Obsessive Compulsive
Disorder
and OC Spectrum
Disorders
J. Hancey, MD
Dept. of Psychiatry
Oregon Health Sciences University
The many faces of OCD
• Dermatologist: Chapped hands, eczema, Trichotillomania
• Oncologist/Infectious disease: Hypochondriasis (Cancer,
AIDS)
• Neurologist: OCD associated with Tourette’s or other
neurologic disorders
• Obstetrician: OCD during pregnancy or postpartum
• Pediatrician: Compulsive behavior, OCD secondary to
Sydenham’s chorea, difficulty in school
• Plastic surgeon: Body dysmorphic disorder
• Dentist: Gum lesions from excessive teeth bleeding
• Family practitioner: Report of family member washing or
checking excessively, comorbid affective or anxiety
disorders, all of the above.
Definitions of OCD
An anxiety disorder characterized by:
Obsessions
Recurrent and persistent ideas, impulses, thoughts,
images that are intrusive and sometimes senseless
Compulsions
Repetitive, seemingly purposeful behaviors performed in
response to an obsession (e.g., ritualistic or stereotypic
behavior)
Anxiety arises around resistance to obsessions
and/or compulsions
Anxiety may or may not be the primary feature of
OCD
Diagnostic Criteria for OCD
• Either obsessions or compulsions
• Recognized by patients as excessive or
unreasonable
• Obsessions or compulsions cause marked
distress, are time consuming, or
significantly interfere with functioning
DSM-IVtm 1994:417-423
Obsessive-Compulsive Spectrum
Disorders
Preoccupations with
bodily sensations or
appearance
Body Dysmorphic Disorder
Depersonalization
Anorexia nervosa
Hypochondriasis
OCD
Impulsive
disorders
Sexual compulsions
Trichotillomania
Pathological gambling
Kleptomania
Self-injurious behavior
Hollander et al, J Clin Psychiatry, 1966
Tourette’s syndrome
Sydenham’s chorea
Torticollis
Neurologic
Autism
disorders
ADHD
Epidemiology of OCD
• 6-month point prevalence: 1.6%
• Life-time prevalence: 2.5%
• An estimated 3.9 million Americans
had OCD in 1990
• 4th most common psychiatric
disorder
• Double that of panic disorder or
schizophrenia
Biological Differences of OCD
• Anatomy
• decreased caudate nucleus volume
• Biochemistry
• increased CSF 5-HIAA
• Physiology
• increased frontal and pre-orbital
glucose utilization
Precipitating Factors
• 25%--depression and/or anxiety
accompanied the initial symptoms
• 50% - 60%--stressors around the time
of onset of symptoms
--pregnancy
--childbirth
--sexual problems
--death in family
• Streptococcal pharyngitis
The Streptococcal Connection
• Increasing evidence for an
autoimmune etiology
• Group A beta hemolytic
streptococcus
• Antineuronal antibodies
• Genetic vulnerability
D8/17 positivity as a marker
PANDAS
•
•
•
•
•
•
Pediatric
Autoimmune
Neuropsychiatric
Disorders
Associated with
Streptococcal infections
Treatment
• Medications
• Cognitive Behavioral Therapy
COGNITIVE
THERAPY
Cognitive Therapy
•
•
•
•
Re-label
Re-attribute
Re-focus
Re-evaluate
Schwartz, J. Brain Lock
Pearl: Use a “mental garbage can”.
BEHAVIOR
THERAPY
Behavior Therapy
Effective behavior therapy involves
• Exposure: facing feared or avoided
object, thought, situation, or place,
preferably in vivo
• Response or ritual prevention: delaying
and diminishing anxiety-reducing
compulsions
SUD’S List: (Subjective Units
of Distress)
•
•
•
•
•
List compulsive behaviors
Assign SUD’s value to each (0-100)
Rank order from top to bottom
Begin at the bottom of the list
Best source: Baer, Lee. Getting Control.
Pearl: Break up complex rituals into various parts
Serotonin Reuptake Inhibitors
in the Treatment of
Obsessive Compulsive
Disorder
Fluoxetine vs Clomipramine
• 20 week crossover
• No difference between
Y~BOCS
• Delayed response to 2nd drug
• Relapse occurred during
washout
• <ADR with fluoxetine
ADR = adverse drug reaction
Pigott et al. Arch Gen Psychiatry, 1990;47:926-932.
Factors Affecting Serum Drug
Levels
•
•
•
•
Absorption
Protein binding
Metabolism
Elimination
Utilizing P450 Inhibition
1A2
CMI
2D6
Desmethyl CMI
inactive
The Role of Anxiolytics
When, What, and When to
Worry
• Initial stages of treatment, prn
• BZD’s - the long and short of it
• abuse, dependence and
addiction
Benzodiazepine Issues
• Abuse
• Physical dependence
• Addiction
Treatment Strategies
• SSRI beginning at low doses,
gradually increasing to
maximum doses
• minimum 10 week trial
• switch SSRIs
• augmentation
–
–
–
–
clonazepam
atypicals
opioid agonism/antagonism
acamprosate
• cognitive-behavioral therapy
• surgery
Gamma Knife