OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

1. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS Dan J. Stein University of Cape Town

2. OCD • OBSESSIONS: Recurrent and persistent thoughts • COMPULSIONS: Repetitive behaviors or mental acts • Distress/Dysfunction

3. OCD • Contamination concerns  hand-washing • Possible harm concerns  checking • Symmetry concerns  symmetry behaviours

4. NOT OCD • Obsessive-compulsive personality disorder • Pathological or problem gambling, compulsive sexual disorder, problematic internet use • Hoarding concerns  hoarding behaviors • Being a meticulous professional or student

5. OCD • 4th most common psychiatric disorder in one USA study • 10th most disabling of all medical disorders in WHO BoD study • Subclinical washing, checking, symmetry, symptoms are common (Ruscio et al, 2008)

6. OCD Spectrum • Range of disorders with intrusive thoughts and repetitive behaviors • - Tourette’s syndrome • - Body Dysmorphic Disorder • - Hypochondriasis • - Hoarding Disorder • - Trichotillomania • - Skin Picking Disorder

7. Psychodynamic Approach Character  Neurosis  Psychosis • Similarity in central unconscious conflicts • Differences in certain psychodynamics

8. Cognitive-Behavioral Approach OCDS  OCD  OCDS • Similarity in cognitive-behavioral function • Differences in particular contents

9. Psychobiological Approach OCDS  OCD  OCDS • Similarity in central psychobiol mechanisms • Differences in certain psychobiol processes

11. OCD Pre/Post SSRI Baseline After SSRI

12. So: Range of Presentations • Dermatologist: Dermatitis, Loss of Hair • Neurologist: Tics • Plastic Surgeon: Somatic concerns • Internist: Hypochondriacal concerns • Pediatrician: Early onset • Obstetrician: Pregnancy

13. But: Overlapping Neurobiology • OCD OCD+Tics  Tics • 5-HT genes  DA genes?? • Good evidence that OCD and TS have a genetic relationship

14. And: Overlapping Pharmacology SRIs more effective than NRIs: • OCD • Body Dysmorphic Disorder, Hypochondriasis? • Hoarding Disorder? • Trichotillomania, Skin Picking Disorder? • O-C symptoms in Tourette’s, in autism, in intellectual disability

15. Animal StereotypyPre-SSRIPost-SSRI

17. Animal Stereotypy

18. Animal Stereotypy

19. “From Bench to Bedside” (Harvey et al, 2008)

20. Somatic Preoccupations

21. Somatic Preoccupations OCD  BDD/ORS/HYP  anorexia (with or without insight) • BDD is in DSM-5 OCRD section • ORS likely in ICD-11 OCRD section • HYP likely in ICD-11 OCRD section

22. Somatic Preoccupations OCD  BDD/ORS/HYP  anorexia (with or without insight) • First line Rx of BDD/ORS/HYP is SSRI / CBT

24. Hoarding Behaviours

25. Hoarding Behaviours (Saxena et al, 2004)

26. Hoarding Behaviours OCD  Hoarding  OCPD hoarding • Hoarding Disorder is in DSM-5 OCRD • Criteria do not overlap with Collecting! • Neuroanatomy slightly different from OCD

27. Hoarding Behaviours OCD  Hoarding  OCPD hoarding • First line Rx of Hoarding Disorder is SSRI / CBT

28. Stereotypies/Grooming

30. “From Bench to Bedside”

31. Stereotypies/Grooming OCD  TTM/SPD  SMD/SIB • TTM/SPD are in DSM-5 OCRD • Partly due to consumer advocacy!

32. Stereotypies/Grooming OCD  TTM/SPD  SMD/SIB • First line Rx of TTM/SPD is CBT • Growing interest in N-acetylcysteine

33. Tics/Involuntary Movements

34. Tics/Involuntary Movements OCD/soft signs  OCD/tics TS • OCD has a tic specifier in DSM-5 • TS likely in ICD-11 OCDR section • Some evidence of overlapping neuroimmunology

35. PANDAS

36. “From Bench to Bedside”

37. “From Bench to Bedside” (Harvey et al, 2008)

38. Tics/Involuntary Movements OCD/soft signs  OCD/tics TS • Rx options in Tourette’s Disorder include DA blockers / CBT

39. Treatment-Resistant OCD 27 short-term trials of Rx-resistant anxiety 19 investigated augmentation in OCD Similar design features eg low doses of antipsychotic agents in SRI non-responders Overall symptom severity reduced to a larger extent with these agents (Ipser et al, 2006)

40. OCD Treatment Principles • Useful to screen for intrusive thoughts and repetitive behaviours • Patients with one OCRD may well have another, or MDD / etc

41. OCD Treatment Principles • Range of standardized OCS symptom severity measures available eg YBOCS • Range of accurate information available on internet eg OCF, TLC

42. OCD Treatment Principles • Exposure and response prevention is a highly effective form of Rx • Many resources available eg OCF, www.stoppulling.com • Important to involve partners and/or family

43. OCD Treatment Principles • SSRIs are effective for OCD and for several OCRD • Higher dose and longer duration than in MDD • Consider referral after 2 different 12 week trials of SSRIs fail

44. Psychobiology:Pharmacotherapy * * * * * * * * ** ** ** ** * ** ** * p<0.05 vs PBO, ** p<0.01 vs PBO (Stein et al, 2007)

45. Treatment Resources • MRC Unit Anxiety Disorders (cl2@sun.ac.za) • GSH OCD Evaluations (dan.stein@uct.ac.za) • Internet: • SADAG Support Groups • Obsessive-Compulsive Foundation (OCF) • Trichotillomania Learning Centre (TLC)

46. CONCLUSION • OCRD are seen universally (and indeed DSM-5 field surveys were from RSA) • The psychobiology and treatment of OCD is increasingly understood

47. CONCLUSION • Provides the basis for the DSM-5 / ICD-11 construct of OC and Related Disorders • Aims to help recognize and Rx some key prevalent, overlooked, disabling conditions

48. CONCLUSION • Initial Rx of these disorders should be initiated in primary care • Referral resources are available in more refractory cases