Ocd overview

ETIOLOGY AND SOMATIC TREATMENT OF OCD

1. Obsessive Compulsive Disorder Presenter :- Dr. Anant (Resident) Guide :- Dr. D. K. Sharma (Prof. & Head)

2. Obsessive Compulsive Disorder OCD is an anxiety disorder distinguished by recurring thoughts that cause anxiety and the impulse to perform certain actions in order to relieve the anxiety. (Obsessions and Compulsion)

3. Obsession Recurrent persistent thoughts, impulses, images that Enters the mind Can’t be eliminated by consciousness by logic/reasoning Involuntary Ego- dystonic

4. Obsession - Characteristic features Subjective sense of struggle Conviction that to think is to make it more likely to happen Recognized as own Regarded as untrue and senseless Generally about matters that are distressing Often accompanied by compulsion

5. Compulsion Pathological need to act on an impulse that if restricted produce anxiety Repetitive behavior in response to an obsession, performed according to certain rules with no true end in itself

6. The obsessions or compulsions are a significant source of distress to the individual.

7. OCD Cycle OBSESSIONS COMPULSIONS R ELIEF ANXIETY

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

9. 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

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

11. Causes BIOLOGICAL 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 you are bound to act upon those certain behaviors or actions . These impulses are brought to ones conscience and after your brain has sent you 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.

12. GENETIC FACTORS 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 .

13. 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.

14. 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.

15. 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

16. Model: Stimuli in the form of unpleasant intrusive thoughts, of either external or internal origins are experienced The thought is ego- dystonic , that is, it is inconsistent with the individual’s belief system It usually involves an element of blame, responsibility, or control, which interacts with the content of the intrusive thought Disturbances in mood and anxiety follow, which in turn lead to neutralizing behavior

17. Main consequences of neutralizing behavior It results in reduced discomfort, which leads to the development of compulsive behavior as a tool for dealing with stress. This reinforcing behavior may result in a generalization of this strategy Neutralizing will be followed by non-punishment, and can lead to an effect on the perceived validity of the beliefs The neutralizing behavior itself becomes a powerful and unavoidable triggering stimulus. The neutralizing behavior serves to reinforce the belief that something bad may happen

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. Contamination 45 % Pathological doubt 42 % Somatic 36 % Aggressiveness 28 % Sexual 26 % Obsessions Affective Disorder

24. Checking 63 % Washing 50 % Counting 36 % Symmetry & precision 28 % Compulsions Affective Disorder

25. With OCD I feel… Misunderstood, nobody seems to get me, they can’t understand why I am the way I am.

26. Depressed… I feel depressed because I get stuck in my ways and nobody gets them or can help me.

27. CRAZY! My obsessions drive me crazy. I wish they would stop.

28. Repetitive I repeat myself and actions, over and over and over and over and over and over and over and over again….

29. Out of Control I cant control my thoughts, actions, or myself. Its like I am a character in a video game.

30. Hyper OCD makes me also feel hyper and wild sometimes, when its not ruining my life.

31. Introverted I find that I am very unfond of others even my closest friends, when my compulsions are really bad.

32. Lazy I don’t enjoy doing things or leaving my house because of the anxiety it causes. I’d rather just sit and wait.

33. Nervous Not knowing what is going to happen makes me super nervous. Everything has to be planned out and go exactly according to plan.

34. Anxious I get anxious when I have compulsions and I obsess over the little things, it’s a feeling that never goes away for me.

35. Scared I get scared when people don’t understand me and judge me and when things don’t go according to plan, I get afraid something will happen to me.

36. OCD- Prevalence Is chronic psychiatric disorder and is one of the 10 most disabling medical conditions worldwide 4th most common psychiatric disorder OCD is not received due attention and with its high prevalence it is being labeled as the ‘hidden epidemic’

37. T REATMENT

38. Psychotherapy

39. Thought stopping Response prevention Exposure etc. Most effective for OCD. Supportive therapy is always helpful Cognitive Behavioral Therapy

40. Pharmacotherapy TCA/ Clomipramine SSRI fluvoxamine fluoxetine paroxetine sertraline citalopram Escitalopram 3. Atypical antipsychotics:- preferably Olanzapine, Quetiapine, Risperidone 4. Antianxiety drugs :- preferably short acting as clonazepam

41. 5 . Adjunctive medications Tryptophan Buspirone Lithium Pimozide Trazodone Methylphenidate 6. Venlafaxine, mirtazepine, tianeptine 7.  Research :- Riluzole ,  mimentine ,  gabapentine ,  N- acetylcysteine and  lamotrigine .

42. ECT- Anti obsessional property? APA task force on ECT- unless severe depression is prominent ECT is not an effective treatment option. Reports and efficacy of ECT treatment in refractory OCD is sparse in literature. Study- retrospective review 32 patients OC and depressive symptoms baseline survey ECT improvement in refractory OCD and depressive symptoms Fallacy- Retrospective study ECT conditions and parameters frequency & number criteria/reasons of stopping ECT were not specified

43. Study- Open label 11 patients Maintenance ECT for refractory OCD- 2or3 per week for ten sessions. Significant improvement in initial 3-4 wks Maintained till 4 months Pre-treatment state within 6 months

44. Research Question Is ECT is more beneficial in patients of OCD having co-morbid psychosis/Schizophrenia?

45. Repetitive Trans-cranial Magnetic Stimulation

46. Repetitive Transcranial Magnetic Stimulation (rTMS) In rTMS pulsed magnetic field is applied to the scalp induces electric currents that depolarizes underlying cortical neurons influencing their function Possible Hypothesis- directly altering the hyper functioning of PFC with rTMS ameliorate symptoms of OCD Speed of Stimulation > 1Hz- high frequency - activates stimulated areas Speed of stimulation < 1Hz- low frequency - inhibit cortical stimulation

47. Study- Crossover randomized investigator blind study 12 right handed pts having current or past depression Single session of rTMS at 80% of RMT( resting motor threshold ) at 20Hz/2 second per minute for 20 minutes On right lateral pre-frontal, left lateral pre-frontal and mid-occipital(control) site Result - Compulsions decreased significantly for 8hrs after Rt lateral PFC stimulation with modest increase in positive mood Non-significant reduction in compulsion urges 30 minutes after left lateral PFC stimulation Non-significant increase in compulsive urges after mid-occipital stimulation Obsession did not change significantly

48. Study- Open label 12 Rt handed OCD refractory pts none having depression Randomly assigned to 10 sessions of Rt or Lt pre-frontal rTMS of 10Hz, 110% RMT, 30 trains of 5 second each Site- in relation to activating 1 st dorsal interosseous muscle Result - 33% of either group showed clinically significant improvement (40% reduction in YBOCS) No significant differences b/w Rt & Lt sided rTMS No difference b/w obsessions & compulsions score

49. Study ( Alonso et al ) Double blind randomized placebo controlled parallel group design 18 Rt handed pts with no other psychiatric co-morbidity 10 pts assigned to thrice weekly sessions for 6wk at 1Hz on Rt pre-frontal at 110% of RMT- 2 pts showed 40% reduction in YBOCS 8 pts assigned to placebo group- 1 responded Improvement appeared following 5 th wk of t/t Real rTMS receivers had non-significant greater reduction in obsessions

50. Study ( Sachdev et al ) Double blind randomized placebo controlled parallel group design 18 pts without depression 10 pts received real rTMS over Lt DLPFC 8 pts received placebo rTMS After 2 wks t/t status were informed to the pts with option of further 2 wks of rTMS to real rTMS receiver & 4 wks of rTMS to placebo receivers Improvement in 1 st 2 wks was not different among both groups 6 pts had clinically significant improvement Result - study did not support efficacy of high frequency DLPFC rTMS given over 2 wks in OCD

51. Study- Double blind randomized placebo controlled parallel group design To assess whether rTMS facilitates effect of anti-depressants in OCD In 33 t/t resistant OCD pts Study failed to find any difference in either group

52. Study- Double blind randomized placebo controlled parallel group design Aimed to enhance efficacy of rTMS by combining two forms of stimulation sequentially over Rt DLPFC & supplementary motor areas 21 t/t resistant pts with coexistent depression 2 pts in either group had a 25% reduction in YBOCS score 1 pt in active group had clinically significant reduction in MADRS Result- study did not find any clinically significant difference b/w two groups

53. Study- Open label study from India 42 Rt handed pts 10Hz rTMS, 110% RMT over Rt DLPFC Both active & placebo groups evinced significant improvement in obsession and compulsion However active rTMS was not superior to placebo Result- no significant effect of rTMS in t/t of OCD but modest effect on co-morbid depression

54. Limitations of above mentioned studies Very small no. of subjects Pt selection was not uniform Definition of t/t resistant was not clear No consistency in symptoms subtypes Criteria for response were not very consistent Technical parameters of rTMS as exact site of stimulation, side, method of site selection, strength and duration of sessions have no consensus Presence of co-morbid depression makes it difficult to dissociate improvement in YBOCS from that due to improvement in depression

55. With the information from current trials for rTMS in OCD- negligible evidence as none of the randomized controlled studies was able to find any difference b/w real and placebo group Both NICE and APA practice guideline for t/t of OCD conclude “currently rTMS cannot be recommended as a t/t option”

56. Research Need For larger double blind placebo controlled rTMS studies in co-morbidity free OCD pts with comparison across different stimulation sites For longer follow up periods to assess if the beneficial effects are enduring

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58. Thank you