Obsessive Compulsive Disorder

1. Epidemiology
   1. Lifetime Prevalence: 1.6 to 2.5%
   2. Onset: late adolescent or early adulthood
   3. Occurs equally in men and women
2. Risk factors: Childhood findings suggestive of OCD Development
   1. Separation anxiety
   2. Resistance to change or novelty
   3. Risk aversion
   4. Submissiveness
   5. Sensitivity
   6. Perfectionism
   7. Hyper-morality
   8. Ambivalence
   9. Excessive devotion to work
3. Pathophysiology
   1. Involvement of dorsolateral prefrontal cortex, basal ganglia, and thalamus
   2. Serotonin mediated
   3. Possible association with PANDA Syndromes
4. Symptoms
   1. Obsessions
      1. Intrusive distressing thoughts, impulses, or images
         1. Contamination (50%)
            1. Worry about infection from shaking hands
         2. Pathologic doubt (42%)
            1. Persistent worrying about an unlocked door, or oven left on
         3. Somatic (33%)
         4. Need for symmetry or Order (32%)
         5. Aggressive (31%)
            1. Intrusive images of hurting another person
         6. Sexual (24%)
            1. Intrusive pornographic images
         7. Religious
            1. Worry about unknowingly commiting a sin
      2. Obsessions are not related to real-life problems
      3. Attempts to ignore, suppress or neutralize Obsessions
      4. Recognition that Obsessions are product of own mind
   2. Compulsions
      1. Repetitive behaviors as a response to Obsessions
         1. Checking (61%)
         2. Washing (50%)
         3. Counting (36%)
         4. Need to ask or confess (34%)
         5. Symmetry and precision (28%)
         6. Hoarding trash or other items (18%)
         7. Praying
         8. Repeating words silently
      2. Compulsions are intended to reduce distress
         1. Not connected realistically to preventing Obsession
         2. Excessive measures
5. History: Sample Questions
   1. Do certain thoughts keep coming into your head?
      1. Is this despite your trying to keep the thoughts out?
      2. Do the thoughts make sense or do they seem absurd?
      3. What do you do to try to counteract these thoughts?
   2. Do you feel a need to do something over and over again?
      1. Is this despite your not wanting to do these things?
      2. Do these actions seem reasonable or excessive?
6. Signs
   1. Raw chapped hands (constant hand washing)
   2. Unproductive hours spent on homework
   3. Erasure holes in test papers and school work
   4. Repeatedly asking the same question
   5. Persistent fear of illness
   6. Persistent fear that someone else will experience harm
   7. Difficulty leaving the house
   8. Recurrent tardiness
   9. Significant increase in laundry
   10. Unusually long time to get ready for bed or dressing
   11. Hoarding useless objects
   12. Peculiar patterns of walking or sitting
7. Diagnosis
   1. Obsessions or Compulsions as described above
   2. Insight that Obsessions or compulsions are excessive
   3. Impaired function
      1. Marked distress
      2. Time consuming (more than an hour per day)
      3. Interfere with patient's normal routine
      4. Interfere with occupation, education, relationships
   4. Not limited to an Axis I Diagnosis (examples follow)
      1. Eating disorder and preoccupation with food
      2. Substance Abuse and preoccupation with drugs
   5. Obsessions or Compulsions not due to secondary cause
      1. Not due to Substance Abuse
      2. Not due to underlying medical condition
8. Tools: Self-Assessment
   1. Diagnosis
      1. Obsessive-Compulsive Inventory-Revised
      2. Florida Obsessive-Compulsive Inventory
   2. Monitoring for severity
      1. Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
9. Differential Diagnosis
   1. Consider PANDAS in children with abrupt onset of OCD symptoms
   2. Major Depression
   3. Generalized Anxiety Disorder
   4. Panic Disorder
   5. Hypochondriasis
   6. Tourette's Syndrome
   7. Schizophrenia
10. Associated Conditions
    1. OCD Spectrum Disorders
       1. Body Dysmorphic Disorder
       2. Trichotillomania
       3. Hypochondriasis
       4. Eating disorders
    2. Comorbid axis I disorders (common)
       1. Major Depression (>66% lifetime comorbid Prevalence)
       2. Suicidality (Suicidal Ideation >50%)
       3. Panic Disorder
       4. Social Phobia
       5. Substance Abuse
11. Types: Subtypes of Obsessive Compulsive Disorder
    1. Early-Onset
       1. Onset before Puberty and hereditary
       2. Severe, frequent compulsions
       3. Often refractory to first-line treatments
    2. Hoarding
       1. Lower insight into own condition
       2. Symptoms are severe and often refractory to treatment
    3. Just-Right
       1. Perfectionists need to repeat actions until feels right
    4. Primary Obsessional (25%)
       1. Often obsess about sex, Violence and religion without compulsions
    5. Scrupulosity
       1. Religious or moral Obsessions and compulsions focused around whether they have committed sin
    6. Tic-Related
       1. Associated with early onset OCD, OCD-Spectrum Disorders and Tourette Syndrome
       2. May require combination therapy with SSRI and atypical Antipsychotics
    7. References
       1. Fenske (2009) Am Fam Physician 80(3): 239-45
       2. McKay (2004) Clin Psychol Rev 24(3): 283-313
12. Management: Medications
    1. General
       1. Continue therapy if effective for 1-2 years
    2. First-Line: Selective Serotonin Reuptake Inhibitors (SSRI)
       1. Agents FDA approved for OCD
          1. Fluoxetine (Prozac) 40 to 80 mg per day
          2. Fluvoxamine (Luvox) 200 to 300 mg per day
          3. Paroxetine (Paxil) 20 to 60 mg per day
          4. Sertraline (Zoloft) 50 to 200 mg per day
       2. Other agents found to be effective for OCD
          1. Citalopram (Celexa) 40 to 60 mg orally daily
          2. Escitalopram (Lexapro) 20 to 40 mg orally daily
    3. Second-Line Agents
       1. Venlafaxine (Effexor) 75 to 225 mg orally daily
       2. Tricyclic Antidepressants
          1. Most effective agents, but rarely used now due to intentional overdose safety concerns
          2. Clomipramine (Anafranil) 150 to 250 mg/day
    4. Third-Line Agents: Atypical Antipsychotics (typically in combination with a SSRI or SNRI)
       1. Risperidone (Risperdal)
       2. Quetiapine (Seroquel)
       3. Olanzapine (Zyprexa)
13. Management: Cognitive Behavioral Therapy (80-90% effective)
    1. Exposure and Desensitization over 13-20 week period (1-2 hours per session)
       1. Patients taught to confront fearful situations that lead to Obsessions, compulsions
          1. Examples: Touch objects in public bathroom
       2. Increasingly expose patient to avoided stimulus
    2. Response prevention
       1. Prevented from performing associated rituals
    3. Thought stopping
14. Precautions
    1. Diagnostic delay is common, averaging 11 years between onset and formal diagnosis
       1. Pinto (2006) J Clin Psychiatry 67(5): 703-11
15. Resources
    1. Obsessive-Compulsive Foundation, Inc
       1. Address: 90 Depot St. PO Box 70, Milford, CT 06460
       2. Phone: (203) 878-5669
16. References
    1. APA (1994) DSM IV, APA, p. 417-23
    2. Black (1997) Resident Staff Physician 43(3):64-76
    3. Bagheri (1999) Am Fam Physician 59(8):2263-72
    4. Eddy (1998) Am Fam Physician 57(7):1623-8
    5. Rasmussen (1992) Psychiatr Clin North Am, 15:743-58
    6. Fenske (2009) Am Fam Physician 80(3): 239-45