Obsessive and Related Disorders Flashcards
What is Obsessive Compulsive Disorder?
A chronic disorder starting in childhood or adolescence involving obsessions, compulsions, or both. Time consuming >1 hour/day or causes significant distress of impaired functioning:
—Obsessions- recurrent intrusive, unwanted anxiety provoking thoughts, urges, or images
—Compulsions- response to obsessions with repeated, ritualistic behaviors or mental acts
The goal of the person is to reduce anxiety or distress by preventing some dreaded event or situation, often illogical
OCD Epidemiology
—2 to 3% or the general population
—Men=Women
—Mostly Chronic course (85%)
—better outcome with milder sx and good premorbid functioning
—poorer outcomes with early onset and personality disorders
—Depression is a common comorbidities and sx are usually worsened in times of stress or depression
Neurobiological components of OCD
—Genetic component
—occurs more often in pts with seizure disorders and brain trauma
—linked to birth injury, abnormal EEGs, growth delays, and abnormal neuropsych testing
— PET and SPECT have shown increased glucose metabolism in the caudate nuclei and orbital cortex of frontal lobes (improves w tx)
—SSRIs are the only meds with benefits
Behavioral Components of OCD
—Learned behavior therapy
—anxiety becomes paired with an external event
—Compulsive ritual decreased anxiety and becomes reinforced
Psychodynamic Components of OCD
—Obsessions and compulsions are signs of unconscious conflict that you might be trying to suppress, resolve, or cope with
—these conflicts are extremely repulsive or distressing so the pt can only deal with them indirectly by transferring the conflict to something that is more manageable like the compulsion they do
DDx for OCD
—Schizophrenia: it’s important to distinguish between Delusional thoughts (are not resisted against) and obsessions (unwanted and resisted by pt)
—MDD: distinguish between morbid thoughts (fears and anxieties) vs the excessive guilt of depression
—Tourette’s Disorder: can co occur with OCD, vocal and motor tics
—PTSD: also has recurrent intrusive, unwanted thoughts
—OCPersonalityDisorder: perfectionism and orderliness, but pt does not resist this
OCD Treatment
Medication + Exposure response prevention
—SSRI is first line: Fluoxetine, paroxetine, sertraline, fluvoxamine, and clomipramine
- higher doses and lengthy trials often needed (12-16wks)
- for refractory cases add a 2nd gen antipsychotic
For severe cases: neurosurgical procedures like cingulotomy or deep brain stimulation
What is Body Dysmorphic Disorder
Preoccupation with 1 or more perceived physical defects that are not observable by others or seem slight.
Pt performs repetitive behaviors or mental acts in response to preoccupation with appearance.
Causes significant distress or impairment and does not meet criteria for eating disorder
Body Dysmorphic Disorder Etiology
1-3% of gen population
Women>men
Onset is adolescence or early adulthood
Face and head is most common, they literally see faces and objects differently
High rates of comorbid major depressive disorder and social phobia. High rates of functional impairment and suicidal ITP
Common behaviors of Body Dysmorphic Disorder
—Mirror checking
—Camouflaging
—Ritualized grooming
—Requests for reassurance
Can people with body Dysmorphic disorder be convinced that a perceived flaw is not true?
No.
You do need to distinguish from delusional disorder somatic type by the compulsive behavior criteria
Body Dysmorphic disorder treatment
—Cosmetic Tx does NOT improve sx
—SSRI + CBT
—If pt does not have insight into disorder, can add 2nd generation antipsychotic (Olanzapine or Risperidone)
-meds decrease the distress and preoccupation with the perceived flaw and allow improved social and occupational functioning
—CBT aimed at distorted beliefs and modifying compulsive behavior
What is Hoarding disorder?
Persistent difficulty discarding or parting with possessions regardless of their actual value d/t an emotional attachment to the objects.
There is also a perceived need to save and to avoid the distress associated with discarding those items.
this results in an accumulation of objects of limited value and leads to significant clutter.
The person experiences impairment from the clutter and unsanitary conditions
What are the most common items to be hoarded
Newspapers, magazines, and clothes
What are the Hoarding disorder specifiers
—Excessive acquisition: active, driving need to acquire more and more things
—Level of insight:
- with good or fair insight- the pt recognized the behaviors are problematic
- with poor insight- “mostly” feels the behaviors are not problematic despite evidence to the contrary
- with absent insight/delusional beliefs- 100% believes the behaviors are not problematic despite evidence
DDx for Hoarding disorder
—OCD: up to 30% of people with OCD exhibit some degree of hoarding; focus on the primary motive for the behavior
—Prader Willi syndrome: a genetic disorder associated with short stature, hyperphagia, insatiability, and food seeking behavior, will mostly hoard food
—MDD, GAD, schizophrenia can coexist
—CNS lesions, dementia, TBI, and stroke
Hoarding disorder treatment
—The best is an experienced therapist who will do home visits and follow up
—Declutter the living space and shopping trips without buying
—Group and family therapy
—Can try SSRI in milder cases but not as effective if not OCD
What is Trichotillomania
Recurrent pulling of ones hair resulting in hair loss. Repeated attempts to decrease or stop the pulling.
Not due to another Dermatological medial condition
Trichotillomania Epidemiolgy
—Lifetime prevalence est at 1-2%
Pts have increased sense of tension before pulling hair, and have relief and satisfaction after pulling.
Chronic. Women>men
Typical age of onset is 12-13
Trichotillomania Treatment
—Assess for comorbidities: OCD, social anxiety, GAD, MDD, ADHD, BDD
— Drugs of abuse can cause sx: crystal meth, cocaine, stimulant abuse
—Psychological is tx of choice: Habit Reversal Therapy HRT
—Pharmacological Tx: SSRI or N-acetylcysteine (NAC) amino acid/antioxidant
Habit Reversal Therapy
—Self monitoring with a daily diary
—Awareness training to identify triggers
—Competing response- replace behavior for a brief period of time until the urge subsides
—stimulus control, modify the environment to reduce triggers
Duration 1-6 months
What is Excoriation disorder
Similar to Trichotillomania, people repetitively and compulsively pick at their skin leading to tissue damage and possibly infections
Most common site of picking is face, followed by hands, fingers, torso, arms and legs
Chronic but fluctuating illness
Excoriation disorder tx
—R/O effect of medications or drugs
—R/O other medical conditions like scabies, atopic dermatitis
—R/O other mental disorders like hallucinations/delusions
—Meds recommendations same as Trichotillomania SSRI+Behavioral therapy
