Obsessive Compulsive Disorder

recurrent and persistent thoughts, urges, or images that are experienced at some time during disturbance, as intrusive and unwanted and in most individuals cause marked anxiety or distress

obsession

individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other though or action

obsession

repetitive behaviors or mental acts that individual feels driven to perform in response to obsession or according to rules that must be applied rigidly

compulsion

behaviors or mental acts aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation, behaviors or mental acts not connected in realistic way with what they are designed to neutralize or prevent, or are clearly excessive

compulsion

OCD specifier: individual recognizes OCD beliefs are definitely or probably not true or that they may or may not be true

with good or fair insight

OCD specifier: individual thinks OCD beliefs are probably true

with poor insight

OCD specifier: individual is completely convinced that OCD beliefs are true

with absent insight/delusional beliefs

OCD specifier: individual has current or past history of a tic disorder

tic-related

repetitive thought, intrusive and unwanted repetitive thoughts, urges, or impulses that often lead to a marked increases in anxiety or distress

obsession

repetitive action, repetitive behaviors or mental acts that are done in response to obsessions, or in a rigid, rule-bound way

compulsion

lifetime prevalence of OCD in general population

2-3%

OCD % outpatient in psych clinic

10%

OCD mean age of onset, 19 men, 22 women

20

OCD lifetime prevalence of MDD

67%

OCD lifetime prevalence of social phobia

25%

dysregulation of this neurotransmitter is involved in symptom formation of ocd

serotonin

OCD % who had premorbid obsessional traits

15-35%

OCD termed obsessive-compulsive neurosis from what phase of psychosexual development

oedipal to anal

most common symptom pattern of obsession in adults

contamination

2nd most common symptom pattern of obsession in adults

pathologic doubt

other common symptom pattern of obsession in adults

somatic, need for symmetry, aggressive

most common symptom pattern of compulsion in adults

checking

2nd most common symptom pattern of compulsion in adults

washing

other common symptom pattern of compulsion in adults

counting, need to ask, symmetry and precision, hoarding

most common symptom pattern of obsession in pediatrics

concern or disgust with bodily wastes or secretions

2nd most common symptom pattern of obsession in pediatrics

fear something terrible may happen

other common symptom pattern of obsession in pediatrics

concern or need for symmetry, scrupulosity

most common symptom pattern of compulsion in pediatrics

excessive or ritualized handwashing, showering

2nd most common symptom pattern of compulsion in pediatrics

repeating rituals

other common symptom pattern of compulsion in pediatrics

checking doors, cleaning, touching

OCD differential, new onset ocd in older individual

basal ganglia disease

OCD differential, 90% of patients have compulsive symptoms

Tourette’s

conditions easily distinguished in that only OCD is associated with true syndrome of obsessions and compulsions, in this disorder is ego-syntonic

OCPD or obsessive compulsive personality disorder

distinguish OCD from this are patients with OCD acknowledge unreasonable nature of symptoms

psychosis

OCD % precipitated by stressful event

50-70%

OCD fraction with MDD

1/3

factors associated with poor prognosis in OCD

childhood onset, bizarre compulsion, delusional belief, need of hospitalization, presence of personality disorder, yielding rather than resisting to compulsion, presence of overvalued ideals

factors associated with good prognosis in OCD

good social and occupational adjustment, presence of precipitating event, episodic nature of symptoms

pharmacological treatment for OCD

SSRI fluoxetine or clomipramine

therapy for OCD

behavioral therapy, psychotherapy

OCD due to another medical condition

PANDAS - Pediatric autoimmune neuropsychiatric disorder associated with streptococcus

OCD-like symptoms reported in children following

group A β-hemolytic streptococcal infection

persistent preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

body dysmorphic disorder

body dysmorphic disorder patients worry about how many body areas

5-7

body dysmorphic disorder commonly associated symptoms

ideas or delusions of reference

body dysmorphic disorder most common location worry

hair

body dysmorphic disorder 2nd most common location worry

nose

body dysmorphic disorder 3rd most common location worry

skin

body dysmorphic disorder patient of more than % has preoccupation with a particular aspect of appearance

50%

body dysmorphic disorder patient more than % had experience major depressive episode

90%

body dysmorphic disorder patient experienced anxiety disorder

70%

body dysmorphic disorder patient experienced psychotic disorder

30%

neurotransmitter involved in body dysmorphic disorder

serotonin

BDD differential, excessive bodily preoccupation generally restricted to concerns about being fat

anorexia nervosa

BDD differential, sense of wrongness about, his or her primary and secondary sex characteristics

gender identity disorder

BDD differential, mood congruent cognitions involving appearance that occur exclusively during

major depressive episode

BDD differential, may worry about being embarrassed by imagined or real defects in appearance

avoidant personality disorder or social phobia

BDD differential, preoccupation with imagined defect in appearance is held with a delusional intensity

delusional disorder, somatic type

BDD treatment

fluoxetine, clomipramine

% of patients in plastic surgery clinic had BDD as diagnosis

7-8%

persistent difficulty discarding or parting with possessions, regardless of actual value

hoarding disorder

common and often disabling phenomenon associated with impairment in eating, sleeping, grooming

compulsive hoarding

people with the disorder acquire things of little or no values and cannot throw them away

compulsive hoarding

commonly hoarded items in compulsive hoarding

newspapers, mail, magazines, old clothes, bags, books, lists, notes

hoarding disorder occur in what percent of population

2-5%

lifetime prevalence of hoarding disorder

14%

comorbidities associated with hoarding disorder

ADHD, schizophrenia, dementia, eating disorders, kleptomania, compulsive gambling

% of hoarders reporting at least 1 first-degree relative with hoarding behavior

80%

gene on chromosome 22q11.21 that can contribute to genetic susceptibility

COMT gene

hoarding disorder differentials

OCD, dementia, schizophrenia, bipolar disorder

most effective treatment for hoarding disorder that includes training in decision making and categorizing

cognitive behavioral therapy

recurrent pulling out of one’s hair, resulting in hair loss; repeated attempts to decrease or stop hair pulling

trichotillomania

trichotillomania coined by ? in 1889. trich (hair), and tillein (to pull/pluck)

Francois Hallopeau

hair pulling type, use of intentional act to control unpleasant personal experiences such as urge, bodily sensation

focused pulling

hair pulling type, occurs outside person’s awareness and most often during sedentary activities

automatic pulling

lifetime prevalence of trichotillomania

0.6-3.4%

trichotillomania female to male ratio

10:1

percent of patients with hair pulling disorder chew or swallow hair that they pull out

35-40%

fraction of patients with trichotillomania that develop hazardous bezoars (hairballs)

1/3

trichotillomania differentials

OCD, factitious disorder, stereotypic movement disorder

trichotillomania most frequent before age of

17

early onset of trichotillomania at what age and tends to remit more readily

6

late onset of trichotillomania associated with increased likelihood of chronicity and poorer prognosis

13

trichotillomania pharma treatment

topical steroids and hydroxyzine hydrochloride (Vistaril)

trichotillomania treatment/therapy

insight-oriented psychotherapy

recurrent skin picking resulting in skin lesions, repeated attempts to decrease or stop skin picking

excoriation disorder

excoriation disorder patients felt embarrassed

87%

excoriation disorder patients avoiding social situations

58%

lifetime prevalence of excoriation disorder in general population

1-5%

comorbidities associated with excoriation disorder

OCD, trichotillomania, substance dependence, MDD

excoriation disorder abnormalities in what neurotransmitter metabolism

serotonin, dopamine, glutamate

most common site of skin picking

face

nonpsychiatric differentials for excoriation disorder

eczema, psoriarsis, diabetes, liver or kidney disease

psychiatric differentials for excoriation disorder

OCD, body dysmorphic disorder, substance use disorder

skin-picking is target of self-inflicted injury and patient uses more elaborate methods to self-induce skin lesions. presence of completely normal, unaffected skin adjacent to horrific-looking lesions

factitious dermatitis

onset of skin-picking disorder either in early adulthood or between

30-45 years old

onset in children of excoriation disorder before what age

10

mean age of onset between what age in excoriation disorder

12-16

% of women report amount of picking coincides with menstrual cycle

44%

treatment of excoriation disorder

SSRIs, lamotrigine, habit reversal, cognitive-behavioral therapy