Oc spectrum disorder

powerpoint presentation on Obsessive Compulsive Spectrum Disorder

1. Obsessive Compulsive Spectrum Disorder Presenter :- Dr. Vijay Saini (Resident) Guide :- Dr. Anant Rathi

2. Obsessions R epetitive and constants thoughts, images or impulses that cause anxiety or distress. not about real-life problems. Try to ignore or counter act recognized as a product of one’s own mind and not imposed from without.

3. Compulsions Repetitive behaviors or mental acts person does in reaction to obsessions. done to avoid or decrease distress. acts are clearly excessive or not realistic.

4. According to DSM – 5 Obsessions are defined by the following features. 1. Recurrent or Persistent thoughts, urge or images that are experienced at some time during the disturbance as intrusive and unwanted and that causes marked anxiety and distress. 2. Attempt to ignore or suppress such thoughts ,urge or image to neutralize them with some other thought or action.

5. Compulsions are defined as follows : 1. Repetitive behaviours or mental act that the person feels driven to perfrom in response to an obsession or according to rules that must be rigidly applied. 2. Behaviours or mental act aimed at preventing or reducing anxiety or distress, or preventing some dreaded events or situations; Those behaviours or mental acts are either unconnected realistically with what they are designed to neutralize or prevent or clearly excessive.

6. DSM-5 &OCD DSM-5 has a separate chapter for OCD and related disorders They are no longer considered anxiety disorders. Disorders in this chapter include Obsessive-compulsive disorder, Body dysmorphic disorder and Trichotillomania (hair-pulling disorder),

7. - Hoarding disorder - Excoriation (skin-picking) disorder. Obsessive-compulsive and related disorders can include body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive-compulsive and related disorder. Specifier :- - Insight- Good/fair, Poor and absent/Delusional - Tic related

8. EPIDEMIOLOGY Lifetime prevalence - 2 to 3 percent. 10 percent of outpatients in psychiatric clinics. Among adults, men and women are equally likely to be affected, but among adolescents, boys are more commonly affected than girls. mean age of onset is about 20 yr, although men have a slightly earlier age of onset (mean about 19 years) than women (mean about 22 years ) .

9. CO-MORBIDITIES L ifetime prevalence for major depressive disorder in persons with OCD is about 67 percent and for social phobia, about 25 percent. The incidence of Tourette's disorder in patients with OCD is 5 to 7 percent, and 20 to 30 percent of patients with OCD have a history of tics. Other common comorbid psychiatric diagnoses in patients with OCD include alcohol use disorders, generalized anxiety disorder, specific phobia, panic disorder, eating disorders, and personality disorders.

10. Diagnostic Criteria (ICD-10) For a definite diagnosis obsessional symptoms or compulsive acts, or both, must present on most days for at least 2 successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following characteristic :- (a) They must be recognised as the individual's own thoughts or impulses. (b) There must be at least one thought or act that is still resisted unsucessfully , even though others may be present which sufferer no longer resist. (c) The thought of carrying out the act must not in itself be pleasurable. (d) The thoughts, images or impulses must be unpleasantly repetitive.

11. Neurobiological Psychological Environmental Causes of OCD in short Causes of OCD in short

12. Neurobiological factors Neurotransmitter Levels Serotonin “ocd.jpg” “normal.jpg” CSF Platelets Low 5HT 5HIAA DA – Hyper functioning in PFC 5HT – Hypo functioning in basal ganglia Dysfunction of the so-called ' cortico - striato -thalamic' loops

13. Cortico-striatal-thalamocortical loop The orbitofrontal cortex has a circuit that sends information to the thalamus such as aggression, sexuality and bodily excretions. When these parts of the brain are activated we are bound to act upon those certain behaviors or actions. These impulses are brought to ones conscience and after brain has sent the information and have acted upon that information the impulse eventually decreases and you move on to your daily routine. Within people who have OCD, some certain impulses cannot be turned off or ignored by that part of the brain, which causes them to repeat the same action over and over again. Eventually they become obsessed with these actions and they have become integrated into their routine and they have no control over it.

14. Brain Imaging Studies CT / MRI : Decrease size of caudate nuclei PET: Increased activity in frontal lobe (OFC) & basal ganglia(caudate), Thalamus

15. Genetic factor OCD has significant genetic component . Three to five times higher probability of OCD in relatives of probands with OCD. Concordance for OCD in twins is significantly higher for monozygotic twins than for dizygotic twins

16. Environmental factors Early childhood conflicts: This is an early theory that suggests conflicts or problems during childhood are the roots of OCD. This is specifically looking at either permissive or mainly unengaged parenting techniques.

17. Psychological - COGNITIVE THEORY OF OCD Obsessional thoughts: It’s not the thought itself that is disturbing, but rather the interpretation of the thought. The issue of responsibility is believed to be a core belief or cognitive distortion of people with OCD.

18. Compulsive behaviors: Neutralizing, either through compulsive behaviors or mental strategies, is aimed at preventing terrible consequences, or averts the possibility of being responsible Seeking reassurance is another form of neutralizing, as it can serve to spread responsibility to others, thus diluting that of the individual Avoidance, though not an overt neutralizing behavior, is often used to prevent contact with particular stimuli

19. OCD Cycle –Learning Theory OBSESSIONS COMPULSIONS R ELIEF ANXIETY

20. PSYCHODYNAMIC FACTORS ISOLATION It protects an individual from anxiety provoking affects and impulses. isolation less effective Patient experience a partial awareness of the impulse without fully recognizing its meaning Impulse is displaced from the true object to other people or object.

21. PSYCHODYNAMIC FACTORS (CONTD.) UNDOING When impulse`s constant threat escape primary defense of isolation Secondary defensive operations is started Compulsive act that is performed in an attempt to prevent or undo the consequences that the patient irrationally anticipates from a frightening obsessional thought or impulse.

22. PSYCHODYNAMIC FACTORS (CONTD.) REACTION FORMATION Manifest patterns of behaviour and consciously experienced attitudes that are exactly the opposite of the underlying impulses Reaction formation results into formation of character traits of OCD.

23. PSYCHOANALYTIC FACTORS AMBIVALENCE Present in normal children during the anal sadistic development phase. Children feel both love and murderous hate towards the same object. Patients with OCD often consciously experience both love and hate toward an object. Conflict of opposing emotions is evident in a patient` doing and undoing patterns of behaviour and in paralyzing doubt in the face of choice.

24. PSYCHOANALYTIC FACTORS (CONTD.) MAGICAL THINKING Inherent in magical thinking is omnipotence of thought. An event can occur merely by thinking without intermediate physical actions. This feeling causes them to fear having an aggressive thought.

25. Contamination 45 % Pathological doubt 42 % Somatic 36 % Need for symmetry 31 % Aggressiveness 28 % Sexual 26 % Obsessions Percentage

26. Checking 63 % Washing 50 % Counting 36 % Symmetry & precision 28 % Compulsions Percentage

27. In children- Obsession :- -concern or disgust with bodily waste or secretion, dirt, germs, environmental toxins and -fear something terrible may happen Compulsion :- -Excessive or ritualized hand washing,bathing,tooth brushing or grooming - Repeating rituals (going in and out of door, up and down from chair)

28. OCD pts in other specialities Dermatologist – chapped hand , eczematoid hand Oncologist – insistent beliefs that they aquired some type of tumor . Infectious disease – infectious with HIV . Pediatrician – sydenhams chorea . Dentist – gum lesion

29. Famous People With OCD Charles Darwin Leonardo Dicaprio Jessica Alba Donald Trump David Beckham Michel Jackson Priyanka Chopra Farhan Akhtar

30. Disease Differential diagnosis OCD and delusional disorder Not a fixed belief , ego-dystonic , not accompanied by hallucination Idiopathic OCD And OCD-like associated disorder Basal ganglia mostly involved and another symptomatic pattern are present such as sydenhams chorea . OCD and Tourettes Disoder Must present before 18 yr , at least 1 year pattern of multiple motor and one or more vocal tics , never tics free of 3 months or more . OCD and obsessive -compulsive personality disorder Personality traits are ego-syntonic , present before 18 yr , no true syndrome of obsession and compulsion . OCD and obsessive thoughts in psychosis Patient have insight to there symptoms , no other features of psychosis (delusion , hallucination ) OCD and depression Obsessive thoughts present during depression episode , while in OCD they persist .

31. T REATMENT

32. Psychotherapy

33. Behaviour therapy Many clinician consider behaviour therapy treatment of choice. The principal behavioural approach in OCD is exposure and response prevention. Others are desensitization, thought stopping, flooding ,implosion therapy etc. They are less useful. Supportive psychotherapy and family therapy also useful.

34. Pharmacotherapy TCA/ Clomipramine SSRI Venlafaxine , mirtazepine , tianeptine 4. Augmentation agents :- Antipsychotics:- Preferably Aripiprazole , Risperidone Haloperidol, Olanzapine , Qutiapine Glutaminergic agents:- Memantine , lamotrigene , Topiramate , Riluzole , N-Acetyl cysteine 5-HT Antagonist:- Ondensetron , Granisetron Others:- Buspirone , Li, Clonazepam , Opioids , IV Clomipramine , Pimozide

35. Dose of Anti OCD Drugs CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF OBSESSIVE COMPULSIVE DISORDER (IPS Guideline committee) Drug Usual starting dose(mg) Usual target dose(mg) Usual max.dose (mg) Fluvoxamine 50 200 300 Fluxotine 20 40-60 60 Sertraline 50 150 225 Citalopram 20 40-60 60 Clomipramine 25-50 100-250 250 Paroxetine 20 50 60

36. Unique proprties of Fluvoxamine No active metabolite and Action on sigma1 receptor Lesser droping out of treatment as compared to others. Its efficacy in OCD has been firmly established by both placebo-controlled ( Jenike  et al, Goodman et al ,Hollander E et al ) and active-comparison studies .( Freeman CP et al,Mundo et al, zoher et al)  Among the SSRIs, fluvoxamine is one of the weakest inhibitors of norepinephrine and dopamine reuptake. it has relatively few and mild cardiovascular and anticholinergic effects. Better tolareted so lesser drop out from treatment.

37. Repetitive Transcranial Magnetic Stimulation (rTMS) Possible Hypothesis-it has been postulated that low frequency rTMS can have therapeutic benefits in patient with OCD by inhibiting the hyper-excitable CSTC circuit. Explorations of rTMS to the DLPFC, OFC, or SMA in a total of 10 studies have demonstrated only acute efficacy for obsessive-compulsive symptoms of rTMS .( Riannee M. Bloom et al.Update on Repetitive Transcranial Magnetic Stimulation in Obsessive-Compulsive Disorder: Different Targets. Curr Psychiatry Rep . 2011 Aug; 13(4): 289–294) Both NICE and APA practice guideline for t/t of OCD conclude “currently rTMS cannot be recommended as a t/t option

38. Electroconvulsive Therapy Can be used in resistant cases Although 60 % of review shows some positive response to ECT, but it can not be stated that this provide evidence that ECT is indeed effective for OCD .( Fontelle et al) ECT, as currently administered, should be reserved for selected cases of patients with OCD displaying severe mood disorders .( Martines et al) The American Psychological Association (APA) task force on ECT in 1990 stated that ECT is an effective treatment option for patients suffering from OCD with severe depression. However this is not evidenced by RCTs.

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40. Treatment resistant OCD Term Treatment resistant is generally applied to those patients who have not shown a satisfactory response to adequate trials to at least two SRIs . The term treatment refractory or intractable connote greater degree of treatment resistance, as reflected in failure to respond to a variety of anti OCD treatment strategies (including combination of agents) as well as behaviour therapy . Dan, J. Stein, Eric Hollander (2002). The American Psychiatric Publishing Textbook of Anxiety Disorders

41. OCD in Bipolar disorder Treatment of comorbid BD with OCD is huge challenge for clinicians as management of one can worsen other and researchers into treatment aspects of this entity is sparse. Mood stabilizer along with adjuvant topiramate or with olanzapine -SSRI/ Clomipramine combination can be used. Use of other conventional agents is limited to case reports. Management of obsessive-compulsive disorder comorbid with bipolar disorder.Firoz Kazhungil , E.Mohandas . IJP 2016;58(3).259-269

42. Body Dysmorphic Disorder A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive. B. The preoccupation causes clinically significant distress or impairment in functioning. C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

43. Most common age of onset b/w 15 and 30 years Women affected more ETIOLOGY:- -Similarity to OCD, comorbidity with depression and higher family history of mood disorder S/O role of serotonin. - Psychodynamic model- it reflecting the displacement of sexual and emotional conflict onto nonrelated part.

44. CLINICAL FEATURES :- -Affected area- facial flaws followed by breasts, genitalia. - Ideas or delusion of reference -Can result either excessive mirror imaging or avoidance - Person may be housebound

45. Differential Diagnosis Anorexia Nervosa-restricted to concern about being fat Avoidant personality disorder and Social phobia – may worry about being embrassed by imagined or real defect but concern is not prominent, persisting ,distressing or impairing. Delusional disorder

46. HOARDING DISORDER The disorder characterized by acquiring and not discarding things that are deemed to be little or no value resulting in excessive clutter of living space Commonly driven by obsessive fear of losing important items. Distorted belief about importance of possession and by extreme emotional emotional attachment to possession.

47. 2-5 per. Prevelance , equally among male and female and associated with social anxiety, withdrawl and dependent personality traits. ETIOLOGY:- - 80 per of hoarders reporting at least one first degree relative with hoarding. - Lower metabolism in posterior cingulate cortex and occipital cortex which account for attention and decision making deficits. - Link b/w hoarding and markers on chromosomes 4q,5q, 17q and COMT gene on ch 22q.

48. Clinical features Most pts do not perceive their behaviour problematic i.e.ego syntonic Overemphasize the importance of recall information and possession Avoid making decision about discarding items. Other problems-Pest infestations, Fire in collected items Social, Occupational and functional impairement

49. Co-morbidities 30 per of OCD pts have hoarding. Symptoms in OCD are ego- dystonic whereas in hoarding they are ego syntonic 20 per met criteria for ADHD. Hoarding behaviour noted in dementia, surgery in prefrontal and orbitofrontal cortex and schizophrenia.

50. It is very difficult to treat. SSRI having mixed results. The most effective treatment is cognitive model that include training in decision making and categorizing; exposure and habituation to discarding ;and cognitive restructuring.

51. TRICHOTILLOMANIA Term coined by Francois Hallopeau in 1889 There is increased tension prior to hair pulling and a sense of relief after pulling All the areas of body may affect but mostly scalp 2 types- Focused and automatic Hair loss is characterized by short, broken strands appearing together with long, normal hairs in affected areas

52. Hair pulling may associated with trichophagy (35-40 %) Patient usually deny that and hide alopecia. EPIDEMIOLOGY:- Lifetime prevalence ranging from 0.6 to 3.4 % with F:M is 10:1, Begin in early to mid adolescence age Childhood type occur approx equal in both sex Patient is likely to be only or oldest child in family.

53. ETIOLOGY It is multi determined, although its onset may linked with stressful situations i.e. disturbed mother-child relation, fear of being left alone. Family members of d/o have history of tic, impulse control disorder ,OCD suggestive of genetic predisposition. Smaller volume of left putamen and left lenticular areas. Relationship b/w serotonin receptor gene polymorphism and trichotillomania .

54. Course and treatment Early onset(before 6 yr) tend to remit rapidly and respond well to t/t while late onset( after 13 yr) is associated with chronicity and poor prognosis. Treatment usually involve psychiatrist, psychologist and dermatologist. Topical steroid with hydroxyzine along with SSRI. Poor response to SSRI can be augmented with lithium, pimozide , venalafexine , naltrexone , buspirone and trazadone . Biofeedback, densensitization ,habit reversal and insight oriented psychotheraphy are sucessful behavioral treatment.

55. EXCORIATION (SKIN PICKING)DISORDER Another names – skin picking syndrome, emotional excoriation, nervous scratching artifact, epidermotillomania and para artificial excoriation. DSM 5 criteria requires recurrent skin picking resulting in skin lesion and repeated attempts to decrease or stop picking. The skin picking must cause clinically relevant distress or impairement in functioning.

56. Epidemiology and etiology Lifetime prevalence 1-5 % in general population, approx 12 % in adolescent psychiatric population and 2% with other skin disorders. Women more affected. Some theorists speculate that skin picking is a manifestation of repressed rage at authoritarian parents. According to psychoanalytic theories skin is erotic organ. Picking having masturbatory equivalance and source of erotic pleasure. Many pts start picking at onset of skin dz and continue to pick after skin dz cleared.

57. Abnormalities in serotonin,dopamine and glutamate have been hypothesized. Pt may pick as a means to relieve stress i.e. marital conflicts, loss of loved one ,unwanted pregnancy etc.

58. Clinical features Face is most common site. Other are legs, arms, hand, fingers and scalp. In severe case , picking leads to disfigurement require surgical intervention. Pt may feel tension before picking which relieved after picking. Many pt often feel guit and negative feeling after act. Many pt avoid social situations and may attempt suicide.

59. Diiferential diagnosis 1. OCD - equal in both sex, Compulsion of skin picking less likely. Skin picking if present associated with obsession of contamination. 2. Body dysmorphic disorder- Skin picking is centered on removing believed imperfection. 3.Substance like coccaine and amphetamine can result in skin picking due to formication .

60. 4. Factitious Dermatitis- self inflicted injury. It can present as aggravation of dermatosis targeting variety of lesion including blisters, ulcers, erthyma , edema and sinuses. The morphology of lesion is bizzare with clearcut , angulated or geometric edges. Presence of normal unaffected skin adjacent to horrible skin lesion is diagnostic clue. Pt ‘s description of history of lesion is vague and lacks detais about appearance and evolution of lesion.

61. Treatment Usual onset at adolescent age (mean age 12 to16) but may be in adulthood. Lag phase b/w onset and diagnosis. Difficult to treat. SSRI have some efficacy specially fluxotine as compared to placebo. Naltrexone reduce urge to pick. Glutaminergic agent and lamotrigene have shown efficacy. Nonpharamacological treatment include habit reversal and CBT.

62. REFERENCES The ICD-10 classification of mental and behavioural disorders. Clinical descriptive and diagnostic guidelines,WHO The Synopsis of Psychiatry,11 th edition. Benjamin James Sadock , Virginia Alcott Sadock , Pedro Ruiz. Diagnostic and statistical manual of mental disorders DSM-5 Fifth Edition. American Psychiatric Society. Management of obsessive-compulsive disorder comorbid with bipolar disorder.Firoz Kazhungil , E.Mohandas . IJP 2016;58(3).259-269 Dan, J. Stein, Eric Hollander (2002). The American Psychiatric Publishing Textbook of Anxiety Disorders Textbook of psychiatry. Alan tassman The Comprehensive textbook of Psychiatry. Benjamin James Sadock , Virginia Alcott Sadock , Pedro Ruiz Drug treatment of obsessive-compulsive disorder.Michael Kellner Dialogues Clin Neurosci . 2010 Jun; 12(2): 187–197

63. Goodman WK, Price LH, Rasmussen SA, Delgado PL, Heninger GR, Charney DS. Efficacy of fluvoxamine in obsessive-compulsive disorder.  Arch Gen Psychiatry . 1989; 46(1):36-44. Jenike MA, Hyman S, Baer L, et al. A controlled trial of fluvoxamine in obsessive-compulsive disorder: implications for a serotonergic theory.  Am J Psychiatry . 1990;147(9):1209-1215.   Zohar J, Judge R. Paroxetine versus clomipramine in the treatment of obsessive-compulsive disorder. OCD Paroxetine Study Investigators.  Br J Psychiatry . 1996;169(4):468-474. Mundo E, Maina G, Uslenghi C. Multicentre, double-blind, comparison of fluvoxamine and clomipramine in the treatment of obsessive-compulsive disorder.  Int Clin Psychopharmacol .  2000;15(2):69-76. Diagnosis and Treatment of Obsessive-Compulsive Disorder.  . Andrea Allen, PhD, and Eric Hollander, MD Primary Psychiatry December 1, 2005 Electroconvulsive therapy for obsessive-compulsive disorder: a systematic review. Fontenelle LF et al 2015 Electroconvulsive Therapy in Obsessive-Compulsive Disorder: A Chart Review and Evaluation of Its Potential Therapeutic Effects Natália M. Lins -Martins et al