Obsessive Compulsive Disorder
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Introduction
Affects less than 1% of youth, and 2-3% of adults. Onset is usually during childhood and adolesence.
can be either obsessions or compulsions
- significant distress
- take at least one hour per day
- affect functioning
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Pathophysiology
Three psychological dysfunctions seem to be related to OCD:
- abnormal risk assessment
- pathological doubt
- need for certainty or perfection
Genetics
- 10% of patients have direct relatives with OCD (Pauls, 1986)
There are direct neurological correlates to OCD
- basal ganglia (caudate), witht thalamic and frontal cortex involvement
- appears to be serotonin abnormality
- traumatic brain injury
Signs and Symptoms
- history
- physical exam
History
- repetitive resisted, recognized, not real
Obsessions:
usually one of three underlying themes:
- abnormal risk assessment
- pathological doubt
- need for certainty and perfection
recurrent thoughts, impulses or images that intrude and cause marked anxiety or distress. Patients make efforts to ignore or suppress.
Compulsions:
Repetitive, purposeful, intentional behaviours (checking) or mental acts (counting) driven to do things or rules to prevent dreaded event. These are drive by obsessions and typically according to certain rules design to respond to obsessions. Compulsions include:
- cleaning, washing
- checking
- ordering or arranging
- counting
- collecting, hoarding
can be ego dystonic (unnatural) or ego syntonic (connected with who you are)
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Differential Diagnosis
Co-morbid conditions include:
- Depression is common (50%) as function is progressively impaired by OCD
- phobias, panic disorders
- alcohol abuse
- Tourette's syndrome in 20-40%
Treatments
As you fight one, a new one can come in. but kicking the new one's butt is easier to stop.
"A new one slides in"
mild OCDs can be treated by behaviour therapy
moderate-severe OCD: SSRI/clomipramine (serotonergic TCA) plus behaviour therapy
- if no effect, change SSRI or add another SSRI, or perhaps buspirone
if tics, trichotillomania, delusional symptoms present, add pimozide, haloperidol, lithium
psychotropics work 50:50; takes months to kick in
fixed dose RCTs - 12 weeks of fluoxetine (20 mg, 40 mg, 60 mg) = 52%, 54%, 58%
- more or less the same effects, but people get onto high dose because of the lag in treatment effect
Consequences and Course
Resources and References
Topic Development
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