Chapter 9 ： Neurosis (3) Obsessive-compulsive disorder

1. Chapter 9：Neurosis (3)Obsessive-compulsive disorder Jining Medical University Zhai Jin-guo zhaijinguo@yahoo.com.cn

2. Outline • Concept • Epidemiology • Etiology • Clinical features • Diagnosis • Treatment

3. What is OCD? • Obsessive-compulsive disorder (OCD): Characterised by the presence of either obsessions (repetitive, distressing, unwanted thoughts) or compulsions (repetitive, distressing, unproductive behaviours) – commonly both. Symptoms cause significant functional impairment/distress 5

4. What’s OCD?(CCMD-3) • This disorder is a kind of neurosis predominated by obsessive symptoms. The feature is coexistence of conscious self-obsession and antiobsession, the sharp conflicts of the two give patients anxiety and affliction. The patients have the experience of ideas or impulses stemming from ego, but against own will ; they try to resist but unable to control; they are aware of abnormality of obsessive symptoms, but unable to break away. The patients with delayed duration may be predominated by ceremony acts, and their mental affliction decreases, but social function severely impairs.

5. 强迫症 • 指一种以强迫症状为主的神经症，其特点是有意识的自我强迫和反强迫并存，二者强烈冲突使病人感到焦虑和痛苦；病人体验到观念或冲动系来源于自我，但违反自己意愿，虽极力抵抗，却无法控制；病人也意识到强迫症状的异常性，但无法摆脱。病程迁延者可以仪式动作为主而精神痛苦减轻，但社会功能严重受损。

6. Epidemiology • Onset age : 20 year • Prevalence 0.3‰（China，1982） • Nemiah，1985: 0.5‰ • M=F

7. Etiology • Genetic factors • Biochemical factors: • 5－HT dysfunction: clomipramine, fluxetine treatment effect. • 5－HTreceptor antagnist can change the effect of clomipramine • Dopamine and choline system involed in OCD partly

8. Etiology • Brain pathology: abnormality of neural circuit in frontal lobe(额叶), basal ganglia (基底节) • Psychological theory : Behaviorism theory • Life events and personality

9. Clinical features Obsessive idea • Obsessivethought • 强迫性穷思竭虑 • Obsessivedoubt • Obsessiveassociation • Obsessiverecall • Obsessiveintentions

10. Clinical features Obsessive acts and behaviors • Obsessive checking • Obsessive washing • Obsessive ceremony acts • Obsessive asking

12. Diagnosis • A. Symptom criteria： • (1) The patient's conditions meet the diagnostic criteria of neurosis; • (2) Predominated by compulsive acts, with at least 1 of the following: ①predominated by obsessive thoughts, including obsessive ideas, recall or images, obsessive opposite thoughts, obsessive rumination(沉思), obsessive fear of loss of self-control; ②predominated by compulsive behavior ( acts) ,including repeatedly washing checking, examining or asking; ③mixed form of above; • (3) The patients view obsessive symptoms as being from their own heart, not imposed by others or external influence; • (4) The patients try to resist but do not succeed.

13. B. Severity criteria: Impairment of daily life and social function. • C. Course criteria: Its conditions meeting symptom criteria last for at least 3 months. • D. Exclusion: • (1) Excluding obsessive symptoms secondary to other mental disorders, such as schizophrenia, depression, phobia; • (2) Excluding obsessive symptoms secondary to organic disease especially pathological change of basal ganglion.

14. Differential Diagnosis • Schizophrenia, depression • Organic mental disorders • Phobia and anxiety disorder

15. Treatment • Psychology therapy • Drug Clomipramine SSRIs

16. How to use pharmacological treatments Starting treatment • address common concerns about taking medication with the patient e.g. potential side effects including worsening anxiety • explain that OCD responds to drug treatment in a slow and gradual way and that improvements may take weeks or months Choice of drug • initial pharmacological treatment should be an SSRI • if drug treatment effective, consider continuing for 12 months to prevent relapse and then review with the patient • consider prescribing a different SSRI if prolonged side effects 23

17. How to use pharmacological treatments Monitoring risk • Monitor closely on a regular basis particularly: - during the early stages and during dose changes of SSRI treatment - adults younger than 30 - people who are depressed or considered to present an increased suicide risk • Consider prescribing limited quantities of medication and enlisting others e.g. other carers may contribute to the monitoring until the risk is no longer significant 24

18. How to use pharmacological treatments Poor response to initial treatment • if symptoms not responded adequately within 12 weeks to treatment with an SSRI or CBT - conduct multidisciplinary review • consider offering combined treatment of CBT and an SSRI • consider offering a different SSRI or clomipramine if symptoms not responded to combined treatment • then if not responded, consider referral to multidisciplinary team with specificexpertise in OCD for comprehensive assessment and further treatment planning 25

19. How to use pharmacological treatment Discontinuing treatment • taper the dose gradually when stopping treatment in order to minimise potential discontinuation/withdrawal symptoms • encourage people to seek advice if they experience significant discontinuation/withdrawal symptoms 26

20. When to use pharmacological treatments – children and young people • If CBT ineffective or refused - carry out a multidisciplinary review and consider adding an SSRI • Sertraline and fluvoxamine are the only SSRIs licensed for use in children and young people with OCD* • Monitor carefully and frequently • If successful, continue for 6 months post remission • Withdraw slowly with monitoring 27

21. Special issues for children and families • Symptoms are similar in children, young people and adults and they respond to the same treatments • Stressful life events may worsen symptoms or relapse may occur: - school transitions - examination times - relationship difficulties - transition from adolescence to adult life • Parents may feel guilty and anxious • Increase in severity if left untreated 28

22. Needs of people with OCD • Early recognition, diagnosis and effective treatment • Information about the nature of OCD and treatment options • Respect and understanding • What to do in case of relapse • Information about support groups • Awareness of family/carer needs 29

23. Implementation for clinicians Diagnosis: • Increase your awareness and recognition of symptoms of OCD - be aware of those at higher risk and how difficult initial disclosure is for many people with OCD • Ask the ‘right’ questions – assessment Treatment: • Involve patients and when appropriate, family/carers, fully in treatment options • Offer CBT • If pharmacological treatment is required, regularly monitor side effects of SSRIs 30

24. Implementation for clinicians Access to services: • Be aware of how to access specialist teams • Ensure you have access to local protocols Training: • Identify your training needs in the use of CBT • Less therapist-intensive interventions have a role to play, particularly in primary care 31

25. Psychological interventions CBT is the mainstay of psychological treatment • Consider CBT for patients with obsessive thoughts without overt compulsions • Consider cognitive therapy adapted for OCD: 20

26. Psychological interventions • If a family member/carer is involved in compulsive behaviours, avoidance or reassurance seeking, treatment plans should help them to reduce their involvement in a supportive way • The intensity of intervention is dependent upon the degree of functional impairment and patient preference 21

27. Psychological interventions – children and young people • Guided self-help, CBT recommended • Work collaboratively and engage the family or carers • Identify initial and subsequent treatment targets collaboratively with the patient • Consider the wider context including other professionals involved with the child • Maintain optimism in child and family or carers • Consider including rewards to enhance motivation 22