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Obsessive Compulsive Disorder ( OCD )

Obsessive-compulsive disorder ( OCD ) is characterized by the presence of either obsessions or compulsions , but commonly both

 

Obsession is defined as an unwanted intrusive thought , image or urge that repeatedly enters the persons mind that are ego-dystonic

 

Compulsions are repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied

 

How common- Described as common condition in literature Prevalence quoted in papers ranges from 1% to 3 % ( Pallanti et al )
○ Weissman MM et al report that OCD occurs in 1.2 % of the population in US
○ NICE ( 2005 ) quotes a range of 1-2 % and adds that some studies have estimated the rate to be between 2% to 3 %
○ Albina et al inform that epidemiological surveys describe current and lifetime prevalence rates of full blown OCD around 1 % and 2.5 % respectively About 1/3rd of the adult population report experiencing obsessions or compulsions at some point of their lives OCD is described as the 4th most common psychiatric illness and a leading cause of disability ( Y C Janardhan Reddy et al 2017 ) Mean age of diagnosis 20 yrs, 70 % onset before age 25 , 15 % after age 35 
( Oxford handbook of psychiatry ) Men, women suffer equally ( most studies )

 

What happens Possibly result from multiple variables Genetic factors have been implicated Environmental and hereditary factors Role of glutamate , dopamine and possibly other neurochemicals has been suggested OCD has also been reported as neuro-psychiatric disorder

 

Risk factors – Age ( more common in young adults ) Genetics – OCD tends to run in families Presence of other psychiatric / social conditions as
○ anxiety disorders ○ depression ○ Tourette syndrome ○ ADHD ○ substance abuse ○ eating disorders○ some personality disorders ○ emotional physical and sexual abuse , neglect ○ social isolation ○ bullying Stress Pregnancy and post-partum.

 

Morbidity and mortality – In a study in Denmark ( Sandra M Meier et al 2016 ) it was found that the risk of premature death among persons with OCD was doubled compared with general population It is well known that individuals with OCD frequently have additional psychiatric conditions concomitantly or at some time during their lifetime Misdiagnosis is common People with OCD have a reduced QoL and suffer high levels of social and occupational impairment Even with appropriate treatment symptoms can wax and wane Symptoms which often start during childhood or adolescence may persist for life Dermatitis ( due to excessive hand washing ) Increased risk of self harm and suicide.

 

Screening questions – Do you have frequent unwanted thoughts that seem uncontrollable Do you try and get rid of these thoughts and if so what do you do Do you have rituals and repetitive behaviours that take a lot of time in a day Do you wash or clean a lot Do you check things a lot About thoughts that keeps bothering them that they would like to get rid but can not Daily activities take a long time to finish Are they concerned about putting things in a special order or are they very upset with mess Are they bothered / troubled by these problems Do these behaviors make sense to you

 

DSM 5 diagnostic criteria

 

  • Presence of obsessions , compulsions or both Young children may not be able to articulate the aims of these behaviours or mental acts
  • These are time consuming for e.g
○ they take more than an hour / day Or these cause significant distress or impairment in
○ social
○ occupational
○ other important areas of functioning
  • These disturbances cannot be explained by any other mental disorder These can include
○ generalised anxiety disorder
○ body dysmorphic disorder
○ hoarding disorder
○ trichotillomania
○ skin picking disorder
○ stereotypic movement disorder
○ eating disorder
○ substance related and addictive disorder
○ illness anxiety disorder
○ paraphilic disorder ( sexual urges or fantasies )
○ disruptive impulse control and conduct disorders
○ major depressive disorder
○ schizophrenia spectrum and other psychotic disorders
○ autism spectrum disorder
  • Insight that the person recognises that the OCD beliefs are definitely or probably not true or that they may or may not be true – Good or fair insight they believe that the OCD beliefs are probably true – Poor insight They are completely convinced that OCD beliefs are true – Absent insight / delusional beliefs

 

Further assessment in primary care – Symptoms may start suddenly Comorbid psychiatric problemscomorbid conditions are common 
- it is reported that in their lifetime 90 % of patients with OCD would meet criteria for atleast one other psychiatric disorder
- most common ones are anxiety disorders , mood disorders particularly major depressive disorder , impulse control disorder and substance use disorder
○ patients may not disclose symptoms as they may feel embarrassed
○ h/o self harm or current thoughts
- high risk of suicide in persons with OCD– in one community survey 63 % with OCD had experienced suicidal thoughts and 26 % had attempted suicide
○ are they taking any medications
○ previous contact with mental health services
○ Social history
○ family ( relationship , children , have other members suffered with mental health problems ) 
○ occupation ( able to function , maintain occupation )
○ smoking , drug and alcohol misuse
○ support network Skin changes – frequent washing may cause 
severe dermatitis Medical history Has the patient filled a questionnaire

 

Obsessions – contamination sexual pathological doubt scrupulosity harm , aggression religious / blasphemy symmetry , exactness Others as
○ need to know remember
○ intrusive non-violent images or thoughts
○ superstitious fears
○ lucky / unlucky numbers , colours

 

Compulsions – washing / cleaning repetitive checking repeating counting ordering and arranging repetitive confession, prayer etc

 

How to manage – Provide information and support Management will be guided by 
○ degree of functional impairment – can be mild , moderate or severe
○ associated co-morbidities
○ risk of suicide and self harm
○ previous experience with treatment , engagement with mental health services
○ patient expectations Setting treatment goals Quantification of the severity can be judged by using standardized rating scales as the Yale – Brown Obsessive-Compulsive Scale 2nd edition ( find it under links )
Consider using the scale and documenting clearly level of severity if planning to initiate Rx in primary care Ability to arrange follow up / monitoring

 

Psychological treatment- for patients with mild impairment or those who prefer for a low intensity approach these include
○ CBT – including ERP ( Exposure Response Prevention )
○ these can be low intensity , more intensive
○ individual or group
○ stand alone or in combination with SSRIs

 

SSRIs – considered effective beware increased risk of suicidal thoughts and self-harm in people with depression and in younger people first line SSRIs are fluoxetine , fluvoxamine , paroxetine , sertraline or citalopram only prescribe if you are confident of your assessment of moderate functional impairment and arrange f/u and monitoring high doses are often needed

 

Clomipramine – can be used if SSRIs cannot be used Clomipramine -start with low doses Not first line toxic in overdose and patient needs to be monitored for the emergence of other psychiatric symptoms and emergence of suicidality If the patient at risk of CVD obtain and ECG / BP before starting treatment Do not use any other other tricyclic AD in 1° care

 

Refer secondary care – risk suicide patient has another significant co-morbidity as substance misuse , severe depression , eating disorder or schizophrenia treatment failure in 1° care adults with moderate or severe functional impairment women who are pregnant or post-partum 
( consider referral / advice ) children and young people under 18

 

Exposure and response prevention – ERP is a form of CBT It tries to break the two types of associations 
○ between sensation of distress and the objects , situations or thoughts that lead to this distress 
( obsession – anxiety up )
○ carrying out the ritual and decreasing the anxiety ( anxiety down )

It breaks the bond ( conditioned response ) between the feelings of anxiety and ritual behaviours 
( vicious circle of OCD )
 ERP is recommended as safe and 1st line treatment for OCD – it disonfirms people’s distorted beliefs through exposure 
( particularly effective when combined with medications )
 Based on the principle that obsessions are formed through classical conditioning and compulsions are maintained by operant conditioning

Consider referral for ERP for most people with OCD.

 

About 40- 60 % of patients may respond to clomipramine or any particular SSRI and it cannot be predicted which patient will respond to which drug

Edited by Dr Mahajan , Consultant Psychiatrist

References

  1. Ruscio, A M et al. “The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication.” Molecular psychiatry vol. 15,1 (2010): 53-63. doi:10.1038/mp.2008.94
  2. NICE Guidance OCD and body dysmorphic disorder: treatment November 2005 https://www.nice.org.uk/guidance/cg31
  3. CKS NHS Obsessive-Compulsive disorder https://cks.nice.org.uk/topics/obsessive-compulsive-disorder/
  4. Macul Ferreira de Barros, P., do Rosário, M.C., Szejko, N. et al. Risk factors for obsessive–compulsive symptoms. Follow-up of a community-based youth cohort. Eur Child Adolesc Psychiatry (2020). https://doi.org/10.1007/s00787-020-01495-7
  5. Risk factors for Obsessive-Compulsive Disorder (OCD) https://www.winchesterhospital.org/health-library/article?id=19910
  6. OCD : Epidemiology and aetiology South West London and St George’s Mental Health NHS Trust https://www.swlstg.nhs.uk/resources/ocd-bdd/ocd-a-guide-for-professionals/ocd-epidemiology-and-aetiology
  7. OBSESSIVE-COMPULSIVE DISORDER (OCD) IN GENERAL PRACTICE D J H Niehaus
    MB ChB, MMed (Psych) Consultant Psychiatrist Department of Psychiatry Stellenbosch University and MRC Unit for Anxiety and Stress Disorders Tygerberg October 2004 Vol.22 No.10 CME 565
  8. OCD Program Stanford Medicine https://med.stanford.edu/ocd/treatment/pharma.html
  9. Meier, Sandra M et al. “Mortality Among Persons With Obsessive-Compulsive Disorder in Denmark.” JAMA psychiatry vol. 73,3 (2016): 268-274. doi:10.1001/jamapsychiatry.2015.3105
  10. Pallanti, Stefano et al. “Obsessive-compulsive disorder comorbidity: clinical assessment and therapeutic implications.” Frontiers in psychiatry vol. 2 70. 21 Dec. 2011, doi:10.3389/fpsyt.2011.00070
  11. Simpson, Helen Blair, and Y C Janardhan Reddy. “Obsessive-compulsive disorder for ICD-11: proposed changes to the diagnostic guidelines and specifiers.” Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999) vol. 36 Suppl 1,Suppl 1 (2014): 3-13. doi:10.1590/1516-4446-2013-1229
  12. Diagnosing OCD https://www.ocduk.org/ocd/diagnosing-ocd/
  13. Clinical Definition of OCD https://beyondocd.org/information-for-individuals/clinical-definition-of-ocd
  14. Diagnostic and Statistical Manual of Mental Disorders and OCD https://www.ocduk.org/ocd/clinical-classification-of-ocd/dsm-and-ocd/

  15. OCD : Differential diagnosis and screening questions https://www.swlstg.nhs.uk/resources/ocd-bdd/ocd-a-guide-for-professionals/ocd-differential-diagnosis-and-screening-questions
  16. Fenske JN, Petersen K. Obsessive-Compulsive Disorder: Diagnosis and Management. Am Fam Physician. 2015 Nov 15;92(10):896-903. PMID: 26554283.
  17. Exposure and Response Prevention Marie Chellingsworth University of Exeter https://bedfordshirewellbeingservice.nhs.uk/wp-content/uploads/2020/05/Exposure-and-Response-Prevention.pdf
  18. Introduction to Exposure Therapy for Obsessive Compulsive Disorder Katherine L. Muller, Psy.D., ABPP Director & Founder Valley Center for Cognitive Behavioral Therapy
    Center Valley, PA https://cdn.ymaws.com/www.papsy.org/resource/collection/3BB998DF-0641-434F-B985-593DDD53DC1D/54_-_Exposure_Therapy_for_OCD.pdf
  19. Law, Clara, and Christina L Boisseau. “Exposure and Response Prevention in the Treatment of Obsessive-Compulsive Disorder: Current Perspectives.” Psychology research and behavior management vol. 12 1167-1174. 24 Dec. 2019, doi:10.2147/PRBM.S211117

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