OCD

Question 1

Define Obsessions

Answer 1

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

Question 2

Define Compulsions

Answer 2

repetitive behaviours or mental acts
in response to an obsession or according to rules that must be applied rigidly
prevent events or relieve distress

Question 3

Epidemiology

Answer 3

2-3 % of population
Females slightly >males, males earlier
Onset late adolescence/young adulthood

Question 4

Why is it important?

Answer 4

Common
Debilitating & high socioeconomic cost
Delayed help-seeking

Question 5

Pathogenesis

Answer 5

Genetics: 25-50% in twin studies.
Neurobiology: CSTC ‘loops’: impaired control of inhibition.
Serotonin: SSRI’s improve symptoms
Dopamine: Iatrogenic (methylphenidate,cocaine)

Question 6

Anatomy

Answer 6

“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

Answer 7

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

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

Question 8

Z-FOCS

Answer 8

Do you wash or clean a lot?

Do you check things a lot?

Is there any thought that keeps bothering you that you would like to get rid of but can’t?

Do your daily activities take long time to finish?

Are you concerned about orderliness or symmetry?

Question 9

DSM 5: Diagnosis

Answer 9

Obsessions: recurrent and persistent thoughts/urges/images experienced as intrusive/unwanted & cause anxiety/distress.

Compulsions: repetitive behaviours/mental acts that feel driven to perform in response to obsession or according to rules that must be applied rigidly. The acts aim to reduce anxiety/distress, but are not realistic/are too excessive. Wasting of time (>1hour/day)/↓functioning/distress.

Question 10

DSM 5: OCD cluster symptoms

Answer 10

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 11

Mx: Pharmacological

Answer 11

• SSRI (e.g. Fluoxetine/Citalopram)
• Consider availability/SE’s/interactions
• General: higher doses & longer durations than MDD

Specialist Level:
- Another SSRI OR Clomipramine (TCA)
- Augment with antipsychotic

Question 12

Mx: Non-pharmacological

Answer 12

CBT (Cognitive Behavioural Therapy)

ERP (Exposure & Response Prevention)

Question 13

Mx: Other

Answer 13

Transcranial Magnetic Stimulation

Neurosurgical interruption of CSTC

Deep Brain Stimulation

Question 14

DSM 5: Body dysmorphic disorder

Answer 14

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

Question 15

BDD: Affects which areas

Answer 15

Commonly affected areas are skin, hair, nose

Question 16

BDD: Prevalence & where do they often present?

Answer 16

0.7-2.4%

Often present to dermatologists/plastic surgeons first

Question 17

BDD: Tx

Answer 17

High dose SSRI’s
CBT/ERP

Question 18

Hoarding disorder: DSM 5

Answer 18

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

Question 19

HD: Prevaleve

Answer 19

2-6%
Females>males

Question 20

HD: Tx

Answer 20

More resistant to treatment.
SSRI’s
Therapy (MI/CBT

Question 21

Trichotillomania (hair-pulling)- DSM 5

Answer 21

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 22

Excoriation (skin-picking)- DSM 5

Answer 22

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 23

OCD vs OCPD

Answer 23

OCD:
Obsessions and/or compulsions.
Marked distress and dysfunction.

OCPD:
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.