Obsessive Compulsive Disorder

1. Obsessive CompulsiveDisorder

2. Facts about Obsessive Compulsive Disorder • Obsessive Compulsive Disorder is also known as OCD • OCD is a medical disorder that causes problems in the information processing. • OCD is classified by the DSM-IV as an anxiety disorder • Affects over 3.3 Million Americans.

3. Obsession: Contamination of fears of germs or dirt • Compulsion: • Repeatedly washing • Obsession: Needing to have things “just so” • Compulsion: • Hoarding or saving things

4. Obsessions • Unwanted thoughts, images, or impulses that occur over and over • Are accompanied by uncomfortable feelings such as fear, doubt, or disgust.

5. Compulsions • Repetitive behaviors • In response to the Compulsions • Most common is washing and checking things.

6. OCD is often confused with these other disorders: • Major Depressive Disorder • Panic Disorder • Social Phobias • ADHD

7. Onset • Can occur any time from preschool age through adulthood • Typically by 40’s • Equally common in both male and female

8. Diagnosis Criteria according to DSM-IV • Compulsion or Obsessions (Typically both are present) • The Compulsion or Obsessions cause marked distress • Typically no physical symptoms • Scales are available, but they take lots of time • Get a History • Communication between patient and medical practitioner is key

9. Typical Course of OCD • Long process • On average 3-4 doctors and over 9 years before receiving the correct diagnosis. • Early diagnosis is important • Medicine and Cognitive behavior therapy helps most individuals experience long term relief.

10. Assessment • Visits • The Anxiety Disorder Interview Schedule-Revised (ADIS-R) • The Yale-Brown Obsessive-Compulsive Symptom Checklist (Y-BOC) • The Leyton Obessional Inventory (LoI) • The State Trait Anxiety Inventory of Children (STAIC)

11. Cause of OCD • No concrete causes • Parents role and non-role • Organic reasons • Head injuries • Brain Chemistry • Basal Ganglia • Encephalitis

12. Differential Diagnosis

13. Depressive Disorder vs. OCD • Preoccupation with depressive thoughts • “I have no friends” • Realistic vs. absurd

14. Generalized Anxiety Disorder vs. OCD • Excessive worrying and thinking • Again realistic vs. absurd • Patient with OCD may have extremely intense/irrational thoughts • The presence of compulsive rituals

15. Hypochondrias vs. OCD • Closely related • Unrealistic preoccupation of medical concerns • Presence of “checking rituals” to decrease anxiety

16. Other illnesses and neurological disorders vs. OCD • Anorexia and Dysmorphic disorder • Occur in the context of another psychiatric disorder • Tourette’s syndrome-increased rate of OCD • Trichotillomania • Compulsive behavior of pathological gamblers and substance abusers

17. Main Ideas of Differential Diagnosis • The presence of obsessive compulsive rituals • The manner of the compulsive thoughts For example: unrealistic vs. realistic appropriate vs. inappropriate

18. Treatment • Two types • A. Pharmacotherapy • B. Behavioral Therapy

19. Use of medications • Controlling the symptoms of OCD • Lessening the intensity and frequency of the obsessions and compulsions • Examples of SSRI’s • Prozac • Luvox • Paxil • Zoloft

20. Medications Continued • Improvement usually takes 3 weeks • Symptoms are reduced but not eliminated • Anafranil– 1st SRI used • Side effects: Sedation, blurry vision, weight gain, and sexual dysfunction • Side effects of SSRI’s • Side effects: Insomnia, motor restlessness, nausea, and diarrhea • Long-Term treatment needed

21. Behavioral Therapy • “Exposure” and “Response Prevention” • Not able to eliminate their anxiety • Extremely uncomfortable for OCD patient • 80-90% improvement • Symptoms are reduced but not eliminated • Follow-up sessions needed for relapse prevention

22. Use of both therapies • Severe case of OCD • Mild case of OCD • Use of SSRI’s and behavior therapy prove to have a 70% success rate • Therapy determined by patient • Willingness to take a medication • Willingness to work with a psychologist

23. Environmental Factors • Positive and motivated patient • Fully trained therapist during behavior therapy • OCD Groups • Family provides encouragement and constant reassurance • Showing frustration with the patient may impact the compulsive behavior

24. New Research • A new cognitive-behavioral therapy • Emphasizes changing the OCD sufferer’s belief and thinking patterns

25. Case Study of Obsessive Compulsive Disorder Women with Postpartum-Onset OCD Lesley M. Arnold, M.D.Presented by Lawrence Pierce

26. Several lines of evidence suggest that postpartum women are at increased risk for the development or worsening of obsessive-compulsive disorder

27. Recruiting Process • Subjects were recruited from outpatient practice at the University of Cincinnati Medical Center and advertising for a study for postpartum women. • Nine potential subjects were identified. • Two were excluded because they did not meet the DSM-IV criteria for OCD • Of the 7 subjects, 5 respondents through advertisement, 2 were referred

28. Initial Screening • Psychiatric evaluation • Yale-Brown Obsessive Compulsive Scale (Y-BOCS) • Data on Demographic and Clinical features • Family History of any psychiatric disorder in first-degree relatives

29. Symptom Obsessions Aggressive Contamination Religious Pathological doubt Sexual Symmetry Other Number % 7 100 5 71 3 43 2 29 1 14 1 14 1 14 Obsessions in 7 Women with Postpartum-Onset OCD

30. Symptom Compulsions Checking Cleaning Ordering Counting Superstitious behaviors Number % 4 57 1 14 1 14 1 14 1 14 Compulsions in 7 Women with Postpartum-Onset OCD

31. Psychiatric Disorders in First Degree Relatives of 7 subjects. Relatives Affected (N = 18) Total of 60 Disorder N % Mood disorders Bipolar disorder 4 22 Major depression 9 50 Psychotic disorders 0 0 Psychoactive substance use disorders Alcohol 5 28 Other 2 11 Anxiety disorders 0 0

32. Age 28 Current Diagnoses: Age Bipolar disorder I 12 Panic disorder 13 OCD 19 GAD 13 Past Diagnoses: Age PTSD 26 Anorexia nervosa 14 Subject 1 Current/Past DSM IV Diagnosis

33. Age 31 Current Diagnoses: Age Recurrent MDD 17 OCD 29 GAD 10 Past Diagnoses: Age Alcohol abuse 28 Social Phobia 10 Subject 2 Current/Past DSM IV Diagnosis

34. Age 41 Current Diagnoses: Age Recurrent MDD 39 OCD 41 Past Diagnoses: Age Binge eating disorder ? Subject 3 Current/Past DSM IV Diagnosis

35. Age 42 Current Diagnoses: Age Recurrent MDD partial remission 39 OCD 31 Binge eating disorder 17 Past Diagnoses: Age Cannabis dependence 19 Subject 4 Current/Past DSM IV Diagnosis

36. Age 26 Current Diagnoses: Age Recurrent MDD 15 OCD 26 PTSD 15 Past Diagnoses: Age Alcohol abuse 23 Subject 5 Current/Past DSM IV Diagnosis

37. Age 28 Current Diagnoses: Age Panic Disorder 25 OCD 25 Past Diagnoses: Age MDD 25 Subject 6 Current/Past DSM IV Diagnosis

38. Age 26 Current Diagnoses: Age Bipolar disorder II depressed 26 OCD 26 Past Diagnoses: Age None Subject 7 Current/Past DSM IV Diagnosis

39. Of the 7 subjects 4 did not enter the fluvoxamine trial. • 3 were excluded because they wish to continue breast feeding • 1 was excluded because of the diagnosis of bipolar I

40. The Test • Subjects received fluvoxamine 50 mg/day • The dose was increased on a flexible schedule as tolerated with a maximum dose of 300 mg/day • Subjects received no psychotropic medication except zolpidem tartrate 5 to 10 mg at bedtime as needed to help with insomnia • Subjects evaluated weeks 1,2,3,4,6,8 and 12 and reported any treatment-related illness then

41. Measure of Success • Primary successful outcome measure was the Y-BOCS was defined as greater than or equal 30% decrease its total score • Corresponding with clinical improvement in symptoms • Secondary outcome measures were changes in the Hamilton Rating Scale for Depression (HAM-D) and anxiety (HAM-A)

42. Subject 2 • Completed 12 weeks • Final dose was 300 mg/day • Side effects headache, heartburn, dry mouth and insomnia • Had a past history of no response to 3 trials of serotonin reuptake inhibitors • No improvement with fluvoxmine

43. Subject 4 • Completed 12 weeks • Final dose was 200 mg/day • Reported side effects: headache, dry mouth, heart palpitations and anorgasmia • Positive response to drug

44. Subject 5 • Completed 3 weeks due to car accident (unrelated) • Final dose was 150 mg/day • Reported side effects: anorgasmia • Positive response to drug

45. Case Study Conclusion • 2 of the 3 subjects improved with treatment • This subject that did not improve had a history of poor response to multiple treatment • This trial was limited by its uncontrolled nature and the small number of subjects • Larger controlled study is needed responsiveness of postpartum-onset OCD to serotonin reuptake inhibitors

46. Obsessive CompulsiveDisorder