OCD

1. What are the criteria for OCD (3)

2. What are obsessions?

3. What are compulsions

4. What are the different specifiers

Criteria for Obsessive- Compulsive Disorder

• Obsession or compulsions or both

• PT realizes excessiveness/unreasonable

• obsessions or compulsions are time-consuming or causes distress/impairments

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Obsessions

• Recurrent/persistent thoughts, urges or images that are intrusive/ inappropriate -> anxiety or distress

• Pt attempts to ignore/suppress/neutralize

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Compulsions

• Actions pt feels driven to perform in response to obsession or rigid rules 

• Actions aimed at preventing/reducing anxiety/distress or preventing dreaded event

  • No logical connection or logical excess

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Specifiers:

• Good/fair insight

• Poor insight

• absent/delusional beli

Biological findings?

Biological Findings

• Dysfunction @ Corticostriatal circuit

  • Orbitofrontal cortex

  • Caudate nuclei

  • Globus pallidus

• Also maybe @ basal ganglia 

1. What are the biological findings

2. Patterns of Anxiety?

   • Panic attacks

   • Anticipatory anxiety

   • Typical cognitions

   • Typical physical symptoms

   • Typical behaviors

Biological Findings

• Dysfunction @ Corticostriatal circuit

  • Orbitofrontal cortex

  • Caudate nuclei

  • Globus pallidus

• Also maybe @ basal ganglia 

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Pattern of Anxiety

• Panic attacks

  • If present, related to obsessive fears

• Anticipatory anxiety

  • For situations that trigger obsessions or compulsions

• Typical cognitions

  • Obsessive fears of contamination, causing harm to others, not doing something “just right”

• Typical physical symptoms

  • Nonspecific

• Typical behaviors

  • Washing/cleaning, checking, ordering, avoiding contaminants

What are the treatments of OCD?

• First line: 4

• Second line: 1

OCD: Treatment

• First-line

  • SSRI’s

  • Clomipramine

  • Cognitive-behavioral therapy

    • Exposure therapy

    • Fear and avoidance hierarchy

  • Family therapy

• Second-line

  • Atypical antipsychotic augmentation

1. What are the Dx criteria for Body Dysmorphic Disorder (3)

2. Specifiers?

3. How to treat

Body Dysmorphic Disorder Diagnosis Criteria

• Preoccupation with perceived defects or flaws in physical appearance

  • Benign or not observable to others

• Pt performed repetitive behaviors or mental acts in response to perception

• Causes clinically significant distress/impairment

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Specifiers

• With muscle dysmorphia

  • Preoccupation with small or insufficiently muscular body build

• With good or fair insight

• With poor insight

• With absent insight/delusional beliefs

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How to treat:

• Express empathy and instill hope

• Education 

• Focus on suffering and impact on life

• First-line treatments:

  • CBT: 

  • SSRI’s 

• No evidence for efficacy with antipsychotics

• Don’t refer to a plastic surgeon

Describe Hoarding Disorder

• Dx criteria

• Tx

  • Focuses on?

  • Plans?

Hoarding Disorder

• Dx Criteria:

  • Persistent difficulty discarding possessions

    • Regardless of value

  • Difficult b/c perceived need to save items + distress discarding

  • Causes sig. distress or impairment

• Tx:

  • Focuses on:

    • Excessive acquisition

    • Difficulty discarding

    • Disorganization/Cluttering -> impairs function 

  • Plans:

    • CBT

      • Thoughts and feelings about not acquiring things

        • Avoidance of anxiety due to lack of object

        • Test what will happen if does not acquire

      • Thoughts and feelings about getting rid of possessions

        • Avoids anxiety about being less than perfectly prepared

        • Testing of predictions about how this will feel

  • Data very limited on psychopharmacological interventions

    • Maybe SSRIs

Describe Trichotillomania

• Dx criteria

• Tx (4)

Trichotillomania

Dx Criteria:

• Recurrent pulling of hair -> hair loss

• Has repeated attempts to stop behavior

• Sig. distress/impairment 

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Tx:

• Behavior therapy

  • Self-monitoring 

    • (habit record)

  • Habit reversal

    •  (apply barriers to hairpulling)

    • FIRST LINE TREATMENT

• Meds:

  • Clomipramine 

    • most promising

  • N-acetylcysteine 

    • (glutamate modulator)

  • Memantine

  • olanzapine

• Cog. Therapy

  • Correct faulty beliefs about self; improve self-esteem

• Hypnosis

Describe Excoriation Disorder

• What is it?

• Tx (4)

Excoriation Disorder

What is it?

• Recurrent skin picking -> lesions

• Attempts to stop

• Sig. Distress 

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Tx:

• Meds

  • SSRI’s

  • lithium, gabapentin, olanzapine

  • Low dose doxepin (cyclic AD) may help

• Behavior therapy

  • Self-monitoring

  • Habit reversal 

• Cog Therapy

• Hypnosis

Describe PANDAS

• AKA

• What is it?

• Labs

• MOA

• Tx

PANDAS

• AKA:

  • Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection

• What is it:

  • Strep infection -> OCD/Tics/Basal Gang. Dysfunction

    • Glabellar tap reflex

    • Tongue movements

    • Milkmaid’s grip

    • Choreiform movements

• Labs:

  • Positive anti-streptococcal antibody titer

• MOA:

  • Unknown; possible ABs interfere w/ basal ganglia function

• Tx:

  • SSRI 

  • CBT