Lecture 9: OCD 1 Flashcards
onset of OCD
usually between:
- 5 and 10
- 15 and 20
- 20 and 30
-> because of stressful periods
course of OCD
usually very chronic. overall only partial remission. often periods with waves of symptoms around periods of stress
OCD-related disorders=
- hoarding disorder
- body dysmorphic disorder
- trichotillomania
- skin picking disorder
- obsessive-compulsive or related disorder due to substance/medication
- obsessive-compulsive or related disorder due to a somatic condition
- otherwise specified obsessive-compulsive or related disorder
- unspecified obsessive-compulsive or related disorder
model van OCD
obsessions cause anxiety, distress, or other negative feelings, which brings about compulsions to reduce them. When these compulsions are performed, there is a temporary reduction in distress, which acts as negative reinforcement.
wat is het doel van CBT voor OCD
normalize the obsessions so that they are not appraised a s a real threat, personally significant or provoking a high level of uncertainty (vooral via het aanpakken van cognitieve biases)
cognitive techniques for overcoming cognitive biases
- 2-column technique: finding evidence for and against the beliefs, which often shows that there is much more evidence against.
- weighing the alternative: ask what an alternative explanation could be, and weighing the likelihood of both
- measuring chance: asking what the real chance is taht the belief would actually come true (for some patients this doesnt work because the chance is not always 0%).
- worst-case scenario: walkthrough the worst-case scenario that the patient imagines. just jump in deep and face your fears in exposure.
- estimation of catastrophe: inschatten hoe likely alles is en dan cumulative chance berekenen.
- pie chart technique: for estimation of responsibility
pharmacotherapy voor OCD
Antidepressants (SSRIs) are often used for OCD. The protocol is often to start with a maximum dosage of SSRI, then switch to a different SSRI, clomipramine and finally a low dosage of an antipsychotic.
Medication can lower the experienced fear, which can help exposure therapy. Of course, antidepressants always have side-effects. On top of that, they need at least a 1-year continuation without lowering the dosage.
neurobiology of OCD
cortical-striatal-thalamo-cortical (CSTC) loop
Cortical-striatal-thalamo-cortical (CSTC) loop
a brain network that, among others, consists of the orbito-frontal cortex (OFC), the nucleus accumbens (NAcc), the putamen, and the caudate. OCD is highly characterized by a dysfunctional CSTC network, in which there is hyperactivity.
wat doen ze voor mensen die nonresponders zijn
Around 10% of OCD patients does not respond to the CBT and pharmacotherapy. For this patient group, deep brain stimulation (DBS) is sometimes used.
deep brain stimulation=
a treatment method in which an electrode is implanted in the CSTC network. This area is subsequently stimulated. This is a method that is successfully used for (heavy) compulsive patients. Affective symptoms improve within minutes to hours, obsessions within days, and compulsions within a few weeks. Thus, this symptom improvement is rather rapid.
adverse effects associated with DBS:
- Complications: there can be complications related to the surgical implantation of the device or device or hardware-related problems.
- Stimulation: there are several undesired effects caused by stimulation or reduction of stimulation (hypomania). Fortunately, it is brief or at least reversible.
OCD symptom dimensions
I. Contamination & cleaning
I. Responsibility for causing or not preventing harm &
checking/ reassurance seeking
III. Taboo thoughts about sexual activity, violence and
blasphemy & checking
IV. Need for order and symmetry & ordering/ counting
specifiers of OCD
- With good or fair insight: acknowledges/ reluctantly admits absurdity or excessiveness of ideas.
- With poor insight: ideas are not unreasonable/ absurd, but acknowledges validity of contrary evidence.
- With absent insight/delusional beliefs: The individual is completely convinced that obsessive compulsive disorder beliefs are true.
- Tic-related: current or past history of tics.
- Medical disorders: dementia, TBI, PANDAS
- Medication/ drugs: clozapine, amphetamines, cocaine
- Excessive worries in generalized anxiety disorder or major depressive disorder
- Preoccupation with appearance in body dysmorphic disorder
- Difficulty discarding or parting with possession in hoarding disorder
- Repetitive and stereotyped behavior in autism spectrum disorder, Tourette syndrome, mental
retardation, frontal lobe lesion, Parkinson, schizophrenia - Ritualized eating behavior (eating disorders)
- Preoccupation with substances or gambling (substance-related and addictive disorders)
- Sexual urges or fantasies (paraphilic disorders)
- Thought insertion or delusional ideas (schizophrenia spectrum and psychotic disorders
hoef je niet te weten maar wel interestingggg
OCD related disorders (9)
- Obsessive Compulsive Disorder (OCD)
- Body Dysmorphic Disorder (BDD)
- Hoarding Disorder
- Trichotillomania
- Excoriation (Skin Picking) Disorder
- Substance/Medication-induced Obsessive-Compulsive and related Disorder
- Obsessive-Compulsive and Related Disorder due to another medical condition
- Other specified Obsessive-Compulsive and Related Disorder
- Unspecified Obsessive-Compulsive and Related Disorder
OCD vs OCDP
OCD: obsessions and compulsions, anxiety, egodystonic, one/few domains
OCDP: rigidity and need for control and perfectionism, tension, egosyntonic, multiple domains
hoe ocd meten
yale-brown obsessions and compulsions schale (Y-BOCS)
- a 10-item, clinician-administered scale
- Most widely used rating scale for OCD.
- Provides five rating dimensions for obsessions and compulsions:
- time spent or occupied
- interference with functioning or relationships
- degree of distress
- resistance to
- control of
- The 10 Y-BOCS items are each scored on a scale from
0 = “no symptoms” to 4 = “extreme symptoms.” - Max = 40 points, 20 (obsessions) + 20 (compulsions)
treatment of OCD
- CBT + ERP
- medication
- neuromodulation (rTMS, DBS)
dysfunctional beliefs associated with obsessions
- inflated responsibility
- overimportance of thoughts
- overestimation of threat
- perfectionism
- intolerance for uncertainty
overimportance of thoughts
1) Belief that the mere presence of a thought makes the thought important.
2) Thought has ethical or moral ramifications.
3) Thinking the thought increases the likelihood of performing corresponding behavior.
intolerance for uncertainty
belief that it is necessary and possible to be completely certain that negative outcomes will not occur
waar is exposure voor en waar is response prevention voor
Exposure: overcoming avoidance
- Dirty the countertop of your kitchen
- Touch the inside of the toilet (flooding)
- Order things asymmetrical on your desk
- Actively think of your gruesome intrusions
Response Prevention: Reducing compulsions
- Do not clean the countertop before starting to cook
- Do not wash your hands following your toilet exposure
- Do not order your desk before starting work
efficacy of CBT for OCD
- 70% responder
- Responder defined as a 35% decrease of the Y-BOCS
- Average symptom decrease of 60-80%
factors associated with poor treatment outcome
severe ocd
greater functional impairment
sexual/religious/hoarding symptoms
poor insight
more comorbidities
resistance to change
low adherence
male
single
lower ses
lower education
family history of ocd
poor therapeutic alliance
greater family accommodation
absence of early response to ssris
medication protocol for ocd
1) Start with a SSRI, maximum dosage, minimum of 3 months (serotonin)
2) Switch to a different SSRI, maximum dosage, inimum of 3 months (serotonin)
3) Switch to clomipramine (Tricyclic antidepressant), maximum dosage, minimum of 3 months, possibility of measuring blood-levels (serotonin)
4) Add a low dosage of an antipsychotic , minimum of 1 month (dopamine) = extra 30% responder rate
hoe ga je vervolgens verder met medicatie
- 1-2 years continuation
- No lowering of dosage
- Gradually lowering dosage in case of prolonged “remission”
waar zouden ze rTMS op doen bij OCD
- Low frequency preSMA
- High frequency bilateral dlPFC
- Low Frequency right dlPFC (highest efficacy)
wat doet DBS
DBS normalizes fronto-striatal hyperconnectivity (directly changes)
sequential symptom improvement of DBC for OCD
- Affective symptoms: minutes to hours
- Obsessions: days
- Compulsions: weeks
-> Rapidity of symptom improvement makes DBS highly interesting for the understanding of the underlying neurobiology of OCD
rTMS=
magnetic coil, very brief, powerful magnetic pulses induce currents in the brain
DBC
much more invasive, put electrodes in the skull, maar weinig complicaties
waar wordt DBS vaak voor gebruikt
parkinson
cognitive functioning does not change due to dbc
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