Obsessive Compulsive Disorder

ByJini P. Abraham

ObsessionRecurrent, intrusive, and distressing

thoughts, images, or impulses

Irrational and absurd

Failure to resist, leads to marked distress

UnpleasantIncreases a person’s anxiety

Common, chronic, and disabling disorder marked by obsessions and/or compulsions that are egodystonic and cause significant distress to the patients and their families.

EpidemiologyPrevalence – 2 to 3 %

Children and adolescents = Adults

Men and women equally affected

Adolescence – Boys > Girls

Mean age of onset – 20 years

DepressionSocial phobiaSpecific phobiaPanic disorderAlcohol – use

disorders

Eating disordersPTSDAnxiety disordersPersonality

disordersSchizophrenia

Co morbidities

Predominantly obsessive thoughts or ruminations

Predominantly compulsive acts (compulsive rituals)

Mixed obsessional thoughts and acts

Clinical syndromes

Biological factors

Behavioural factors

Psychological factors

Etiology

SEROTONIN Dysregulation of

serotonin Abnormality of the

serotonergic system and particularly the hypersensitivity of postsynaptic 5-HT receptors

Neurotransmitters

NORADRENALINE Clonidine lowers the amount of

norepinephrine released from the presynaptic nerve terminals.

DOPAMINE Presence of OCD symptoms in Tourette’s

syndrome, Sydenham’s chorea and postencephalitic parkinsonism

GeneticsHigh concordance rate among monozygotic

twins

First degree relatives – 5 to 7%

PET scan – Increased activity in frontal lobes, basal ganglia and cingulum

CT and MRI studies – Decreased sizes of caudate bilaterally

EEG abnormality marked over temporal lobes

Brain imaging studies

Brain regions involved

Obsessions considered as conditioned stimuli

When a relatively neutral stimulus is coupled with an anxiety – provoking stimulus, through conditioning, it will produce anxiety even when presented alone.

Compulsions are learnt as a way to reduce anxiety.

Once relief of anxiety is produced, the relief serves as reinforce to the compulsion, which are then being repeated by the patient.

Behavioural factors

Sigmund Freud – Obsessional neurosisObsessive symptoms result from unconscious

impulses of an aggressive or sexual nature.These impulses cause extreme anxiety, which

is avoided by the defence mechanisms.

Psychological factors

Phobias

Reaction Formatio

n

New defences

Isolation of affect

Displacement

Obsessive thoughts

Anal sadistic phase

Anxiety related to oedipal conflicts

Regression

Obsessional personality

traits

Undoing

Fixation in developme

nt

Compulsive acts

Early childhood Disturbed

development in

At present In presence of fixation at anal sadistic phase

Reinforcement of Anal/Aggressive impulses

Normally disguised in

Obsessions –o Contaminationo Pathological doubto Need for symmetryo Aggressiveo Sexual

Compulsions –o Checkingo Washingo Countingo Need to ask or

confesso Symmetry and

precisiono Hoarding

Clinical Presentation

Sydenham’s choreaHuntington’s diseaseTourette’s syndromeTic disordersTemporal lobe epilepsyTraumaPsychiatric diagnoses, including phobias and

major depressive disorder

Differential Diagnosis

Onset of symptoms after a stressful event

Obsessive compulsive activities take up > 1 hour per day and are undertaken to relieve the anxiety

Course – usually long, but variable, fluctuating/chronic

More prone to depression and sometimes, suicide

Course and prognosis

Pharmacotherapy

Behavioural therapy

Psychotherapy

Other approaches

Treatment

PharmacotherapyClomipramine – TCASSRI’s –

FluoxetineFluvoxamineParoxetineSertralineCitalopram

Anti – Psychotics, buspirone, clonidine, MAO inhibitors

Effective mode of therapy, with success rate as high as 80%

Exposure and response preventionDesensitizationThought stoppingFloodingImplosion therapy

Patients must be truly committed to

improvement

Behavioural therapy

Attention of family members through provision of emotional support, reassurance, explanation, and advice on how to manage and respond to patient.

Family therapy can build a treatment alliance as well as help in the resistance of compulsions.

Group therapy

Psychotherapy

Electroconvulsive therapy – Severe depression with OCD

Psychosurgery, followed by intensive behaviour therapy aimed at rehabilitation

Other approaches

THANK YOU