Obsessive compulsive symptoms (OCS)

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Obsessive compulsive symptoms: Clinical overview

OBSESSIVE COMPULSIVE SYMPTOMS (OCS) clinical overviewAHMED ELAGHOURY, MDEgyptian Board in PsychiatryTaif, April 2016

ConceptsObsession (Rumination): a thought, repetitive, intrusive, against the pt will EgodystonicCompulsion: obsessional motor act Own thought / act, under control: not passiveLewis 1936: intact insightSchneider 1959: No loss of contact with realityJaspers 1973: Inner struggle ie faces himselfDisorders of disgustApril 20162OCS*Oyebode F (2015). Sims' symptoms in the mind: Textbook of descriptive psychopathology, 5th ed. Saunders Elsevier*Casey P & Kelly B (2007). Fish's clincal psychopathology, 3rd . Royal College of Psychiatrists

Common comorbidities

Substance use ds: esp cannabis (19%), stimulants Punding Schizophrenia / Schizotypal ds: Schizo-obsessive ds (12 30 %)Depression: obsessional ruminations Anxiety ds: panic, phobia, separation anx.Intellectual disability: Fragile X, etcAutismTic ds / Stereotypic movement dsAvoidant / Restrictive food intake ds

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April 2016OCS4Haan LD et al eds (2015). Obsessive-Compulsive Symptoms in Schizophrenia. Springer International Publishing Switzerland

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Poyurovsky M (2013). Schizo-obsessive disorder. Cambridge University Press

DD of OCS in Schizophrenia Attribution & insightUncertaintyContentOnset & CourseAntipsychotic (SGA)-induced OCS: Clozapine & Olanzapine. Aripiprazole & Amisulpiride.

April 2016OCS6*Haan LD et al eds (2015). Obsessive-Compulsive Symptoms in Schizophrenia. Springer International Publishing Switzerland* Poyurovsky M (2013). Schizo-obsessive disorder. Cambridge University Press

OCS with neurologic dsPost TBI: Acute onset OCSDementia: esp non Alzheimer Huntington dsEpilepsyParkinson ds: PundingApril 2016OCS7

PundingCoined by Swedish forensic psychiatrist G. Rylander, in 1968A stereotypical motor behavior in which there is an intense fascination with repetitive handling and examining of mechanical objects. From previous interests / occupationNOT egodystonic.Commonly seen in:Pts on dopaminergic drugs eg Parkinson, RLSAbuser of stimulants ( I/W) : amphetamine type / cocaineApril 2016OCS8*Fernandez HH & Friedman JH. Punding on L-dopa. Mov Disord. 1999 Sep;14(5):836-8. PMID: 10495047. *Fasano A, et al. Cocaine addiction: from habits to stereotypical-repetitive behaviors and punding. Drug Alcohol Depend. 2008 Jul 1;96(1-2):178-82. PMID: 18378407. * Fogel BS & Greenberg DB, eds (2015). Psychiatric care of the medical patient. Oxford University Press

OCS and Psychosis in DSM5The specifier: with absent insight / delusional beliefIt may be a quantitative approach: delusional proportions (Pg 104) Delusional ds Vs OCD / Body dysmorphic ds?It may be two-phase process: acute / chronic (Pg 826)Hoarding ds: without resistance So: OCS and psychosis are on a spectrum Resistance is NOT a defining feature for obsession, esp in long term

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GBD 2000, WHO (2003)

OCD may be familial Verbal recall, set-shifting, response inhibition, and visuoconstructive abilities are impaired in both OCD patients and their first-degree relatives: a potential Endophenotype OMIM (#164230): AD, SNPs in SLC6A4 (SERT), HTR2A (5HT2A)met66 alleleof BDNF: protective May support the previous view: OCD is an anxiety dsApril 2016OCS11JW Psychiatry, Dec 5 2011OMIM

HTR2A gene

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Age of onset: a prognostic factorJuvenile onset: 20% have antibasal ganglia autoantibodies (ABGAs)

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Kaufman, 2013*Williams KA, Swedo SE. Post-infectious autoimmune disorders: Sydenham's chorea, PANDAS and beyond. Brain Res. 2015 Aug 18;1617:144-54. PMID: 25301689. *Nicholson TR, et al. Prevalence of anti-basal ganglia antibodies in adult obsessive-compulsive disorder: cross-sectional study. Br J Psychiatry. 2012 May;200(5):381-6. PMID: 22282431.

HoardingOCS WITHOUT resistance: egosyntonicComorbid with OCS / OCDOCD + hoarding (20%): younger age of onset, more bizarre items & less utilitarian meaning Familial: 50% of hoarders have one relative who hoards May be with other mental ds: Depression, Anxiety, etc

April 2016OCS16*Leckman JF, Bloch MH. A developmental and evolutionary perspective on obsessive-compulsive disorder: whence and whither compulsive hoarding? Am J Psychiatry. 2008 Oct;165(10):1229-33. PMID: 18829875. *DSM5, 2013

OCPD Anankast vs OCDFreud 1908: anal retentive character OCPD is NOT a risk factor for OCD (debated)DD classically through: Onset, course, functional impairment & resistanceRecently (2013): delayed reward delay discounting OCPD shows: excessive capacity to delay reward ie perfectionist & rigid (Type A personality) OCPD traits in old age ( delay discounting): lethality of suicide attempts

April 2016OCS17*Pinto A, et al. Capacity to delay reward differentiates obsessive-compulsive disorder and obsessive-compulsive personality disorder. Biol Psychiatry. 2014 Apr 15;75(8):653-9. PMID: 24199665*JW psychiatry, Dec 3 2013 *Dombrovski AY, et al. Lethal forethought: delayed reward discounting differentiates high- and low-lethality suicide attempts in old age. Biol Psychiatry. 2011 Jul 15;70(2):138-44. PMID: 21329911

SUMMARY POINTSOCS are highly comorbid and non specific for a special disorder, so included in screening measures. Long term & severe OCS may be associated with lost resistance & absent insight / delusional beliefOCD has a worldwide disability burden (10th) Age at onset is the best prognostic factor in OCDFamily history, reproductive history & recent infection / trauma: are essential in clinical assessment of OCSBoth dopaminergic & SGA drugs may be associated with onset / worsening of OCS in some pts. Tics, avoidant food intake & hoarding behavior: may present alone or comorbid with other mental dsOCPD traits (Type A personality) lethality of suicidal attempts in old age

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