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Management of Neuropsychiatric Disorders > OCD/ PANS > Flashcards

OCD/ PANS Flashcards

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1
Q

learning objectives

A

dx of obsessive-compulsive disorder
aetiological theories
evidence-based tx options
theories, controversy and tx approaches for pandas/pans
tx of obsessive compulsive disorder

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2
Q

dx of ocd: obsessions

what are obsessions?

A

reccurent and persistent thoughts, impulse or images
thoughts are intrusive and inapproprate
thoughts cause anxiety or distress
attempts are made to suppress thoughts, impulses etc or neutralise by doing other actions or thinking other things
recognition that obsession thoughts are self-generated

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3
Q

dx of ocd: compulsions

what are compulsions?

A

repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession
behaviours are rules that must be applied rigidly
the actions are aimed to prevent/ reduce distress or prevent a dreaded situation
recognitions that obsessions/ compulsions are excessive or unreasonable
cause distress
time consuming
significantly interfere with usual routine

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4
Q

dx of ocd: compulsions

what is the specifier for diagnostic criteria for compulsions

A

with poor insight

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5
Q

what are the elements of the ocd cycle?

A

obsession
anxiety
compulsion
temporary relief

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6
Q

what is the prevalence of ocd?

A

1-3%

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7
Q

what is the male to female ratio for ocd?

A

1:1

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8
Q

what is the age of onset of ocd?

A

childhood/ adolesence
20-29 years old

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9
Q

who is more commonly diagnosed with ocd in childhood

A

males

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10
Q

what are the most common ocd behaviours in male children

A

symmetry
checking
tics

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11
Q

who is more commonly diagnosed with ocd in young adulthood?

A

females

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12
Q

what are the most common ocd behaviours in young adult females

A

contamination

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13
Q

what are the most common psychiatric comorbidities in ocd?

A

depression
other anxiety disorders

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14
Q

what are different clinical symptoms seen in ocd?

A

contamination/ washing
obsessions/ checking
hoarding/ saving
symmetry/ order

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15
Q

what are the most common obsessive symptoms in ocd?

A

aggressive (69%)
contamination (59%)
symmetry (45%)
somatic (30%)
religious (27%)
hoarding (22%)
sexual (%)

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16
Q

what are the most common cumpulsion symptoms in ocd?

A

checking (71%)
cleaning (60%)
repeating (50%)
counting (35%)
ordering (34%)
hoarding (21%)

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17
Q

what are the most common co occurring conditions with ocd?

8

A

depression
specific phobia
social phobia
eating disorder
alcohol dependence
schizophrenia
panic disorder
tourette’s syndrome

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18
Q

aetiological theories

what are biological mechanisms for ocd?

A

familial/ genetic component
serotonergic hypothesis
neurological conditions
acquired symptoms following a brain lesion
neuroimaging
pandas/ pans

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19
Q

what is the serotonergic hypothesis for ocd?

A

Anormal serotonin pathways may contribute to OCD.
This is evidenced by the effective use of antidepressants that’s inhibit serotonin to reduce OCD sx

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20
Q

what is the neuroimaging evidence for ocd?

A

Increased activity on fMRI in orbito frontal cortex, anterior cingulate cortex, thalamus, caudate nucleus and dorso lateral prefrontal cortex and parietal regions

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21
Q

how do we find out if a disorder is familial?

A

family studies

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21
Q

how do we find out if there is a genetic (genes) component to a disorder?

A

twin and adoption studies

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22
Q

how do we find out what genes are involved in a disorder?

A

linkage and association studies

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23
Q

how do we find out what genes do in a particular disorder?

A

molecular biology and clinical studies

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24
what is the heritability of ocd in children?
obsessive-compulsive symptoms are significantly heritable in children with genetic influences estimated to fall between 45-65%
25
what is the heritability of ocd in adults
27-47%
26
which other factors are important when interpreting the results of twin studies?
unique environmental effects (e.g. stressors, trauma etc.)
27
what effect does shared environments have on heritability of ocd symptoms
the effect is negligible
28
which genes are potential causes of ocd?
serotonin transporter gene glutamate dopamine GABA BDNF (neurodevelopment|) peptides SAPAP3 etc.
29
what environmental factors are implicated in OCD
perinatal insults childhood adversity and trauma stressful life events infections and autoimmune responses gene x environment interaction
30
there is a lack of which type of research into environmental factors in ocd
prospective longitudinal risk factor studies
31
# neuroimaging neuroimaging evidence | Mataix-Cols et al 2004
dsitinct patterns of brain activity (fMRI) in predominantly washing, checking or hoarding ocd exposure to symptoms related vx neutral images imaging scenarios involving images imprortantly controlled for comorbid depression
32
what is the key take away of neuroimaging evidence for ocd
ocd symptoms, specifically washing, hoarding and checking, are characterised by distinct patterns of blood-oxygen levels (BOLD) on fMRI
33
greater activation of which brain areas are associated with washing sx in ocd?
bilateral ventromedial prefrontal regions right caudate nucleus
34
what are the associated roles of the vmpfc and caudate nucles
emotional regulation reward processing
35
greater activation of which brain areas are associated with checking sx in ocd?
subcortical structures such as the putamen, globus pallidum and thalamus dorsal cortical regions
36
the pattern of brain activation in checking sx in ocd is associated with what dysfunction?
dysfunction in frontostriatalthalamic circuits
37
what processes do frontastriatothalamic circuits regulate?
error detection decision-making cognitive control
38
what pattern of brain activation is associated with hoarding sx in ocd?
left precentral gyrus right orbitofrontal cortex
39
what do the left precentral gyrus and right orbitofrontal cortex contribute to
decision making inhibitory control
40
what is the schwartz 4 step method
relabel reattribute refocus revalue
41
what is pandas? | swedo et al 1998
paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections
42
what is the diagnostic criteria for pandas
presence of ocd and/ or a tic disorder paediatric onset (3 years to puberty) episodic course of symptom severity group A Beta-haemolytic streptococcal infection neurological abnormalities abrupt onsetor worsening sx
43
how do you confirm a group a strep infection according to the pandas diagnositc criteria?
positive strep throat culture hx of scarlet fever
44
what are Koch's postulates
criteria established to link a specific microorganism to a particular disease
45
what are the four criteria (requirements) of koch's postulates?
the organism is present in all causes of the disorder the organism can be extracted from from those with the disorder and cultured (grown in pure culture) transferring the organism into healthy subjects causes the disorder the organism can be reisolated from the infected party and is identical to the original isolated pathogen
46
what are the limitations to the koch criteria
many viruses can't be cultured on artificial media/ require a living host to replicate pathogens can be found in healthy individuals some diseases are caused by multiple factors or interactions
47
what are some limitations of a positive swab needed for dx?
strep infections occur at least 3 times before puberty high prevalence of strep throat culture in school children in autumn, winter and early spring not all children with strep bateria develop an infection postiive and negative throat cultures in children with pandas sx positive and negative throat cultures can occur in the same child
48
what is the antibiotic regimen for strep throat?
at least 10 days of antibiotics
49
what is the evidence from case reports that contradicts the antibiotic regimen for strep throat?
ocd and tic behaviour sx improve overnight after one antibiotic dose
50
what are the four criteria for a disorder to be autoimmune?
there is a self reactive antibody a target for the antibody (autoantigen is found) disorder can be caused in animals transferring the antibodies from one animal to another triggers the disorder (passive transfer)
51
ASO
anti-streptolysin O
52
ASO titres
high titres without an infection and a negative throat swab high titres persisting up to a year post infection and recovery normal aso levels in children with pandas and throat swabs cunningham antibody panel poorly correlated with pandas flare
53
is there a reliable temporal link between group a strep and exacerbation of pandas symptoms
not statistically significant effect of infections triggering worsening of sx
54
there is a lack of evidence supporting the pathophysiology of pandas
longitudinal studies clinical/ cognitive features don't discriminate well between pandas and other ocd and tic disorders anti-dopamine antibodies relevant in other strep related neuropsychiatric disorders lack of evidence for prophylaxis or tonsillectomy
55
anti-dopamine receptor antibodies are also present in which other strep related neuropsychiatric disorder?
sydenham's chorea
56
why is the term pans better than pandas
removes criteria that the disorder is autoimmune sx do not need to be caused by strep
57
what does pans stand for
paediatric acute-onset neuropsychiatric syndrome
58
what are the differential dx for pans
infections post infectious drug induced autoimmune metabolic traumatic psychogenic
59
european multicentre tics in childrens studies (emtics)
assessing recent group a strep exposure in children with tic disorders is not clinically significant co occurrence is due to chance
60
there is a lack of evidence for which tx for pans
antibiotics (azithromycin) immunoglobulins (ivig)
61
pans dx criteria
**abrupt, dramatic onset of ocd or severely restricted food intake** plus at least two of the following neuropsychiatric symptoms anxiety emotional lability irritability behavioural deterioration in school sensory/ motor abnormalities somatic symptoms e.g. sleep disturbance, involuntary or urinary frequency sx not better explained by sydenham's chorea, sle, tourettes etc.
62
nice guidelines for tx
mild - guided self help and information for family moderate to severe - cbt +erp ssri mdt review ssri + cbt inc erp alternative ssri or clomipramine
63
cbt for ocd
formuation of predisposing, precipitating and maintaining factors anxiety/ ocd psychoeducation goal setting hierarchy of situations and associated anxiety (graded exposure) (self) exposure and ritual prevention
64
what is erp
(self) exposure and ritual prevention
65
what rating scales are used in ocd/ pans/ pandas
clinican administered - children's yale-brown obsessive compulsive scale (cy-bocs) self rated- obsessive compulsive inventory
66
# erp - e what is exposure
deliberate exposire to all avoided and anxiety provoking situations
67
# erp - rp what is ritual prevention
prevention of any rituals or any strategy aimed at neutralising the anxiety
68
how much erp is needed
as much as possible more erp is highly correlated with sx improvement
69
how long should you spend in the exposure
until the anxiety at least halves
70
how long can it take for anxiety to half in the feared situation
at least 2 hours
71
when can you move on
until you don't feel anxiety at that level
72
medications for ocd
SSRIs antipsychotics
73
which SSRIs can be used to treat ocd
clomipramine fluoxetine fluoxamine sertraline citalopram escitalopram paroxetine
74
what proportion of people have a meaningful response to antipsychotics?
approx 1/3
74
when might antipsychotics be used to treat ocd
in SRI refractory ocd pts who have been treated for at least 3 months with a maximum tolerated SSRI dose with suboptimal effect
75
which group of patients are likely to benefit to antipsychotic augmentation
patients with comorbid tics
76
what is antipsychotic augmentation
Antipsychotic augmentation involves adding a second antipsychotic medication to an existing antipsychotic treatment regimen, often to improve the efficacy of the original medication or manage its side effects
77
what other somatic tx might be used to treat ocd
psychosurgery cingulotomy capsulotomy
78
what is the response rate to psychosurgery
40-50%
79
limitations of psychsurgery to treat ocd
no randomised control trials highly invasive controversial
80
what new experimental tx are being researched to treat ocd
tms dbs
81
what are the targets for dbs to treat ocd
nucleus accumbens internal capsule
82
dbs for ocd long term outcomes (3 years)
ventral capsule/ ventral striatum significant decrease on yale brown obsessive compulsive scale from severe to moderate approx 35% had sustained benefit
83
adverse effects of dbs
asymptomatic haemorrhage seizure event superficial infection transiety psychiatric side effects e.g. hypomanic sx remergence or worseing of ocd symptoms when the dbs battery died continuous stimulation is needed

Management of Neuropsychiatric Disorders (25 decks)

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