Obsessive Obsessive CompulsiveCompulsive

DisorderDisorder

Facts about Obsessive Compulsive DisorderObsessive Compulsive Disorder is also known as OCDOCD is a medical disorder that causes problems in the information processing.OCD is classified by the DSM-IV as an anxiety disorderAffects over 3.3 Million Americans.

Obsession:Contamination of fears of germs or dirt

Compulsion:Repeatedly washing

Obsession: Needing to have things “just so”

Compulsion: Hoarding or saving things

ObsessionsUnwanted thoughts, images, or impulses that occur over and overAre accompanied by uncomfortable feelings such as fear, doubt, or disgust.

CompulsionsRepetitive behaviorsIn response to the CompulsionsMost common is washing and checking things.

OCD is often confused with these other disorders:

Major Depressive DisorderPanic DisorderSocial Phobias

ADHD

OnsetCan occur any time from preschool age through adulthoodTypically by 40’sEqually common in both male and female

Diagnosis Criteria according to DSM-IVCompulsion or Obsessions (Typically both are present)The Compulsion or Obsessions cause marked distressTypically no physical symptomsScales are available, but they take lots of timeGet a HistoryCommunication between patient and medical practitioner is key

Typical Course of OCDTypical Course of OCD Long processLong process On average 3-4 doctors and over 9 years On average 3-4 doctors and over 9 years

before receiving the correct diagnosis.before receiving the correct diagnosis. Early diagnosis is importantEarly diagnosis is important Medicine and Cognitive behavior Medicine and Cognitive behavior

therapy helps most individuals therapy helps most individuals experience long term relief.experience long term relief.

AssessmentAssessment VisitsVisits The Anxiety Disorder Interview The Anxiety Disorder Interview

Schedule-Revised (ADIS-R) Schedule-Revised (ADIS-R) The Yale-Brown Obsessive-Compulsive The Yale-Brown Obsessive-Compulsive

Symptom Checklist (Y-BOC)Symptom Checklist (Y-BOC) The Leyton Obessional Inventory (LoI) The Leyton Obessional Inventory (LoI) The State Trait Anxiety Inventory of The State Trait Anxiety Inventory of

Children (STAIC) Children (STAIC)

Cause of OCDCause of OCD No concrete causesNo concrete causes Parents role and non-roleParents role and non-role Organic reasonsOrganic reasons

Head injuriesHead injuries Brain ChemistryBrain Chemistry Basal GangliaBasal Ganglia Encephalitis Encephalitis

Differential Differential DiagnosisDiagnosis

Depressive Disorder vs. Depressive Disorder vs. OCDOCD

Preoccupation with depressive Preoccupation with depressive thoughtsthoughts

““I have no friends”I have no friends” Realistic vs. absurdRealistic vs. absurd

Generalized Anxiety Disorder Generalized Anxiety Disorder vs. OCDvs. OCD

Excessive worrying and thinkingExcessive worrying and thinking Again realistic vs. absurdAgain realistic vs. absurd Patient with OCD may have extremely Patient with OCD may have extremely

intense/irrational thoughtsintense/irrational thoughts The presence of compulsive ritualsThe presence of compulsive rituals

Hypochondrias vs. OCDHypochondrias vs. OCD Closely relatedClosely related Unrealistic preoccupation of medical Unrealistic preoccupation of medical

concernsconcerns Presence of “checking rituals” to Presence of “checking rituals” to

decrease anxietydecrease anxiety

Other illnesses and neurological Other illnesses and neurological disorders vs. OCDdisorders vs. OCD

Anorexia and Dysmorphic disorderAnorexia and Dysmorphic disorder Occur in the context of another Occur in the context of another

psychiatric disorderpsychiatric disorder Tourette’s syndrome-increased rate of Tourette’s syndrome-increased rate of

OCDOCD TrichotillomaniaTrichotillomania Compulsive behavior of pathological Compulsive behavior of pathological

gamblers and substance abusersgamblers and substance abusers

Main Ideas of Differential Main Ideas of Differential DiagnosisDiagnosis

The presence of obsessive compulsive The presence of obsessive compulsive ritualsrituals

The manner of the compulsive The manner of the compulsive thoughtsthoughtsFor example: unrealistic vs. realisticFor example: unrealistic vs. realisticappropriate vs. inappropriate appropriate vs. inappropriate

TreatmentTreatment Two typesTwo types

A. PharmacotherapyA. Pharmacotherapy B. Behavioral TherapyB. Behavioral Therapy

Use of medicationsUse of medications

Controlling the symptoms of OCDControlling the symptoms of OCD Lessening the intensity and frequency Lessening the intensity and frequency

of the obsessions and compulsionsof the obsessions and compulsions Examples of SSRI’sExamples of SSRI’s

ProzacProzac LuvoxLuvox PaxilPaxil ZoloftZoloft

Medications ContinuedMedications Continued

Improvement usually takes 3 weeksImprovement usually takes 3 weeks Symptoms are reduced but not Symptoms are reduced but not

eliminatedeliminated Anafranil– 1Anafranil– 1stst SRI used SRI used

Side effects: Sedation, blurry vision, Side effects: Sedation, blurry vision, weight gain, and sexual dysfunctionweight gain, and sexual dysfunction

Side effects of SSRI’sSide effects of SSRI’s Side effects: Insomnia, motor restlessness, Side effects: Insomnia, motor restlessness,

nausea, and diarrheanausea, and diarrhea Long-Term treatment neededLong-Term treatment needed

Behavioral TherapyBehavioral Therapy

““Exposure” and “Response Prevention”Exposure” and “Response Prevention” Not able to eliminate their anxietyNot able to eliminate their anxiety Extremely uncomfortable for OCD Extremely uncomfortable for OCD

patientpatient 80-90% improvement 80-90% improvement Symptoms are reduced but not Symptoms are reduced but not

eliminatedeliminated Follow-up sessions needed for relapse Follow-up sessions needed for relapse

preventionprevention

Use of both therapiesUse of both therapies

Severe case of OCDSevere case of OCD Mild case of OCDMild case of OCD Use of SSRI’s and behavior therapy Use of SSRI’s and behavior therapy

prove to have a 70% success rateprove to have a 70% success rate Therapy determined by patientTherapy determined by patient

Willingness to take a medicationWillingness to take a medication Willingness to work with a psychologistWillingness to work with a psychologist

Environmental FactorsEnvironmental Factors

Positive and motivated patientPositive and motivated patient Fully trained therapist during Fully trained therapist during

behavior therapybehavior therapy OCD GroupsOCD Groups Family provides encouragement and Family provides encouragement and

constant reassuranceconstant reassurance Showing frustration with the patient Showing frustration with the patient

may impact the compulsive behaviormay impact the compulsive behavior

New ResearchNew Research

A new cognitive-behavioral therapyA new cognitive-behavioral therapy Emphasizes changing the OCD sufferer’s Emphasizes changing the OCD sufferer’s

belief and thinking patternsbelief and thinking patterns

Case Study of Case Study of Obsessive Obsessive

Compulsive Compulsive DisorderDisorder

Women with Women with

Postpartum-Onset OCDPostpartum-Onset OCD Lesley M. Arnold, M.D. Lesley M. Arnold, M.D.Presented by Lawrence Presented by Lawrence

PiercePierce

Several lines of evidence Several lines of evidence suggest that postpartum suggest that postpartum women are at increased women are at increased risk for the development risk for the development

or worsening of or worsening of obsessive-compulsive obsessive-compulsive

disorderdisorder

Recruiting ProcessRecruiting Process Subjects were recruited from outpatient Subjects were recruited from outpatient

practice at the University of Cincinnati practice at the University of Cincinnati Medical Center and advertising for a Medical Center and advertising for a study for postpartum women.study for postpartum women.

Nine potential subjects were identified.Nine potential subjects were identified. Two were excluded because they did not Two were excluded because they did not

meet the DSM-IV criteria for OCDmeet the DSM-IV criteria for OCD Of the 7 subjects, 5 respondents through Of the 7 subjects, 5 respondents through

advertisement, 2 were referredadvertisement, 2 were referred

Initial ScreeningInitial Screening Psychiatric evaluationPsychiatric evaluation Yale-Brown Obsessive Compulsive Yale-Brown Obsessive Compulsive

Scale (Y-BOCS)Scale (Y-BOCS) Data on Demographic and Clinical Data on Demographic and Clinical

featuresfeatures Family History of any psychiatric Family History of any psychiatric

disorder in first-degree relativesdisorder in first-degree relatives

Obsessions in 7 Women Obsessions in 7 Women with Postpartum-Onset with Postpartum-Onset

OCDOCDSymptomSymptomObsessions Obsessions

AggressiveAggressiveContaminationContaminationReligiousReligiousPathological doubtPathological doubtSexualSexualSymmetrySymmetryOther Other

Number Number % %

77 100100 5 5 71 71 3 433 43 2 292 29 1 141 14 1 141 14 1 141 14

Compulsions in 7 Women Compulsions in 7 Women with Postpartum-Onset with Postpartum-Onset

OCDOCDSymptomSymptomCompulsions Compulsions

CheckingCheckingCleaningCleaningOrderingOrderingCountingCountingSuperstitious Superstitious behaviorsbehaviors

Number Number % %

44 57 1 57 1 14 14

1 141 14 1 141 14 1 141 14

Psychiatric Disorders in First Degree Relatives Psychiatric Disorders in First Degree Relatives of 7 subjects.of 7 subjects.

Relatives Affected (N = 18) Total of 60Relatives Affected (N = 18) Total of 60Disorder N Disorder N

%%Mood disordersMood disorders

Bipolar disorder 4 Bipolar disorder 4 2222Major depressionMajor depression 9 9 50 50

Psychotic disordersPsychotic disorders 0 0 0 0Psychoactive substance use disorders Psychoactive substance use disorders

AlcoholAlcohol 5 28 5 28OtherOther 2 11 2 11

Anxiety disordersAnxiety disorders 0 0 0 0

Subject 1 Current/Past DSM Subject 1 Current/Past DSM IV DiagnosisIV Diagnosis

Age 28Age 28Current Diagnoses: Current Diagnoses:

AgeAgeBipolar disorder I Bipolar disorder I

12 12Panic disorder Panic disorder

13 13OCDOCD

1919GAD GAD

1313

Past Diagnoses: Past Diagnoses: AgeAge

PTSD PTSD 2626

Anorexia nervosa Anorexia nervosa 14 14

Subject 2 Current/Past DSM Subject 2 Current/Past DSM IV DiagnosisIV Diagnosis

Age 31Age 31Current Diagnoses: Current Diagnoses:

AgeAgeRecurrent MDD Recurrent MDD

1717OCDOCD

2929GAD GAD

1010

Past Diagnoses: Past Diagnoses: AgeAge

Alcohol abuse Alcohol abuse 2828

Social Phobia Social Phobia 1010

Subject 3 Current/Past DSM Subject 3 Current/Past DSM IV DiagnosisIV Diagnosis

Age 41Age 41Current Diagnoses: Current Diagnoses:

AgeAgeRecurrent MDD Recurrent MDD

3939OCDOCD

4141

Past Diagnoses: Past Diagnoses: AgeAge

Binge eating disorder Binge eating disorder ? ?

Subject 4 Current/Past DSM Subject 4 Current/Past DSM IV DiagnosisIV Diagnosis

Age 42Age 42Current Diagnoses: Current Diagnoses:

AgeAgeRecurrent MDDRecurrent MDD

partial remission partial remission 3939

OCD OCD 3131

Binge eating disorder Binge eating disorder 17 17

Past Diagnoses: Past Diagnoses: AgeAge

Cannabis dependence Cannabis dependence 1919

Subject 5 Current/Past DSM Subject 5 Current/Past DSM IV DiagnosisIV Diagnosis

Age 26Age 26Current Diagnoses: Current Diagnoses:

AgeAgeRecurrent MDD Recurrent MDD

1515OCD OCD

2626PTSD PTSD

1515

Past Diagnoses: Past Diagnoses: AgeAge

Alcohol abuse Alcohol abuse 2323

Subject 6 Current/Past DSM Subject 6 Current/Past DSM IV DiagnosisIV Diagnosis

Age 28Age 28Current Diagnoses: Current Diagnoses:

AgeAgePanic Disorder Panic Disorder

2525OCD OCD

2525

Past Diagnoses: Past Diagnoses: AgeAge

MDD MDD 2525

Subject 7 Current/Past DSM Subject 7 Current/Past DSM IV DiagnosisIV Diagnosis

Age 26Age 26Current Diagnoses: Current Diagnoses:

AgeAgeBipolar disorder IIBipolar disorder II depressed depressed

2626OCDOCD

2626

Past Diagnoses: Past Diagnoses: AgeAge

NoneNone

Of the 7 subjects 4 did not Of the 7 subjects 4 did not enter the fluvoxamine trial.enter the fluvoxamine trial.

3 were excluded because they wish to 3 were excluded because they wish to continue breast feedingcontinue breast feeding

1 was excluded because of the 1 was excluded because of the diagnosis of bipolar Idiagnosis of bipolar I

The TestThe Test Subjects received fluvoxamine 50 mg/daySubjects received fluvoxamine 50 mg/day The dose was increased on a flexible schedule The dose was increased on a flexible schedule

as tolerated with a maximum dose of 300 as tolerated with a maximum dose of 300 mg/daymg/day

Subjects received no psychotropic medication Subjects received no psychotropic medication except zolpidem tartrate 5 to 10 mg at except zolpidem tartrate 5 to 10 mg at bedtime as needed to help with insomnia bedtime as needed to help with insomnia

Subjects evaluated weeks 1,2,3,4,6,8 and 12 Subjects evaluated weeks 1,2,3,4,6,8 and 12 and reported any treatment-related illness and reported any treatment-related illness thenthen

Measure of SuccessMeasure of Success Primary successful outcome measure was Primary successful outcome measure was

the Y-BOCS was defined as greater than the Y-BOCS was defined as greater than or equal 30% decrease its total scoreor equal 30% decrease its total score

Corresponding with clinical improvement Corresponding with clinical improvement in symptomsin symptoms

Secondary outcome measures were Secondary outcome measures were changes in the Hamilton Rating Scale for changes in the Hamilton Rating Scale for Depression (HAM-D) and anxiety (HAM-Depression (HAM-D) and anxiety (HAM-A)A)

Subject 2Subject 2 Completed 12 weeksCompleted 12 weeks Final dose was 300 Final dose was 300

mg/daymg/day Side effects headache, Side effects headache,

heartburn, dry mouth heartburn, dry mouth and insomnia and insomnia

Had a past history of no Had a past history of no response to 3 trials of response to 3 trials of serotonin reuptake serotonin reuptake inhibitorsinhibitors

No improvement with No improvement with fluvoxminefluvoxmine

Subject 4Subject 4 Completed 12 weeksCompleted 12 weeks Final dose was 200 Final dose was 200

mg/daymg/day Reported side Reported side

effects: headache, effects: headache, dry mouth, heart dry mouth, heart palpitations and palpitations and anorgasmiaanorgasmia

Positive response to Positive response to drugdrug

Subject 5Subject 5 Completed 3 weeks Completed 3 weeks

due to car accident due to car accident (unrelated)(unrelated)

Final dose was 150 Final dose was 150 mg/daymg/day

Reported side Reported side effects: anorgasmiaeffects: anorgasmia

Positive response to Positive response to drugdrug

Case Study ConclusionCase Study Conclusion 2 of the 3 subjects improved with 2 of the 3 subjects improved with

treatmenttreatment This subject that did not improve had a This subject that did not improve had a

history of poor response to multiple history of poor response to multiple treatmenttreatment

This trial was limited by its uncontrolled This trial was limited by its uncontrolled nature and the small number of subjectsnature and the small number of subjects

Larger controlled study is needed Larger controlled study is needed responsiveness of postpartum-onset OCD responsiveness of postpartum-onset OCD to serotonin reuptake inhibitorsto serotonin reuptake inhibitors

Obsessive Obsessive CompulsiveCompulsive

DisorderDisorder