Obsessive Compulsive and Related Disorders

OBSESSIVE-COMPULSIVE DISORDER (OCD)

 

What is an obsession?

An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. Obsessions are mental events.

What is a compulsion?

A compulsion is a conscious, standardized, recurrent behavior, such as counting, checking, or avoiding. Compulsions are mental and/or behavioral events. Compulsive acts are carried out in an attempt to relieve the anxiety associated with the obsession. Sometimes it works, sometimes it doesn’t work. Resisting a compulsive act increases anxiety

NOTE: In OCD, obsessions and compulsions are ego-dystonic (i.e., patient is disturbed by them)

 

A Disorder of Pathological Doubt

OCD can be thought of as a disorder of doubt. There are numerous symptom “clusters” that can occur. 

Epidemiology

  • OCD is the 4th most common outpatient psychiatric diagnosis with approximately 10% of patients having the diagnosis in psychiatric clinics

  • Epidemiological studies in Europe, Asia, and Africa have confirmed these rates across cultural boundaries

  • Approximately 40% of patients do not achieve a clinical response from SSRIs

  • Females are slightly more than males in adulthood

  • Boys are 2-3 times more affected than girls in childhood

  • Mean age of onset is approximately 19.5 years old (Boys, 19yo; Girls 22yo)

  • OCD rarely presents after age 35

  • Males typically have an earlier age of onset than females

Possible Risk Factors

  • Genetic factors (monozygotic concordance rate of 0.57)

  • Environmental factors (trauma, abuse, perinatal, infectious)

  • Psychosocial and developmental factors

  • Controversy and debate continues about childhood streptococcal infections increasing the risk of OCD (PANDAS, see below) 

Associated/Co-morbid Conditions

90% of patients with OCD have psychiatric comorbidities including

76% Anxiety disorders
63% Mood disorders
56% Impulse control disorders
39% Substance use disorders
30% of patients with OCD have accompanying tic disorder

Comorbidities reported in up to 50% pediatric patients

ADHD
Separation anxiety disorder
Specific phobias
Anxiety disorders
Tourette disorder
Common Symptom Patterns in OCD

Neurobiology of OCD

Treatment of OCD

 

Current evidence suggests the combination of medication and therapy (Cognitive Behavioral Therapy) is the most effective approach to treating OCD

 

Medication Options

  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Fluoxetine
  • Fluvoxamine
  • Paroxetine
  • Sertraline
  • Citalopram
  • Clomipramine TCA most selective for serotonin reuptake
  • Glutamatergic Agents (Ketamine, NAC)
  • Opioid Medications (Naltrexone, Buprenorphine)

 

Other Options

  • ECT
  • Surgery (Psychosurgery)
  • Deep Brain Stimulation


Psychotherapy Options

  • Cognitive Behavioral Therapy
  • Exposure-Response Prevention Therapy (Type of CBT)
  • Mindfulness-Based Therapies

 

Problems with current treatment

  • Only 20-30% of patients have significant improvement in symptoms
  • 40-50% of patients have moderate improvement
  • 20-40% of patients do not respond or get worse!
  • Higher doses of SSRIs may be required to alleviate symptoms in OCD (but side effects become problematic) 

American Psychiatric Association (APA) Treatment Algorithm for OCD:

Body Dysmorphic Disorder (BDD)

Body Dysmorphic Disorder is a type of OCD-related disorder whereby individuals are preoccupied with an imagined defect in appearance which causes clinically significant distress. If a slight physical anomaly is actually present, the individual’s concern with the anomaly is excessive and bothersome. BDD is often accompanied by compulsions such as Mirror checking, Excessive grooming, and Comparing appearance to others. 

Women are more commonly affected than men and the age of onset is typically between 15 years old and 30 years old

Individuals with BDD often suffer with mood disorders, anxiety disorders, and psychotic disorders.

Individuals with BDD are more commonly seen in Plastic Surgery Clinics, Dermatology Clinics, and/or Primary Care Clinics

Treatment Options for BDD

Medications

  • Fluoxetine
  • Clomipramine
  • TCAs
  • MAOIs

Psychotherapy 

Surgical/procedural interventions rarely benefit these patients

Hoarding Disorder 

Hoarding Disorder is another type of OCD-related disorder whereby individuals acquire and “hoard” unimportant possessions with little or no value due to an obsessive fear that may be needed in the future. This is a disorder of distorted beliefs about the importance of possessions. There is often excessive emotional attachment to possessions. The hoarding behavior leads to Cluttering, Unsanitary living conditions, Health risks (falls, animal born diseases), and Fire risks. Hoarding Disorder is commonly diagnosed in single persons with social anxiety or dependent personality traits. However, Hoarding Disorder can occur as a manifestation of other disorders/diseases such as dementia, Cerebrovascular disease, and schizophrenia. Unfortunately, most individuals with Hoarding Disorder not present to mental health clinics because most lack insight into their illness (ego-syntonic).

Treatment Options

Medications aren’t effective

Cognitive behavioral interventions are most effective

Hair-Pulling Disorder (Trichotillomania)

Trichotillomania was coined by a French dermatologist Francois Hallopeau in 1889 and is a chronic disorder characterized by repetitive hair pulling which results in hair loss. There is increased tension prior to hair pulling and relief of tension or gratification after the hair pulling. Women are affected more than men (10:1). Roughly 35%-40%  of individuals with Trichotillomania chew or swallow their hair. Swallowing hair increases the risk of Bezoars (hairballs in the GI tract) which can cause obstruction.

Treatment Options

Medication Options

SSRIs
SNRIs
Lithium
Pimozide
Naltrexone
Buspirone
Clonazepam
Trazodone

Therapy Options

Exposure Response Prevention

Cognitive Behavioral Therapy

Insight-oriented psychotherapy

Hypnotherapy

Biofeedback

 

Excoriation (Skin-Picking) Disorder

Compulsive and repetitive picking of the skin. 1-5% lifetime prevalence. Women are affected more than Men. It is important to rule out stimulant-induced excoriation. Skin picking is most often seen on the Face but also Legs, Arms, Torso, Hands, Cuticles, Fingers, Scalp. Embarrassment leads to avoidance and social withdrawal. 12% of skin-picking patients have attempted suicide

Treatment Options

Medications

Fluoxetine
Naltrexone
Lamotrigine

Therapy Options

Exposure Response Prevention

Cognitive Behavioral Therapy

Insight-oriented psychotherapy

Hypnotherapy

Biofeedback

Habit Reversal

 

Olfactory Reference Syndrome

A false belief by the patient that he or she has a foul body odor. The odor is not perceived by others. Leads to excessive showering, changing clothes. May rise to level of somatic delusion (Delusional Disorder). It is important to rule out “organic” illnesses such as Temporal lobe epilepsy, Pituitary tumors, and Sinusitis. Currently there is little evidence for treatment. 

Medication or Drug-Induced OCD-like Disorder

Psychostimulants
Amphetamines
Methylphenidate (rare)
Methamphetamine
Cocaine
Nicotine
MDMA (Ecstasy)
PCP
Synthetic Cathinones (“Bath Salts”)
Dopamine agonists
L-dopa
Ropinirole
Pramipaxole
Aripiprazole (Abilify)
Bromocriptine
Amantadine 
Bupropion

Medical Problems that often present with OCD-like Symptoms

Huntington’s Disease
Wilson’s Disease
Seizures
Surgery-Related
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS)

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS)

References

  1. Afshar, Hamid et al. “N-Acetylcysteine Add-On Treatment in Refractory Obsessive-Compulsive Disorder.” Journal of Clinical Psychopharmacology (2012): 797-803. Print.
  2. Pauls, David L., Amitai Abramovitch, Scott L. Rauch, and Daniel A. Geller. “Obsessive–compulsive Disorder: An Integrative Genetic and Neurobiological Perspective.” Nature Reviews Neuroscience Nat Rev Neurosci (2014): 410-24. Print.
  3. Oliver, Georgina, Olivia Dean, David Camfield, Scott Blair-West, Chee Ng, Michael Berk, and Jerome Sarris. “N-Acetyl Cysteine in the Treatment of Obsessive Compulsive and Related Disorders: A Systematic Review.” Clin Psychopharmacol Neurosci Clinical Psychopharmacology and Neuroscience (2015): 12-24. Print.
  4. “Obsessive Compulsive Disorder.” Dynamed.
  5. Sadock, Benjamin J., and Harold I. Kaplan. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/clinical Psychiatry. 10th ed. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print.
  6. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association, 2013. Print.
  7. Stahl’s Essential Psychopharmacology, 4th Edition. Cambridge University Press. 2013