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Obsessive Compulsive Disorder(OCD) Dr. Bob Carey Regional Support Associates
As Good as It Gets
What is OCD? Disorder causing worries, doubts, and superstitious beliefs during everyday life. Described by some as “mental hiccups that won’t go away”.
Obsessions? Compulsions? Obsessions – repetitive and unwelcome thoughts, images, or impulses that are difficult to dismiss or control. Compulsions – repetitive behavioral responses – can be resisted only with great difficulty. Recent studies have found lifetime prevalence of OCD in North America to be about 2.5/100 people.
Obsessions Thoughts, images, or impulses that repetitively occur to become out of one’s own control. Person suffering from these obsessions finds them intrusive and disturbing – recognizes they don’t make sense.
Obsessions - continued Obsessions often accompanied by uncomfortable feelings such as fear, disgust, or doubt. For example, people with OCD may worry excessively about dirt and germs, and obsessed with the idea that they are contaminated or may contaminate others
Compulsions These are acts that are continually performed to provide relief from discomfort caused by obsessions. OCD compulsions do not give the person pleasure (unlike drinking, gambling, etc.). For example, a person may repeatedly check to see if their stove was left on in fear of burning the house down.
Most people with OCD have multiple OCD symptoms
OCD – time spent thinking about the act and performing the act
Most Common Symptoms Sets of common obsessions and compulsions are observed in developmentally disabled individuals with OCD. Typically, these sets are described best as “just so” behaviors, in which certain things have to be arranged or performed in a particular way to relieve the anxiety. The most clinically useful and detailed symptoms checklist is included in the Yale-Brown Obsessive-Compulsive Scale.
OCD and Developmental Disability may not to be able to identify obsessions may not recognize that obsessions don’t make sense diagnosis often based on compulsions misdiagnosis is common – both inaccurate diagnosis of OCD or misdiagnosis of another disorder.
Common Themes The most common theme of obsessions are contamination themes, and the related compulsive behavior is washing, usually compulsive handwashing. Along with contamination themes, problems with aggressive obsessions, sexual obsessions, the need for symmetry and order, obsessions about harm to oneself or others, and the need to confess exist. These excessive thoughts result in the common compulsive behaviors of washing, repeating, checking, touching, counting, arranging, hoarding, or praying.
Misdiagnosis is Common Because the behaviors observed in persons with OCD often are stereotypical and repetitive, 2 other disorders, both in the developmental disability spectrum, commonly are confused with OCD. First, children with mild autism or Asperger disorder also may have repetitive thoughts and specific stereotypic compulsive behaviors. While disorders in the autistic spectrum are considered to be pervasive developmental disorders (PPD) and quite different than OCD, at times the differential diagnosis between the 2 sets of disorders is somewhat difficult to make.
How to Tell the Difference Remember - Social difficulties and communication problems are key intrinsic features of Asperger disorder on the PDD spectrum.
Co-Morbid Disorders – Differential Diagnosis
Diagnostic Issues in DD Difficult to distinguish with personality traits in persons with DH that engage in repetitive questions (repetitive speech, echolalia) that can occur in anxious individuals with limited verbal skills or in autistic spectrum disorders. Compulsive behaviours are common in adults with intellectual disability – stereotyped behaviour and movement disorders from underlying brain damage.
When does OCD begin? Begin anywhere from preschool age to adulthood (40 years). Obsessive-compulsive behavior affects both males and females equally but is more common among adolescent boys than adolescent girls. The mean age of onset is about 20 years (2,10), but cases have been reported in children as young as 2 years (10-12). On average, people with OCD see 3-4 doctors and spend over 9 years seeking treatment before they receive a correct diagnosis. OCD tends to go under-diagnosed and under-treated because people with the illness often act secretive about their symptoms.
Epidemiology of OCD The majority of patients with obsessive-compulsive disorder have both obsessions and compulsions, some have only one or the other. Most patients realize the irrational nature of their thoughts and rituals but feel helpless and hopeless about controlling them. In one epidemiologic survey, 18 children were found to have OCD, and only 4 were receiving any professional mental health care. Not one of these 4 was diagnosed properly.
Gender & Culture Boys are more likely to have a prepubertal onset and a family member with OCD or Tourette syndrome. Girls are more likely to have onset of OCD during adolescence. OCD is more common in whites than African American children in clinical samples. However, epidemiologic data suggest no differences in prevalence as a function of ethnic group or geographic region.
Prevalence of OCD The World Health Organization lists obsessive-compulsive disorder as one of the five major causes of disability throughout the world. It is considered the fourth most common psychiatric condition, ranking after phobias, substance abuse disorders, and major depressive mood disorder.
Prevalence: Underestimated Prevalence of OCD is underestimated – why? 60% of all persons with a diagnosable anxiety disorder never see a mental health professional – they may turn to their family physician, religious leader or another family member for help.
Prevalence with Intellectual Disability In the general population, the prevalence is estimated to be around 1% In populations with intellectual disability, the prevalence has been estimated to be between 1 and 3.5%
What Causes OCD? The probable biologic explanations of obsessive-compulsive disorder include heredity, brain lesions, abnormal brain glucose metabolism, and serotonergic dysfunction. No specific gene associated with OCD – however, when a parent has OCD there is an increased risk that the child will also develop the illness. Problems in the front part of brain (orbital cortex) and deeper structures (basal ganglia).
Brain Differences – persons with OCD use different brain circuitry in performing a cognitive task than people without the disorder – (Rauch et al. J. of Neuropsychiatry, 1997)
Genetic Link? If one twin has OCD, the other twin is more likely to have OCD if the children are identical twins rather than fraternal twin pairs. OCD is increased among first-degree relatives of children with OCD, particularly among fathers (Lenane et al., 1990). It does not appear that the child is simply imitating the relative’s behavior, because children who develop OCD tend to have symptoms different from those of relatives with the disease (Leonard et al., 1997).
Role of Serotonin Studies showing that serotonin plays a role in the pathophysiology of obsessive-compulsive disorder have led to new and highly effective treatments
Infection Causes? Recent research suggests that some children with OCD develop the condition after experiencing one type of streptococcal infection (Swedo et al., 1995). This condition is referred to by the acronym PANDAS, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Its hallmark is a sudden and abrupt exacerbation of OCD symptoms after a strep infection. The cause of this form of OCD appears to be antibodies directed against the infection mistakenly attacking a region of the brain and setting off an inflammatory reaction.
OCD Cause: Summary Although a definitive cause of obsessive-compulsive disorder has not yet been found, it is considered the product of interactions between biologic predisposition and various developmental and psychosocial influences
OCD Assessment For adults with intellectual disability: Compulsive Behavior Checklist (Gedye, 1996) This list uses 25 types of compulsions done by adults with developmental disabilities – grouped into 5 categories – ordering, completeness, cleaning, checking/touching, deviant grooming. Ratings are done by caregiver who has familiarity with person.
OCD Assessment Also – we can use the Obsessive Speech Checklist – designed for use only with developmentally disabled people who talk in sentences and use meaningful speech This is used to help determine if they meet the criteria for OCD
Treatment During last 20 years, two effective methods for treating OCD have been developed: Cognitive-Behavioural Psychotherapy (CBT) Medication with a serotonin reuptake inhibitor (SRI)
Stages of Treatment Acute Treatment Phase: Treatment is aimed at ending the current episode of OCD. Maintenance Treatment: Treatment is aimed at preventing future episodes of OCD.
Components of Treatment Education: Educate family and patients on how to manage OCD and prevent complications. Psychotherapy: Cognitive-Behavioural Therapy (CBT) is the key element of treatment for most patients with OCD. Medication: Medication with a serotonin reuptake inhibitor is helpful for many OCD patients.
Treatment Considerations Use of both medication and psychotherapy results in a better outcome than use of either alone. Many patients with obsessive-compulsive disorder are very secretive about their illness. Therefore, a detailed review of symptoms may be necessary. Many patients have somatic complaints (eg, fatigue, pain, hypochondriacal symptoms, excessive worrying, chronic sadness). Thus, a comprehensive medical evaluation is essential to rule out any preexisting medical and psychiatric condition.
More Treatment Considerations The impact of obsessive-compulsive disorder on interpersonal relationships, employment, marriage, and academic performance needs to be evaluated early in the diagnostic process. Coexisting psychiatric conditions (eg, major depression, panic disorder, phobias, eating disorders) should be treated along with obsessive-compulsive disorder. Similarly, obsessive-compulsive patients with ongoing alcohol or drug abuse problems should be treated for these before medication is considered. Although obsessive symptoms can be reduced with medications, the interpersonal relationships, social skills, work habits, and ability to resist compulsions require a comprehensive treatment plan that involves several aspects of each patient's life.
Cognitive Behavioural Psychotherapy (CBT) Exposure and response intervention. Exposure – person remains in contact with something they usually fear until their anxiety is diminished. Response intervention – person’s rituals or avoidance behaviours are blocked (those afraid of germs are not only exposed to germs but refrained from ritualized washing). Exposure is usually more helpful in decreasing anxiety and obsessions, while response intervention is better at decreasing compulsive behaviours.
CBT (Cont’d) Patients who complete CBT report a 50-80% reduction in OCD symptoms after 11-20 sessions. Using CBT on a weekly basis, can take 2 months or longer to show full effects. Practiced in the therapist’s office, and do daily E/RP homework. When the OCD is very severe, it is sometimes better to practice CBT in a hospital setting.
Treatment Effectiveness Behavioural techniques are most effective for certain types of OCD symptoms – particularly cleaning or checking rituals. Best approaches are: DRO in combination with in vivo exposure; Relaxation Training; Stimulus Control techniques.
Medications: First-line drug treatment In a primary care setting with appropriate psychiatric consultation, pharmacotherapy for obsessive-compulsive disorder and comorbid psychiatric conditions can be quite successful. Between 50% and 70% of patients respond well to medication. The tricyclic antidepressant clomipramine hydrochloride (Anafranil) and various selective serotonin reuptake inhibitors (SSRIs) have been approved by the US Food and Drug Administration (FDA) for treatment of obsessive-compulsive disorder. The approved SSRIs include fluvoxamine maleate (Luvox), paroxetine hydrochloride (Paxil), sertraline hydrochloride (Zoloft), and fluoxetine hydrochloride (Prozac).
Medication – Efficacy Studies Double Blind studies have shown the effectiveness of: Clomipramine (may be the best but has the most adverse side effects) Fluvoxamine Fluoxetine Sertraline They inhibit the reuptake of serotonin into synaptic nerve terminals
Side Effects to Watch for Teratogenetic concerns: avoid all medications during pregnancy unless symptoms are disabling . All SSRIs are excreted in breast milk and therefore should not be used by nursing mothers. Hepatic disease and hepatic metabolism: SSRIs should be used cautiously in patients with chronic hepatic diseases. Clinical monitoring and dose reductions are recommended to prevent drug interactions and undesirable side effects. Sexual dysfunction: Although most side effects associated with SSRIs are well tolerated over time, sexual dysfunction is perhaps the most troubling adverse effect and can lead to discontinuation of or noncompliance with drug therapy. Cessation of therapy: Abrupt discontinuation of SSRIs can lead to development of the "interruption-discontinuation syndrome." This is manifested by emergence of adverse effects and worsening of obsessive-compulsive symptoms. Therefore, gradual tapering of doses or shifting among various SSRIs is recommended (17).
Adjunctive drug therapy Buspirone hydrochloride (BuSpar), a specific nonbenzodiazepine anxiolytic medication, has been shown to benefit some obsessive-compulsive patients with comorbid anxiety. Mood stabilizers (eg, lithium, carbamazepine, valproic acid [Depakene, Depakote]) can be used to augment the efficacy of SSRIs or to treat obsessive-compulsive patients with comorbid bipolar disorder .
Med. Treatment Issues Clomipramine and SSRI’s as anti-compulsive agents have the potential to precipitate hypomania and mania Risperidone is useful as an acute hypomanic agent, has mood stabilizing properties.
When insight is poor Motivation is necessary for CBT to be effective OCD behaviour is of itself reinforcing When insight is poor, behavioural techniques may help If you block one compulsion, usually another is established
Behavioural Techniques Behavioural techniques are most effective for certain types of OCD symptoms – particularly cleaning or checking rituals. Best approaches are: Differential Reinforcement in combination with Relaxation Training and Stimulus Control techniques.
Differential Reinforcement Very effective and efficient but difficult to do on a consistent basis Reinforce behaviours that are appropriate Ignore behaviours that are not appropriate Redirect
Relaxation Techniques Identify anxiety behaviours Relaxation – Deep breathing, muscle relaxation Guided Imagery Provide concrete visual cues Quiet place
Stimulus Control Set up person for success Identify triggers /stimulus Instigating conditions Vulnerability conditions Maintaining (reinforcing) conditions Reduce the internal triggers - medication Modify environment Teach coping skills
Is this the hill you want to die on? Restricting behaviour will escalate behaviour Compromise Allow behaviour within defined limits E.g., defined space for hoarding
Best Treatment Approach Multi-Modal – that considers the Bio-Psycho-Social aspects of the person: OCD may improve with habilitative changes, person centred planning, specific behavioural intervention plans and appropriate medication treatment and ongoing monitoring of effectiveness.
Difficulties in Producing Change
Case History Story of Ala’a – Severe OCD
Ala’a Diagnostic uncertainty – English is not first language; possible High Functioning Autism or Asperger’s syndrome
Ritualistic Behaviours Will perform ritualistic behaviours all day long – cleaning, repetitive questions, routine and ordering Will become agitated during performance of rituals – can become very aggressive at these times
Case: Ala’a Severe Aggression – led to placement in Institutional setting where he was given 3:1 staffing ratio (Ala’a & 3 staff) He was not allowed out
Ala’a: environment He was kept in a locked room most of day (TV room with locked half door) He was moved (e.g. to bathroom) with 3 staff encircling him and having him keep his hands in pockets
Case: Ala’a CTO was used for extreme aggression He would also engage in SIB – hundreds of times per day He would also engage in Property Destruction – holes in walls, broken toilets, etc…
Case: Ala’a – Treatment Plan Use of DRO – Contingency Management – Token Economy – absence of target behaviours Greatly improving the quality of his time and interactions with staff doing fun activities Eliminate locked areas in house but reserving use of CTO for extreme aggression Develop prompting strategy so as not to inadvertently reinforce repetitive questions (one reminder – prompt – and withdraw attention)
Ala’a: Treatment Expose him to many other reinforcing activities to lessen his obsessions around specific video movies, food, cleaning New Psychiatrist – new medications with use of SSRI’s . Propranolol & Nozinan seem to be helping
Ontario OCD Resources The Ontario OCD Network.Contact Details for Resource DirectoryCorinna de Beer120 Lombard St., Suite 301, Toronto, Ontario, M5C 3H5Ph: 416-970-2611Fax: 416-703-7151eMail: firstname.lastname@example.org
OCD Network Ontario Obsessive Compulsive Disorder NetworkPO Box 151Markham, OntL3P 3J7tel: 416-410-4772fax: 905-472-4473web site: http://home.interhop.net/~oocdnEmail is email@example.com
Added On : 7 Years ago.
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