OBSESSIVE-COMPULSIVE AND
RELATED DISORDERS
Dan J. Stein
University of Cape Town
OCD
• OBSESSIONS:
Recurrent and persistent thoughts
• COMPULSIONS:
Repetitive behaviors or mental
acts
• Distress/Dysfunction
OCD
• Contamination concerns  hand-washing
• Possible harm concerns  checking
• Symmetry concerns  symmetry behaviours
NOT OCD
• Obsessive-compulsive personality disorder
• Pathological or problem gambling, compulsive
sexual disorder, problematic internet use
• Hoarding concerns  hoarding behaviors
• Being a meticulous professional or student
OCD
• 4th most common psychiatric disorder in
one USA study
• 10th most disabling of all medical
disorders in WHO BoD study
• Subclinical washing, checking,
symmetry, symptoms are common
(Ruscio et al, 2008)
OCD Spectrum
• Range of disorders with intrusive
thoughts and repetitive behaviors
•
•
•
•
•
•
- Tourette’s syndrome
- Body Dysmorphic Disorder
- Hypochondriasis
- Hoarding Disorder
- Trichotillomania
- Skin Picking Disorder
Psychodynamic Approach
Character  Neurosis  Psychosis
• Similarity in central unconscious conflicts
• Differences in certain psychodynamics
Cognitive-Behavioral Approach
OCDS  OCD  OCDS
• Similarity in cognitive-behavioral function
• Differences in particular contents
Psychobiological Approach
OCDS  OCD  OCDS
• Similarity in central psychobiol mechanisms
• Differences in certain psychobiol processes
OCD Pre/Post SSRI
Baseline
After
SSRI
So: Range of Presentations
•
•
•
•
•
•
Dermatologist:
Neurologist:
Plastic Surgeon:
Internist:
Pediatrician:
Obstetrician:
Dermatitis, Loss of Hair
Tics
Somatic concerns
Hypochondriacal concerns
Early onset
Pregnancy
But: Overlapping Neurobiology
• OCD  OCD+Tics  Tics
• 5-HT genes 
DA genes??
• Good evidence that OCD and TS have
a genetic relationship
And: Overlapping Pharmacology
SRIs more effective than NRIs:
•
•
•
•
•
OCD
Body Dysmorphic Disorder, Hypochondriasis?
Hoarding Disorder?
Trichotillomania, Skin Picking Disorder?
O-C symptoms in Tourette’s, in autism, in
intellectual disability
Animal Stereotypy
Pre-SSRI
Post-SSRI
Animal Stereotypy
Stereotypy
Animal Stereotypy
80
70
60
50
40
30
20
10
0
Placebo
Fluoxetine
Weeks (0-8)
“From Bench to Bedside”
(Harvey et al, 2008)
Somatic Preoccupations
Somatic Preoccupations
OCD  BDD/ORS/HYP  anorexia
(with or without insight)
• BDD is in DSM-5 OCRD section
• ORS likely in ICD-11 OCRD section
• HYP likely in ICD-11 OCRD section
Somatic Preoccupations
OCD  BDD/ORS/HYP  anorexia
(with or without insight)
• First line Rx of BDD/ORS/HYP is
SSRI / CBT
Hoarding Behaviours
Hoarding Behaviours
(Saxena et al,
2004)
Hoarding Behaviours
OCD  Hoarding  OCPD hoarding
• Hoarding Disorder is in DSM-5 OCRD
• Criteria do not overlap with Collecting!
• Neuroanatomy slightly different from OCD
Hoarding Behaviours
OCD  Hoarding  OCPD hoarding
• First line Rx of Hoarding Disorder is
SSRI / CBT
Stereotypies/Grooming
“From Bench to Bedside”
Stereotypies/Grooming
OCD  TTM/SPD  SMD/SIB
• TTM/SPD are in DSM-5 OCRD
• Partly due to consumer advocacy!
Stereotypies/Grooming
OCD  TTM/SPD  SMD/SIB
• First line Rx of TTM/SPD is CBT
• Growing interest in N-acetylcysteine
Tics/Involuntary Movements
Tics/Involuntary Movements
OCD/soft signs  OCD/tics TS
• OCD has a tic specifier in DSM-5
• TS likely in ICD-11 OCDR section
• Some evidence of overlapping
neuroimmunology
PANDAS
“From Bench to Bedside”
“From Bench to Bedside”
(Harvey et al, 2008)
Tics/Involuntary Movements
OCD/soft signs  OCD/tics TS
• Rx options in Tourette’s Disorder include
DA blockers / CBT
Treatment-Resistant OCD
• 27 short-term trials of Rx-resistant anxiety
• 19 investigated augmentation in OCD
• Similar design features eg low doses of
antipsychotic agents in SRI non-responders
• Overall symptom severity reduced to a
larger extent with these agents
(Ipser et al, 2006)
OCD Treatment Principles
• Useful to screen for intrusive thoughts
and repetitive behaviours
• Patients with one OCRD may well
have another, or MDD / etc
OCD Treatment Principles
• Range of standardized OCS symptom
severity measures available eg YBOCS
• Range of accurate information available
on internet eg OCF, TLC
OCD Treatment Principles
• Exposure and response prevention is
a highly effective form of Rx
• Many resources available eg OCF,
www.stoppulling.com
• Important to involve partners and/or
family
OCD Treatment Principles
• SSRIs are effective for OCD and for
several OCRD
• Higher dose and longer duration than
in MDD
• Consider referral after 2 different 12
week trials of SSRIs fail
Psychobiology:
Pharmacotherapy
0
PBO
PAR40
ESC10
ESC20
Estimate
-5
**
**
-10
*
*
*
**
*
****
**
**
*
**
-15
0
2
4
6
8
10
12
14
16
18
20
22
24
Week
* p<0.05 vs PBO, ** p<0.01 vs PBO
(Stein et al, 2007)
Treatment Resources
• MRC Unit Anxiety Disorders (cl2@sun.ac.za)
• GSH OCD Evaluations (dan.stein@uct.ac.za)
• Internet:
– SADAG Support Groups
– Obsessive-Compulsive Foundation (OCF)
– Trichotillomania Learning Centre (TLC)
CONCLUSION
• OCRD are seen universally (and indeed DSM5 field surveys were from RSA)
• The psychobiology and treatment of OCD is
increasingly understood
CONCLUSION
• Provides the basis for the DSM-5 / ICD-11
construct of OC and Related Disorders
• Aims to help recognize and Rx some key
prevalent, overlooked, disabling conditions
CONCLUSION
• Initial Rx of these disorders should be
initiated in primary care
• Referral resources are available in more
refractory cases