Obsessive Compulsive Disorder Flashcards
Define
ICD-10: recurrent obsessional thoughts or compulsive acts
- Obsessional thoughts and/or compulsive acts, present on most days for ≥2 consecutive weeks
- Usually both are present
- Must be a source of stress ± interfere with ADLs
Obsessions – involuntary intrusive thoughts, images, impulses which are… (important for diagnosis)
- Self-recognised as a product of own mind (NOT thought insertion)
- ≥1 thought or act resisted unsuccessfully
- Thoughts of carrying out the act are not pleasurable
- Thoughts must be unpleasantly repetitive
- Themed commonly… contamination, aggression (to self or others), infection, sex, religion
- Egodystonic (themes/ideas against that which the person associates with their ego)
Compulsions – repetitive mental operations or physical acts
- Compelled to perform in response to own obsessions or irrationally defined rules
- Not inherently enjoyable and don’t result in completion of inherently useful tasks.
- Usually recognized by the person as pointless or ineffectual and repeated attempts are made to resist them.
- Performed to reduce anxiety through irrational belief they will prevent a dreaded event or to achieve a sense of completeness or relieve anxiety
Epidemiology
4th most common psychiatric illness after depression, alcohol/ substance misuse and social phobia
In childhood-onset OCD, boys > girls, but overall 1:1 - EQUAL PREVALENCE IN F AND M
Depression - 50% OCD comorbid
- differentiate from depression – if symptoms develop together, prioritise what developed first; if unknown, depression priority
Aetiology
Genetics (but means of transmission unknown) - x3 risk
- Anti-basal ganglia antibodies have been shown in people who develop OCD following streptococcal throat infection
- Basal ganglia is affected in Sydenham’s chorea, encephalitis lethargica, tourette’s syndrome
- OCD is linked with a deficit in frontal lobe inhibition, suggesting that intrusive and ritualistic thoughts might be harder to suppress in OCD.
- Anxiety is almost invariably present; if compulsive acts are resisted the anxiety gets worse.
Personality – 25% have premorbid anankastic personality (rigid, orderliness)
Risk Factors
- Family history
- Age- bimodal onset (10 and 21 years)
- Developmental factors- emotional, physical and sexual abuse, neglect, social isolation
- pregnancy and postnatal period
Symptoms
Common obsessions include:
- Contamination from dirt, germs, viruses, bodily fluids or faeces, chemicals etc.
- Fear of harm
- Excessive concern with order and symmetry
- Superstition, fear of ‘bad’ numbers ‘magical’ thinking, religious obsessions
- ‘Forbidden’ thoughts or images (e.g. harming own baby, paedophile, blasphemy)
- Often egodystonic (very different to the patient’s normal beliefs and values)
- Sexual content is not unusual
- Pseudohallucinations - when voices are coming from inside head (true hallucinations is when voices are from outside the head)
Common compulsions include:
- Repetitive handwashing- due to fear of contamination
- Checking (e.g. doors are locked, electrical items are unplugged)
- Ordering, arranging, and/or repeating
- Mental compulsions (e.g. special words or prayers are repeated in a set manner)
- Memory checking and avoidance of triggers
In children and young people:
- Obsessional thoughts are more likely to include ‘magical’ or superstitious thinking (e.g. “if I count to 20, my parents will die”)
- Members of the family are usually involved in the young person’s compulsive rituals
- May have concurrent depression, anxiety or substance misuse, body dysmorphic disorder, eating disorder
The symptoms are NOT a manifestation of another health condition and are NOT due to the effects of a substance or medication on the CNS
- It is NOT triggered by a specific stimulus but is instead continuous and generalised
- Stress may precipitate symptoms of OCD
- Patients are usually very insightful into the experiences
Investigations
In order to DIAGNOSE OCD:
- Obsessions and compulsions MUST be time-consuming (e.g. taking > 1 hour per day) and results in significant distress or significant impairment of personal, family, social, educational, occupational or other important areas of functioning
Pt realises thoughts are their own and irrational
Yale-Brown Obsessive-Compulsive Scale
OCD screening questions… ask these to check for OCD
- Do you wash or clean a lot? Do you check the time a lot?
- Is there any thought that keeps bothering you that you would like to get rid of?
- Do your daily activities take a long time to finish? How long?
- Are you concerned about putting things in a special order or are you very upset by a mess?
- Do these problems trouble you?
- How is it affecting your life? - ask about work, at home and relationships
- When you don’t do _____, what happens? How anxious do you become?
- How much of an effort do you make to resist the obsessive thoughts or compulsions?
- How much control do you have over your obsessive thoughts? How strong is the drive to perform the compulsions?
Differentials
Obsessive-compulsive (Anakastic) personality disorder (OCPD) — suggested by a preoccupation with orderliness, details, rules, organisation, or schedules, to the degree that the point of the activity is lost, with absence of obsessions and compulsions, but may involve discomfort if things are sensed not to have been done completely.
Body dysmorphic disorder (BDD) — suggested by obsessive preoccupation with a perceived defect in physical appearance.
Somatic symptom disorder — suggested by excessive thoughts, feelings, or behaviours related to somatic symptoms or associated health concerns.
Illness anxiety disorder (hypochondriasis) — suggested by a preoccupation with having or acquiring serious illness and excessive health-related behaviours, such as repeatedly checking for signs of illness. May demonstrate maladaptive avoidance, such as avoiding medical appointments.
Autism spectrum disorder (including Asperger’s syndrome) — suggested by stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements), impaired social interaction, problems with verbal and non-verbal communication, and unusual, repetitive, compulsive behaviour or severely limited activities and interests.
Hoarding disorder — suggested by persistent difficulty in discarding or parting with possessions, regardless of actual value, due to perceived need to save items and distress associated with discarding them.
Trichotillomania (hair-pulling disorder) — suggested by recurrent pulling out of hair, resulting in hair loss.
Excoriation (skin-picking) disorder — suggested by recurrent picking of skin, resulting in skin lesions.
Substance-induced or medication-induced obsessive-compulsive disorder — suggested by OCD-type symptoms that are attributable to effects of medication or drug of abuse and develop during or soon after substance intoxication or withdrawal or after exposure to substance.
Depression - can occur within depression and up to 50% of patients with OCD
Other anxiety disorders
Management
At a glance: CBT (with ERP) and/or SSRIs
- Education, suport and self-help
Mild functional impairment: CBT w/ ERP (Exposure and Response Prevention)
- Background – CBT aims to prevent compulsive behaviour as a tool to reduce obsessions allowing the tolerated anxiety to be habituated and eventually, extinguished
- Therapy -> ‘Exposure and Response Prevention’ = gradual/graded approach:
· (1) Pt. supported to (i.e.) touch something dirty (e.g. dustbin) and, instead of immediately washing hands, is supported and talks the experience through with a therapist
· (2) Pt. constructs hierarchy of feared situations and works through them
Moderate functional impairment: intensive CBT w/ ERP or SSRI:
- Intensive CBT with ERP
- SSRI ** (continue for 12m after remission) Fluoxetine > Sertraline (licenced)
- Depression -> 20mg
- Anxiety à 40mg Gradually tapered off after 12m
- OCD, Bulimia Nervosa -> 60mg or 80mg
** N.B. inform about possible side effects of SSRIs + how they shouldn’t suddenly stop it and at the initial anxiety in starting it
Severe functional impairment: referral
- 3rd line (after 12w of SSRI): TCA or alternative SSRI Clomipramine
- 2nd line (off-label; done by specialists): SNRI
- 3rd line (off-label; done by specialists): atypical antipsychotic
Complications
Complications
- Reduce QoL
- Dermatitis
- Self-harm and suicide
Prognosis
- If left untreated, course is usually chronic, often with waxing and waning symptoms
- Remission is 20% in untreated
- SSRIs or clomipramine are effective in treatment of OCD
PACES
OCD is a mental health condition where a person has obsessive thoughts and compulsive behaviours. Obsessive thoughts can be repetitive, unwanted and intrusive, while compulsive behaviours can be a way of releasing the stress of these thoughts and can be ritualistic in nature.
OCD can be more active in periods of depression and less active when things are going relatively well, but the condition can never be ‘cured’.
Common symptoms include those you’ve told me about today (recall symptoms). We manage OCD by taking a biopsychosocial approach, addressing the body, mind and social life.
Starting with the body, we’d suggest physically coping with stress through exercise, good sleep hygiene and a healthy diet. We can also give medication called selective serotonin reuptake inhibitors (SSRIs) – these reduce the removal of serotonin (responsible for positive mood) from your brain so more is around. However, these come with significant side-effects and can cause an initial worsening in symptoms to begin with.
We’d start by addressing the mind with CBT to help understand how our thoughts, feelings and behaviours all relate to each other. CBT aims to help patients tolerate the anxiety they feel, to normalise it and to eventually extinguish it.
To help socially, we can put you in touch with support groups to meet people with similar issues and how they overcame them. It would also be wise to inform your loved ones about your diagnosis so they can support you through overcoming your thoughts and compulsions.
