OBSESSIVE COMPULSIVE SYMPTOMS (OCS)

clinical overview

AHMED ELAGHOURY, MDEgyptian Board in Psychiatry

Taif, April 2016

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Concepts

• Obsession (Rumination): a thought, repetitive, intrusive, against the pt will “Egodystonic”

• Compulsion: obsessional motor act • Own thought / act, under control: not passive• Lewis 1936: intact insight• Schneider 1959: No loss of contact with reality• Jaspers 1973: Inner struggle ie faces himself• Disorders of disgust

April 2016

*Oyebode F (2015). Sims' symptoms in the mind: Textbook of descriptive psychopathology, 5th ed. Saunders Elsevier*Casey P & Kelly B (2007). Fish's clincal psychopathology, 3rd . Royal College of Psychiatrists

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Common comorbidities

• Substance use ds: esp cannabis (19%), stimulants “Punding”

• Schizophrenia / Schizotypal ds: Schizo-obsessive ds (12 – 30 %)

• Depression: obsessional ruminations • Anxiety ds: panic, phobia, separation anx.• Intellectual disability: Fragile X, etc• Autism• Tic ds / Stereotypic movement ds• Avoidant / Restrictive food intake ds

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Haan LD et al eds (2015). Obsessive-Compulsive Symptoms in Schizophrenia. Springer International Publishing Switzerland

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Poyurovsky M (2013). Schizo-obsessive disorder. Cambridge University Press

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DD of OCS in Schizophrenia • Attribution & insight• Uncertainty• Content• Onset & Course• Antipsychotic (SGA)-induced OCS: ↑

Clozapine & Olanzapine. ↓Aripiprazole & Amisulpiride.

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*Haan LD et al eds (2015). Obsessive-Compulsive Symptoms in Schizophrenia. Springer International Publishing Switzerland* Poyurovsky M (2013). Schizo-obsessive disorder. Cambridge University Press

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OCS with neurologic ds

• Post TBI: Acute onset OCS• Dementia: esp non Alzheimer • Huntington ds• Epilepsy• Parkinson ds: “Punding”

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Punding• Coined by Swedish forensic psychiatrist G. Rylander, in 1968• A stereotypical motor behavior in which there is an intense

fascination with repetitive handling and examining of mechanical objects.

• From previous interests / occupation• NOT egodystonic.• Commonly seen in:

– Pts on dopaminergic drugs eg Parkinson, RLS– Abuser of stimulants ( I/W) : amphetamine type / cocaine

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*Fernandez HH & Friedman JH. Punding on L-dopa. Mov Disord. 1999 Sep;14(5):836-8. PMID: 10495047. *Fasano A, et al. Cocaine addiction: from habits to stereotypical-repetitive behaviors and punding. Drug Alcohol Depend. 2008 Jul 1;96(1-2):178-82. PMID: 18378407. * Fogel BS & Greenberg DB, eds (2015). Psychiatric care of the medical patient. Oxford University Press

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OCS and Psychosis in DSM5• The specifier: with absent insight / delusional belief• It may be a quantitative approach: delusional

proportions (Pg 104) • Delusional ds Vs OCD / Body dysmorphic ds?• It may be two-phase process: acute / chronic (Pg 826)• Hoarding ds: without resistance • So:

– OCS and psychosis are on a spectrum – Resistance is NOT a defining feature for obsession, esp in

long term

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GBD 2000, WHO (2003)

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OCD may be familial • Verbal recall, set-shifting, response inhibition,

and visuoconstructive abilities are impaired in both OCD patients and their first-degree relatives: a potential “Endophenotype”

• OMIM (#164230): AD, SNPs in SLC6A4 (SERT), HTR2A (5HT2A)

• met66 allele of BDNF: protective • May support the previous view: OCD is an

anxiety ds

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JW Psychiatry, Dec 5 2011OMIM

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HTR2A gene

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OMIM (*182135)

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Age of onset: a prognostic factor

• Juvenile onset: <18 years• Adult-onset: 18-39 years• Late-onset: ≥40 years• Juvenile onset: familial, greater impairment, less

remission• Late-onset : significantly associated with female

gender, presence of precipitating factors, and less aggressive obsessions.

April 2016

* Clark DA & Gonz´alez AP (2014). Ch 24 Obsessive-Compulsive Disorder. In: The Wiley Handbook of Anxiety Disorders, First Edition. Edited by Paul Emmelkamp and Thomas Ehring.John Wiley & Sons, Ltd.*Sharma E, et al. Is late-onset OCD a distinct phenotype? Findings from a comparative analysis of "age at onset" groups. CNS Spectr. 2015 Oct;20(5):508-14. PMID: 26189938.

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OCD in adult females

• Reproductive cycle events are periods of increased risk for onset and exacerbation of OCD in women.

• At menarche, in pregnancy, postpartum & at menopause

• Exacerbation in first pregnancy: significantly associated with exacerbation in second pregnancy

• Weakness: retrospective self-reports

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*Guglielmi V, et al. Obsessive-compulsive disorder and female reproductive cycle events: results from the OCD and reproduction collaborative study. Depress Anxiety. 2014 Dec;31(12):979-87. PMID: 24421066.*JW Psychiatry, Feb 10 2014

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Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, PANDAS

• Post-infectious autoimmune ds due to “molecular mimcry” after group A β strep inf: eg rheuamtic heart, arthritis, PSGN, etc

• A controversial, wide concept, started by Swedo et al in 1998.

• Neurologists: Sydenham chorea “St Vitus dance”

• Tics + OCS • Adults with OCD: > 20% have anti–basal

ganglia autoantibodies (ABGAs)

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Kaufman, 2013

*Williams KA, Swedo SE. Post-infectious autoimmune disorders: Sydenham's chorea, PANDAS and beyond. Brain Res. 2015 Aug 18;1617:144-54. PMID: 25301689. *Nicholson TR, et al. Prevalence of anti-basal ganglia antibodies in adult obsessive-compulsive disorder: cross-sectional study. Br J Psychiatry. 2012 May;200(5):381-6. PMID: 22282431.

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Hoarding

• OCS WITHOUT resistance: egosyntonic• Comorbid with OCS / OCD• OCD + hoarding (20%): younger age of onset, more

bizarre items & less utilitarian meaning • Familial: 50% of hoarders have one relative who

hoards • May be with other mental ds: Depression, Anxiety,

etc

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*Leckman JF, Bloch MH. A developmental and evolutionary perspective on obsessive-compulsive disorder: whence and whither compulsive hoarding? Am J Psychiatry. 2008 Oct;165(10):1229-33. PMID: 18829875. *DSM5, 2013

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OCPD “Anankast” vs OCD• Freud 1908: anal retentive character • OCPD is NOT a risk factor for OCD (debated)• DD classically through: Onset, course, functional

impairment & resistance• Recently (2013): delayed reward “delay discounting” • OCPD shows: excessive capacity to delay reward ie

perfectionist & rigid (Type A personality) • OCPD traits in old age ( ↓ delay discounting): ↑↑

lethality of suicide attempts

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*Pinto A, et al. Capacity to delay reward differentiates obsessive-compulsive disorder and obsessive-compulsive personality disorder. Biol Psychiatry. 2014 Apr 15;75(8):653-9. PMID: 24199665*JW psychiatry, Dec 3 2013 *Dombrovski AY, et al. Lethal forethought: delayed reward discounting differentiates high- and low-lethality suicide attempts in old age. Biol Psychiatry. 2011 Jul 15;70(2):138-44. PMID: 21329911

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SUMMARY POINTS• OCS are highly comorbid and non specific for a special disorder, so included in

screening measures. • Long term & severe OCS may be associated with lost resistance & absent

insight / delusional belief• OCD has a worldwide disability burden (10th) • Age at onset is the best prognostic factor in OCD• Family history, reproductive history & recent infection / trauma: are essential

in clinical assessment of OCS• Both dopaminergic & SGA drugs may be associated with onset / worsening of

OCS in some pts. • Tics, avoidant food intake & hoarding behavior: may present alone or

comorbid with other mental ds• OCPD traits (Type A personality) ↑↑ lethality of suicidal attempts in old age

April 2016