ocd_flashcards

Question 1

What is Obsessive-compulsive disorder (OCD)?

Answer 1

OCD is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.

Question 2

What is an obsession?

Answer 2

An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.

Question 3

What is a compulsion?

Answer 3

Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

Question 4

What is the prevalence of OCD in the population?

Answer 4

It is thought that 1 to 3% of the population have OCD.

Question 5

What are the risk factors for OCD?

Answer 5

Risk factors include family history, age (peak onset is between 10-20 years), pregnancy/postnatal period, and history of abuse, bullying, neglect.

Question 6

How does NICE recommend classifying impairment in OCD?

Answer 6

NICE recommends classifying impairment into mild, moderate, or severe, using the Y-BOCS scale.

Question 7

What is an example of ‘severe’ OCD?

Answer 7

An example of ‘severe’ OCD would be someone who spends more than 3 hours a day on their obsessions/compulsions, has severe interference/distress, and has very little control/resistance.

Question 8

What is the management for mild functional impairment in OCD?

Answer 8

For mild functional impairment, low-intensity psychological treatments such as cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) are recommended.

Question 9

What should be offered if psychological therapy is insufficient for mild OCD?

Answer 9

If psychological therapy is insufficient or the patient can’t engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP).

Question 10

What is the management for moderate functional impairment in OCD?

Answer 10

For moderate functional impairment, offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP). Consider clomipramine as an alternative first-line drug treatment to an SSRI if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated.

Question 11

What is the management for severe functional impairment in OCD?

Answer 11

For severe functional impairment, refer to the secondary care mental health team for assessment. Whilst awaiting assessment, offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative.

Question 12

What is ERP in the context of OCD treatment?

Answer 12

ERP (exposure and response prevention) is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response.

Question 13

How long should SSRI treatment be continued if effective for OCD?

Answer 13

If treatment with SSRI is effective, then continue for at least 12 months to prevent relapse and allow time for improvement.

Question 14

How does SSRI treatment for OCD compare to treatment for depression?

Answer 14

Compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response.

Question 15

summarise

Answer 15

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.

An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

It is thought that 1 to 3% of the population have OCD.

Risk factors
family history
age: peak onset is between 10-20 years
pregnancy/postnatal period
history of abuse, bullying, neglect

Management
NICE recommend classifying impairment into mild, moderate or severe
they recommend the use of the Y-BOCS scale
an example of ‘severe’ OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance
If functional impairment is mild
low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
If this is insufficient or can’t engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)
If moderate functional impairment
offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
consider clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated
If severe functional impairment
refer to the secondary care mental health team for assessment
whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative as above

Notes on treatments
ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response

Question 16

A 32-year-old man presents with several months of worsening low mood and behaviours that he feels he cannot control. He often feels distressed and finds that the only way to obtain some relief is to repeat a certain phrase in his mind. He has no significant past medical history and is physically well.

What is this symptom an example of?

Compulsion
Insertion
Intrusion
Obsession
Withdrawal

Answer 16

Compulsion

An obsession is an intrusive, unpleasant and unwanted thought. A compulsion is a senseless action taken to reduce the anxiety caused by the obsession

The act of a repetitive behaviour that a patient feels driven to perform, whether mental or physical, is a compulsion. Whilst this is a mental compulsion - repeating a phrase in the mind until feeling calmer - a physical compulsion may be an act such as repeatedly washing hands, or checking that a door is locked, until satisfied.

Thought insertion is the feeling of one’s thoughts not being one’s own - belonging to someone else and having been inserted into the mind. This does not fit with the scenario presented above. Insertion is a feature of schizophrenia.

An intrusive thought is an unwelcome, involuntary thought. These may be experienced by the general population, but if frequent and distressing, may develop into obsessions, which are seen as a more severe form of intrusive thought.

Obsessions, as mentioned above, are unwanted, intrusive thoughts that repeatedly enter the mind. These cause distress/discomfort. Coupled with compulsions, these form part of obsessive-compulsive disorder (OCD).

Thought withdrawal is a delusion, like insertion, where the patient believes that thoughts have been removed from their mind by a third-party. This is found in schizophrenia.

Question 17

A 40-year-old female who has a past medical history of agoraphobia for the last 2 months is seen via telemedicine to discuss any issues she is currently facing. When asked why she feels she cannot leave the house she states that she feels that the outside is too dirty and she will catch an illness and die. Every day in her house she has to wash her hands 6 times with soap and water after touching anything. As a result she has lost her job as an accountant, due to not having the time to do her work and missing deadlines. She feels she cannot stop herself doing this and is washing her hands exactly 6 times every time.

Her mental state examination is unremarkable. Over the video conversation you ask to see her hands and note they appear erythematous, dry and cracked.

What is the best management option for her?

Antipsychotic medication
Cognitive behavioural therapy (CBT)
Intensive exposure and response prevention (ERP)
SSRI and CBT (including ERP)
Selective serotonin reuptake inhibitor (SSRI)

Answer 17

SSRI and CBT (including ERP)

For more severe OCD, or if unresponsive to CBT/exposure and response prevention then add an SSRI

SSRI and CBT (including ERP) is the correct option as the above case describes a severe form of obsessive-compulsive disorder (OCD) with functional impairment resulting in the loss of her job and the break-down of the skin integrity of her hands. The obsession here is the cleanliness of her hands and the dirtiness of the outside and the compulsions are the resultant action of washing her hands 6 times.

Antipsychotic medication is incorrect as there are no features of psychosis present here and the mental state examination does not show evidence of a psychotic disorder.

CBT alone is incorrect as this is not a mild form of OCD, which would be more amenable to CBT alone. However, ERP addition is specific for OCD and would be more likely to be successful if given as a component of the CBT and is indicated for milder OCD, without the requirement of psychotropic medication.

Intensive exposure and response prevention (ERP) is incorrect as this measure alone is unlikely to be successful in this form of severe OCD, where concurrent SSRIs would raise the likelihood of successful treatment.

SSRI is incorrect as the pharmacological option alone would not be effective without the talking therapies of CBT with ERP for this severe OCD case.

Question 18

A 14-year-old girl with Tourette’s syndrome is brought to the GP by her mother as she is worried about some odd behaviours she has noticed. During the consultation, you find that she has been very worried about her exam results. She has felt the urge to clean all the door handles in the house 3 times each morning as otherwise, she finds herself worrying more about these exams.

Which of the following features would point towards a diagnosis of psychosis over obsessive-compulsive disorder?

Female gender
She truly believes that if she does not perform these acts that she will definitely fail her exams
Previous medical history of Tourette’s syndrome
Needing to perform more of these acts over a time to feel comfortable
There being no family history of obsessive-compulsive disorder

Answer 18

She truly believes that if she does not perform these acts that she will definitely fail her exams

Obsessive-compulsive disorder can be differentiated from psychosis by the level of insight into their actions

Obsessive-compulsive disorder (OCD) is a disorder characterised by obsessions and compulsions. Obsessions are unwanted intrusive thoughts that cannot be removed from your head, and compulsions are acts that patients do to try and reduce the number of obsessions that they get.

In this case, the correct answer is number 2, where she truly believes that if she does not perform these acts that she will definitely fail her exams. In OCD the patients normally have a good level of insight into their condition and understand that if they did not perform the acts their obsessive though would not come true. However, they still get the urge to perform them anyway, just to put their mind at ease.

This lack of insight into the condition she has may indicate that there is a delusional element to her symptoms and this may not be an obsessive-compulsive disorder and may have some form of psychosis.

There is no link between gender and OCD and some causes of psychosis e.g. schizophrenia are more common in males than females

A previous medical history of Tourette’s is associated with obsessive-compulsive disorder and not psychosis

Many patients with untreated OCD find themselves needing to perform more and more acts over time to reduce their intrusive thoughts and so this is not a feature that would indicate psychosis

While there is a genetic link to OCD, if a patient did not have a family history it would not point you towards another underlying diagnosis.

Question 19

A 32-year-old man visits his GP, troubled by some thoughts he is having. For several weeks now, he has been having thoughts of needing to repeatedly check that his front door is locked when leaving the house, despite knowing he locked it. He occasionally feels a need to physically check the front door, but more often than not, it is just thoughts.

He denies low mood or any delusions/hallucinations. He is otherwise physically well and has no past medical history, nor family history. He does not take any regular medication.

Given the likely diagnosis, which of the following is recommended first-line?

Clomipramine
Exposure and response prevention
Eye movement desensitisation and reprocessing
Routine referral to psychiatry
Sertraline

Answer 19

Exposure and response prevention

Exposure and response prevention involves exposing a patient with OCD to an anxiety provoking situation (e.g. having dirty hands)

The diagnosis here is that of obsessive-compulsive disorder (OCD), given the clear history. This scenario presents mildly - the patient is having obsessive thoughts but rarely having a compulsion to act on them. The correct answer is therefore exposure and response prevention (ERP) therapy. ERP is where a patient is exposed to their trigger (e.g. seeing a locked door) and then is prevented from engaging in their usual compulsive behaviour (repeatedly checking the door), to break the habit.

Sertraline is incorrect - if the patient had previously not responded to ERP, or the response was inadequate, he would be treated as having moderate OCD, for which selective serotonin reuptake inhibitors (SSRIs) such as sertraline would be appropriate.

Clomipramine is incorrect - this is recommended for moderate impairment second-line to SSRIs, if the patient has not tolerated SSRIs, or the patient prefers clomipramine.

Eye movement desensitisation and reprocessing is incorrect - this is a form of therapy used in the management of post-traumatic stress disorder. The patient focuses their memory on the problem and the therapist simultaneously asks the patient to use their eyes to follow the therapist’s finger. This is not routinely used for OCD.

Interpersonal therapy is incorrect - this can be used in the management of depression. This therapy focuses specifically on helping people with depression to address problems in their relationships with others. This would not be of benefit in OCD.

Psychodynamic psychotherapy is incorrect - this is used for a variety of conditions, including depression, but does not routinely play a role in the management of OCD.

A referral to psychiatry is incorrect at this stage - ERP should be tried first. A selective serotonin reuptake inhibitor may also be tried. If these methods fail, then a referral to secondary care may be warranted.

Question 20

A 19-year-old student presents describing obsessive thoughts that she will hurt someone. These concerns began when she moved out of her family home to university. She has particular worries about using the communal kitchen in her flat due to concerns that she will harm her flatmates, so she tends to prepare and eat all her meals during the night when they are in bed. She is asked to complete a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) - her results suggest ‘mild’ symptoms of OCD.

Given the likely diagnosis, what is the most appropriate treatment option?

Clomipramine
Cognitive behavioural therapy
Dialectical behaviour therapy
Fluoxetine
Venlafaxine

Answer 20

Cognitive behavioural therapy

OCD with mild impairment: low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) is first-line

The likely diagnosis here is obsessive-compulsive disorder (OCD). The first-line treatment for patients with mild symptoms of OCD is cognitive behavioural therapy (CBT), which usually involves some exposure and response prevention (ERP).

Clomipramine is a tricyclic antidepressant (TCA) that is sometimes used in the treatment of OCD but it is not first-line in mild cases. It is licenced for use in depression and phobias when other antidepressants haven’t been effective.

Dialectical behaviour therapy is generally used in the management of personality disorders, not in OCD. Therapies generally used in OCD include CBT and/or exposure and response prevention.

Fluoxetine is an SSRI antidepressant that can sometimes be used in the treatment of OCD but it is not first-line in mild cases. Fluoxetine is most commonly prescribed for depression but is also licenced for use in bulimia nervosa, OCD, and menopausal symptoms.

Venlafaxine is an SNRI antidepressant that is occasionally used in the treatment of OCD but it is not first-line in mild cases. It is most commonly used to treat depression and anxiety when SSRIs have not been effective.