OCD

Question 1

Epidemiology

Answer 1

Lifetime and 12-month prevalence of 1.0-2.3% and 0.7%-1.2% in adults, respectively Mean age ~20 years Under-recognised and under-treated Risk factors: Social isolation, history of physical abuse, and negative emotionality one-quarter of patients with OCD have attempted suicide

Question 2

Co-morbidity

Answer 2

Highly co-morbid 60-90% Mood, anxiety, somatoform, psychotic disorders, bipolar disorders, substance use disorders

Question 3

Diagnosis

Answer 3

• Presence of either obsessions, compulsions, or both ○ Obsessions are defined by the following: • Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that cause marked anxiety or distress • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with other thoughts or actions ○ Compulsions are defined by the following: • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rigid rules • Compulsions are aimed preventing or reducing anxiety or preventing some dreaded situation or event; however, they are not connected in a realistic way with what they are designed to neutralize or are clearly excessive • The obsessions or compulsions are time-consuming (e.g., take >1 h/day) or cause clinically significant distress or functional impairment • Specify patient’s degree of insight as to reality of OCD beliefs: ○ Good or fair insight (i.e., definitely or probably not true) ○ Poor insight (i.e., probably true) ○ Absent insight (i.e., completely convinced beliefs are true)

Question 4

Category of “obsessive-compulsive and related disorders

Answer 4

OCD, body dysmorphic disorder, hoarding disorder, hair-pulling disorder (trichotillomania), and skin picking disorder

Question 5

Types of obsessions

Answer 5

Aggressive COntamination Sexual Hoarding/saving Somatic Religious Symmetry/exactness Miscellaneous

Question 6

Types of compulsions

Answer 6

Cleaning/washing Checking Repeating Hoarding/collecting’Miscellaneous

Question 7

Assessment of OCD

Answer 7

1. Assess the presence of intrusive thoughts, images, or urges, and to inquire about repetitive behaviours and mental rituals (egodystonic). The frequency, amount of time consumed, and the extent to which obsessions/compulsions cause the patient distress or interfere with his or her life. 2. Identify main symptom dimension-> inform treatment and monitor changes in severity 3. Co-occurring psychiatric disorders 4. Differential - Anxiety disorders - Generalised anxiety disorder - specific phobia (feared objects in specific phobia are usually more circumscribed than those in OCD, and not characterized by rituals) - social anxiety disorder (limited to social interactions or performance situations. Avoidance or reassurance-seeking is focused on reducing this social fear.) - hoarding (persistent difficulty discarding or parting with possessions, marked distress associated with discarding items, and excessive accumulation of objects.) - major depression (mood-congruent and are not necessarily experienced as intrusive) - tic disorders (typically less complex than compulsions and are not aimed at neutralizing obsessions) - psychotic disorders (What distinguishes OCD from a delusional disorder or psychotic disorder, not otherwise specified, is that patients with OCD have obsessions and compulsions, and not other features of schizophrenia or schizoaffective disorder (eg, hallucinations or disorganized thinking/formal thought disorder ) - OCPD (enduring and pervasive maladaptive pattern of excessive perfectionism and rigid control that often leads to ritualized behavior) 5. Hx strep infections 6. Severity rating scale-> YBOCS 7. Risk assessment 8. Social/family support

Question 8

Proportion of patients that do not respond to SRI’s or CBT in short and long term

Answer 8

40-60%

Question 9

two instruments widely used for assessing treatment response

Answer 9

Yale-Brown Obsessive-Compulsive Symptom Severity Scale (Y-BOCS) and the Clinical Global Impression – Severity and Improvement scales (CGI-S and CGI-I). Most trials of acute-phase treatment in OCD have defined response as a decrease of more than 25% or 35% of the Y-BOCS score from baseline.

Question 10

Treatment of OCD

Answer 10

1. Psychological treatment - Mainly CBT w/ exposure and response prevention. Therapist guided exposure better than self-exposure. - ACT - Modular cognitive therapy-> addressing OCD beliefs - Cognitive therapy-> addressing obsessional doubt - Organisation training - Mindfulness training - ICBT->easily accessible treatment that has the potential to reach untreated patients and motivate them for face-to-face psychotherapy if necessary 2. Pharmacotherapy *combined better than meds alone, not better than CBT* - SSRI’s first line, SNRI’s (Venlafaxine) & clomipramine second & third line - Level 1 SSRI’s: escitalopram, fluoxetine, fluvox, parox, sertraline (same efficacy, better tolerated than clomipramine) - Level 1 AP: adjunctive Aripiprazole, risperidone, olanzapine, quetiapine - Level 1 anticonvulsants: topiramate - Level 1 TCA’s: clomipramine 3. Family psychoeducation-> address family accommodation 3. Biological and alternative therapies - rTMS- conflicting results, Level 1 - Open trials suggest that capsulotomy (Level 3) or cingulotomy (Level 3) may be effective in reducing symptoms in patients with severe, treatment-refractory OCD (treatments are usually considered last resorts) - Open studies suggest that adjunctive moderate-intensity aerobic exercise may help improve OCD symptoms (Level 3) - Milk thistle (level 2), St John’s warts (level 3) 4. Risk management 5. Family involvement and supports

Question 11

Is EMDR recommended for patients with EDMR

Answer 11

No

Question 12

Benefits of group therapy

Answer 12

individual therapy the therapist may have the advantage of being more aware of the patient’s dysfunctional beliefs, however, the group therapy setting may offer the advantages of group encouragement, reciprocal support, imitation, and interpersonal learning which may result in increased motivation and reduced discontinuation of treatment

Question 13

Family accommodation and impact on OCD treatment

Answer 13

Family accommodation (i.e., family members taking part in the performance of rituals, avoidance of anxiety-provoking situations, or modification of daily routines to assist a relative with OCD) has been associated with poorer response to both behavioural and pharmacological treatments consider targeting family accommodation in order to improve treatment outcomes for some patients.

Question 14

Pharmacotherapy management for OCD

Answer 14

First-line (high dose) Escitalopram (40mg), fluoxetine, fluvoxamine, paroxetine, sertraline Second-line Citalopram, clomipramine, mirtazapine, venlafaxine XR Third-line IV citalopram, IV clomipramine, duloxetine, phenelzine, tramadol, tranylcypromine Adjunctive therapy First-line: aripiprazole, risperidone Second-line: memantine, quetiapine, topiramate Third-line: amisulpride, celecoxib, citalopram, granisetron, haloperidol, IV ketamine, mirtazapine, N-acetylcysteine, olanzapine, ondansetron, pindolol, pregabalin, riluzole, ziprasidone Not recommended: buspirone, clonazepam, lithium, morphine Not recommended Clonazepam, clonidine, desipramine

Question 15

Assessment of treatment resistance

Answer 15

1. Exclude ‘pseudo-resistance’-> inadequate dose, duration, non-adherence, inappropriate treatment. 2.. Need higher dose for longer 10-12 weeks 3. Careful review of adequacy of psychological treatments should be carried out.

Question 16

Psychoeducation for OCD treatment

Answer 16

OCD is a relatively rare, yet severe, mental disorder, with an onset in the 20s or earlier. It is characterized by the presence of obsessions (persistent, intrusive thoughts) and/or compulsions (repetitive behaviors the individual feels compelled to perform). OCD is associated with substantial functional impairment and a high prevalence of comorbid disorders. CBT, and notably ERP, are effective first-line options for the treatment of OCD, being equivalent or superior to pharmacotherapy. CBT can be effectively delivered in both individual and group settings, as well as via self-exposure, self-help books, telephone, and internet-based programs. The benefits of CBT are maintained over one to five years of follow-up. The combination of psychotherapy and pharmacotherapy appears to be superior to pharmacotherapy alone, but not to CBT alone, and data suggest that adding CBT to pharmacological treatment may yield better long-term outcomes. Pharmacotherapeutic approaches should begin with a first-line SSRI such as escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline. If response to optimal doses is inadequate or the agent is not tolerated, therapy should be switched to another first-line agent before considering second-line medications. Second-line choices include citalopram, clomipramine, mirtazapine, and venlafaxine XR. OCD can be difficult to treat; therefore, in order to preserve any benefits of a therapy, adjunctive strategies may be important early in treatment. Patients who do not respond to multiple courses of therapy are considered to have treatment-refractory illness. In such patients it is important to reassess the diagnosis and consider comorbid medical and psychiatric conditions that may be affecting response to therapy. Third-line agents, adjunctive therapies, as well as biological and alternative therapies may be useful when patients fail to respond to optimal treatment trials of first- and second-line therapies used alone and in combination.

Question 17

Pathogenesis

Answer 17

The etiology of obsessive-compulsive disorder (OCD) is unknown. 1. Genetic factors are critically involved in the transmission and expression of OCD Immune responsivity to infections with group A beta-hemolytic streptococcus (GABHS) is believed to result in basal ganglia inflammation and resultant OCD, tic and/or ADHD symptoms . Increases in psychological stress lead to the upregulation and proliferation of “immature” circulating monocytes, which can enter the brain and have an enhanced capacity to release proinflammatory cytokines. These proinflammatory cytokines act to propagate the neuroinflammatory response and may also affect brain function and the metabolism and availability of different neurotransmitters 2. Perinatal trauma- some associated higher risk 3. Neuroimaging: cortico-striatal-thalamic circuits have been implicated 4. Functional: increased caudate and orbital frontal activity 5. Neurochemistry

Question 18

ERP- key elements and goals, Stepped process

Answer 18

Meyer 1966

The key elements of ERP are:

 Identification of stimuli that trigger obsessions.

 Deliberate exposure to relevant stimuli.

 Resisting the urge to engage in compulsions to relieve the resulting anxiety / distress.

 Remain in the situation (or confronting the trigger) until anxiety / distress has reduced by at least 50%.

The goal of ERP is to break the reinforcement cycles that are maintaining the disorder. The repeated exposure to the obsessive thoughts, situations, events or other triggers of the obsessive thoughts without engaging in the compulsive behaviour will result in:

1. Reduced anxiety in response to the trigger(s).
2. Insight that the thoughts can be tolerated without the need for the compulsive behaviour.
3. Insight that the thoughts are not dangerous.
4. Learning that it is possible to have anxious thoughts but remain safe.

A graded approach to tolerating the anxiety associated with relevant stimuli and obsessional thoughts is generally best tolerated by patients. This is achieved by creating a “hierarchy” in terms of fear level (usually measured subjectively by the Subjective Units of Distress Scale (SUDS) and given a score out of 10 or 100). In general, patients should confront triggers that cause SUDS of about 40-60/100 as these are most tolerable but still result in treatment gains.

Question 19

For example, an approach to reducing handwashing in response to fears about germs

Answer 19

The patient identifies that after touching a doorknob at their work their anxiety level would be 50/100 if they resisted the urge to wash their hands; after catching the bus to work their anxiety would be 70/100; after shaking hands with someone they didn’t know their anxiety would be 60/100. They would therefore start with the doorknob. The therapist would ask them to resist washing their hands after touching doorknobs at their work. However, they may wash their hands normally before eating or after toileting.

Question 20

CBT for OCD

Answer 20

Situation-> thoughts-> physical reactions->behaviour->moods/feelings