OCD and Psychiatric Co-morbidities

1. OCD and Psychiatric Co-morbidities Deepak Joshi Med/Psych PGY-4

2. DISCLOSURES

3. Learning Objectives • Neuro-circuitry of OCD in the context of an anxiety disorder. • Discuss similarities between OCD and the OCD spectrum disorders. • Demonstrate awareness of the high co-morbidity of psychiatric disorders in OCD and OCD Spectrum disorders. • Understand treatment responsiveness along the compulsive – Impulsive dimension, keeping OCD spectrum disorders in mind.

4. Outline • Neuro circuits in Anxiety. • Neuro circuits in OCD. • OCD Spectrum disorders. • Co-morbidities with OCD. • Treatment options for OCD.

5. Prevalence • 2% to 3% afflicted worldwide. [5]. • The rates are consistent across most cultures. • Males with an earlier onset - have a worse course than females. • Symptoms are present an average of 10 years prior to clinical presentation. • Patients with OCD often feel shame regarding their symptoms and put great effort into concealing them from family, friends, and health care providers.

6. Prevalence Contd. • Sex: • Equal in males and females. • Childhood-onset OCD is more common in males and more likely to be linked genetically with ADHD and Tourette syndrome. • Age: • Symptoms usually begin in individuals aged 10-24 years.

7. Introduction • OCD is an anxiety disorder. • For diagnosis, either obsessions and/or compulsions must be present. • Although many different types of cognitive and behavioral symptoms are present in OCD, anxiety appears to underlie both obsessive thoughts and compulsive behaviors.

8. Anxiety disorders • Fear • Worry

9. Anxiety • Start from Amygdla. • Fear – Ventro-Medial prefrontal cortex. • Worry – Dorsolateral PFC.

10. Anxiety • Fear: • If episodic – Panic attacks or panic disorder. • Social phobia etc. • Generalized anxiety.

11. Anxiety • Worry: • like a thought. • Can be random or evoke fear. • Cortico Striatal Thalamo Cortical loop. (Worry loop). • If afraid – Paranoia. • If excessive – Obsession.

12. Worry vs Obsession • Worry: • Perceived, as triggered by internal or external event. • Content – normal everyday experiences (family, finances etc) - Worry: is in the form of a thought. • Obss: as thoughts, images or impulses. • Worry does not appear to be resisted as strongly nor it is as intrusive, as obsessional thinking.

13. Associated Symptoms • Amygdla  different structures in the brain stem. • Hypothalamus – Cortisol. • Locus Ceruleus – Tachycardia. • Parabrachial Nuclei – Tachypnea. • Periaqueductal gray – Fight, Flight or Flee.

16. Neuro circuits in Anxiety • Neuro circuits in OCD. • OCD Spectrum disorders. • Co-morbidities with OCD. • Treatment options for OCD.

18. DSM Classification • Obsession &/Compulsion. • Recognized as excessive or unreasonable. • Causes marked distress, time consuming (> 1hr/day) or interferes with functioning. • Content is not due to Axis I disorder. • Not due to substance abuse or Gen medical condition. • Specify: Poor insight type (--10% of pts).

19. Major Symptom factor of OCD. • Aggression / Harm obsession and checking compulsion. • Contamination obsession and cleaning compulsion. • Symmetry / order obsession and arranging or precision compulsion. • Saving / Collecting obsession and hoarding/saving compulsion.

20. Neural correlates of OCD Symptom factors Aggression / Harm Increased activity of striatum Contamination Increased activity of Orbito frontal cortex & Anterior Cingulate Gyrus. Symmetry / Order Decreased activity of striatum Saving / Collection Decreased activity of Cingulate gyrus. Ranch et al 1998; Saxena et al 2003.

21. Etiology of OCD. • Is not known. • Genetic: In some cohorts, OCD, ADHD, and Tourette syndrome/tic disorders co-vary in an autosomal dominant fashion with variable penetrance. • Infectious: PANDAS - group A streptococcal infections, herpes simplex virus. • These infections trigger a CNS immune response that produces neuropsychiatric symptoms.

22. Etiology contd. • Stress: worsens OCD symptoms. • Interpersonal relationships: • OCD symptoms can interact negatively with interpersonal relationships, and families can become involved with the illness in a counterproductive way. • Parenting style or upbringing does not appear to be a causative factor in OCD

25. Self Stimulation & Repetitive Behaviors Self Stimulation PleasureImpulse controldisorder-Gambling-Sex-Shopping-Hair pulling-Fire setting StereotypesAutism-Rocking-Head banging-Echolalia Tourettes -Tics Reward deficient statesADHDAddiction disorders-Substance use-Sexual addictions

26. CompulsivityDrive: Discomfort ImpulsivityDrive: Pleasure/Pain Inability to delay Repetitive Behavior

27. Neuro circuits in Anxiety • Neuro circuits in OCD. • OCD Spectrum disorders. • Psychiatric Co-morbidities with OCD. • Treatment options for OCD.

28. Preoccupation with bodily sensation or appearance OCD Spectrum disorders BDD Depersonalization Anorexia Nervosa Hypochondriasis Neurologic Tourettes Sydenhams ch. Torticolis Autism Impulsive disorders OCD Sexual Compulsions Trichotillomania Pathological gambling Kleptomania Self injurious behaviors

29. OCD Spectrum Compulsive Impulsive PG Klep BPD. OCD BDD A.N. DEP HYPO. T.S. Sexual Comp. Trich Comp. Buy Binge Eating Anti Social PD Risk Seeking Risk Aversive

30. Clinical Implications • Awareness of the high co-morbidity of these d/o with one another and with other psychiatric d/o, esp mood d/o. • Trt responsiveness will also vary along the compulsivity-impulsivity dimension. • Consideration of an OCD spectrum d/o in pt inadequately responsive to standard trt might lead to consideration of other, possibly more effective intervention (eg. Delusional d/o not responsive to antipsychotic might be in fact a delusional OCD spectrum d/o preferentially responsive to SRIs).

31. Neuro circuits in Anxiety • Neuro circuits in OCD. • OCD Spectrum disorders. • Psychiatric Co-morbidities with OCD. • Treatment options for OCD.

32. Psychiatric co-morbidities Comorbidities Estimated prevalence 63 % Personality disorders 28 to 31% MDD Simple phobia 7 to 48% 11 to 16% Social phobia Bipolar disorder 15% Eating disorders 8 to 13% Alcohol abuse 8% Panic disorder 6 to 12 %

33. Is OCD Primary • OCD-like obsessive thoughts or repetitive behaviors may be evident in a number of psychiatric disorders. • Distinguishing OCD from masquerading or co-occurring conditions is important because interventions can differ.

34. OCD contd. • GAD - ruminative, anxious thoughts that mimic obsessions. • Somatoform conditions : (hypochondriasis or bodydysmorphicdisorder) - intense preoccupation with illness or appearance. • Repetitive or compulsive behaviors may be seen in impulse control or developmental disorders such as pathologic gambling, trichotillomania, and Asperger’s disorder.

35. How to differentiate • Consider the function of a patient’s symptoms. • In OCD, obsessions - ego-dystonic great anxiety. • OCD patients perform compulsive rituals to alleviate anxiety but do not gain pleasure from their actions. • Trichitollomania’s — commonly experienced as pleasurable or gratifying. • GAD’s ruminative thoughts — seen as ego-syntonic worries about real-life situations.

36. ASSESSING OCD, COMORBID CONDITIONS • In specialty OCD clinics, the Structured Clinical Interview for DSM-IV (SCID-IV)15 • or Anxiety Disorders Interview Schedule for the DSM-IV (ADIS-IV)10 are routinely given to assess the most common comorbid conditions. • In clinical practice, however, these instruments can take up to several hours to perform, especially for patients who meet criteria for several disorders.

37. ASSESSING OCD, COMORBID CONDITIONS Structured clinical interviews Time Use Anxiety Disorders Interview Schedule-IV (ADIS-IV) Detailed assessment of anxiety disorders 2+ hrs Mini-International Neuropsychiatric Interview (MINI) 15 to 30 min Brief screen for diagnosis

38. OCD-specific measures Structured clinical interviews Time Use Yale-Brown Obsessive Compulsive Scale (YBOCS) Severity and OCD symptom types 30 min Obsessive Compulsive Inventory-Revised (OCI-R) 5 to 10 min Self-report severity of OCD symptoms

39. OCD Severity • The Yale-Brown Obsessive Compulsive Scale (YBOCS) is widely used.12,13 • It includes a checklist of common obsessions and compulsions plus 10 items measuring interference with daily living, distress, resistance, control, and time spent on symptoms. Each item is scored from 0 to 4, for a total score of 0 to 40.

40. OCD Severity • The YBOCS has good reliability and validity. • Is available in both clinician-rated and self-rated versions. • Can be given repeatedly to measure treatment progress. • A Children’s Yale-Brown Obsessive-Compulsive Scale (CYBOCS) is useful for patients ages 6 to 17.16

41. TREATING UNCOMPLICATED OCD • CBT: first line treatment for only OCD, w/o other concurrent diagnosis (expert consensus guidelines) 17. • Exposure and response prevention (ERP) therapy which is the specialized CBT for reducing anxiety that triggers obsessive-compulsive symptoms — report reduced symptoms and often maintain those gains over time.18

42. TREATING UNCOMPLICATED OCD • ERP for 2 hours / day, 3 to 5 times per week for about 3 weeks (Specialty clinics). • Although studies find excellent outcomes with intensive OCD treatment,18 it is not always practical or indicated (as in patients with moderate symptoms). • Less-intensive protocols, such as biweekly sessions, have also shown promise in studies.19

43. Behavioral therapy • 20% to 25% refuse to go through the therapy. The patient may not comply with the therapeutic directions, including homework. • Pt may substitute ritualistic thoughts in place of overt behaviors to diminish the anxiety. (This will defeat the purpose of the behavioral interventions, although it might appear on the surface that the individual is improving). • Finally, - limited availability of behavioral programs.

44. Other treatments • Functional imaging studies suggest that OCD results from dysregulation in the so called “OCD circuit”—the orbitofrontal cortex, anterior cingulate, and caudate nucleus. • In patients with OCD, metabolic activity in this region is increased at rest relative to controls, increases further with symptoms, and decreases after successful treatment.21

45. OCD • The serotonin hypothesis—which emerged from observation that OCD symptoms responded to serotonergic medications but not to noradrenergic ones—suggests serotonin system dysregulation in patients with OCD.

46. Medications • High dosages of SSRIs or Clomipramine (TCA) — are first-line OCD medications. • However Clomipramine is rarely used. • Double-blind clinical trials have found: • Clomipramine, • Fluoxetine, • Sertraline, • Paroxetine, • Fluvoxamine, • Citalopram (Not FDA approved)

47. SSRIs Drug Starting dose Target dosage (adults) Clomipramine 25 mg / day 150 to 200 mg / d Fluoxetine 20 mg /day 60 to 80 mg/d Fluvoxamine 50 mg / day 150 to 300 mg / d Paroxetine 20 mg / day 40 to 60 mg / d Sertraline 50 mg / day 150 to 200 mg / d * 10- to 12-week medication trials at target doses; sequential trials may be required to achieve treatment response.

48. Side effects • Sedation • Insomnia • GI side effects • Sexual dysfunction. • Clomipramine is rarely used as a first-line agent because of its anticholinergic side effects.

49. Non Response • 10 to 12 weeks at target dosages. • Sequential medication trials may be needed to achieve a response. • Complete remission is rare, and relapse rates are high when medication is discontinued.22 • Up to 40% of patients who do not respond to SSRI, require alternate strategies:

50. When augmenting an SSRI • Adding Clomipramine, 25 to 50 mg/d, is a reasonable choice. • Fluoxetine or paroxetine can inhibit clomipramine metabolism by cytochrome P-450 (CYP) 2D6, with potential for cardiac arrhythmias or seizures. • Sertraline or fluvoxamine are less likely to elevate clomipramine levels.