OCD Flashcards
Prevalence and onset
1-3%
2 onset peaks
- Early age onset: peak ~12
- Late age onset: peak ~26
DSM: OCD criteria
Anxiety disorder
Obsessions defined by:
1) recurrent and persistent thoughts,impulses, or images that are experienced as intrusive and inappropriate and cause marked anxiety or disorders
2) individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some thought or action
Compulsions defined by:
1) Repetitive behaviours (for example, hand washing, ordering or
checking) or mental acts (for example, praying, counting or
repeating words silently) that the individual feels driven to perform
in response to an obsession or according to rules that must be
applied rigidly.
2) The behaviours or mental actsa
are aimed at preventing or reducing
anxiety or distress, or preventing some dreaded event or situation;
however, these behaviours or mental acts are not connected in a
realistic way with what they are designed to neutralize or prevent, or
are clearly excessive.
OCD symptom dimensions
Contamination fear: compulsive washing
Harm-related: checking behaviors e.g locks and doors
Symmetry / ordering
Aggressive /sexual / taboo thoughts
Hoarding
Time-consuming
cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
Public and the self
delay in seeking treatment due to stigma
Causes of OCD
Genetics and environmental influences (early life stress, bacterial infection)
Co-morbidities of OCD
depression, anxiety, ADHD, tic disorder
obsessive-compulsiive related disorders
- body dismorphic disorder, trichotilomania, hoarding, skin picking
symptoms of OCD
fear of losing control, persistent worries about uncertainties, persistent thoughts about hurting yourself or someone else, excessive attention on superstitious thoughts or luck
some know their thoughts are definitely or probably not true, some think their OCD beliefs are true
1st line of OCD treatment
Pharmacological
- e.g high-dose SSRIs, anti-psychotics, TCAs, SNRIs
Psychotherapy
- CBT, ERP, ACT
(g=0.74-0.97)
Best OCD treatments often combine medication and therapy
Treatment response unclear due to low societal participation
Alternative OCD treatment
transcranial magnetic stimulation (device sending pulsed magnetic field onto activated neurons turning them into resting neurons)
DBS
Cingulotomty (incision in anterior cingulate cortex)
Brain-networks and their involvement
‘Sensorimotor’ circuit
- stimulus-response-based habitual behavior
‘Dorsal cognitive’ CSTC ircuit
- working memory, planning and emotion regulation
Frontoparietal network
- coordination and cognitive control
Ventral cognitive CSTC circuit
- stimulus-outcome-based motivational behavior
Frontolimbic circuit
- fear extinction
In early phases of OCD, alterations within the dorsal cognitive, ventral cognitive and ventral reward cortico–striato–thalamo–cortical (CSTC) circuits and the frontolimbic circuit are hypothesized to be related to symptoms involving anxiety, uncertainty, and goal-directed behaviours.
In later phases of OCD, alterations within the sensorimotor, dorsal cognitive and ventral cognitive CSTC circuits are hypothesized to be related to symptoms involving habitual behaviours
OCD pathophysiology
Dysfunction of CSTC circuits
- Dysfunction of frontostriatal cortex: Caudate, putamen, thalamus, etc
- Frontolimbic circuit is hyperactive
- Dorsal cognitive circuit is more diminished
Heterogeneity / biotypes
rTMS
transcranial magnetic stimulation
> stimulate DLPFC (Dorsolateral Prefrontal Cortex) + preSMA (Presupplementary Motor Area) both effective compared with sham (placebo)
Pre-treatment state
- Behavioral effect depends on network properties in healthy participants
- Behavioral effect depends on network properties in OCD patients
Essentially pre-treatment state matters
OCD overview
OCD is a highly debilitating disorder with high non-response
Directly modulating brain networks may
provide a promising treatment strategy
But requires large-scale RCTs and …
* Insight into neurobiology
* Insight into treatment predictors
Neurological lesions causing OCD
Basal ganglia, frontal lobe
Factors associated with poor treatment outcome in OCD
Clinical characteristics
* More severe obsessive–compulsive disorder (OCD)
* Greater functional impairment
* Sexual, religious and hoarding symptoms
* Poor insight
* Higher number of comorbidities
* Comorbid major depression, agoraphobia or social anxiety disorder
* Lower willingness to fully experience unpleasant thoughts
* Greater resistance to change
* Lower adherence to treatment
Sociodemographic characteristics
* Male sex
* Single relationship status
* Lower socioeconomic status
* Lower educational level
Other characteristics
* Family history of OCD
* Poor therapeutic alliance
* Greater family accommodation
* Absence of early response to selective serotonin reuptake inhibitor treatment
Selection criteria for neurosurgery for intractable OCD
Inclusion criteria
* Obsessive–compulsive disorder (OCD) must be the main diagnosis
* Yale-Brown Obsessive–Compulsive Scale score ≥28 (or ≥14 if only
obsessions or only compulsions are present)
* 5 years of severe OCD symptoms despite adequate treatment trials
* Independent confirmation of refractoriness to treatment
– 3 adequatea
trials with a serotonin reuptake inhibitor (at least one
with clomipramine)
– 2 adequate augmentation strategies (such as antipsychotics or
clomipramine)
– 20 hours of OCD-specific cognitive–behaviour therapy (such as
exposure and response prevention)b
* Age 18–75 yearsc
* Ability to provide informed consent
* Appropriate expectations of the outcomes of surgery
Exclusion criteria
* Comorbid mental or substance use disorder that may impair treatment (for
example, severe personality disorder or psychosis)
* Clinically meaningful condition affecting brain function or structure
* Intellectual disability
* Past history of head injury with post-traumatic amnesia
* Recent suicide attempt or active suicidal ideation
