E1: behavioral health - obsessive-compulsive and related disorders

what disorder is characterized by obsessions, compulsions or both that are time consuming (more than 1 hour per day) and cause significant distress or impairment in social, occupational or other important areas of functioning?

OCD

recurrent and persistent thought, urges or images

obsessions

repetitive behaviors or mental acts

compulsions

when does OCD typically present?

~ 19 y/o

if OCD presents before age 11, what disease is often associated?

Tic disorder

what are causes of OCD?

familial component

group A strep infection → PANDAS

hormonal changes

s/p trauma or neuro lesions

abnormal neuroanatomical circuits in the brain

in children with suspected cases of OCD, look for signs of??

Autism

Anxiety disorder

behavior disorders

hair pulling

ADHD

depression

in adults with suspected cases of OCD, look for signs of??

generalized anxiety disorder

phobia

mood disorder, depressive disorder

obsessive-compulsive personality disorder

Tic disorder

Trichotillomania disorder

eating disorders → anorexia nervosa, bulimia nervosa

what are common obsessions (thoughts) of OCD?

contamination fears

doubt/harm

symmetry

intrusive/forbidden thoughts (sexual, violent)

what are common compulsions (rituals) of OCD?

- compulsive washing/cleaning

- checking behaviors (locks, stove)

- counting/repeating (list making)

- routine behavior

- touching

- extreme orderliness

- hoarding

- aggressive behavior

- avoidance

what is the key difference in OCD presentation in children vs adults?

compulsions occur w/o children being able to report their obsessions

more impairment in children than adults

are children or adults more likely to include their family in their ritualistic behaviors?

children

what are psychosocial concerns of OCD?

poor work performance

family conflicts

avoidance behavior

what are medical concerns of OCD?

derm problems → skin lesions, infections

Trichotillomania

compulsive scratching

skin picking

eating disorders

↑ anxiety, depression OCD, delusions, paranoia

what is the treatment for OCD?

CBT

pharm → SSRIs, TCAs (clomipramine), SNRI (venlafaxine), atypical antipsychotics

what is the treatment for mild to moderate adult OCD?

CBT is 1st line

what is the treatment for moderate to severe adult OCD?

SSRI + CBT or SSRI alone

what is the treatment for mild to moderate pediatric OCD?

CBT is 1st line

what is the treatment for severe pediatric OCD?

CBT + SSRI (fluoxetine, fluvoxamine, sertraline)

refractory = clomipramine (TCA)

OCD responds best to _______ doses of medications

higher

what disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value resulting in accumulation of possessions that congest & clutter their living areas?

hoarding disorder (HD)

which disorder is characterized by recurrent pulling out of one's hair, resulting in hair loss most commonly on the scalp, eyebrows or eyelashes

trichotillomania

what comorbidities are seen with trichotillomania?

excoriation disorder

repetitive behaviors

OCD

trichphagia

anxiety/depression

Tourette's disorder

eating disorders

personality disorders

what is seen on physical exam of trichotillomania?

various bald spots, irregularly shaped - often concealed w wigs, scarves or makeup

broken hairs, uneven stuble

no scaling on scalp

hair density is normal

excoriations on scalp, evidence of nail biting/picking or thumb sucking

what is the treatment for trichotillomania?

psychotropic medications

topical medications

CBT

habit reversal training (HRT)

SSRI

which disorder is characterized by recurrent skin picking resulting in lesions most commonly on the face, arms and hands?

excoriation (skin-picking) disorder

what are causes of excoriation disorder?

manifestation of repressed rage

stress

pleasure

acne

what DDx should you have in mind with excoriation disorder?

methamphetamine use

what is the treatment for excoriation disorder?

CBT

topical/systemic ABX

topical steroids

semi-occlusive dressings

SSRIs → start at lowest dose

habit reversal training