Obsessions
• repetitive and constants thoughts, images, or
impulses that cause anxiety or distress
• thoughts, images, or impulses not about real-life
problems
• Try to ignore or counter act thoughts, images, or
impulses
• thoughts, images, or impulses “recognized as a
product of one’s own mind and not imposed from
without”
Compulsions
• Repetitive behaviors or mental acts
person does in reaction to obsessions
• behaviors or mental acts done to avoid
or decrease distress
• behaviors or mental acts are clearly
excessive or not realistic
• ICD-10(F.42)
• DSM IV TR (300.3)
Obsessive-Compulsive Disorder
• Obsessions- repetitive unwanted ideas that
the person recognizes are irrational
• Compulsions- repetitive, often ritualized
behavior whose behavior serves to
diminish anxiety caused by obsessions
EPIDEMIOLOGY
• Affects almost 3% of world’s
population
• In India life time prevalence of OCD
is 2-3%
• common in persons from upper social
class and with high intelligence
Demographic characteristics
• Gender Distribution
Women appear to develop OCD slightly
more frequently than men (1.5:1)
Males develop OCD at a younger age than do
females
• Marital status
% of patients who had never married was
significantly higher rate
In India OCD is more common in unmarried
males. (other countries are not reported)
Course and nature of history
• Age at onset
Usually in childhood or early adult life
The onset for males occurred earlier than for
females (19.5±9.2 yrs Vs 22.0 ±9.8yrs)
• Course of illness
It is continuous and chronic in which patients
rarely symptom free at follow up
• A long term follow up studies shows that
about 25% remained unimproved overtime,
50% had moderate to marked improvement
while 25% had recovered completely.
I.BIOLOGICAL THEORIES:
• Neurotransmitters
Brain Serotonin(5HT) function may
contribute to anxiety symptoms
• Noradrenalin
Higher plasma free 3- methoxy 4-hydroxy
phenyl glycol and plasma nor-epineherine
levels
• Genetics
Family history:- OCD is found in 5-7% of
first degree relatives of patients with OCD
Strongest evidence comes from twin
studies
Electro physiological studies
EEG abnormalities can lead to OCD
( temporal lobe spikes and increased theta
waves in sleep EEG)
Neuropsychological studies
• Frontal deficit, although non dominant –
parietal deficits also seen in patients with
OCD
Brain imaging
Cranial CT and MRI scans
Non specific abnormalities are found in
patients with OCD
PET scans indicate differences in brain activity of OCD
patients versus normal
II. Behavioral theories
Learning theory suggest that obsession
ritual are the equivalent of avoidance
responses.
 Ritual acts produce relief and thus through
negative reinforcement increase the
possibility of repetition of the phenomena
Psychodynamic theory
• Freud suggested that obsessional
symptoms results from repressed impulses
of an aggressive or sexual nature.
• Obsession symptom occur as a result of
regression to the anal stage of development
• It is consistent with the obsessional
patient’s frequent concerns over excretory
functions and dirt
Early Disturbed development in
Child
Normally disguised by
Anal sadistic phase
hood
Fixation in
development
Anxiety related
to oedipal
conflicts
At present
Reaction
formation
Regression
In presence of fixation
at anal sadistic phase
Obsessional
Personality
traits
Reinforcement of
anal/aggressive impulses
New defenses
Needed as reaction
formation is not enough
Isolation affect
Obsessive thoughts
undoing
compulsive acts
Displacement
phobias
Clinical features
•
Four clinical syndromes
1.
2.
3.
4.
Washers
Checkers
Pure obsessions
primary obsessive slowness
washers
• Obsession is with contamination with dirt,
germs, body excretions etc.
• Compulsion is washing of hands or the
whole body repeatedly many times a day
( clothes, bath room, door knobs, personal
articles)
Checkers
• Person has multiple doubts
( door has not been locked, kitchen gas has
been left open, counting of money was not
exact)
• Compulsion of course is checking
repeatedly to remove the doubts.
Pure obsessions
• Repetitive intrusive thoughts, impulses or
images which are not associated with
compulsive acts. The content is usually
sexual or aggressive in nature.
• A variant is obsessive rumination, the
person ruminates in his mind about pros
and cons of the thoughts concerned,
repetitively
Primary obsessive slowness
• Severe obsessive ideas or extensive
compulsive rituals leads to marked
slowness in daily activities.
Assessment of OCD
Maudsley obsessional compulsive
inventory (MOCI)
30 items –true or false questionnaire
Yale Brown obsessive compulsive scale
(Y-BOCS)
Rating on time spent, interference, distress,
resistance and control for obsessions and
compulsions
Diagnosis-ICD-10(F.42)
• Either obsessions or compulsions (or both), present on
most days for a period of at least two weeks.
• The obsessional symptoms should have the following
characteristics:
a. They must be recognized as the individuals own thoughts
and impulses
b. There must be at least one thought or act that is still
resisted un successfully, even though others may be
present which he sufferer no longer resists
c. the thought of carrying out the act must not in itself be
pleasurable
d. the thoughts, images or impulses must be unpleasantly
repetitive.
Differential diagnosis
Generalized anxiety disorder
Panic disorder
Phobic disorder
Depressive disorder
Schizophrenia
Organic cerebral disorders
Types
• F42.0 Predominantly obsessional thoughts
and ruminations
• F42.1 Predominantly compulsive acts
• F42.2 Mixed obsessional thoughts and acts
• F42.8 Other obsessive-compulsive
disorders
• F42.9 Obsessive-compulsive disorder,
unspecified
Pharmacological management
• Benzodiazepines :-eg-alprazolam, clonazepam.
• Antidepressants:SSRI:eg- clomipramine 75-300mg/day
Fluoxetine 20-80mg/day
Sertraline
Fluoxamine
Cont….
• Antipsychotics:Eg:- haloperidol, risperidone, olanzapine
• Buspirone (anxiolytic)
Psychotherapy
• Psychoanalytic therapy (patients)
• Supportive psychotherapy (patients and
family)
Behavioral therapy
• Techniques
Thought stopping
Response prevention
Systematic desensitization
modeling
Electro convulsive therapy
• Indications:Severe depression with OCD
Risk of suicide
Poor response to other mode of treatment
• ECT is not the treatment of first choice in
OCD
Psychosurgery
• Perform incase of not responding to other
mode of treatment
• benefit is the marked reduction in
associated distress and severe anxiety
• Procedures
 Stereotactic limbic leucotomy
Stereotactic subcaodate tractotomy
Reference
• Mary c Townsend.psychiatric mental
health nursing,3rd edition
• Oxford text of psychiatry. 2nd edition
• Judith Haber, Anila S . Comprehensive
psychiatric nursing. 5th edition
• ICD- 10 classification of mental and
behavioural disorder
• www.mayoclinic.com/.../obsessivecompulsive-disorder/DS00189
• www.webmd.com/anxiety.../obsessivecompulsive-disorder