Obsessive Compulsive Disorder - F42 Flashcards
What is the epidemiology of OCD?
4th most common mental illness in western societies
Onset: males - late teens; females – early 20’s
- 2% (12/1000) or more of the UK population will have OCD
i) 50% of these will fall into the severe category; <1/4 are mild
Help seeking may take between 10-15yrs
What are some comorbidities with OCD?
Depression, anxiety, alcohol or substance misuse, BDD, eating disorders
Tic disorders and Tourette’s syndrome
i) C. 50% of those with Tourette’s have OCD also
What are some biopsychosocial risk factors for developing OCD?
Bio - a person with OCD = 4x more likely to have a family member with OCD than someone who does not have OCD
Psycho - more rigid cognitive style, dichotomous thinking ie rights and wrongs, no grey areas
Social - adverse life events or stress can bring out 1/3rd of cases in a genetically susceptible individual
What is responsible for the maintenance of the condition?
Unwanted intrusive thoughts = normal in general population and their content doesn’t differ
Difference is – affected individuals tend to believe that intrusive thoughts and urges are dangerous/immoral and that they are able to prevent harm occurring either to themselves or vulnerable people
Conscious attempts at suppression of these obsessions/compulsions may lead to a paradoxical rebound in their presentation i.e. the harder you try to not obsess, the more you end up obsessing; same thing with the anxiety alleviating rituals
What are some preliminary criteria required for the diagnosis of OCD?
Must present with at least one obsession or compulsion but often they co-occur
Patient must acknowledge the obsessions or compulsions come from within their own mind i.e. not via thought insertion (psychotic) - though degree of insight may be variable, especially when in a high anxiety situation associated with their obsessive fears
One obsession or compulsion must be acknowledged to be excessive, unreasonable and unpleasantly repetitive
Symptoms must cause marked distress or significantly interfere with a patients occupational/social functioning
The thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense
Symptoms not explained by any other mental or organic disorder
Must be present most of the time for at least 2 successive weeks
What is an obsession?
Unwanted, intrusive thought/image/urge/doubts which repeatedly enters a person’s mind
Not imposed by an outside agency
Rumination and perfectionism – arguing with self about what to do so can’t make choices
Viewed as distressing, unreasonable and excessive by those affected
What are some common obsessions?
Contamination from dirt, germs, viruses (e.g. HIV), bodily fluids or faeces, chemicals, sticky substances, dangerous material (e.g. asbestos) - 37.8%
Fear of harm (e.g. door locks are not safe) - 23.6%
Excessive concern with order or symmetry - 10.0%
Obsessions with the body or physical symptoms - 7.2%
Religious, sacrilegious or blasphemous thoughts - 5.9%
Sexual thoughts (e.g. being a paedophile or a homosexual) - 5.5%
Urge to hoard useless or worn out possessions - 4.8%
Thoughts of violence or aggression (e.g. stabbing one’s baby) - 4.3%
What are compulsions?
Repetitive behaviours or mental acts that a person feels driven to perform
Overt and observable or covert personal; covert = more difficult to monitor as can be performed without others watching
Not a pleasurable act (unlike compulsive shopping/gambling etc that comes with a reward) but an anxiety reducing one
Some may appear to have a tic-like nature whilst others are directly related to the reduction of a perceived threat
What are some common compulsions?
Checking (e.g. gas taps) - 28.8%
Cleaning, washing - 26.5%
Repeating acts - 11.1%
Mental compulsions (e.g. special words or prayers repeated in a set manner – thought by the individual to ‘neutralise’ the threats and so anxiety) - 10.9%
Ordering, symmetry or exactness - 5.9%
Hoarding/collecting - 3.5%
Counting - 2.1%
Avoidance of anything that reminds you of worrying thoughts; asking others for constant reassurance
What is important to ask when discussing OCD?
In an anxiety/depression history (or other ones) – ask directly about obsessions and compulsions as patient may be reluctant to disclose (stigma, uncertainty etc)
Types of obsession and compulsions present
i) How much time is wasted
ii) Most significant/distressing symptoms
iii) Risk assessment (though typically murderous thoughts/pictures are not acted out in reality, more likely to be a danger to themselves)
Assess level of insight
Impact on functioning
i) Work
ii) Social
iii) Self care
iv) Other mental health/physical health
Exclusion of
i) Tourette’s and other tic disorders
ii) ASD
iii) Psychosis
What pharmacology should be prescribed in OCD?
SSRIs
i) Response is slow and improvements can take weeks/months – patient to remain at lowest effective dose for several weeks before increasing
ii) Should remain effective for as long as they are continued and continuation prevents against relapse – ½ who stop will relapse but less likely if treatment combined
iii) 6/10 people improve, symptoms reducing by ½
Clomipramine (2nd line)
i) A TCA with more potent serotonin modulation effects
What psychological therapies are indicated for in OCD?
CBT - 2 types
Exposure and Response Prevention (ERP) + Cognitive Therapy
Combined with pharma is the best option
What is the prognosis for people with OCD?
May follow an acute, episodic or chronic course, research shows: 20% experience total remission within 50yrs
80% show an improvement in symptoms within 40yrs
i) 60% of these still experience significant symptoms
ii) 10% show no improvement
iii) 10% had deteriorated
iv) 20% who showed initial improvement subsequently relapsed even after 20yrs w/o symptoms
Intermittent episodic in early stages = more favourable outcome
Early age of onset, esp in males + obsessions and compulsions, poor social adjustment and early chronic course = worst outcomes
Chronic illness present in later stages
