Obsessive Compulsive Disorder (OCD) Dr. Mahesh Kundagol
As Good as It Gets
What is OCD? n n Disorder causing worries, doubts, and superstitious beliefs during everyday life. Described by some as “mental hiccups that won’t go away”.
Obsessions? Compulsions? Obsessions – repetitive and unwelcome thoughts, images, or impulses that are difficult to dismiss or control. n Compulsions – repetitive behavioral responses – can be resisted only with great difficulty. n Recent studies have found lifetime prevalence of OCD in North America to be about 2. 5/100 people. n
Obsessions n n Thoughts, images, or impulses that repetitively occur to become out of one’s own control. Person suffering from these obsessions finds them intrusive and disturbing – recognizes they don’t make sense.
Obsessions - continued Obsessions often accompanied by uncomfortable feelings such as fear, disgust, or doubt. n For example, people with OCD may worry excessively about dirt and germs, and obsessed with the idea that they are contaminated or may contaminate others n
Compulsions These are acts that are continually performed to provide relief from discomfort caused by obsessions. n OCD compulsions do not give the person pleasure (unlike drinking, gambling, etc. ). n For example, a person may repeatedly check to see if their stove was left on in fear of burning the house down. n
Most people with OCD have multiple OCD symptoms
Multiple Compulsions
Common Symptoms Common Obsessions Common Compulsions - Contamination fears of germs, dirt, etc. - Washing. - Imagining having harmed self or others. - Repeating. - Imagining losing control of aggressive - Checking. urges. - Intrusive sexual thoughts or urges. - Touching. - Excessive religious or moral doubt. - Counting. - Forbidden thoughts. - Ordering/Arranging. - A need to have things “just so”. - A need to tell, ask, and confess. - Hoarding or saving. - Praying.
OCD – time spent thinking about the act and performing the act
Ordering Compulsion
Most Common Symptoms n The most clinically useful and detailed symptoms checklist is included in the Yale. Brown Obsessive-Compulsive Scale.
OCD and Developmental Disability may not to be able to identify obsessions n may not recognize that obsessions don’t make sense n diagnosis often based on compulsions n misdiagnosis is common – both inaccurate diagnosis of OCD or misdiagnosis of another disorder. n
Co-Morbid Disorders – Differential Diagnosis Phobias Hypochondriasis Impulse Control Disorder Panic Disorder Major Depression Tourette’s Syndrome Generalized Anxiety Disorder Delusional Disorder Obsessive Compulsive Personality
Diagnostic Issues in DD Difficult to distinguish with personality traits in persons with DH that engage in repetitive questions (repetitive speech, echolalia) that can occur in anxious individuals with limited verbal skills or in autistic spectrum disorders. n Compulsive behaviours are common in adults with intellectual disability – stereotyped behaviour and movement disorders from underlying brain damage. n
When does OCD begin? n n Begin anywhere from preschool age to adulthood (40 years). Obsessive-compulsive behavior affects both males and females equally but is more common among adolescent boys than adolescent girls. The mean age of onset is about 20 years (2, 10), but cases have been reported in children as young as 2 years (1012). On average, people with OCD see 3 -4 doctors and spend over 9 years seeking treatment before they receive a correct diagnosis. OCD tends to go under-diagnosed and under-treated because people with the illness often act secretive about their symptoms.
Gender & Culture n n n Boys are more likely to have a prepubertal onset and a family member with OCD or Tourette syndrome. Girls are more likely to have onset of OCD during adolescence. OCD is more common in whites than African American children in clinical samples. However, epidemiologic data suggest no differences in prevalence as a function of ethnic group or geographic region.
Prevalence of OCD n The World Health Organization lists obsessivecompulsive disorder as one of the five major causes of disability throughout the world. n It is considered the fourth most common psychiatric condition, ranking after phobias, substance abuse disorders, and major depressive mood disorder.
Prevalence: Underestimated Prevalence of OCD is underestimated – why? n 60% of all persons with a diagnosable anxiety disorder never see a mental health professional – they may turn to their family physician, religious leader or another family member for help. n
What Causes OCD? n n n The probable biologic explanations of obsessivecompulsive disorder include heredity, brain lesions, abnormal brain glucose metabolism, and serotonergic dysfunction. No specific gene associated with OCD – however, when a parent has OCD there is an increased risk that the child will also develop the illness. Problems in the front part of brain (orbital cortex) and deeper structures (basal ganglia).
Brain Differences – persons with OCD use different brain circuitry in performing a cognitive task than people without the disorder – (Rauch et al. J. of Neuropsychiatry, 1997)
Genetic Link? n n If one twin has OCD, the other twin is more likely to have OCD if the children are identical twins rather than fraternal twin pairs. OCD is increased among first-degree relatives of children with OCD, particularly among fathers (Lenane et al. , 1990). It does not appear that the child is simply imitating the relative’s behavior, because children who develop OCD tend to have symptoms different from those of relatives with the disease (Leonard et al. , 1997).
Role of Serotonin n Studies showing that serotonin plays a role in the pathophysiology of obsessive-compulsive disorder have led to new and highly effective treatments
Infection Causes? n n Recent research suggests that some children with OCD develop the condition after experiencing one type of streptococcal infection (Swedo et al. , 1995). This condition is referred to by the acronym PANDAS, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Its hallmark is a sudden and abrupt exacerbation of OCD symptoms after a strep infection. The cause of this form of OCD appears to be antibodies directed against the infection mistakenly attacking a region of the brain and setting off an inflammatory reaction.
OCD Cause: Summary n Although a definitive cause of obsessivecompulsive disorder has not yet been found, it is considered the product of interactions between biologic predisposition and various developmental and psychosocial influences
OCD Assessment For adults with intellectual disability: Compulsive Behavior Checklist (Gedye, 1996) n This list uses 25 types of compulsions done by adults with developmental disabilities – grouped into 5 categories – ordering, completeness, cleaning, checking/touching, deviant grooming. n Ratings are done by caregiver who has familiarity with person. n
OCD Assessment Also – we can use the Obsessive Speech Checklist – designed for use only with developmentally disabled people who talk in sentences and use meaningful speech n This is used to help determine if they meet the criteria for OCD n
Treatment n During last 20 years, two effective methods for treating OCD have been developed: Cognitive-Behavioural Psychotherapy (CBT) n Medication with a serotonin reuptake inhibitor (SRI) n
Stages of Treatment Acute Treatment Phase: Treatment is aimed at ending the current episode of OCD. n Maintenance Treatment: Treatment is aimed at preventing future episodes of OCD. n
Components of Treatment Education: Educate family and patients on how to manage OCD and prevent complications. n Psychotherapy: Cognitive-Behavioural Therapy (CBT) is the key element of treatment for most patients with OCD. n Medication: Medication with a serotonin reuptake inhibitor is helpful for many OCD patients. n
Treatment Considerations n n n Use of both medication and psychotherapy results in a better outcome than use of either alone. Many patients with obsessive-compulsive disorder are very secretive about their illness. Therefore, a detailed review of symptoms may be necessary. Many patients have somatic complaints (eg, fatigue, pain, hypochondriacal symptoms, excessive worrying, chronic sadness). Thus, a comprehensive medical evaluation is essential to rule out any preexisting medical and psychiatric condition.
Cognitive Behavioural Psychotherapy (CBT) n n Exposure and response intervention. Exposure – person remains in contact with something they usually fear until their anxiety is diminished. Response intervention – person’s rituals or avoidance behaviours are blocked (those afraid of germs are not only exposed to germs but refrained from ritualized washing). Exposure is usually more helpful in decreasing anxiety and obsessions, while response intervention is better at decreasing compulsive behaviours.
CBT (Cont’d) Patients who complete CBT report a 50 -80% reduction in OCD symptoms after 11 -20 sessions. n Using CBT on a weekly basis, can take 2 months or longer to show full effects. n Practiced in therapist’s office, and do daily E/RP homework. n When the OCD is very severe, it is sometimes better to practice CBT in a hospital setting. n
Treatment Effectiveness Behavioural techniques are most effective for certain types of OCD symptoms – particularly cleaning or checking rituals. n Best approaches are: DRO in combination with in vivo exposure; Relaxation Training; Stimulus Control techniques. n
Medication – Efficacy Studies Double Blind studies have shown the effectiveness of: - Clomipramine (may be the best but has the most adverse side effects) - Fluvoxamine - Fluoxetine - Sertraline They inhibit the reuptake of serotonin into synaptic nerve terminals n
When insight is poor Motivation is necessary for CBT to be effective n OCD behaviour is of itself reinforcing n When insight is poor, behavioural techniques may help n If you block one compulsion, usually another is established n
Behavioural Techniques Behavioural techniques are most effective for certain types of OCD symptoms – particularly cleaning or checking rituals. n Best approaches are: Differential Reinforcement in combination with Relaxation Training and Stimulus Control techniques. n
Differential Reinforcement Very effective and efficient but difficult to do on a consistent basis n Reinforce behaviours that are appropriate n Ignore behaviours that are not appropriate n Redirect n
Relaxation Techniques Identify anxiety behaviours n Relaxation – Deep breathing, muscle relaxation n Guided Imagery n Provide concrete visual cues n Quiet place n
Stimulus Control Set up person for success n Identify triggers /stimulus n Instigating conditions n Vulnerability conditions n Maintaining (reinforcing) conditions n Reduce the internal triggers - medication n Modify environment n Teach coping skills n
Is this the hill you want to die on? Restricting behaviour will escalate behaviour n Compromise n Allow behaviour within defined limits n E. g. , defined space for hoarding n
Best Treatment Approach Multi-Modal – that considers the Bio-Psycho. Social aspects of the person: n OCD may improve with habilitative changes, person centred planning, specific behavioural intervention plans and appropriate medication treatment and ongoing monitoring of effectiveness. n
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