Obsessive Compulsive Disorder

(OCD)

Dr. Bob Carey Regional Support Associates

As Good as It Gets

Monk

What is OCD?

Disorder causing worries, doubts, and superstitious beliefs during everyday life. Described by some as mental hiccups that wont go away.

Obsessions? Compulsions?

Obsessions repetitive and unwelcome thoughts, images, or impulses that are difficult to dismiss or control. Compulsions repetitive behavioral responses can be resisted only with great difficulty. Recent studies have found lifetime prevalence of OCD in North America to be about 2.5/100 people.

Obsessions

Thoughts, images, or impulses that repetitively occur to become out of ones own control. Person suffering from these obsessions finds them intrusive and disturbing recognizes they dont make sense.

Obsessions - continued

Obsessions often accompanied by uncomfortable feelings such as fear, disgust, or doubt. For example, people with OCD may worry excessively about dirt and germs, and obsessed with the idea that they are contaminated or may contaminate others

Compulsions

These are acts that are continually performed to provide relief from discomfort caused by obsessions. OCD compulsions do not give the person pleasure (unlike drinking, gambling, etc.). For example, a person may repeatedly check to see if their stove was left on in fear of burning the house down.

Most people with OCD have multiple OCD symptoms

Multiple Compulsions

Common Symptoms
Common Obsessions
- Contamination fears of germs, dirt, etc.

Common Compulsions
- Washing.

- Imagining having harmed self or others.

- Imagining losing control of aggressive urges. - Intrusive sexual thoughts or urges. - Excessive religious or moral doubt. - Forbidden thoughts.
-

- Repeating.
- Checking. - Touching. - Counting. - Ordering/Arranging. - Hoarding or saving. - Praying.

A need to have things just so.

- A need to tell, ask, and confess.

OCD time spent thinking about the act and performing the act

Ordering Compulsion

Most Common Symptoms

Sets of common obsessions and compulsions are observed in developmentally disabled individuals with OCD. Typically, these sets are described best as just so behaviors, in which certain things have to be arranged or performed in a particular way to relieve the anxiety. The most clinically useful and detailed symptoms checklist is included in the YaleBrown Obsessive-Compulsive Scale.

OCD and Developmental Disability

may not to be able to identify obsessions may not recognize that obsessions dont make sense diagnosis often based on compulsions misdiagnosis is common both inaccurate diagnosis of OCD or misdiagnosis of another disorder.

Common Themes

The most common theme of obsessions are contamination themes, and the related compulsive behavior is washing, usually compulsive handwashing. Along with contamination themes, problems with aggressive obsessions, sexual obsessions, the need for symmetry and order, obsessions about harm to oneself or others, and the need to confess exist. These excessive thoughts result in the common compulsive behaviors of washing, repeating, checking, touching, counting, arranging, hoarding, or praying.

Misdiagnosis is Common

Because the behaviors observed in persons with OCD often are stereotypical and repetitive, 2 other disorders, both in the developmental disability spectrum, commonly are confused with OCD. First, children with mild autism or Asperger disorder also may have repetitive thoughts and specific stereotypic compulsive behaviors. While disorders in the autistic spectrum are considered to be pervasive developmental disorders (PPD) and quite different than OCD, at times the differential diagnosis between the 2 sets of disorders is somewhat difficult to make.

How to Tell the Difference

Remember - Social difficulties and communication problems are key intrinsic features of Asperger disorder on the PDD spectrum.

Co-Morbid Disorders Differential Diagnosis

Phobias Hypochondriasis Impulse Control Disorder Tourettes Syndrome Obsessive Compulsive Personality

Panic Disorder Generalized Anxiety Disorder

Major Depression Delusional Disorder

Diagnostic Issues in DD

Difficult to distinguish with personality traits in persons with DH that engage in repetitive questions (repetitive speech, echolalia) that can occur in anxious individuals with limited verbal skills or in autistic spectrum disorders. Compulsive behaviours are common in adults with intellectual disability stereotyped behaviour and movement disorders from underlying brain damage.

When does OCD begin?

Begin anywhere from preschool age to adulthood (40 years). Obsessive-compulsive behavior affects both males and females equally but is more common among adolescent boys than adolescent girls. The mean age of onset is about 20 years (2,10), but cases have been reported in children as young as 2 years (1012). On average, people with OCD see 3-4 doctors and spend over 9 years seeking treatment before they receive a correct diagnosis. OCD tends to go under-diagnosed and under-treated because people with the illness often act secretive about their symptoms.

Epidemiology of OCD

The majority of patients with obsessive-compulsive disorder have both obsessions and compulsions, some have only one or the other. Most patients realize the irrational nature of their thoughts and rituals but feel helpless and hopeless about controlling them. In one epidemiologic survey, 18 children were found to have OCD, and only 4 were receiving any professional mental health care. Not one of these 4 was diagnosed properly.

Gender & Culture

Boys are more likely to have a prepubertal onset and a family member with OCD or Tourette syndrome. Girls are more likely to have onset of OCD during adolescence. OCD is more common in whites than African American children in clinical samples. However, epidemiologic data suggest no differences in prevalence as a function of ethnic group or geographic region.

Prevalence of OCD

The World Health Organization lists obsessivecompulsive disorder as one of the five major causes of disability throughout the world. It is considered the fourth most common psychiatric condition, ranking after phobias, substance abuse disorders, and major depressive mood disorder.

Prevalence: Underestimated

Prevalence of OCD is underestimated why? 60% of all persons with a diagnosable anxiety disorder never see a mental health professional they may turn to their family physician, religious leader or another family member for help.

Prevalence with Intellectual Disability

In the general population, the prevalence is estimated to be around 1% In populations with intellectual disability, the prevalence has been estimated to be between 1 and 3.5%

What Causes OCD?

The probable biologic explanations of obsessivecompulsive disorder include heredity, brain lesions, abnormal brain glucose metabolism, and serotonergic dysfunction. No specific gene associated with OCD however, when a parent has OCD there is an increased risk that the child will also develop the illness. Problems in the front part of brain (orbital cortex) and deeper structures (basal ganglia).

Brain Differences persons with OCD use different brain circuitry in performing a cognitive task than people without the disorder (Rauch et al. J. of Neuropsychiatry, 1997)

Genetic Link?

If one twin has OCD, the other twin is more likely to have OCD if the children are identical twins rather than fraternal twin pairs. OCD is increased among first-degree relatives of children with OCD, particularly among fathers (Lenane et al., 1990). It does not appear that the child is simply imitating the relatives behavior, because children who develop OCD tend to have symptoms different from those of relatives with the disease (Leonard et al., 1997).

Role of Serotonin

Studies showing that serotonin plays a role in the pathophysiology of obsessive-compulsive disorder have led to new and highly effective treatments

Infection Causes?

Recent research suggests that some children with OCD develop the condition after experiencing one type of streptococcal infection (Swedo et al., 1995). This condition is referred to by the acronym PANDAS, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Its hallmark is a sudden and abrupt exacerbation of OCD symptoms after a strep infection. The cause of this form of OCD appears to be antibodies directed against the infection mistakenly attacking a region of the brain and setting off an inflammatory reaction.

OCD Cause: Summary

Although a definitive cause of obsessivecompulsive disorder has not yet been found, it is considered the product of interactions between biologic predisposition and various developmental and psychosocial influences

OCD Assessment

For adults with intellectual disability: Compulsive Behavior Checklist (Gedye, 1996) This list uses 25 types of compulsions done by adults with developmental disabilities grouped into 5 categories ordering, completeness, cleaning, checking/touching, deviant grooming. Ratings are done by caregiver who has familiarity with person.

OCD Assessment

Also we can use the Obsessive Speech Checklist designed for use only with developmentally disabled people who talk in sentences and use meaningful speech This is used to help determine if they meet the criteria for OCD

Treatment

During last 20 years, two effective methods for treating OCD have been developed:
Cognitive-Behavioural Psychotherapy (CBT) Medication with a serotonin reuptake inhibitor (SRI)

Stages of Treatment

Acute Treatment Phase: Treatment is aimed at ending the current episode of OCD. Maintenance Treatment: Treatment is aimed at preventing future episodes of OCD.

Components of Treatment

Education: Educate family and patients on how to manage OCD and prevent complications. Psychotherapy: Cognitive-Behavioural Therapy (CBT) is the key element of treatment for most patients with OCD. Medication: Medication with a serotonin reuptake inhibitor is helpful for many OCD patients.

Treatment Considerations

Use of both medication and psychotherapy results in a better outcome than use of either alone. Many patients with obsessive-compulsive disorder are very secretive about their illness. Therefore, a detailed review of symptoms may be necessary. Many patients have somatic complaints (eg, fatigue, pain, hypochondriacal symptoms, excessive worrying, chronic sadness). Thus, a comprehensive medical evaluation is essential to rule out any preexisting medical and psychiatric condition.

More Treatment Considerations

The impact of obsessive-compulsive disorder on interpersonal relationships, employment, marriage, and academic performance needs to be evaluated early in the diagnostic process. Coexisting psychiatric conditions (eg, major depression, panic disorder, phobias, eating disorders) should be treated along with obsessive-compulsive disorder. Similarly, obsessive-compulsive patients with ongoing alcohol or drug abuse problems should be treated for these before medication is considered. Although obsessive symptoms can be reduced with medications, the interpersonal relationships, social skills, work habits, and ability to resist compulsions require a comprehensive treatment plan that involves several aspects of each patient's life.

Cognitive Behavioural Psychotherapy (CBT)

Exposure and response intervention. Exposure person remains in contact with something they usually fear until their anxiety is diminished. Response intervention persons rituals or avoidance behaviours are blocked (those afraid of germs are not only exposed to germs but refrained from ritualized washing). Exposure is usually more helpful in decreasing anxiety and obsessions, while response intervention is better at decreasing compulsive behaviours.

CBT (Contd)

Patients who complete CBT report a 50-80% reduction in OCD symptoms after 11-20 sessions. Using CBT on a weekly basis, can take 2 months or longer to show full effects. Practiced in the therapists office, and do daily E/RP homework. When the OCD is very severe, it is sometimes better to practice CBT in a hospital setting.

Treatment Effectiveness

Behavioural techniques are most effective for certain types of OCD symptoms particularly cleaning or checking rituals. Best approaches are: DRO in combination with in vivo exposure; Relaxation Training; Stimulus Control techniques.

Medications: First-line drug treatment

In a primary care setting with appropriate psychiatric consultation, pharmacotherapy for obsessive-compulsive disorder and comorbid psychiatric conditions can be quite successful. Between 50% and 70% of patients respond well to medication. The tricyclic antidepressant clomipramine hydrochloride (Anafranil) and various selective serotonin reuptake inhibitors (SSRIs) have been approved by the US Food and Drug Administration (FDA) for treatment of obsessive-compulsive disorder. The approved SSRIs include fluvoxamine maleate (Luvox), paroxetine hydrochloride (Paxil), sertraline hydrochloride (Zoloft), and fluoxetine hydrochloride (Prozac).

Medication Efficacy Studies

Double Blind studies have shown the effectiveness of: - Clomipramine (may be the best but has the most adverse side effects) - Fluvoxamine - Fluoxetine - Sertraline They inhibit the reuptake of serotonin into synaptic nerve terminals

Side Effects to Watch for

Teratogenetic concerns: avoid all medications during pregnancy unless symptoms are disabling . All SSRIs are excreted in breast milk and therefore should not be used by nursing mothers. Hepatic disease and hepatic metabolism: SSRIs should be used cautiously in patients with chronic hepatic diseases. Clinical monitoring and dose reductions are recommended to prevent drug interactions and undesirable side effects. Sexual dysfunction: Although most side effects associated with SSRIs are well tolerated over time, sexual dysfunction is perhaps the most troubling adverse effect and can lead to discontinuation of or noncompliance with drug therapy. Cessation of therapy: Abrupt discontinuation of SSRIs can lead to development of the "interruption-discontinuation syndrome." This is manifested by emergence of adverse effects and worsening of obsessivecompulsive symptoms. Therefore, gradual tapering of doses or shifting among various SSRIs is recommended (17).

Adjunctive drug therapy

Buspirone hydrochloride (BuSpar), a specific nonbenzodiazepine anxiolytic medication, has been shown to benefit some obsessivecompulsive patients with comorbid anxiety. Mood stabilizers (eg, lithium, carbamazepine, valproic acid [Depakene, Depakote]) can be used to augment the efficacy of SSRIs or to treat obsessive-compulsive patients with comorbid bipolar disorder .

Med. Treatment Issues

Clomipramine and SSRIs as anti-compulsive agents have the potential to precipitate hypomania and mania Risperidone is useful as an acute hypomanic agent, has mood stabilizing properties.

When insight is poor

Motivation is necessary for CBT to be effective OCD behaviour is of itself reinforcing When insight is poor, behavioural techniques may help If you block one compulsion, usually another is established

Behavioural Techniques

Behavioural techniques are most effective for certain types of OCD symptoms particularly cleaning or checking rituals. Best approaches are: Differential Reinforcement in combination with Relaxation Training and Stimulus Control techniques.

Differential Reinforcement

Very effective and efficient but difficult to do on a consistent basis Reinforce behaviours that are appropriate Ignore behaviours that are not appropriate Redirect

Relaxation Techniques

Identify anxiety behaviours Relaxation Deep breathing, muscle relaxation Guided Imagery Provide concrete visual cues Quiet place

Stimulus Control

Set up person for success Identify triggers /stimulus

Instigating conditions Vulnerability conditions Maintaining (reinforcing) conditions

Reduce the internal triggers - medication Modify environment Teach coping skills

Is this the hill you want to die on?

Restricting behaviour will escalate behaviour Compromise

Allow behaviour within defined limits E.g., defined space for hoarding

Best Treatment Approach

Multi-Modal that considers the Bio-PsychoSocial aspects of the person: OCD may improve with habilitative changes, person centred planning, specific behavioural intervention plans and appropriate medication treatment and ongoing monitoring of effectiveness.

Difficulties in Producing Change

Case History

Story of Alaa Severe OCD

Alaa

Diagnostic uncertainty English is not first language; possible High Functioning Autism or Aspergers syndrome

Ritualistic Behaviours

Will perform ritualistic behaviours all day long cleaning, repetitive questions, routine and ordering Will become agitated during performance of rituals can become very aggressive at these times

Case: Alaa

Severe Aggression led to placement in Institutional setting where he was given 3:1 staffing ratio (Alaa & 3 staff) He was not allowed out

Alaa: environment

He was kept in a locked room most of day (TV room with locked half door) He was moved (e.g. to bathroom) with 3 staff encircling him and having him keep his hands in pockets

Case: Alaa

CTO was used for extreme aggression He would also engage in SIB hundreds of times per day He would also engage in Property Destruction holes in walls, broken toilets, etc

Case: Alaa Treatment Plan

Use of DRO Contingency Management Token Economy absence of target behaviours Greatly improving the quality of his time and interactions with staff doing fun activities Eliminate locked areas in house but reserving use of CTO for extreme aggression Develop prompting strategy so as not to inadvertently reinforce repetitive questions (one reminder prompt and withdraw attention)

Alaa: Treatment

Expose him to many other reinforcing activities to lessen his obsessions around specific video movies, food, cleaning New Psychiatrist new medications with use of SSRIs . Propranolol & Nozinan seem to be helping

Ontario OCD Resources

The Ontario OCD Network. Contact Details for Resource Directory Corinna de Beer 120 Lombard St., Suite 301, Toronto, Ontario, M5C 3H5 Ph: 416-970-2611 Fax: 416-703-7151 eMail: cdebeer@rogers.com

OCD Network

Ontario Obsessive Compulsive Disorder Network PO Box 151 Markham, Ont L3P 3J7

tel: 416-410-4772 fax: 905-472-4473

web site: http://home.interhop.net/~oocdn Email is oocdn@interhop.net