Obsessive Compulsive Disorder

 A common, chronic condition, often associated with marked anxiety and depression,
characterized by obsessions & compulsions.
 Obsessions/compulsions must cause distress or interfere with the person's social or
individual functioning (usually by wasting time), and should not be the result of another
psychiatric disorder.
 At some point in the disorder, the person recognizes the symptoms to be excessive or
unreasonable.

Epidemiology

 LTP: 2-3%
 M:F = 1:1
 Age: Adolescence/ Early adulthood, 70% before 25 Y
 FH: 35% 1st Degree

Course & Prognosis

 Waxing & Waning

 20-30% significantly improve
 40-50% moderately improve
 20-40% worsen

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 DSM IV Diagnostic Criteria
A: Obsessions: Thoughts, Images, Impulses that are:

 Recurrent, persistent, regarded by ptn as intrusive & inappropriate, cause marked anxiety
 Not simply excessive worries about real life problems.
 Ptn recognizes them as product of his own mind & senseless & attempts to resist them.
Compulsions: Repetitive behaviors (hand washing, ordering), mental acts (praying, count)

 Ptn feels driven to perform in response to obsession, to ↓ anxiety of feared event

 Not connected é what they are designed to prevent, or clearly excessive
 Ptn recognizes them as senseless & attempts to resist them

B: Person recognize that OC unreasonable or excessive

C: Impair social, occup function

D: Not caused by direct effect of subst /GMC

** é poor insight: If person not recognize that OC are unreasonable

Clinical Features
 Checking (63%),
 Washing (50%),
 Contamination (45%),
 Doubting (42%),
 Bodily fears (36%),
 Counting (36%),
 Insistence on symmetry (31%),
 Aggressive thoughts (28%).

Comorbidity
 Depressive disorder (70%),
 Alcohol- and drug-related disorders,
 Social phobia,
 Specific phobia,
 Panic disorder,
 Eating disorder,
 Tic disorder
 Associations
 Avoidant, dependent, histrionic traits (40% of cases),
 Anankastic/obsessive-compulsive traits (15%) prior to disorder.
 In schizophrenia, 45% of patients may present with symptoms of OCD (schizo-obsessive
poorer prognosis).

Differential Diagnosis
 Normal (but recurrent) thoughts, worries, or habits;
 Anankastic PD/ OCDPD,
 Schizophrenia;
 Phobias;
 Depressive disorder;
 Hypochondriasis;
 Body dysmorphic disorder;
 Trichotillomania.

Aetiology
Neurochemical:
Dysregulation of the 5HT system, or 5HT/DA interaction.
Immunological:
Cell-mediated autoimmune factors may be associated (e.g. against basal ganglia peptides).
Imaging CT and MRI:
bilateral reduction in caudate size. PET/SPECT: hyper metabolism in orbitofrontal gyrus and
basal ganglia (caudate nuclei) that normalizes following successful treatment (either
pharmacological or psychological).
Genetic:
Suggested by family and twin studies (35% of first-degree relatives affected, MZ: 50-80% DZ:
25%.).
Psychological:
Defective arousal system and/or inability to control unpleasant internal states.
Obsessions are conditioned (neutral) stimuli, associated with an anxiety-provoking event.
Compulsions are learned (and reinforced) as they are a form of anxiety reducing avoidance.
Psychoanalytical:
Regression from Oedipal stage to pre-genital anal-erotic stage of development as a defense
against aggressive or sexual (unconscious) impulses.
Associated defenses:
Isolation,
Undoing,
Reaction formation.

Management
Drugs better > PT

Best is combined ttt

Psychotherapy
 Supportive: valuable (including family members, use of groups);
 Psychoanalytical: no unequivocal evidence of effectiveness (insight-orientated
psychotherapy may be useful in some patients).
 Behavioral therapy: Response prevention useful in ritualistic behavior; thought stopping
may help in ruminations; exposure techniques for obsessions.
 Cognitive therapy so far not proven effective.

Pharmacological:
 Antidepressants:
o SSRIs: fluoxetine, fluvoxamine, sertraline, or paroxetine should be considered first-
line (no clear superiority of any one agent, high doses usually needed e.g. 40-60 mg
fluoxetine, Allow at least 4-12 wks for treatment response, Regard as a long-term).
o Clomipramine: (e.g. 200-300 mg) has specific anti-obsessional action (first-or
second-line choice).
 Augmentative strategies:
o Buspirone if marked anxiety;
o Antipsychotic (risperidone, haloperidol, pimozide) if psychotic features, tics, or
schizotypal traits.
o Lithium if marked depression.
 Physical:
o ECT consider if patient suicidal or severely incapacitated.