Obsessive and Related Disorders

Question 1

What is Obsessive Compulsive Disorder?

Answer 1

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

Question 2

OCD Epidemiology

Answer 2

—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

Question 3

Neurobiological components of OCD

Answer 3

—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

Question 4

Behavioral Components of OCD

Answer 4

—Learned behavior therapy
—anxiety becomes paired with an external event
—Compulsive ritual decreased anxiety and becomes reinforced

Question 5

Psychodynamic Components of OCD

Answer 5

—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

Question 6

DDx for OCD

Answer 6

—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

Question 7

OCD Treatment

Answer 7

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

Question 8

What is Body Dysmorphic Disorder

Answer 8

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

Question 9

Body Dysmorphic Disorder Etiology

Answer 9

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

Question 10

Common behaviors of Body Dysmorphic Disorder

Answer 10

—Mirror checking
—Camouflaging
—Ritualized grooming
—Requests for reassurance

Question 11

Can people with body Dysmorphic disorder be convinced that a perceived flaw is not true?

Answer 11

No.

You do need to distinguish from delusional disorder somatic type by the compulsive behavior criteria

Question 12

Body Dysmorphic disorder treatment

Answer 12

—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

Question 13

What is Hoarding disorder?

Answer 13

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

Question 14

What are the most common items to be hoarded

Answer 14

Newspapers, magazines, and clothes

Question 15

What are the Hoarding disorder specifiers

Answer 15

—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

Question 16

DDx for Hoarding disorder

Answer 16

—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

Question 17

Hoarding disorder treatment

Answer 17

—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

Question 18

What is Trichotillomania

Answer 18

Recurrent pulling of ones hair resulting in hair loss. Repeated attempts to decrease or stop the pulling.
Not due to another Dermatological medial condition

Question 19

Trichotillomania Epidemiolgy

Answer 19

—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

Question 20

Trichotillomania Treatment

Answer 20

—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

Question 21

Habit Reversal Therapy

Answer 21

—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

Question 22

What is Excoriation disorder

Answer 22

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

Question 23

Excoriation disorder tx

Answer 23

—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