OCD

Question 1

What are obsessions?

Answer 1

Obsessions:
recurrent and persistent thoughts, urges, or images
experienced as intrusive and unwanted
cause anxiety.

Question 2

What is the epidemiology of OCD?

Answer 2

Epidemiology
-2-3 % of population
-Females slightly >males, males earlier
-Onset late adolescence/young adulthood.
In a room with 40 people, 1 has OCD.

Slide note: Patients with OCD seek help 7-17 years after first symptoms. Avg – 9 years. Underdiagnosed.
Why? Embarrassed, shame, stigma (keep having intrusive thoughts of killing, guilt), poor literacy & not knowing help.
Also overlooked by us – not even on radar.

Question 3

Explain the pathogenesis of OCD.

Answer 3

Genetics
-25-50% in twin studies

Neurobiology
-CSTC ‘loops’: impaired control of inhibition.
Now, with neuroscience/imaging/psychopharmacology – actually a neuropsychiatric condition that is caused by abnormalities in specific neuronal circuits. Ie hardware error

Question 4

Looking at the anatomy of parts of the brain involved in the pathogenesis of OCD.

Answer 4

-“CSTC loops” : Cortico-Striatal-Thalamo-Cortical Circuit.
Cortex = GM on outer brain
A decision-making hub
Striatum = GM deep within WM
Initiates & co-ordinates motor actions
ROLE = modulates and inhibits unwanted actions

Lecture’s notes: Probably enough to know that it is “a problem with neuronal circuits”, but I’ll spend a little time talking about the anatomy because it’s hard to understand when looking at an anatomy book without guidance. You’ll come across these “CSTC loops” so I thought I’d spend 1-2 minutes explaining this.

Need an anatomy lesson
Cortex – GM on outside (grey because made up of cell bodies):conscious thought, then WM (myelinated tracts), then ‘deep GM’ – more cell bodies, called ‘nuclei’: help control movements/actions
Loops – each hemisphere – C-S-T-back to C

Question 5

Describe the functions of frontal lobe part of the Loop hypothised to be involved in causing OCD.

Answer 5

Frontal lobe: Responsible for functions like error detection, working memory & goal-directed behaviour, sends a signal through the striatum.

FASCINATING: CBT and pharmacology BOTH NORMALISE activity in CSTC circuits

Question 6

How do you diagnose OCD?

Answer 6

First step is to ask
Patient and their family
How?
Screening with Z-FOCS takes <60s
If identified, then a detailed enquiry
Why?
Longer untreated OCD is associated with poorer treatment outcomes

C-FOCS:
1. Do you wash or clean a lot?
2. Do you check things a lot?
3.Is there any thought that keeps bothering you that you would like to get rid of?
4.Do your daily activities take a long time to finish?
5.Are you concerned about orderliness or symmetry?

Question 7

What comorbidities are associated with OCD?

Answer 7

-Anxiety (76%) also eating disorders/alcohol
-MDD (66%)
-Tic disorders (up to 30%)
-Children – ADHD/ASD
-Suicide Risk

Question 8

What are the OCD symptom clusters?
(This is a table in the slides matching the obsession with the compulsion.)

Answer 8

Obsessions:
-Contamination concerns.
-Harm to self/others, sexual/religious concerns.
-Symmetry, precision concerns.
-Completeness concerns/inability to discard.

Compulsions:
-Washing, bathing, showering.
-Checking, praying, asking for reassurance.
-Arranging,ordering.
-Collecting/hoarding.

Question 9

What is the Pharmacological management of OCD?

Answer 9

SSRI (e.g. Fluoxetine/Citalopram)
-Consider availability/SEs/interactions
-General: higher doses & longer durations than MDD

Specialist Level:
2. Another SSRI OR
Clomipramine (TCA)

3. Augment with antipsychotic

Question 10

What is the non-pharmacological management of OCD?

Answer 10

-CBT (Cognitive Behavioural Therapy)
-ERP (Exposure & Response Prevention.

Not just counseling/supportive psychotherapy – those can make it worse…

C.B.T. catching the thought and realising it’s not true, it’s just a thought… and can be changed (Awareness)

Provide e.g. contamination – feel dirty and anxious and wash hands to reduce anxiety. Reducing anxiety feels good, so it’s like a reward for doing the unnecessary handwashing.

Keep rewarding, end up 100 times/day. But in long run causes more anxiety because doing it 100 times per day. CBT helps patients understand this is a faulty thought pattern (with a biological basis too) and not their fault. Emphasize that thoughts and what we do are also very different….

Question 11

What other forms of management can you employ to treat OCD?

Answer 11

-Transcranial Magnetic Stimulation
-Neurosurgical interruption of CSTC
-Deep Brain Stimulation

Surgery (BG loop disruption)
Anterior cingulotomy – trying to put a circuit-breaker in that faulty circuit
Anterior capsulotomy
DBS
- neurosurgical procedure involving the placement of a medical device called a neurostimulator (sometimes referred to as a “brainpacemaker”), which sends electrical impulses, through implanted electrodes, to specific targets in thebrain(brainnuclei)

Question 12

What other OC-related disorders exist?

Answer 12

-Body dysmorphic disorder
-Hoarding disorder
-Trichotillomania (hair-pulling)
-Excoriation (skin-picking)
-“Other”: due to substance/medication or AMC or un/specified

Question 13

How is body dymorphic disorder treated?

Answer 13

Very similar to OCD: 1st line pharm SRI’s (Fluoxetine, Clomipramine etc), also CBT (ERP)

Question 14

How do people with body dysmorphic disorder react?

Answer 14

DSM 5:
Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g. comparing his or her appearance with that of others) in response to the appearance concerns

Causes clinically significant distress or impairment.

-Commonly affected areas are skin, hair, nose
-Prevalence 0,7-2,4%
-Often present to dermatologists/plastic surgeons first
-Treatment very similar to OCD
-High dose SSRI’s
CBT/ERP

Question 15

How do people with hoarding disorder react?

Answer 15

DSM 5:
Persistent difficulty discarding or parting with possessions, regardless of their actual value
This difficulty is due to a perceived need to save the items and distress associated with discarding. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use.
Causes clinically significant distress/impairment

Prevalence 2-5%, females>males
Somewhat different neurobiology to OCD
More resistant to treatment, but recent evidence shows that SRI’s and therapy (MI/CBT) can work pretty well

Question 16

How do people with trichotillomania(hair-pulling) present?

Answer 16

DSM 5:
Recurrent pulling out of one’s hair, resulting in hair loss
Repeated attempts to decrease or stop hair pulling
The hair pulling causes significant distress and impairment in at least one important area of functioning

Challenging diagnosis as hair loss can be a common complaint

12 month prevalence 1-2%, females 10x more likely

Limited research
Habit Reversal Therapy/CBT

Question 17

How do people with excoriation(skin-picking) present?

Answer 17

DSM 5:
Recurrent skin picking resulting in skin lesions
Repeated attempts to decrease or stop skin picking
Causes clinically significant distress/impairment

Often follows a dermatological condition (e.g. acne/psoriasis)
Can also cause life-threatening infection

Limited research
SSRI’s = mixed results
Habit Reversal Therapy

Question 18

What is the difference between OCD and OCPD?

Answer 18

OCD
Obsessions and/or compulsions
Marked distress and dysfunction

OCPD (OC Personality Disorder)
No obsessions/compulsions
Estimated prevalence 2-8%, 2 x males
Longstanding & pervasive pattern:
Orderliness/perfectionism/”in control”
At expense of flexibility/openness/efficiency
Diagnosed 4+/8 e.g. perfectionism that interferes with task completion

Question 19

What are compulsions?

Answer 19

Compulsions:
repetitive behaviors or mental acts in response to an obsession or according to rules that must be applied rigidly prevent events or. relieve stress

Question 20

Why is it important to know about OCD?

Answer 20

-Common
-Debilitating & high socioeconomic cost
-Delayed help-seeking.

Question 21

Describe the functions of the Striatum in the Loop hypothised to be involved in causing OCD.

Answer 21

Striatum: Either passes the signal or acts like a brake & inhibits it.

Question 22

Describe the functions of Thalamus in the Loop hypothised to be involved in causing OCD.

Answer 22

Thalamus: Controls subconscious movements, receives the signal from the striatum and sends it back to the frontal lobe. If the signal is too “loud”, it can disrupt activity there.

Question 23

Exposure and Response prevention therapy(ERP) is a non-pharmacological treatment therapy used in OCD. How does it work?

Answer 23

Exposure and response prevention = proven & best
exposure = systematic, repeated, and prolonged confrontation with stimuli that provoke anxiety and the urge to perform compulsive rituals
response prevention = refraining from performing compulsive rituals
learn that these situations are not harmful and that their anxiety will subside without compulsions
Then ask them to wash 10 times/day, then 0, then touch something dirty and not wash. Ie GRADED. Very anxiety-inducing, but helps them break the loop and convince themselves it’s not necessary to do all that washing.
Recommend 13-20 weeks, therefore expensive