Obsessive compulsive spectrum disoder

0BSESSIVE COMPULSIVE SPECTRUM DISORDER Speaker: Dr. Santanu Ghosh Post Graduate Student , Moderator: Dr. Sabita Dihingia Asst. Professor, DEPARTMENT OF PSYCHIATRY,ASSAM MEDICAL COLLEGE

Outline of presentation: Introduction. Classification of obsessive compulsive spectrum disorder. obsessive compulsive disorder. Impulse control disorder. Neurological disorder. Preoccupation with bodily symptoms disorder. Current Nosological status of OCD. Future Directions. Conclusion. Bibliography.

INTRODUCTION A range of psychiatric disorder have been proposed by Eric Hollander in 1998 to be included as Obsessive Compulsive Spectrum Disorder on the observation that OCD & OCSD share many common feature. These features are shared feature. These are: Similar clinical symptoms- repetitive behavior & thought. Similar age of onset. Chronic clinical course. Co morbidity of similar symptoms. Insight ranging from full to poor.

Contd … Similarities in brain circuits and neurotransmitter involved. Similar demographic & family history. Response to same antiobsessional drugs & not other antianxiety agents or antidepressants.

CLASSIFICATION: Hollander divided OCD into the following categories- - Preoccupation with bodily symptoms - Impulsive disorder. - Neurological disorder. 17/10/10

Obsessive-compulsive – related disorder Ref: CTP 8 th ed Page: 2036

17/10/10 Compulsivity-impulsivity dimension CTP 8 th ed page-2036 B. Dimensional approach: Hypochondriasis Compulsive Body dysmorphic disorder Anorexia nervosa Impulsive Depersonalization disorder Tourette’s syndrome Trichotillomania Pathological gambling Sexual compulsion Impulsive personality disorder

Compulsivity-Impulsivity dimension: 17/10/10 Compulsivity/unipolar Mixed compulsive- impulsive&/or affective states Impulsivity/Bipolarity OCD/Major depression OCD with impulsive feature ICDs/Bipolar compulsive ICD, ICDs co morbid disorder with OCD,Bipolar II disorder

17/10/10 Compulsivity-unipolarity Impulsivity-bipolar Harm avoidant behavior. Harmful behavior. Presence of insight Lack of insight. Resistance to impulses & behavior. Little resistance to impulses & behavior. Absence of pleasure. Pleasurable feeling.

C. Based on Insight: This was given by Hollander. Insight is present in OCD But there can be a range of insight in OCSD.OCD with poor insight are those patient who do not recognize their symptoms to be excessive or unreasonable. 17/10/10 OCSD OCD INSIGHT -ve +ve Without Insight With Insight

Contd… The above classification was modified by Akiskal & Insel in to two. Obsessive compulsive neurosis Obsessive compulsive psychosis. OCSD OCD INSIGHT +VE -VE Obsessive compulsive neurosis Obsessive compulsive psychosis

Obsessive compulsive disorder: An obsession is defined as : An idea, impulse or image which intrudes in to the conscious awareness repeatedly. Recognized as one’s own idea, impulse or image but is perceived as egoalien . Insight is present. Patient tries to resist against it but is unable to . Failure to resist, leads to marked distress.

Contd... A compulsion is defined as : A form of behavior which usually follows obsession. Aimed at - preventing / neutralizing the distress or fear arising out of obsession. The behavior is not realistic and is irrational or excessive. Insight is present, so the patient realizes the irrationality of compulsion. The behavior is performed with a sense of subjective compulsion.

Neurobiology of OCD Biological factors : Neurotransmitters: Serotonin: Dysregulation of serotonin is associated with OCD Variable findings - CSF concentration of serotonin metabolites & affinities & number of platelet binding site of imipramine. Clomipramine treatment - 5HIAA in CSF. 17/10/10

Contd.. Noradrenergic system: less evidence exists. Clonidine Improves OCD. Neuroimmunology: Group A beta hemolytic streptococcal infection- rheumatic fever & approximately 10-30% of patient develop Sydenham’s chorea & OCD.

Contd.. Brain imaging: Altered function in neurocircuitry between orbitofrontal cortex, caudate nucleus & thalamus. Abnormalities in corticostriatal- thalamocrtical pathway. PET scan - increased metabolism and blood flow in the frontal lobe, basal ganglia & the cingular cortex. Both CT & MRI studies have found bilaterally smaller caudate nucleus in patients with OCD.

Contd.. c) Genetics: 3-5 fold higher prordbability of having OCD or obsessive compulsive features in relatives of OCD patient. Twin studies - higher concordance rate of OCD for monozygotic twins than dizygotic twins. d) Other biological data: Sleep EEG - decreased REM latency in both OCD & depression. Neuroendocrine studies - non suppression on dexamethasone suppression in about 1/3 rd patient & decreased growth hormone secretion with clonidinie infusion in OCD & depreesion.

Behavioral factors: Obsession & compulsion: Neutral stimuli Obsessions(condition stimuli) Anxiety or discomfort Compulsion(learned behavior) Fear or anxiety Nox ious or anxiety producing events

Psychodynamic theory: Sigmund Freud found obsessions & phobias to be psychogenetically related. Early childhood Normally disguised by Disturbed development in Fixation in development Reinforcement of anal Aggressive impulses At Present In presence of fixation at anal sadistic phase Anal Sadistic Phase Obsessional personality trait Reaction Formation Anxiety related to oedipal complex Regression New Defense Isolation of Affects Obsessive Thoughts Undoing Displacement Compulsive Acts PHOBIA

Symptoms Patterns: Contamination(washers). Pathological doubt(checkers). Intrusive thought(pure obsession). Symmetry(primary obsessional slowness). Others-religious obsession & compulsion 17/10/10

Comorbid disorders : Major depressive disorder-67%. Social phobia- 25%. Tourette's syndrome- 5-7%. Specific phobia. GAD/Panic attack. Eating disorder. Personality disorders. Alcohol abuse disorder. 17/10/10

Treatment: Behavior therapy: Exposure techniques. Exposure & response prevention. Blocking & punishing techniques. Aversive technique. Time out. Thought stopping. Cognitive behavioral Therapy.

Contd… Psychotherapy : Classical psychoanalysis. Short term dynamic psychotherapy. Pharmacotherapy: SSRI: These are the drug of choice. Drugs used are- . Fluvoxamine>fluoxetine> paroxetine> sertraline. TCA: Drug used is clomipramine. Drug augmentation: By clonazepam, lithium, tryptophane, pindolol,trazodone & buspirone,venlafexine,MAOIs. 17/10/10

Contd… Other non- pharmacological strategies: Transcranial magnetic stimulation Deep brain stimulation. ECT Psychosurgery: Cingulotomy, Subcaudate tractotomy (capsulotomy). 17/10/10

Impulse-control Disorder: Six conditions comprises of this category. These are- Intermittent explosive behavior Kleptomania Pyromania Pathological gambling Trichotillomania Impulse control disorder-NOS 17/10/10

Intermittent explosive behavior: Discreet episode of loosing control of aggressive impulses result in serious assault & destruction of property. The aggressiveness is expressed is grossly out of proportion to any stressors. The symptoms comes in spells or attack within minutes or hours and regardless of duration remit spontaneously. Genuine regret or self-reproach & symptomfree in between episodes. 17/10/10

Contd… Epidemiology: Underreported. Male> female(80% are male.) More common in 1 st degree relative of person with this disorder. Comorbidity: Pyromania & other impulse control disorder Mood disorder, anxiety disorder & eating disorder. Substance use disorder. 17/10/10

Contd… Physical findings & Laboratory investigation: High incidence of soft neurological sign(reflex asymmetry). Non specific EEG findings & abnormal neuropsychological testing result. MRI suggest abnormality in prefrontal cortex. Course & prognosis: Begin at any stage of life(usually late adolescence- early adulthood) Onset- sudden, Course- chronic. Decreases in severeity with the onset of middle age. 17/10/10

Contd… Treatment: Psychotherapeutic approach - Group psychotherapy. - Family therapy. Pharmacotherapy: - Anticonvulsant: Carbamazepine,Valproate/ divalproate,Phenytoin & gabapentin - Lithium. - Antipsychotic: phenothiazine,SDA - SSRI, trazodone, bupropion, propranolo,CCB.

KLEPTOMANIA: Recurrent failure to resist impulses to steal objects not needed for personal use or for monitory value. The objects taken are often given away, returned surreptitiously or kept and hidden. Mounting tension before the act followed by gratification & lessening of tension with or without guilt, remorse or depression after the act. The stealing is not planned & does not involve others. Object stolen is not the goal, the act of stealing is the goal. 17/10/10

Contd… Epidemiology: Prevalence 0.6%. Male: female= 1: 3. Comorbidity: Major affective illness mainly depressive. Anxiety disorder. Other impulse control disorder mainly pathological gambling. Eating disorder. Substance abuse disorder mainly alcoholism. 17/10/10

Contd.. Course & prognosis : Begins in childhood. Course- chronic but waxes & wanes. Spontaneous recovery is unknown. Prognosis with treatment can be good. Treatment: Psychotherapy : insight oriented psychotherapy & psychoanalysis. Behavior therapy : Systematic desensitization & aversive conditioning. Pharmacotherapy: - SSRI - fluoxetine, fluvoxamine. - TCA -trazodone. - Lithium, valproate, naltraxone.ECT

Pyromania: It is recurrent, deliberate & purposeful setting of fires. Associated with tension or affective arousal before setting fire. Fascination with or interest or curiosity about or attraction to fire & activities & equipment associated with firefighting. Pleasure, gratification or relief when setting fire or when witnessing or participating in the act. 17/10/10

Contd.. Epidemiology : Prevalence: No data available. Male: female = 8:1. More than 40% arrested arsonist is younger than 18 yrs. Comorbidity: Substance abuse disorder mainly alcoholism. Affective disorders. Other impulse control disorder mainly kleptomania. Personality disorder mainly borderline PD Attention deficit & learning disabilities. 17/10/10

Contd.. Course & Prognosis: Begins in childhood. When onset in adulthood fire setting tend to be destructive. Course: Episodic with waxes & wanes. Prognosis for treated child is good. Treatment: Behavioral approach: supervision of parents to prevent repeated episode of setting fire. Family therapy. Intensive intervention to prevent & not for punishment.

Pathological gambling: Persistent & recurrent maladaptive gambling that causes economic problems & significant disturbance in personal ,social & occupational functioning. Aspects of maladaptive behavior include: A preoccupation with gambling. Need to gamble with increasing money to achieve desired excitement. Repeated unsuccessful efforts to control, cut back or stop the act. Gambling to recoup loss. Lying to conceal the extent of the involvement. Commission of illegal act to finance gambling . Reliance on others for money to pay off the debts.

Contd.. Epidemiology: Prevalence: 3-5% White man of comfort economical background,35-50yrs. Comorbidity: Mood disorder- major depression & bipolarity. Substance abuse disorder mainly alcohol,coccaine,caffine,nicotine. ADHD. Full blown OCD is uncommon. 17/10/10

Contd.. Psychological Testing & Laboratory Examination: Abnormalities of platelet MAO activity. High impulsivity on neuropsychological test. Cortisol level in saliva while they gamble. Course & Prognosis: Begins in adolescence in male & late in life in female. Phases: The wining phase. The progressive loss phase. The desperate phase. The hopeless stage.

Contd... Treatment: Hospitalization: helps by removing the patient from environment. Insight oriented psychotherapy. Family therapy. Cognitive behavioral therapy. Pharmacotherapy: Addictive type: Naltraxone. OCD type: SSRI. Impulsive type: Carbamazepine.

Trichotillomania: Coined by French dermatologist Francois Hallopeau . Recurrent pulling out of one’s hair resulting in noticeable hair loss. An increasing sense of tension immediately before pulling out the hair or attempting to resist the behavior. Pleasure, gratification or relief during pulling out the hair. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. 17/10/10

Contd.. Epidemiology : Prevalence: 0.6- 3.4% Male: female = 1:9. 33-40% Trichotillomania patient develops trichophagia. Comorbidity: OCD. Taurett’s syndrome. Affective illness mainly depressive condition. Eating disorder. Personality disorder: OC PD, borderline, narcicistic PD. 17/10/10

Contd... Pathology & Laboratory Examination : Mild leukocytosis & hypochromic anemia due to blood loss. Punch biopsy of the scalp is indicated for confirmation of diagnosis. Course & Prognosis: Mean age of onset- early teens most frequently before 17 yrs. Course- not known, both chronic & remitting course can occur. Late onset is associated with increased likelihood of chronicity & poorer prognosis. In 1/3 rd patient subsides in 1 yr. In some cases lasts for two decades.

Contd.. Treatment: Involves both Psychiatrist & dermatologist. Topical steroids & hydroxizine hydrochloride. Antidepressants: TCA- clomipramine, trazodone. SSRI- fluoxetine & other related drugs. Augmentation with pimozide+ SSRI if necessary. Other drugs: Lithium, clonazepam,naltraxone. Habit reversal training.

Other impulsive disorder: Sexual addiction. Compulsive buying. Internet addiction. Cellular phone addiction.

Neurological disorder: Tourette's syndrome: It is a prototype of tic disorder. These are sudden, repetitive, stereotyped, nonrhythmic movements(motor tics) and utterance(phonic tics) that involve discrete muscle groups. Chronic tic disorder is either single or multiple, motor or phonic tics(not both) present more then a year. Corpolalia: spontaneous utterance of socially objectionable or taboo words or phrases.

Contd… Tourette's syndrome & OCD: Similarities: Both are associated with repetitive act. Both have chronic course. Similar illness in 1 st degree relative. Group A hemolytic streptococcus is associated with both the condition. SSRI is effective in both the cases. 17/10/10

Contd… Dissimilarities: Tourette's syndrome-dopamine. OCD- serotonin. Different anatomical region of brain is associated. Treatment: Pharmacotherapy: Typical antipsychotic: Haloperidol in low dose. Atypical antipsychotic: Resparidone, olanzepine in low dose. SSRI: Fluoxetine. In resistant cases: augmentation with pimozide or clonidine. Behavioral therapy: Used as an adjunct, 17/10/10

Sydenham’s chorea: Rapid uncoordinated jerking movements affecting primarily the face, feet & hands. Other motor symptoms include facial grimacing, hypotonia, loss of fine motor control & a gait disturbance. Associated with Group A beta hemolytic streptococcus infection. Recovery: - 50% spontaneously in 2-6 months - Others in 2 yrs 17/10/10

Contd… Treatment: IV antibiotic other prophylactic treatment of ARF. Dopamine antagonist: Haloperidol. Anticonvulsant: Valproate sodium. Adjunct therapy with pimozide. 2 nd line treatment : Immunomodulatory treatment with steroid, IV immunoglobulin, plasmapherssis.

Torticollis(neck wry): Head is tilted towards one side & chin is elevated & turned towards the opposite. Causes: Congenital. Acquired: - Atlantoaxial rotatory sublaxation. - Tumor of the skull base(post. Cranial fossa) - Adenoidectomy. - Use of antipsychotic. 17/10/10

Contd… Treatment: Gentle stretching exercises (The face is turned away from the affected muscle while the head is tilted in the opposite direction with the neck extended. This position is held for a count of 5 and repeated 10 times twice daily. 17/10/10

Autism: Marked impairment in reciprocal & social & interpersonal interaction. Absent social smile. Lack of eye to eye contact. Lack of awareness of others existence or feeling treats people as furniture. Lack of attachment to parents and absence of separation anxiety. No or abnormal social play; prefers solitary games. Marked impairment in making friends. Lack of imitative behavior. Absence of fear in presence of danger. 17/10/10

Contd… Treatment: Behavioral therapy. Psychotherapy. Pharmacotherapy: Antipsychotics: haloperidol, chlorpromazine, resperidone. Anticonvulsants: to control seizure. Others: SSRI, amphetamine, methysergide, imipramine, multivitamins, triiodothyronine. 17/10/10

Preoccupation with bodily sensation: Eating Disorder: Anorexia Nervosa: Female> male. Mean age: 13-19 yrs. Intense fear of becoming obese. Body image disturbance. Refusal to maintain body weight above a normal minimum weight for the age, sex & height. Significant weight loss(> 25% of original body weight). Amenorrhea(primary/secondary) in female & impotency in male. 17/10/10

Contd.. Treatment: Short term treatment ensure weight gain. Long term treatment maintain near normal weight. Modalities: Behavioral therapy. Individual psychotherapy. Hospitalisation. Group therapy & family therapy. Pharmacotherapy- chlorpromazine, antidepressant, cyproheptadine. 17/10/10

Hypochondriasis: Persistent preoccupation with a fear(or belief) of having one or more serious disease(s), based on the person’s own interpretation of normal body function or a minor physical abnormality. Important features: complete physical examination & investigations are normal. Fear persists despite assurance to the contrary. The fear or belief is not delusion. Preoccupation with medical terms & syndromes. Onset- late third decade. 17/10/10

Contd… Treatment: Often difficult. Supportive psychotherapy. Treatment of associated or underlying depression and/or anxiety, if present. 17/10/10

Body dysmorphic disorder: Excessively concerned about & preoccupied by a imagined or minor defect in their physical features. Complains specific features or a single feature, or a vague feature or general appearance causing psychological distress that impairs occupational /social functioning. Prevalence: 1-2% of world population. 17/10/10

Contd… Common symptoms: Obsessive thoughts about perceived appearance defect. Obsessive & compulsive behavior related to the thought. MDD symptoms. Delusional thoughts related to the perceived appearance defect. Social & family withdrawal, social phobia, loneliness & self imposed social isolation. Suicidal ideation. 17/10/10

Contd… Treatment: Counselling and Psychotherapy. Pharmacotherapy: SSRI

Depersonalisation disorder: Alteration in the perception or experience of self. It is an ‘ as if’ phenomenon. Accompanied by derealisaton . Causes significant social, interpersonal or occupational impairment. Distress/anxiety present. Insight is present. Feeling of loss of control/speech may occur. Onset & termination of episode is usually sudden. 17/10/10

Contd… Treatment: Usually not very successful though comorbid anxiety & depression can be treated. Supportive psychotherapy. Drug therapy with antidepressant; rarely amphetamine or antipsychotics are also tried.

Current Nosological Status: OCD is included under anxiety disorder. Impulse control- impulse control disorder-not elsewhere classified. Hypochondriasis is placed under somatoform disorder. Eating disorder: behavioral syndromes associated with physiological disturbances & physical factors. 17/10/10

Future Directions: As proposed by Hollandar OCD should be removed from anxiety disorder. Will be placed under Obsessive compulsive spectrum disorder under the broad heading of thought disorder. 17/10/10

CONCLUSION: Although obsessive compulsive disorder has been described since 15 th century, it was thought to be rare.OCD was often thought to be an affliction requiring religious intervention. The catholic church, labeled the condition ‘excessive scrupulosity’ when rituals & compulsions were exhibited by priest & parishioners. OCD is unique among anxiety disorder by appearing to be much more dominated by cognitive & related complex behavioral symptomatology with autonomic dysregulation playing little role.

Bibliography: CTP- Kaplan & Sadock ; 8 th edition. Synopsis of Psychiatry- Kaplan & sadock; 10 th edition. Textbook of Post graduate psychiatry- Vyas & Ahuja. A short textbook of Psychiatry; Niraj Ahuja. Handbook on OCD- Abbott India limited. Obsessive- compulsive & related disorders- Lorrin M. koran. ICD-10. DSM-IV. Internet: www. wikipedia .com www. emedicine.com. www. medspace.com. www. googleimage.com. 17/10/10

Obsessive compulsive spectrum disoder

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