Obsessive compulsive disorder

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Obsessive Compulsive Disorder

Obsessive Compulsive DisorderByJini P. Abraham

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 = AdultsMen and women equally affectedAdolescence Boys > GirlsMean age of onset 20 years

DepressionSocial phobiaSpecific phobiaPanic disorderAlcohol use disordersEating disordersPTSDAnxiety disordersPersonality disordersSchizophrenia

Co morbidities

Predominantly obsessive thoughts or ruminations

Predominantly compulsive acts (compulsive rituals)

Mixed obsessional thoughts and actsClinical syndromes

Biological factorsBehavioural factorsPsychological factorsEtiology

SEROTONIN Dysregulation of serotonin Abnormality of the serotonergic system and particularly the hypersensitivity of postsynaptic 5-HT receptorsNeurotransmitters

NORADRENALINE Clonidine lowers the amount of norepinephrine released from the presynaptic nerve terminals.

DOPAMINE Presence of OCD symptoms in Tourettes syndrome, Sydenhams chorea and postencephalitic parkinsonism

Genetics

High 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 lobesBrain 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

PhobiasReaction FormationNew defencesIsolation of affectDisplacementObsessive thoughtsAnal sadistic phaseAnxiety related to oedipal conflictsRegressionObsessional personality traitsUndoingFixation in developmentCompulsive actsEarly childhoodDisturbed development inAt present In presence of fixation at anal sadistic phaseReinforcement of Anal/Aggressive impulsesNormally disguised in

Obsessions ContaminationPathological doubtNeed for symmetryAggressiveSexual

Compulsions CheckingWashingCountingNeed to ask or confessSymmetry and precisionHoardingClinical Presentation

Sydenhams choreaHuntingtons diseaseTourettes syndromeTic disordersTemporal lobe epilepsyTraumaPsychiatric diagnoses, including phobias and major depressive disorderDifferential 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, suicideCourse and prognosis

PharmacotherapyBehavioural therapyPsychotherapyOther approachesTreatment

PharmacotherapyClomipramine TCASSRIs FluoxetineFluvoxamineParoxetineSertralineCitalopramAnti Psychotics, buspirone, clonidine, MAO inhibitors

Effective mode of therapy, with success rate as high as 80%Exposure and response preventionDesensitizationThought stoppingFloodingImplosion therapyPatients must be truly committed to improvementBehavioural 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 therapyPsychotherapy

Electroconvulsive therapy Severe depression with OCD

Psychosurgery, followed by intensive behaviour therapy aimed at rehabilitationOther approaches

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