Psychiatry - Neurosis/OCD

Question 1

Obsessive Compulsive Disorder?

Answer 1

• Common, chronic condition,
• Often associated with marked anxiety and depression
• ‘Obsessions’ / ‘compulsions’ – cause distress / interfere with the person’s social or individual functioning (usually by wasting time)
• At some point in the disorder, the person recognises the symptoms to be excessive or unreasonable

DSM-V separate category – Obsessive-compulsive and related disorders

Content of obsessions/compulsions:

• Checking (63%), washing (50%)
• Contamination (45%), doubting (42%)
• Bodily fears (36%), counting (36%)
• Insistence on symmetry (31%)

Aggressive thoughts (28%)

Question 2

Obsessive Compulsive Disorder?

Associations?

Answer 2

• Avoidant, dependent, histrionic traits (~40% of cases)
• Anankastic/obsessive–compulsive traits (5–15%) prior to disorder
• In schizophrenia: 5–45% of patients may present with symptoms of OCD (‘schizo-obsessives—poorer prognosis)
• Sydenham’s chorea (up to 70% of cases) and other basal ganglia disorders (e.g. Tourette’s syndrome, post-encephalitic Parkinsonism)

Question 3

Obsessive Compulsive Disorder?

Management?

Answer 3

Psychological

• CBT—recommended by NICE, exposure and response prevention (ERP)
• Behavioural therapy—ritualistic behaviour; ruminations
• Psychotherapy—supportive

Pharmacological

• Antidepressants
• Augmentative strategies: antipsychotic (risperidone, haloperidol, pimozide) esp. if psychotic features, tics, or schizotypal traits (less evidence for olanzapine, quetiapine, aripiprazole)

Physical
• ECT—consider if patient suicidal or severely incapacitated
• Psychosurgery
• Deep brain stimulation (DBS) efficacy remains to be established (severe refractory cases)

Question 4

Obsessive Compulsive Disorder?

Course & Outcomes?

Answer 4

• Usually occurs following stressful event but presentation may be delayed by 5–10yrs due to secrecy, symptom intensity may fluctuate (phasic Vs chronic)
• 20–30% significantly improve
• 40–50% show moderate improvement
• 20–40% have chronic or worsening symptoms
• Relapse rates are high after stopping medication
• Suicide rates increased esp. if there is secondary depression

Question 5

Obsessive Compulsive Disorder?

Prognosis?

Answer 5

Poor prognosis

• Giving in to compulsions, longer duration, early onset, male, presence of tics, bizarre compulsions, hoarding, symmetry, comorbid depression,
• delusional beliefs or over-valued ideas, personality disorder (esp. schizotypal PD)

Prognosis is poorer when schizophrenia develops in childhood or adolescence

Better prognosis

• Good premorbid social and occupational adjustment, a precipitating event, episodic symptoms, less avoidance