OCD

Question 1

Screening questions for OCD

Answer 1

OBSESSIONS
Some people often get very distressing thoughts or images in their minds that are not under their control, do you ever get anything like that?

• How often do you get them?
• How do you feel when this happens?
• How do you deal with this? do you attempt to ignore or suppress such thoughts?

Are these your own thoughts or have they been put there by someone ?

COMPULSIONS

o Do you do things to lower your anxiety when these thoughts come into your mind?

• How long do you spend doing these actions / rituals?
• how do you feel when you don’t do something

FUNCTION
- Does it feel unreasonable/ excessive but you still feel compelled to do it ?
- How are they affecting your life - work, school, family, marriage, leisure activities, ADLS
- How much time do you spend on [obssession/ compulsions]

Question 2

What is the definition/ diagnostic criteria for OCD

Answer 2

A. Presence of obsessions and/or compulsions

B. The obsessions and compulsions are time-consuming (e.g. ≥1hr/day) or cause clinical significant distress/impairment in social/occupational/other important areas of functioning

C. Not attributable to a substance (drug of abuse, medication) or medical condition

D. Not better explained by another psychiatric disorder

Question 3

What is the definition of obsession and compulsions (both parts required for each)

Answer 3

Obsessions
- Recurrent/persistent thoughts/urges/images which are intrusive and unwanted
and in most cases cause marked anxiety/ distress
- Individual attempts to ignore/suppress such thoughts/urges/images or to neutralise them (e.g. by performing a compulsion)

Compulsions
- Repetitive behaviours (e.g. hand washing) or mental acts (e.g. counting) that the individual is driven to perform in response to an obsession or according to rules that must be applied rigidly

• Aimed at preventing/reducing anxiety/distress or preventing a dreaded event/situation. However, these behaviours are
  not a realistic way to neutralise/prevent these situations or are clearly excessive

Question 4

What are the 4 specifiers of dx of ocd

Answer 4

• With good/fair insight - recognises beliefs are definitely/probably not true
• With poor insight - thinks beliefs are probably true
• With absent insight/delusional beliefs - completely convinced that beliefs are true
• Tic-related - current/past history of a tic disorder

Question 5

Differential ddx of OCD

Answer 5

• OCD personality disorder ( pt happy with compulsions)
• Schizophrenic disorder vs. poor insight OCD (delusions)

Question 6

Management + initial ix

Answer 6

Initial Ix
o Safety
o Collateral hx
o Exclude medical cause – urine tox, bloods (TFTs)

Management
Psychological
- Psychotherapy : CBT first line
- exposure and response prevention therapy
-psychoeducation
- psychodynamic therapy
Mindfulness, relaxation techniques
Lifestyle : self help books, sleep hygiene, diet/exercise, limit alcohol and caffeine intake

Biological
1. SSRI / SNRI
2. TCA with serotinergic action - eg. clomipramine
3. Atypical antipsychotic eg. quetiapine

Social
- Family/friends support
- Work/school
- Home/living conditions improvement
- Spiritual/cultural

Question 7

Ocd prognosis and age of onset, related disorders

Answer 7

Prognosis : chronic -50% have partial response to treatment, full remission uncommon

Peak age of onset 24-34. Often in childhood.
Comorbid depression is common

related disorders
- Hoarding
- Trichotillomania (compulsion to pull out one’s own hair)
- Body dysmorphic disorder

Question 8

Explain in laymans terms OCD dx and treatment

Answer 8

Obsessive compulsive disorder (OCD) is a mental health disorder that affects people of all ages [1] and walks of life, and occurs when a person gets caught in a cycle of obsessions and compulsions Obsessions are unwanted, intrusive thoughts, images, or urges that trigger intensely distressing feelings. Compulsions are behaviors an individual engages in to attempt to get rid of the obsessions and/or decrease distress.

The first step to treatment is psychotherapy which can be helped with medications

https://iocdf.org/about-ocd/

Question 9

What are the dosing of clomipramine hydrochloride, and adverse effects and contraindications

Answer 9

adult 25mg TDS increase by 25 mg every few days to 100-150mg daily in divided doses/nocte

Contraindication
- immediate recovery period after myocardial infarction; arrhythmias (particularly heart block); in the manic phase of bipolar disorder; treatment of depression in children aged 12 years and under; use of monoamine oxidase inhibitor within 14 days

SAME TCA adverse effects
- antimuscarinic : (including dry mouth, blurred vision, constipation, urinary retention
- QT prolongation - risk of torsade de points
- serotonin syndrome

Specifically
- abdominal pain, diarrhoea, hypertension, flushing, restlessness, fatigue, aggression, impaired memory, muscle weakness, muscle hypertonia, myoclonus, mydriasis, yawning