Obsessive Compulsive Disorder

1. 2007 Obsessive Compulsive Disorder

2. Who gets it • Any age form 6yrs – first time in old age • Prevalence • 0.25% 5-15yr olds • 0.8% in adults • In the WHO top 20 of most disabling diseases • Persists if untreated • Effective treatments are available

3. Symptoms • Obsessions • Intrusive thoughts (ideas, images or impulses) that repeatedly enter a person’s mind against his or her will. They generate considerable anxiety and are difficult to dismiss.

4. Symptoms • Compulsions • Rituals or repetitive acts that are performed in an attempt to reduce anxiety caused by the obsessions. The relief is only temporary. Later in the course of the illness the rituals can become more automatic and increase, rather than reduce the anxiety.

5. Psychological theories • Psychological theories suggest that ritualising maintains the problem as it prevents habituation to the anxiety and disconfirmation of the patients fears. • Psychological therapies aim to break this cycle by persuading the patient to expose themselves to the feared situation whilst refraining from performing any ritual = exposure and response prevention

6. Definition of OCD • Either obsessions or compulsions or both present on most days of the week for 2/52 • Obsessions and compulsions share the following features • Acknowledged as originating in the mind of the patient • Repetitive and unpleasant and at least one recognised as excessive or unreasonable • At least one unsuccessfully resisted • Carrying out obsessive thought or compulsive act not intrinsically pleasurable

7. Obsessions • Fear of causing harm to someone else • Fear of harm coming to self • Fear of contamination • Need for symmetry and exactness • Sexual and religious obsessions • Fear of behaving unacceptably • Fear of making a mistake

8. Compulsions • Behaviours • Cleaning • Hand washing • Checking • Ordering and arranging • Hoarding • Asking for reassurance

9. Compulsions • Mental acts • Counting • Repeating words silently • Ruminations • Neutralising thoughts

10. Quick Screen for OCD • Do you wash or clean a lot • Do you check thing a lot • Is there any thought that keeps bothering you that you would like to get rid of • Do your daily activities take a long time to finish • Are you concerned about orderliness or symmetry • Do these problems trouble you

11. Treatments • Patient and family need to understand the condition • Need help not to feel blame or shame • Clinician needs to instil optimism about recovery

12. Treatment • CBT • Exposure and response prevention therapy • Response rate of up to 85% in those that complete therapy • Patient generates a hierarchy of feared situations and then practises experiencing the situation whilst monitoring the anxiety and experiencing that it lessens without having to carry out the ritual • Start with easiest challenges

13. Treatment • Cognitive therapy • Therapists use cognitive strategies encouraging patients to re-evaluate overvalued beliefs about risk or personnel responsibility. • Whether the addition of cognitive beliefs increases the response rate to exposure and response preention therapy is unknown.

14. Treatments • Drugs • OCD responds to drugs that inhibit the synaptic reuptake of serotonin. i.e. TAD’s (clomipramine) and the more highly selective SSRI’s • Therapeutic response to these drugs increases gradually over weeks and months up to 6/12 requiring a trial of 12/52 at maximum tolerated dose • Relapse often occurs if drugs stopped

15. Treatments • CBT or drugs • Children and adolescents • Try CBT first line as has fewer risks • Adults • CBT or drugs can be offered first • Uncertain whether combining CBT and drugs is superior to either alone. • 40% fail to respond adequately to either treament

16. Conditions related to CBT • Trichotillomania • Hypochondriasis • Anorexia nervosa • Gilles de la tourette’s syndrome