Obsessive Compulsive Disorder pdf - د.صفية الجلبي

pg.

Fifth stage

Psychiatry

Lec-6

.د

الهام

6/11/2016

Obsessive compulsive disorder (OCD)



A common, chronic condition, often associated with marked anxiety and depression,
characterised by obsessions and 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.

Clinical features:



Obsessional symptom



Thoughts



Ruminations



Impulses



'Phobias'



Compulsive rituals



Abnormal slowness



Anxiety



Depression



Depersonalization

Obsessional thoughts



words, ideas, and beliefs



recognized by patients as their own,



intrude forcibly into the mind.



unpleasant, or shocking to the person, (may be obscene or blasphemous).



atempts are made to exclude them.



It is the combination of an inner sense of compulsion and of efforts at resistance that
characterizes obsessional symptoms,



Obsessional thoughts may take the form of single words, phrases, or rhymes,



Obsessional images are vividly imagined scenes, often of a violent or disgusting kind (e.g.
involving sexual practices that the person finds abhorrent.

pg.

Obsessional rumnations



are internal debates in which arguments for and against even the simplest everyday
actions are reviewed endlessly.

Obsessional impulses



are urges to perform acts, usually of a violent or embarrassing kind (e.g. leaping in front
of a car, injuring a child, or shouting blasphemies at a religious ceremony).

Obsessional rituals



include both mental activities (e.g. counting repeatedly in a special way, or repeating a
certain form of words) and repeated but senseless behaviours (e.g.washing the hands 20
or more times a day).

Obsessional slowness



. Although obsessional thoughts and rituals lead to slow performance, a few obsessional
patients are afflicted by extreme slowness that is out of proportion to other symptoms.

Obsessional phobias



. Obsessional thoughts and compulsive rituals may worsen in certain situations-for
example, obsessional thoughts about harming other people may increase in a kitchen or
other place where knives are kept. The person may avoid such situations because they
cause distress.

Anxiety



This is a prominent component of obsessivecompulsive disorders.



Some rituals are followed by a lessening of anxiety, while others are followed by
increased anxiety.

Depression



Obsessional patients are often depressed.



In some patients, depression is an understandable reaction to the obsessional
symptoms; in others, depression appears to vary independently.

Depersonalization



. Some obsessional patients complain of depersonalization.



The relationship between this distressing symptom and the other features of the
disorder is unclear.

pg.

Differential diagnosis



Anxiety disorders



Depressive disorder



Schizophrenia



Organic disorders

Epidemiology



Mean age: 20 yrs,



70% onset before age 25 yrs,



15% after age 35 yrs.



Sex distribution equal.



Prevalence: 0.5-3% of general population.

pg.

Aetiology of OCD:



Neurochemical Dysregulation of the 5HT system, or 5HT/DA interaction.



Immunological Cell-mediated autoimmune factors may be associated (e.g. against basal
ganglia peptides_as in Sydenham’s chorea).



Imaging CT and MRI: bilateral reduction in caudate size. PET/SPECT: hypermetabolism in
orbitofrontal gyrus and basal ganglia (caudate nuclei) that normalizes following
successful treatment (either pharmacological or psychological).



Genetic Suggested by family and twin studies (3-7% of first-degree relatives affected,
MZ: 50-80% DZ: 25%.), no candidate genes as yet identified.



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 defence against aggressive or sexual (unconscious) impulses.
Associated defences:isolation, undoing, and reaction formation.

Associations:



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-
obsessive poorer prognosis).



Sydenham chorea (up to 70% of cases) and other basal ganglia disorders (e.g. Tourette’s
Syndrome, post-encephalitic parkinsonism).

Comorbidity:



Depressive disorder (50-70%),



alcohol- and drug-related disorders,



social phobia,



specific phobia,



panic disorder,

pg.



eating disorder,



PTSD,



tic disorder (up to 40% in juvenile OCD) or TS.

Management:

•

Antidepressants 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 12 wks for treatment response, regard as
long-term).

• **Clomipramine (e.g. 250-300 mg) has specific anti-obsessional action

( second-line choice).

• ***Augmentative strategies:

– antipsychotic (risperidone, haloperidol, pimozide)

pg.

• if psychotic features,

• tics, or

• schizotypal traits;

– buspirone/short term clonazepam if marked anxiety

• ****psychosurgery may be considered for severe, incapacitating intractable cases, i.e

treatment resistance:

– 2 antidepressants,

– 3 combination treatment,

– ECT, and

– behavioural therapy)

• where the patient can given informed consent e.g. stereotactic cingulotomy

(reported up to 65% success). In theory, disrupts the neuronal loop between the
orbitofrontal cortex and the basal ganglia.

Course:



Often sudden onset (e.g. after stressful loss event,e.g loss, pregnancy, sexual problem),



symptom intensity may fluctuate (contact-related/phasic) or be chronic.

Differential diagnosis:



Normal (but recurrent) thoughts, worries, or habits;



anankastic PD/OCD,



schizophrenia;



phobias;



depressive disorder;



hypochondriasis;



body dysmorphic disorder;



trichotillomania.

pg.

Outcome:



20-30% significantly improve,



40-50% show moderate improvement,



but 20-40% have chronic or worsening symptoms.



Relapse rates are high for stopping medication.



Suicide rate increased esp. if there is secondary depression.

Prognostic factors: