Obsessions

• repetitive and constants thoughts, images, or impulses that cause anxiety or distress

• thoughts, images, or impulses not about real-life problems

• Try to ignore or counter act thoughts, images, or impulses

• thoughts, images, or impulses “recognized as a product of one’s own mind and not imposed from without”

Compulsions

• Repetitive behaviors or mental acts person does in reaction to obsessions

• behaviors or mental acts done to avoid or decrease distress

• behaviors or mental acts are clearly excessive or not realistic

• ICD-10(F.42)

• DSM IV TR (300.3)

Obsessive-Compulsive Disorder

• Obsessions- repetitive unwanted ideas that the person recognizes are irrational

• Compulsions- repetitive, often ritualized behavior whose behavior serves to diminish anxiety caused by obsessions

EPIDEMIOLOGY

• Affects almost 3% of world’s population

• In India life time prevalence of OCD is 2-3%

• common in persons from upper social class and with high intelligence

Demographic characteristics

• Gender Distribution

Women appear to develop OCD slightly more frequently than men (1.5:1)

Males develop OCD at a younger age than do females

• Marital status

% of patients who had never married was significantly higher rate

In India OCD is more common in unmarried males. (other countries are not reported)

Course and nature of history

• Age at onset

Usually in childhood or early adult life

The onset for males occurred earlier than for females (19.5±9.2 yrs Vs 22.0 ±9.8yrs)

• Course of illness

It is continuous and chronic in which patients rarely symptom free at follow up

• A long term follow up studies shows that about 25% remained unimproved overtime, 50% had moderate to marked improvement while 25% had recovered completely.

I.BIOLOGICAL THEORIES:

• NeurotransmittersBrain Serotonin(5HT) function may

contribute to anxiety symptoms

• Noradrenalin

Higher plasma free 3- methoxy 4-hydroxy phenyl glycol and plasma nor-epineherine levels

• GeneticsFamily history:- OCD is found in 5-7% of

first degree relatives of patients with OCDStrongest evidence comes from twin

studies

Electro physiological studies

EEG abnormalities can lead to OCD

( temporal lobe spikes and increased theta waves in sleep EEG)

Neuropsychological studies

• Frontal deficit, although non dominant –parietal deficits also seen in patients with OCD

Brain imaging

Cranial CT and MRI scans

Non specific abnormalities are found in patients with OCD

PET scans indicate differences in brain activity of OCD patients versus normal

II. Behavioral theories

Learning theory suggest that obsession ritual are the equivalent of avoidance responses.

Ritual acts produce relief and thus through negative reinforcement increase the possibility of repetition of the phenomena

Psychodynamic theory

• Freud suggested that obsessional symptoms results from repressed impulses of an aggressive or sexual nature.

• Obsession symptom occur as a result of regression to the anal stage of development

• It is consistent with the obsessional patient’s frequent concerns over excretory functions and dirt

Anal sadistic phase

Reaction formation

Anxiety related to oedipal conflicts

Obsessional Personality

traits

New defenses

Isolation affect

Regression

Fixation in development

In presence of fixation

at anal sadistic phase

undoing Displacement

Early Childhood

Disturbed development in

Normally disguised by

Reinforcement of anal/aggressive impulses

Obsessive thoughts compulsive acts phobias

Needed as reaction formation is not enough

At present

Clinical features

• Four clinical syndromes

1. Washers

2. Checkers

3. Pure obsessions

4. primary obsessive slowness

washers

• Obsession is with contamination with dirt, germs, body excretions etc.

• Compulsion is washing of hands or the whole body repeatedly many times a day

( clothes, bath room, door knobs, personal articles)

Checkers

• Person has multiple doubts

( door has not been locked, kitchen gas has been left open, counting of money was not exact)

• Compulsion of course is checking repeatedly to remove the doubts.

Pure obsessions

• Repetitive intrusive thoughts, impulses or images which are not associated with compulsive acts. The content is usually sexual or aggressive in nature.

• A variant is obsessive rumination, the person ruminates in his mind about pros and cons of the thoughts concerned, repetitively

Primary obsessive slowness

• Severe obsessive ideas or extensive compulsive rituals leads to marked slowness in daily activities.

Assessment of OCD

Maudsley obsessional compulsive inventory (MOCI)

30 items –true or false questionnaire

Yale Brown obsessive compulsive scale (Y-BOCS)

Rating on time spent, interference, distress, resistance and control for obsessions and compulsions

Diagnosis-ICD-10(F.42)• Either obsessions or compulsions (or both), present on

most days for a period of at least two weeks.• The obsessional symptoms should have the following

characteristics:a. They must be recognized as the individuals own thoughts

and impulsesb. There must be at least one thought or act that is still

resisted un successfully, even though others may be present which he sufferer no longer resists

c. the thought of carrying out the act must not in itself be pleasurable

d. the thoughts, images or impulses must be unpleasantly repetitive.

Differential diagnosis

Generalized anxiety disorderPanic disorderPhobic disorder Depressive disorderSchizophreniaOrganic cerebral disorders

Types

• F42.0 Predominantly obsessional thoughts and ruminations

• F42.1 Predominantly compulsive acts• F42.2 Mixed obsessional thoughts and acts• F42.8 Other obsessive-compulsive

disorders• F42.9 Obsessive-compulsive disorder,

unspecified

Pharmacological management

• Benzodiazepines :-eg-alprazolam, clonazepam.• Antidepressants:-

SSRI:-

eg- clomipramine 75-300mg/day

Fluoxetine 20-80mg/day

Sertraline

Fluoxamine

Cont….

• Antipsychotics:-

Eg:- haloperidol, risperidone, olanzapine

• Buspirone (anxiolytic)

Psychotherapy

• Psychoanalytic therapy (patients)

• Supportive psychotherapy (patients and family)

Behavioral therapy

• Techniques

Thought stoppingResponse preventionSystematic desensitizationmodeling

Electro convulsive therapy

• Indications:-Severe depression with OCDRisk of suicide Poor response to other mode of treatment

• ECT is not the treatment of first choice in OCD

Psychosurgery

• Perform incase of not responding to other mode of treatment

• benefit is the marked reduction in associated distress and severe anxiety

• Procedures Stereotactic limbic leucotomyStereotactic subcaodate tractotomy

Reference

• Mary c Townsend.psychiatric mental health nursing,3rd edition

• Oxford text of psychiatry. 2nd edition

• Judith Haber, Anila S . Comprehensive psychiatric nursing. 5th edition

• ICD- 10 classification of mental and behavioural disorder

• www.mayoclinic.com/.../obsessive-compulsive-disorder/DS00189

• www.webmd.com/anxiety.../obsessive-compulsive-disorder