OCD introduction and treatment and management

Ppt

1. Obsessive Compulsive Disorders Dr. Priyanka Thapa Dept of Psychiatry Lecturer BMCTH

2. Overview INTRODUCTION CLASSIFICATION CLINICAL FEATURES DIAGNOSTIC CRITERIA EPIDEMIOLOGY COMORBIDITIES TREATMENT REFERENCES

3. Learning Objectives Understand obsessive compulsive disorders Classify them Elaborate clinical features Label diagnostic criteria Outline treatment

4. INTRODUCTION Obsessions : Unwanted, intrusive thoughts Examples: Fear of contamination, aggressive thoughts Compulsions : Repetitive behaviors or mental acts Examples: Excessive cleaning, checking, counting

5. OCD is characterized by time consuming, distressing, or impairing obsessions or compulsions, often accompanied by avoidance behaviors . Overall aggregate current, period, and lifetime OCD prevalence estimates were 1.1%, 0.8%, and 1.3%, (1.5% in women and 1.0% in men) Age of Onset : Early adulthood (i.e. 20-29 years), late childhood/ early adolescence Course : Mostly Continuous, 1/4 th exhibiting waxing and waning pattern Mean rate of suicide in OCD- 14.2% INTRODUCTION

6. OBSESSIVE-COMPULSIVE DISORDER Symptom dimensions uniform across all cultures – usually non-bizarre content Cleanliness Orderliness Sexual/aggressive/religious – danger signals Patient is usually aware of the excessive/irrationality Not easily getting a sense of “closure”” Doubts – “what if?” – increased error monitoring Socio-territorial concerns regarding safety

7. Clinical features ICD-10 ICD-11 DSM-5 Grouping Neurotic, stress related, and somatoform disorders OCRD OCRD Core Features Obsession and/or compulsion Obsession and/or compulsion Obsession and/or compulsion Definition of Obsessions thoughts, ideas, or images thoughts, images, or impulses/urges ideas, images, or urges Insight as an essential criterion must be recognized as individual’s own thoughts or impulses Similar to DSM‑5; insight can be poor A range of insight permitted Resistance and neutralizing behaviour Requires at least one obsession or compulsion to be unsuccessfully resisted; explicitly not pleasurable Obsessions commonly cause anxiety and the individual attempts to ignore or suppress obsessions or to neutralize them by performing compulsions Obsessions cause marked anxiety or distress, and the person attempts to ignore, suppress or neutralize obsessions (i.e., by performing a compulsion) OBSESSIVE‑COMPULSIVE DISORDER

8. Clinical features ICD-10 ICD-11 DSM-5 Duration criterion at least 2 successive weeks of symptoms Duration criterion removed No duration criterion Functional relationship not acknowledged acknowledged acknowledged Qualifiers Predominantly obsessions Predominantly compulsions Mixed obsessions and compulsions Insight (fair to good and poor to absent) With panic attacks Insight (good/fair, poor, absent‑delusional) Tic‑related

9. Obsessive-Compulsive Disorder (OCD) - ICD-10 Criteria Presence of Obsessions or Compulsions (or Both): Obsessions: Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and unwanted The individual attempts to ignore or suppress such thoughts or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions: Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. Behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; but are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

10. Obsessive-Compulsive Disorder (OCD) - ICD-10 Criteria 2. Recognition of the Symptoms as Unreasonable or Excessive: At some point during the course of the disorder, the individual recognizes that the obsessions or compulsions are excessive or unreasonable . This is not applicable to children. 3. Significant Distress or Impairment: The obsessions or compulsions cause marked distress, are time-consuming (take more than 1 hour per day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships. 4. Not Attributable to Other Conditions: The obsessive-compulsive symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Duration: The symptoms have persisted for at least 2 weeks . Exclusion Criteria: The symptoms are not better explained by another mental disorder (e.g., major depressive disorder, generalized anxiety disorder).

11. Obsessive-Compulsive Disorder (OCD) – DSM 5 Criteria Diagnostic Criteria (DSM-5): Presence of obsessions, compulsions, or both Time-consuming behaviors (>1 hour per day) Significant distress or impairment in social, occupational, or other areas Assessment Tools: Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

12. EPIDEMIOLOGY

13. Pauls et al, Nature Neuroscience Reviews, 2014 Classical model - OCD Loss of cognitive control Activation of limbic circuits Habitual behaviors Reward pathways /fear extinction

14. ETIOPATHOGENESIS Genetic Factors : Family history Biological Factors : Brain structure and function Environmental Factors : Stressful life events CSTC loops

15. Habit formation hypothesis Goal directed behaviors Deliberate, flexible and outcome oriented behaviors Prefrontal cortex and caudate Habitual behaviors Inability to inhibit previously learnt stimulus/response associations Premotor cortex and putamen OCD – hyperactivity of habit formation system Compulsions are primary Obsessions are secondary rationalizations for obsessions

16. Structural Imaging Studies: MRI DTI Functional Imaging Studies : fMRI SPECT (single photon emission computed tomography) PET fNIRS (functional near‑infrared spectroscopy) IMAGING STUDIES

17. ASSESSMENT AND EVALUATION

18. TREATMENT Cognitive Behavioral Therapy (CBT): Exposure and Response Prevention (ERP) Medications: Selective Serotonin Reuptake Inhibitors (SSRIs) Combination of Therapies: Efficacy of combined treatments

19. FIRST LINE TREATMENT

20. NON-INVASIVE BRAIN STIMULATION TECHNIQUES INVASIVE PROCEDURES 1. Electroconvulsive therapy(ECT) 2. Repetitive transcranial magnetic stimulation (rTMS) 3. Transcranial direct current stimulation (tDCS) 1. Ablative neurosurgery 2. Deep brain stimulation NEUROMODULATION

21. Dorsal anterior cingulotomy for severe intractable OCD Anterior cingulate gyrus and the cingulum bundle (Anterior cingulotomy) Anterior limb of internal capsule (Anterior capsulotomy) Corticostriatal tracts ventral to the head of the caudate nucleus ( Subcaudate tractotomy) CINGULOTOMY

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