Obsessive Compulsive

Disorder

Presenter :- Dr. Anant (Resident)

Guide :- Dr. D. K. Sharma (Prof. & Head)

OBSESSIVE COMPULSIVE DISORDER

OCD is an anxiety disorder distinguished by recurring thoughts that cause anxiety and the impulse to perform certain actions in order to relieve the anxiety.

(Obsessions and Compulsion)

Obsession

• Recurrent persistent thoughts, impulses, images that– Enters the mind– Can’t be eliminated by consciousness by

logic/reasoning– Involuntary– Ego-dystonic

Obsession - Characteristic features

• Subjective sense of struggle• Conviction that to think is to make it more

likely to happen• Recognized as own • Regarded as untrue and senseless• Generally about matters that are distressing• Often accompanied by compulsion

Compulsion

• Pathological need to act on an impulse that if restricted produce anxiety

• Repetitive behavior in response to an obsession, performed according to certain rules with no true end in itself

The obsessions or compulsions are asignificant source of distress to theindividual.

OCD Cycle

OBSESSIONS

COMPULSIONS

RELIEF ANXIETY

Neurobiological

PsychologicalEnvironmental

Causes of OCD in shortCauses of OCD in short

Neurobiological factorsNeurotransmitter Levels

Serotonin

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CSFPlatelets

Low 5HT

5HIAA

DA – Hyper functioning in PFC5HT – Hypo functioning in basal ganglia

Dysfunction of the so-called 'cortico-striato-thalamic' loops

Brain Imaging Studies

CT/MRI: Decrease size of caudate nuclei

PET: Increased activity in frontal lobe (OFC) & basal ganglia(caudate), Thalamus

Causes

BIOLOGICAL• The orbitofrontal cortex has a circuit that sends information to the

thalamus such as aggression, sexuality and bodily excretions.

• When these parts of the brain are activated you are bound to act upon those certain behaviors or actions.

• These impulses are brought to ones conscience and after your brain has sent you the information and have acted upon that information the impulse eventually decreases and you move on to your daily routine.

• Within people who have OCD, some certain impulses cannot be turned off or ignored by that part of the brain, which causes them to repeat the same action over and over again.

• Eventually they become obsessed with these actions and they have become integrated into their routine and they have no control over it.

GENETIC FACTORS

OCD has significant genetic component .

Three to five times higher probability of OCD in relatives of probands with OCD.

Concordance for OCD in twins is significantly higher for monozygotic twins than for dizygotic twins .

Environmental factors

Early childhood conflicts:

• This is an early theory that suggests conflicts or problems during childhood are the roots of OCD.

• This is specifically looking at either permissive or mainly unengaged parenting techniques.

Psychological - COGNITIVE THEORY OF OCD

• Obsessional thoughts:

– It’s not the thought itself that is disturbing, but rather the interpretation of the thought.

– The issue of responsibility is believed to be a core belief or cognitive distortion of people with OCD.

Compulsive behaviors:

– Neutralizing, either through compulsive behaviors or mental strategies, is aimed at preventing terrible consequences, or averts the possibility of being responsible

– Seeking reassurance is another form of neutralizing, as it can serve to spread responsibility to others, thus diluting that of the individual

– Avoidance, though not an overt neutralizing behavior, is often used to prevent contact with particular stimuli

• Model:

– Stimuli in the form of unpleasant intrusive thoughts, of either external or internal origins are experienced

– The thought is ego-dystonic, that is, it is inconsistent with the individual’s belief system

– It usually involves an element of blame, responsibility, or control, which interacts with the content of the intrusive thought

– Disturbances in mood and anxiety follow, which in turn lead to neutralizing behavior

Main consequences of neutralizing behavior

It results in reduced discomfort, which leads to the development of compulsive behavior as a tool for dealing with stress. This reinforcing behavior may result in a generalization of this strategy

Neutralizing will be followed by non-punishment, and can lead to an effect on the perceived validity of the beliefs

The neutralizing behavior itself becomes a powerful and unavoidable triggering stimulus. The neutralizing behavior serves to reinforce the belief that something bad may happen

PSYCHODYNAMIC FACTORS

ISOLATIONIt protects an individual from anxiety provoking affects and impulses.

isolation less effective

Patient experience a partial awareness of the impulse without fully recognizing its meaning

Impulse is displaced from the true object to other people or object.

PSYCHODYNAMIC FACTORS (CONTD.)

UNDOINGWhen impulse`s constant threat escape primary defense of isolation

Secondary defensive operations is started

Compulsive act that is performed in an attempt to prevent or undo the consequences that the patient irrationally anticipates from a frightening obsessional thought or impulse.

PSYCHODYNAMIC FACTORS (CONTD.)

REACTION FORMATION

Manifest patterns of behaviour and consciously experienced attitudes that are exactly the opposite of the underlying impulses

Reaction formation results into formation of character traits of OCD.

PSYCHOANALYTIC FACTORS

AMBIVALENCE

Present in normal children during the anal sadistic development phase.

Children feel both love and murderous hate towards the same object.

Patients with OCD often consciously experience both love and hate toward an object.

Conflict of opposing emotions is evident in a patient` doing and undoing patterns of behaviour and in paralyzing doubt in the face of choice.

PSYCHOANALYTIC FACTORS (CONTD.)

MAGICAL THINKINGInherent in magical thinking is omnipotence of thought.

An event can occur merely by thinking without intermediate physical actions.

This feeling causes them to fear having an aggressive thought.

Contamination 45 %

Pathological doubt 42 %Somatic 36 %Aggressiveness 28

%Sexual 26 %

Obsessions Affective Disorder

Checking 63 %Washing 50 %Counting 36 %Symmetry & precision 28 %

Compulsions Affective Disorder

With OCD I feel…• Misunderstood, nobody seems to

get me, they can’t understand why I am the way I am.

Depressed…

• I feel depressed because I get stuck in my ways and nobody gets them or can help me.

CRAZY!

• My obsessions drive me crazy. I wish they would stop.

Repetitive

• I repeat myself and actions, over and over and over and over and over and over and over and over again….

Out of Control

• I cant control my thoughts, actions, or myself. Its like I am a character in a video game.

Hyper

• OCD makes me also feel hyper and wild sometimes, when its not ruining my life.

Introverted

• I find that I am very unfond of others even my closest friends, when my compulsions are really bad.

Lazy

• I don’t enjoy doing things or leaving my house because of the anxiety it causes. I’d rather just sit and wait.

Nervous

• Not knowing what is going to happen makes me super nervous. Everything has to be planned out and go exactly according to plan.

Anxious

• I get anxious when I have compulsions and I obsess over the little things, it’s a feeling that never goes away for me.

Scared• I get scared when

people don’t understand me and judge me and when things don’t go according to plan, I get afraid something will happen to me.

OCD- Prevalence

• Is chronic psychiatric disorder and is one of the 10 most disabling medical conditions worldwide

• 4th most common psychiatric disorder

• OCD is not received due attention and with its high prevalence it is being labeled as the ‘hidden epidemic’

TREATMENT

Psychotherapy

Thought stopping Response preventionExposure etc.

Most effective for OCD.

Supportive therapy is always helpful

Cognitive Behavioral Therapy

Pharmacotherapy

1. TCA/Clomipramine 2. SSRI

• fluvoxamine• fluoxetine • paroxetine• sertraline• citalopram

• Escitalopram

3. Atypical antipsychotics:- preferably Olanzapine, Quetiapine, Risperidone

4. Antianxiety drugs :- preferably short acting as clonazepam

5. Adjunctive medications Tryptophan Buspirone

Lithium Pimozide Trazodone Methylphenidate

6. Venlafaxine, mirtazepine, tianeptine

7. Research :- Riluzole, mimentine, gabapentine, N-acetylcysteine and lamotrigine.

ECT- Anti obsessional property?• APA task force on ECT- unless severe depression is prominent ECT is

not an effective treatment option.• Reports and efficacy of ECT treatment in refractory OCD is sparse in

literature.

• Study- retrospective review 32 patients OC and depressive symptoms

baseline survey ECT improvement in refractory OCD and depressive symptoms

Fallacy- Retrospective studyECT conditions and parametersfrequency & numbercriteria/reasons of stopping ECT were not specified

• Study- Open label 11 patientsMaintenance ECT for refractory OCD-

2or3 per week for ten sessions.Significant improvement in initial 3-4

wksMaintained till 4 monthsPre-treatment state within 6 months

Research Question

• Is ECT is more beneficial in patients of OCD having co-morbid psychosis/Schizophrenia?

Repetitive Trans-cranial Magnetic Stimulation

Repetitive Transcranial Magnetic Stimulation (rTMS)

• In rTMS pulsed magnetic field is applied to the scalp induces electric currents that depolarizes underlying cortical neurons influencing their function

• Possible Hypothesis- directly altering the hyper functioning of PFC with rTMS ameliorate symptoms of OCD

• Speed of Stimulation > 1Hz- high frequency - activates stimulated areas

• Speed of stimulation < 1Hz- low frequency - inhibit cortical stimulation

Study-

• Crossover randomized investigator blind study• 12 right handed pts having current or past depression• Single session of rTMS at 80% of RMT(resting motor threshold)

at 20Hz/2 second per minute for 20 minutes• On right lateral pre-frontal, left lateral pre-frontal and mid-

occipital(control) site

• Result- Compulsions decreased significantly for 8hrs after Rt lateral PFC stimulation with modest increase in positive mood

• Non-significant reduction in compulsion urges 30 minutes after left lateral PFC stimulation

• Non-significant increase in compulsive urges after mid-occipital stimulation

• Obsession did not change significantly

Study-

• Open label 12 Rt handed OCD refractory pts none having depression

• Randomly assigned to 10 sessions of Rt or Lt pre-frontal rTMS of 10Hz, 110% RMT, 30 trains of 5 second each

• Site- in relation to activating 1st dorsal interosseous muscle

• Result- 33% of either group showed clinically significant improvement (40% reduction in YBOCS)

• No significant differences b/w Rt & Lt sided rTMS

• No difference b/w obsessions & compulsions score

Study (Alonso et al)

• Double blind randomized placebo controlled parallel group design

• 18 Rt handed pts with no other psychiatric co-morbidity

• 10 pts assigned to thrice weekly sessions for 6wk at 1Hz on Rt pre-frontal at 110% of RMT- 2 pts showed 40% reduction in YBOCS

• 8 pts assigned to placebo group- 1 responded

• Improvement appeared following 5th wk of t/t

• Real rTMS receivers had non-significant greater reduction in obsessions

Study (Sachdev et al)

• Double blind randomized placebo controlled parallel group design

• 18 pts without depression• 10 pts received real rTMS over Lt DLPFC• 8 pts received placebo rTMS

• After 2 wks t/t status were informed to the pts with option of further 2 wks of rTMS to real rTMS receiver & 4 wks of rTMS to placebo receivers

• Improvement in 1st 2 wks was not different among both groups• 6 pts had clinically significant improvement

• Result- study did not support efficacy of high frequency DLPFC rTMS given over 2 wks in OCD

Study-

• Double blind randomized placebo controlled parallel group design

• To assess whether rTMS facilitates effect of anti-depressants in OCD

• In 33 t/t resistant OCD pts

• Study failed to find any difference in either group

Study-

• Double blind randomized placebo controlled parallel group design

• Aimed to enhance efficacy of rTMS by combining two forms of stimulation sequentially over Rt DLPFC & supplementary motor areas

• 21 t/t resistant pts with coexistent depression

• 2 pts in either group had a 25% reduction in YBOCS score

• 1 pt in active group had clinically significant reduction in MADRS

• Result- study did not find any clinically significant difference b/w two groups

Study-

• Open label study from India• 42 Rt handed pts• 10Hz rTMS, 110% RMT over Rt DLPFC• Both active & placebo groups evinced significant

improvement in obsession and compulsion• However active rTMS was not superior to

placebo• Result- no significant effect of rTMS in t/t of OCD

but modest effect on co-morbid depression

Limitations of above mentioned studies• Very small no. of subjects

• Pt selection was not uniform

• Definition of t/t resistant was not clear

• No consistency in symptoms subtypes

• Criteria for response were not very consistent

• Technical parameters of rTMS as exact site of stimulation, side, method of site selection, strength and duration of sessions have no consensus

• Presence of co-morbid depression makes it difficult to dissociate improvement in YBOCS from that due to improvement in depression

• With the information from current trials for rTMS in OCD- negligible evidence as none of the randomized controlled studies was able to find any difference b/w real and placebo group

• Both NICE and APA practice guideline for t/t of OCD conclude “currently rTMS cannot be recommended as a t/t option”

Research Need

• For larger double blind placebo controlled rTMS studies in co-morbidity free OCD pts with comparison across different stimulation sites

• For longer follow up periods to assess if the beneficial effects are enduring

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