obsessions or compulsions are time-consuming (>1 hour/day) or cause marked distress or impairment
- Not due to physiologic effects of a substance or other medical condition
- Content is not limited to other disorders
5
Q
What are some of the related features of OCD?
A
- Pathological intolerance of uncertainty (“How can I be sure?”)
- Inflated sense of responsibility (“Why did I let that happen?”)
- Pervasive avoidance (e.g., public restrooms, shaking hands)
- Over-importance of thoughts (e.g., forbidden thought is as bad as acting on it; magical thinking)
6
Q
What are other disorders with O&Cs with a focus?
A
- Body dysmorphic disorder
- Eating disorders
- Illness anxiety disorder (hypochondriasis)
7
Q
What are other disorders with compulsions but no prominent obsessions?
A
- Hoarding
- Trichotillomania
- Excoriation
- Tourette’s
8
Q
What is a disorder with obsessions but no compulsions?
A
- PTSD
9
Q
What is the difference between OCD intrusion and depressive rumination?
A
- Distinctions made based on content:
- Rumination: negative, pessimistic, ego syntonic
- Obsession: intrusive, unrelated to mood state (ego dystonic)
- Distinctions made based on response:
- Depressed individual does not try to suppress/ignore depressive thought
10
Q
What is the difference between OCD obsession and worry of generalized anxiety?
A
- GAD: concerns about real-life circumstances that are seen by the person as realistic
- Obsessions: unrealistic or magical and are usually recognized by the individual as inappropriate (ego dystonic)
11
Q
What is obsessive compulsive personality disorder (OCPD)?
A
- Pervasive preoccupation with orderliness, perfectionism, mental & interpersonal control
- Ego syntonic (vs. OCD, which is ego dystonic)
- Charactersitics:
- Perfectionism (so much that tasks don’t get completed)
- Inflexible, rigid and stubborn
- Exclusive devotion to work (few friends)
- So focused on lists, details, and rules that major point of activity is lost
- Reluctant to delegate tasks
12
Q
What is the normal presentation of insight with OCD?
A
- Many have good insight; some have poor
- About 4% have no insight (delusional)
- Fluctuates from good to absent (delusions not fixed for prolonged periods)
13
Q
What is the epidemiology of OCD?
A
- 1 year prevalence of 1.2 per 100
- Mean onset: 19.5yo
- 25% of cases have onset before 14yo
- Comorbidity frequent
- 60-70% have comorbid major depression
- 35-70% had another anxiety disorder
- 6:4 F:M in adulthood
14
Q
What are the major downsides of OCD?
A
- Major disability: one of world’s top ten causes of illness-related disability
- Often under-diagnosed/treated: 50% of pts w/ OCD worldwide untreated
- Not all patients respond to treatment: 10-30%
15
Q
Describe the genetic factors in OCD.
A
- Family studies: Increased rate of OCD in family members (7-17%)
- Twin studies: Concordance rates for OCD:
- MZ: 53-87%
- DZ: 22-47%
- Segregation analyses: suggest a mixed model, not a single gene
- Heterogeneity may be reduced by studying subtypes (e.g., contamination, symmetry)
- Strongest evidence for contamination subtype
16
Q
Describe childhood onset OCD and concurrent tics.
A
- Tics in OCD: 20% of pts w/ OCD have lifetime history of multiple tics
- OCD in tic disorders: 23% of pts w/ tic disorders have OCD
- Tic-related OCD
- Earlier age of onset (prepubertal)
- M>F
- Certain OCD Sx more common:
- Tic-like compulsions (touch, tap, rub)
- Intrusive violent/aggressive thoughts
- Worries about symmetry and exactness
- Rituals done until “just right”
- Respond less well to SSRIs, but improve w/ dopamine antagonists
17
Q
What is Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS)?
A
- Abrupt onset of OCD or tic disorder
- Onset btw. 3 yrs of age & puberty
- Evidence of concurrent GAS during exacerbations & declining titers when better
- Neurologic abnormalities: 95% have choreiform “piano playing” finger movements
- Tx: IV Ig, plasmapharesis
- Prevention: Rapid Abx treatment
- Other infx may also trigger this (e.g., Lyme)
18
Q
What are the various treatment approaches to OCD?
A
- Cognitive behavioral
- Pharmacologic (SSRIs)
- Neurosurgical
- Immunologic
19
Q
Describe the cognitive behavioral model of OCD.
A
- Over-responsibility for harm
- Over-estimation of threat
- Intolerance of uncertainty
- Over-importance of thoughts
- Over-valued need to control
20
Q
Describe the components of behavior therapy for OCD.
A
- Live confrontations with feared situations/objects (“in-vivo exposure”)
- Imaginal confrontations with feared consequences (“imaginal exposure”)
- Ritual prevention (i.e., patient refrains from compulsions and avoidance)
21
Q
What areas of the brain exhibit increased bloodflow/activity in patients with OCD?
A
- Caudate nucleus
- Cingulate cortex
- Orbital prefrontal cortex
22
Q
What have neuroimaging studies of OCD revealed?
A
- Volumetrics:
- Reduced gray matter volume in medial frontal and anterior cingulate gyrus
- Increased volume of lenticular nuclei to caudate
- Metabolic/blood flow studies (PET):
- Increased flow/metabolism in orbitofrontal cortex, anterior cingulate and caudate nucleus
- Activity increased at rest, accentuated during symptom provocation
- Treatment studies:
- Tx result in decreased cerebral blood flow and metabolism in these same areas
23
Q
What are the types of bilateral neurosurgery and how does it work?
A
- Via thermolesion or gamma knife
- Two types:
- Anterior cingulotomy (SR 56%): interrupts fibers in the cingulate bundle
- Anterior capsulotomy (SR 67%): lesions in anterior limb of internal capsule which connect thalamus with frontal lobe
- Interrupt connections between frontal and subcortical structures
24
Q
What is deep brain stimulation, and when is it used?
A
- Lead follows anterior limb of internal capsule; pulse generator in chest
- Approved for severe refractory OCD
- Inhibits transmission via depolarization blockade or neural jamming
25
What are the first line, second line, and third line treatments for OCD?
* First line
* Medications (SSRIs, SNRIs, clomipramine)
* Behavioral therapy (most effective)
* Combo
* Second line
* Augmentation w/ dopamine blocking agents
* When all else fails...
* Neurosurgery/deep brain stimulation
26
What is **body dysmorphic disorder**?
1. Preoccupation with imagined or slight defect in phsyical appearance
2. At some point, pt has performed:
1. Repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking), OR
2. Mental acts in response to appearance concerns (e.g., comparing appearance to others)
3. Causes significant distress or impairment
4. Preoccupations not restricted to concern about body fat or weight
27
Describe the following clinical features of BDD:
1. Demographics
2. Preoccupations
3. Compulsive behaviors
4. Psychological impact
1. Mean onset: 16yo, M:F equal, majority never married
2. Usually involve head/face, asymmetry concerns, focus on flaws 3-8hrs/day
3. Comparing, checking, grooming, camouflaging, reassurance seeking
4. Shame, defective, low self-esteem, rejection sensitive; suicide attempts common (27.5%)
28
What is the prevalence of BDD?
* Point prevalence: 2.4% in US adults
* Common in certain clinical settings:
* Derm: 9-15%
* Cosmetic surgery: 7-8%
* Orthodontia: 8%
* Co-morbidity common:
* OCD: 8-37% have BDD
* Social phobia: 11-13% have BDD
* Trichotillomania: 26% have BDD
* Atypical depression: 14-42% have BDD
* BDD usually not recognized or diagnosed
29
How is patient insight for BDD?
* Generally poor
* 1/3 delusional about "defect" for significant period of time
* Many have ideas or delusions of reference
* Ex: "others are staring at my defect"
* Referential thinking contributes to social isolation
* Insight shifts over time
* Delusional symptoms reduced by SRIs alone, but not by antipsychotics alone
30
Describe **hoarding**.
* Difficulty discarding or parting with possessions
* Perceived need to save items
* Accumulation of large number of possessions that fill up living areas
* Cause clinically significant distress or impairment
31
What have studies of hoarding revealed?
* Lifetime prevalence 2-6%
* M:F same
* 3x more common in older individuals (55+)
* Chronic course: rarely waxing/waning
* May increase in severity over time
* 50% of hoarders have family members who hoard
32
Describe **trichotillomania** and **excoriation disorder.**
Trichotillomania:
* Hair-pulling (e.g., scalp, eyebrows, eyelids)
* 1-2% one-year prevalence
* 10x more common in females than males
Excoriation disorder:
* Recurrent skin picking
Both require repeated attemps to decrease/stop the behavior, and clinically significant distress/impairment
