OCD Flashcards
def
OCD
is a common form of anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear & worry ; by repetitive behaviors aimed at reducing the associated anxiety; or by a combination of such obsessions and compulsions.
Obsessions
Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2.The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion.
Compulsion
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, 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 behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive
Comorbidity with OCD
67% of patients with OCD have MDD
25% of OCD patients have social phobia
The incidence of Tourette syndrome in patients with OCD is 5-7%
20-30% of patients with OCD have history of tics
Other comorbidities with OCD include : alcohol use disorder, eating disorders , specific phobia, GAD, panic disorder , personality disorder
Etiology Neurotransmitters
Neurotransmitters:
Serotonin: studies suggest that dysregulation of serotonin is involved in symptom formation of obsessions and compulsions
Data shows that serotonergic drugs are more effective in treating OCD But!! Whether serotonin is involved in the cause of OCD is NOT CLEAR
One study showed that the level of 5-HIAA (metabolite of serotonin) in the CSF decreased after treatment with Clomipramine (Anfaranil)
Less evidence exists for the dysfunction of the noradrenergic system
There is a positive link between Group A beta hemolytic streptococcal infection , 10-30% of patients develop sydenham’s chorea and show OCD symptoms
etiology Brain imaging studies:
Brain imaging studies:
Neuro imaging implicates altered function in the circuitry between the Orbitofrontal cortex, Caudate and the Thalamus
PET scan have showed increased activity ( metabolism+ blood flow) in the frontal lobes and the basal gangilia ( especially in the caudate and the cingulum )
The corticostriatal pathways in these areas are particularly involved in the pathology of the OCD, NOT the amygdala pathways
CT and MRI found BILATERALLY SMALLER CAUDATES IN OCD PATIENTS
etiology genetics
Genetics:
Relatives of probands have 3 to 5 folds higher probability of having OCD
The following conditions are more common in families of patients with OCD: GAD, TIC disorders, Body dysmorphic disorder , hypochondriasis , eating disorders and habits such as nail biting
etiology Behavioral factors
Behavioral factors :
Obsessions are conditioned stimuli: a neutral stimulus is paired with anxiety producing event
Compulsions are established when a person discovers that a certain action reduces anxiety attached to an obsessional thought
Only 15-35% of patients with OCD have had premorbid obsessional traits
Research suggests that OCD may be precipitated by a number of environmental stressors especially those involving pregnancy, child birth or parental care of children
DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder
DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder
A. Presence of obsessions, compulsions, or both:
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Pattern of symptoms
The most common pattern is an obsession of contamination (45% of adults), followed by washing or accompanied by compulsive avoidance of the contaminated object
Pathological doubt : is the 2nd most common pattern , an obsessional doubt is followed by the compulsion of checking (63%)
Intrusive thoughts : are the 3rd most common pattern , obsessional thoughts without compulsions
Usually thoughts of aggressive or sexual act
Suicidal thoughts may also be obsessive
Symmetry : 4th most common pattern , can lead to a compulsion of slowness
New onset OCD after the age of 30 , should raise questions about potential neurological contribution to the disorder ( Sydenham’s chorea, Huntington’s disease etc..)
Two thirds of patients with Tourette disorder meet the criteria for OCD
Questions used to elicit obsessions and compulsions
. Do you worry about contamination with dirt even when you have already washed?
. Do you have awful thoughts entering your mind despite trying hard to keep them out?
.Do you repeatedly have to check things that you have already done (stoves , lights , taps , etc.)?
. Do you find that you have to arrange, touch or count things many times over?
poor prognosis
A poor prognosis is indicated by yielding to compulsions , bizarre compulsions, childhood onset , the need for hospitalization , the presence of schizotypal personality disorder
good prognosis
A good prognosis is indicated by : good social and occupational adjustment, the presence of precipitating event , the episodic nature of symptoms
Treatment
Behavioral and pharmacological treatment
Placebo response is only = 5%
Initial response of pharmacotherapy is generally seen after 4-6 weeks , 8-16 weeks are required to obtain maximal therapeutic effect
Fluoxetine, fluvoxamine, paroxetine , sertraline , citalopram are all FDA approved treatments of OCD
Clomipramine the first drug approved by the FDA to treat OCD, it should be increased gradually over 2-3 weeks , to avoid gastrointestinal disturbances , orthostatic hypotension , sedation , anticholinergic side effects
Other drugs : lithium , valproate or carbamazepine can be used to augment SSRI or clomipramine
Venlafaxine can be used to treat OCD
Buspirone , tryptamine and clonazepam can be used
Adding atypical antipsychotic such as risperidone has helped in some cases
