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Obsessive-Compulsive Disorder (OCD

Obsessive-Compulsive Disorder (OCD) is characterized by recurrent obsessions and/or compulsions that cause distress and interfere with daily life. Obsessions are intrusive thoughts or images, while compulsions are repetitive behaviors performed to reduce anxiety from obsessions. OCD has a lifetime prevalence of 2-3% and typically onset in early adulthood. Causes involve genetics, neurobiology, and learning processes. Treatment includes SSRIs, CBT, and ERP for severe cases. Prognosis depends on factors like age of onset, comorbidities, and treatment adherence.

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382 views22 pages

Obsessive-Compulsive Disorder (OCD

Obsessive-Compulsive Disorder (OCD) is characterized by recurrent obsessions and/or compulsions that cause distress and interfere with daily life. Obsessions are intrusive thoughts or images, while compulsions are repetitive behaviors performed to reduce anxiety from obsessions. OCD has a lifetime prevalence of 2-3% and typically onset in early adulthood. Causes involve genetics, neurobiology, and learning processes. Treatment includes SSRIs, CBT, and ERP for severe cases. Prognosis depends on factors like age of onset, comorbidities, and treatment adherence.

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Obsessive-Compulsive

Disorder (OCD)
Dr. Abdullah Alqahtani
Assistant Professor and Consultant Psychiatrist
Imam Abdulrahman Bin Faisal University
Objectives

To understand the concept of Obsessive Compulsive Disorder including :


• Definition,
• Symptomatology,
• Epidemiology,
• Etiology,
• Differential diagnosis, and
• Management including pharmacological, psychological, and surgical.
Introduction
• OCD is represented by a diverse group of symptoms that include intrusive thoughts, rituals,
preoccupations, and compulsions.

• These recurrent obsessions or compulsions cause severe distress to the person.

• The obsessions or compulsions are time-consuming and interfere significantly with the
person’s normal routine, occupational functioning, usual social activities, or relationships.

• A person with OCD may have an obsession, a compulsion, or both.


Introduction
• An obsession is a recurrent and intrusive thought, feeling, idea, or sensation.

• In contrast to an obsession, which is a mental event, a compulsion is a behavior. Specifically, a


compulsion is a conscious, standardized, recurrent behavior, such as counting, checking, or
avoiding.

• A patient with OCD realizes the irrationality of the obsession and experiences both the
obsession and the compulsion as ego-dystonic (i.e., unwanted behavior).

• Anxiety is increased when a person resists carrying out a compulsion.

• Although the compulsive act may be carried out in an attempt to reduce the anxiety associated
with the obsession, it does not always succeed in doing so.
Introduction

• OCD is Recurrent Obsessions, Compulsions leading to


- Distress,
- Time consumption, and
- Socio-Occupational dysfunction

• Obsessions: Recurrent and Intrusive Thoughts , Images or Impulses –which are


- Ego-dystonic, and
- Cause Anxiety or Distress
Introduction
• Compulsions: Repetitive, Driven BEHAVIOR (or mental acts) :
- In response to obsessions
- According to certain rules (rituals)
- Aimed at reducing anxiety
- Recognized as unreasonable, ego- dystonic

• Obsessions increase anxiety and Compulsions decrease it.

• Obsessions and Compulsions occur in:


- Normal
- OCD
- Other psychiatric disorder
Epidemiology
• Lifetime prevalence is 2-3% in the general population.

• 10% in OPD in psychiatric clinics.

• It is the 4th most common psychiatric diagnosis after phobias, substance-related disorders, and
MDD.

• Age of onset : mean= 20-22

• Delay in help seeking ( stigma, ignorance )

• Single > married


Comorbidity
• MDD (67% lifetime prevalence in OCD patients)
• Social Phobia (25%)
• Other Anxiety Disorders (GAD, Specific Phobia, Panic Disorder)
• Alcohol Use Disorders
• Eating Disorders
• Personality Disorders

• Tourette’s Disorder (5-7%)


• History of tics (20-30%)
Etiology

• Neurotransmitters:
- Dysregulation (decreased) serotonin is involved in the symptom formation of OCD.
- Less evidence exists for dysfunction in the noradrenergic system.

• NeuroImmunology:
- There is a positive link between streptococcal infection and OCD.
- Group A beta-hemolytic streptococcal infection can cause rheumatic fever.
- 10-30% of patients develop Sydenham’s chorea and show obsessive-compulsive symptoms
(anti-B.G. anti-bodies).
- Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections
(PANDAS)
Etiology
• Brain-Imaging Studies:
- Altered function in the neurocircuitry between orbitofrontal cortex, caudate, and thalamus.

- Positron emission tomography (PET) have shown increased activity (metabolism and blood
flow) in the frontal lobes, the basal ganglia (esp. the caudate), and the cingulum of patients
with OCD.

- Pharmacological and behavioral treatments reportedly reverse these abnormalities.

- Both CT and MRI studies have found bilaterally smaller caudates in patients with OCD.

- Both functional and structural brain-imaging study results are compatible with the observation
that neurological procedures involving the cingulum are sometimes effective in the treatment
of OCD.
Etiology
• Genetics:
- 35% of first-degree relatives have OCD or obsessive-compulsive features.
- Abnormal 5-hydroxytryptamine (5-HT) transporter gene.
- Significantly higher concordance rate for monozygotic twins than for dizygotic twins.

• Cognitive-Behavioral Factors:
- Cognitive Errors : Risk over-estimation, perfectionism, and control.
- Learning ( Conditioning ) : compulsions reinforced by reducing anxiety.

• Psycho-dynamic Factors:
- Isolation, un-doing , and reaction formation.
Clinical Picture
• Obsessions: Recurrent and persistent thoughts, impulses, or images:
- experienced as intrusive & inappropriate,
- cause anxiety or distress.
- Patient attempts to resist, ignore, or neutralize (with other thought or act),
- has insight and knows that it is his own (from inside).

• Forms of Obsessions:
- Thought,
- image,
- doubt,
- impulse, or
- rumination.
Clinical Picture

• Compulsions: Repetitive driven behaviors or mental acts:


- performed according to rigid specific rules (ritual), or in response to obsessions
- aim at reducing anxiety or distress or preventing a dreadful unrealistically related event.
- Patient has insight.

• Obsessions + Compulsions = 75 – 100 % of OCD cases


Obsessions alone = 25 %

• In Chronic Cases : distress, resistance and insight are LOST (delusional OCD).
Clinical Picture

Content (Themes) of Obsessions and Compulsions:

1- Contamination/Washing (or contamination/avoidance)


2- Doubt/Checking ( or doubt/repetition )
3- Sexual or Aggressive
4- Religious: ablution, praying, purity, blasphemous
5- Symmetry and Precision/Compulsion of slowness
6- Hoarding
Differential Diagnosis
1- Depression

2- Phobia & GAD.

3- SCZ.

4- Neuro.: tics , trauma , epilepsy , encephalitis

5- OCPD : OCD :
No O or C O&C
No distress Distress
No onset Onset disorder
No resistance Resistance
Course and Prognosis

• Onset: acute or gradual, usually after stressor.

• Delay: ignorance/stigma, up to several years.

• Course: Chronic, continuous or fluctuating.

• Functional disability:
- 20-30% of patients have significant improvement.
- 40-50% have moderate improvement.
- 20-40% remain ill or their symptoms worsen.
Course and Prognosis

• Poor Prognosis is indicated by:


- Yielding to compulsions (rather than resisting)
- Childhood onset
- Bizarre compulsions
- The need for hospitalization
- A coexisting major depressive disorder
- The presence of delusional beliefs or overvalued ideas
- The presence of a personality disorder (esp. schizotypal).
Course and Prognosis

• Good Prognosis is indicated by:


- Good social and occupational adjustment
- The presence of a precipitating event
- An episodic nature of the symptoms.

• The obsessional content does not seem to be related to prognosis.


Treatment
1- Pharmacotherapy: for obsessions.
- SSRI or Clomipramine (Anafranil )
- Augmentation with lithium, valproate, carbamazepine, or risperidone.

2- Psychotherapy:
- Educational,
- Supportive,
- Family
- CBT
- Behavioral Therapy: ERP.(exposure, and response prevention ): for compulsions.
Treatment
3- ECT (Electroconvulsive Therapy):
- For extreme cases that are treatment-resistant and chronically debilitating.
- Should be tried before surgery.

4- Psychosurgery:
- Cingulotomy
- Capsulotomy (Sub-caudate tractotomy)
OCD-Related Disorders
• Body dysmorphic disorder,
• Trichotillomania (hair-pulling disorder),
• Hoarding disorder, and
• Excoriation (skin-picking) disorder
References:
• Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/clinical Psychiatry, Eleventh
Edition.

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