Obsessive Compulsive and related disorder

1. Obsessive Compulsive and related disorder Jacob Alexander Director of Training TAPPP Director of Training CHSALHN, SABPTC

2. DSM V • OCD • Body dysmorphic disorder • Trichotillomania • Excoriation (Skin Picking)disorder • Hoarding Disorder • Other Specified OC and Related disorders eg Koro/Dhat, Jikoshu-kyofu, Obsessional Jealousy • Unspecified OC and Related disorders

3. OCD-Symptomatology • Obsession- • recurrent and intrusive thought, feeling, idea or sensation • Patient realises the irrationality of the obsession • Compulsion- • a conscious, standardised, recurrent behaviour geared towards reducing the anxiety associated with an obsession • Both the O and C are experienced as being egodystonic • https://www.youtube.com/watch?v=KFVl2j9dRHo

4. Diagnostic criteria- DSM V A: • Os-recurrent or persistent thoughts, impulses or images that are experienced as intrusive and inappropriate- contamination, repeated doubts, order, impulses, sexual images • Cs- repetitive behaviours or mental acts whose goal is to prevent or to reduce anxiety or distress- hand washing, ordering, checking, praying, counting, repeating words • Recognition that the fear is excessive or unreasonable B: Os/Cs cause marked distress, are time consuming (>1hr/day), significant impairment in social, occupational and daily functioning • Qualifier- • 1.Insight (good or fair/poor/absent or delusional beliefs) • 2.Tic related

5. Epidemiology • Lifetime prevalence of 2-3% amongst general population • Lifetime prevalence of OC symptoms estimated at 8.7% • Fairly consistent across cultures • Amongst outpatients in psychiatric clinics- 10% • Gender distribution: equal amongst adults, amongst adolescents- boys more likely to be affected • Onset of symptoms around 20 years of age- onset slightly earlier for men, 2/3rds have onset of symptoms before 25, less than 15% have symptoms originating after the age of 35 • Single>married

6. Co-morbidity • Depression 67% • Social phobia 25% • Alcohol use disorders • Specific phobias • Panic disorder • Eating disorders • Personality disorders • Tourette’s disorder (5-7%), tics (20-30%) • Mood disorders, anxiety disorders, eating disorders and skin picking were more prevalent in women and girls with OCD, whereas tics, Tourette’s syndrome and alcohol dependence were more common in men and boys with OCD

7. Differential diagnosis • Overlap between OCD and apparently related disorders, such as hoarding, trichotillomania, skin picking, Tourette’s syndrome, body dysmorphic disorder, hypochondriasis, is frequently observed but poorly understood • Some contend that hypochondriasis is a variant of OCD but others do not • Hoarding can function as an anxiety relieving compulsion in OCD, but in the absence of other OCD symptoms is marked by significantly less distress, poorer response to treatment and seems to be a clinically distinct syndrome

8. Etiology • Biological factors • Behavioural factors • Psychosocial factors

9. Etiological Factors • Biological factors • Neurotransmitters- serotonergic system > noradrenergic system • Neuro-immunology- Group A-beta haemolytic streptococcal infection • Brain Imaging studies- orbitofrontal cortex-caudate-thalamus, basal ganglia and cingulum • Genetics- (i) Families of probands x 3-5 higher risk of having OCD (ii) Increased risk of GAD, tics, BDD, hypochondriasis, eating dis. and habits like nail biting (iii) Twin studies suggest that OC symptoms in children are heritable, with genetic influences ranging from 45 % - 65%

10. Etiology- Behavioural factors • Learning theory- obsessions are conditioned (respondent) stimuli Neutral stimuli paired with a noxious or anxiety provoking stimulus • Compulsions established differently- learnt by accidental encounter with activites which reduce anxiety

11. Etiology-psychosocial factors • Personality factors- 15-35% pre-morbidly obsessional • Vulnerability seems to be greater when family history is marked by excessive responsibility taking, rigid codes of conduct, equation of thought and action, perfectionism, cognitive inflexibility, or black and white perception that tends to be intolerant of uncertainty and ambiguity.

12. Origin and perpetuation • During periods of stress, an individual who is genetically vulnerable to OCD may experience compelling intrusive thoughts (eg, possible loss of control, possible HIV contamination) that are hard to dismiss • When this occurs the individual is likely to increase efforts to neutralize such thoughts or to seek reassurance repetitively , both of which, over time, worsen anxiety and make the intrusions more salient

13. Origin and Perpetuation • A cycle of escalating intrusions, hypervigilance, futile control of inherently uncontrollable thoughts, reactive panic, and powerfully reinforcing relief through neutralizing rituals becomes self-perpetuating

14. Types…….. • Predominantly obsessive thoughts or ruminations • Predominantly compulsive acts • Mixed obsessional thoughts and acts Majority have both

15. Common Obsessional Themes • The prevention of harm to self or others resulting from contamination (eg., dirt, germs, bodily fluids or faeces, dangerous chemicals) • The prevention of harm resulting from making a mistake ( eg., a door not being locked) • Intrusive religious or blasphemous thoughts • Intrusive sexual thoughts (eg., being a paedophile) • Intrusive thoughts of violence or aggression (eg., of stabbing one’s baby) • The need for order or symmetry

16. Frequency of presenting symptoms in descending order • Contamination- washing or avoidance • Pathological doubt • Intrusive thoughts- sexual/ aggressive • Symmetry – compulsive slowing • Others- religious obsessions or compulsive hoarding

17. Y-BOCS • The standard assessment instrument for OCD is the Yale-Brown Obsessive Compulsive Scale

18. Course and prognosis • >50% have a sudden onset following a stressor • Avg 5-10 years before psychiatric help sought • Course usually long and fluctuating • 20-30% experience significant improvement • 40-50% have moderate improvement • 20-40% remain ill or deteriorate

19. Poor Prognostic Factors Yielding to symptoms Childhood onset Bizarre compulsions Need for hospitalization Coexisting MDD Delusional beliefs/ overvalued ideas Presence of a personality disorder Favourable Prognostic factors Good social and occupational functioning Presence of a precipitating event Episodic nature of the symptoms Prognostic Factors

20. Treatment • Pharmacological- SSRIs, clomipramine Augmentation- NaValp/ Li/ Cbz Other agents- venlafaxine, pindolol, MAOIs (phenelzine) Non-responsive patients- buspirone, 5-HT, l-trytptohan, clonazepam Atypical Antipsychotic augmentation- Risperidone, Aripirazole • BT- as effective as pharmacotherapies, beneficial effects last longer- exposure and response prevention, desensitization, thought stopping, flooding, implosion therapy, ? Aversive conditioning • Psychodynamic/ insight oriented psychotherapy- evidence sparse • ECT, Psychosurgery- singulotomy, capsulotomy

21. TREATMENT • First line pharmacotherapy for OCD consists of those drugs with potent serotonergic actions (ie., SSRI’s and, secondarily because of side effects, clomipramine) • OCD often requires higher eventual SSRI dosing ( 2 – 4 times the standard doses) compared with other anxiety disorders • The treatment for OCD is usually gradual and partial, and many patients do not respond adequately to first line treatment

22. OCD vs Anankastic or OCPD

23. Body Dysmorphic disorder (BDD) • https://www.youtube.com/watch?v=mHRuk4GbaM0 • Preoccupation with an imagined defect in appearance that causes clinically significant distress or impairment in important areas of functioning. • If a slight physical anomaly is actually present, the person’s concern is excessive and bothersome. • Emil Kraeplin-dysmorphophobia • Pierre Janet- obsession de la hontu du corps

24. BDD-commonest feature affected • Hair • Nose • Skin • Eyes • Head/face • Overall body build/ bone structure • Lips • Chin • Stomach, waist • teeth

25. Body Dysmorphic Disorder-etiology • Serotonin pathways? • Psychodynamic explanations- repression, dissociation, distortion, symbolization and projection, displacement • Familial and cultural concepts/ values around beauty • DD-OCD, delusional disorder, Psychosis, depression, anxiety

26. BDD-clinical symptoms • Ideas or delusions of reference • Avoidance of social and even occupational exposure • Excessive mirror checking or avoidance of reflective surfaces • House bound • Suicide in response to distress

27. BDD-course, prognosis and management • Begins in adolescence • Gradual or abrupt onset • Long and undulating course • TCAs, MAOIs, SSRIs • Augmentation of antidepressant • Psychotherapy • Surgical intervention largely unsuccessful

28. Trichotillomania • https://www.youtube.com/watch?v=rWmhmbbvLxs • Chronic disorder characterized by: • Repetitive hair pulling • Driven by escalating tension • Sense of relief or gratification after event • Causes variable hair loss, any body part can be involved • Term coined by French Dermatologist Francois Hallopeau in 1889 • Lifetime prevalence between 0.6%-3.4% • An estimated 33-40% of patients with Trichotillomania also chew or swallow their hair • About 1/3rd of these will develop a trichobezoar

29. Aetiology • Multifactorial • Onset is often stress related • Substance abuse • Depressive dynamics • Self stimulation – primary goal • Inappropriately released motor activity and grooming behaviours • Probands-Increased incidence of tics, other impulse control disorders, OCD

30. Course, Prognosis and Treatment • Onset usually in early teens- good prognosis • Course poorly understood- chronic and remitting forms • Topical steroids • Hydroxyzine hydrochloride • Antidepressant- SSRIs • Antipsychotic agents

31. CBT and Hypnotherapy strategies • Biofeedback • Self- monitoring • Covert desensitization • Habit reversal • Insight oriented psychotherapy

32. Hoarding Disorder • Difficulty discarding or parting with possessions regardless of their actual value • Need to save items and distress associated with getting rid of them • Accumulation leads to clutter and congestion and substantially compromises the use of living spaces. If clutter free, it is due to the intervention of a third party. • Causes clinically significant distress and impairment of functioning • Not attributable to another medical condition (e.g. brain injury or Prader-Willi synd) or as symptoms of another mental disorder • Specifiers- good/poor insight, with excessive acquisition

33. Etiology and risk factors • Etiology- genetics, brain chemistry and stressful life events • Risk Factors: • Age. starts around ages 11 to 15, gets worse with age. • Personality. temperament that includes indecisiveness. • Family history. strong association between having a family member who has hoarding disorder and having the disorder • Stressful life events. Some people develop hoarding disorder after experiencing a stressful life event that they had difficulty coping with, such as the death of a loved one, divorce, eviction or losing possessions in a fire. • Social isolation. typically socially withdrawn and isolated. In many cases, the hoarding leads to social isolation. • https://www.youtube.com/watch?v=pEpCE8klIDo

34. Complications • Unsanitary conditions that pose a risk to health • Increased risk of falls • Injury or being trapped by shifting or falling items • A fire hazard • An inability to perform daily tasks, such as bathing or cooking • Poor work performance • Family conflicts • Loneliness and social isolation • Financial problems • Legal issues, including eviction

35. Treatment • Psychotherapy- CBT • Explore why patient feels compelled to hoard • Learn to organize and categorize possessions to help patient decide which ones to discard • Improve patient’s decision-making and coping skills • Declutter patient’s home during in-home visits by a therapist or professional organizer • Learn and practice relaxation skills • Attend family or group therapy • Have periodic visits or ongoing treatment to help patient keep up healthy habits • Pharmacotherapy-SSRIs

36. The End