Obsessive Compulsive Disorder and OC Spectrum Disorders

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Obsessive Compulsive Disorder and OC Spectrum
Disorders

• J. Hancey, MD
• Dept. of Psychiatry
• Oregon Health Sciences University

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The many faces of OCD

• Dermatologist Chapped hands, eczema,
  Trichotillomania
• Oncologist/Infectious disease Hypochondriasis
  (Cancer, AIDS)
• Neurologist OCD associated with Tourettes or
  other neurologic disorders
• Obstetrician OCD during pregnancy or postpartum
• Pediatrician Compulsive behavior, OCD secondary
  to Sydenhams 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.

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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

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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 1994417-423

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Obsessive-Compulsive Spectrum Disorders
Preoccupations with bodily sensations or
appearance
Body Dysmorphic Disorder Depersonalization
Anorexia nervosa Hypochondriasis
OCD
Tourettes syndrome Sydenhams chorea Torticollis
Autism ADHD
Sexual compulsions Trichotillomania Pathological
gambling Kleptomania
Self-injurious behavior
Neurologic disorders
Impulsive disorders
Hollander et al, J Clin Psychiatry, 1966
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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

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Biological Differences of OCD

• Anatomy
• decreased caudate nucleus volume
• Biochemistry
• increased CSF 5-HIAA
• Physiology
• increased frontal and pre-orbital glucose
  utilization

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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

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The Streptococcal Connection

• Increasing evidence for an autoimmune etiology
• Group A beta hemolytic streptococcus
• Antineuronal antibodies
• Genetic vulnerability
• D8/17 positivity as a marker

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PANDAS

• Pediatric
• Autoimmune
• Neuropsychiatric
• Disorders
• Associated with
• Streptococcal infections

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Treatment

• Medications
• Cognitive Behavioral Therapy

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COGNITIVE THERAPY

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Cognitive Therapy

• Re-label
• Re-attribute
• Re-focus
• Re-evaluate

Schwartz, J. Brain Lock
Pearl Use a mental garbage can.
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BEHAVIORTHERAPY
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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

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SUDS List (Subjective Units of Distress)

• List compulsive behaviors
• Assign SUDs 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
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Serotonin Reuptake Inhibitors in the Treatment
ofObsessive Compulsive Disorder
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Fluoxetine vs Clomipramine

• 20 week crossover
• No difference between YBOCS
• Delayed response to 2nd drug
• Relapse occurred during washout
• ltADR with fluoxetine
• ADR adverse drug reaction
• Pigott et al. Arch Gen Psychiatry,
  199047926-932.

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Factors Affecting Serum Drug Levels

• Absorption
• Protein binding
• Metabolism
• Elimination

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Utilizing P450 Inhibition

• 1A2

2D6
CMI
Desmethyl CMI
inactive
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The Role of AnxiolyticsWhen, What, and When to
Worry

• Initial stages of treatment, prn
• BZDs - the long and short of it
• abuse, dependence and addiction

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Benzodiazepine Issues

• Abuse
• Physical dependence
• Addiction

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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

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Gamma Knife
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