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Management of OCD
CHAIRPERSON:
DR.MANJU
BHASKAR
Introduction
Obsessivecompulsive disorder (OCD) is an
Types
1. Contamination
2.Need for symmetry
3.Somatic Obsessions
4.Sexual and Aggressive Obsessions
5.Pathological Doubt
In a recent meta-analysis ,Bloch et al (2008)
Epidemiology
Community studies: lifetime prevalence-2-
Course
Age of onset: adolescence or early
childhood.
Modal age: males:6-15yrs; females:2029yrs.
Majority: chronic- waxing and waning.
Exacerbated by stress.
15%- progressive deterioration
5%- episodic.
DIAGNOSIS
DSM-IV TR Obsessive- Compulsive
Disorder (300.3)
FEATURES
DSM-IV
ICD-10
Duration
Not mentioned
2weeks
Time consumption
1hour
Not mentioned
Number of obsessions
Not mentioned
Atleast one
obsession/compulsion
must be present that is
considered excessive
and unreasonable.
Yes
Mentions co-morbidity of
depression.
Yes
No
Yes
No
Disorder in DSM-V
A.Either obsessions or compulsions:
Obsessions as defined by (1) and (2):
1. Recurrent and persistent thoughts,
urges, or images that are experienced, at
some time during the disturbance, as
intrusive and unwanted and that in most
individuals cause marked anxiety or
distress.
characterized by:
Good or fair insight
Poor insight:
Absent insight
Specify if:
Tic-related OCD: The individual has a
DIFFERENTIAL DIAGNOSIS
3.Depression
Mood congruent brooding.
Not ego-dystonic
When both of them co-occur:
In an acute episode of disorder:
Precedence
Predominance
In chronic disorders: Persistence
4.Psychotic Disorder
Not characterized by prominent ritualistic
behaviors.
Schizophrenia may be characterized by obsessional
thinking, & other characteristic features of the
disorder, such as prominent hallucinations or
thought disorder, are also present.
The ruminative delusional thoughts and bizarre
stereotyped behaviors that occur in schizophrenia
are not ego-dystonic and are not subjective to
reality testing.
5.Tourettes Disorder:
No mental urge, only physical urge
Just right phenomenon
6.Stereotypic movement disorder
7.Body dysmorphic disorder
8.Hypochondriasis
9.Impulse control disorders.
10.Eating disorders
11.Paraphilias/Non-paraphilic Sexual addiction
12.Pathological jealousy
CHECKING BEHAVIOUR
14.ANXIETY DISORDERS DUE TO GENERAL
MEDICAL CONDITION/SUBSTANCE
This diagnosis is made when the
obsessions and compulsions are judged to
be the direct physiological consequence of
a specific GMC based on history, physical
examination and laboratory findings.
Assessment
1.Assess the patients current
symptoms and severity
A. Diagnostic Interviews
i)Structured Clinical Interview for DSM-IV,
Axis I (SCID-I)
ii)MINI plus
iii)Anxiety Disorders Interview Schedule .
scale
SCORING: 0-7 = SUBCLINICAL
8-15=MILD
16-23=MODERATE
24-31=SEVERE
32-40=EXTREME
iii)Padua Inventory
It has 4 subscales: contamination,
v)Likert scales
vi)Obsessive- Compulsive Inventory
It is 42-item self-report measure.
It comprises 7 subscales : washing ,
Investigations
1.Blood chemistry & urine analysis.
2.5hr GTT
3.Serum B12 and B6.
4.Neuroimaging & EEG
5.Biological challenges
6.Biological markers
7.Immunological findings
others
Assessing the risk for suicide and self-injurious
behavior, as well as the risk for harm to others,
is crucial.
The psychiatrist should also evaluate the
patients potential for harming others.
4.Assessment of psychiatric co-morbidity
Particular attention should be given to mood
7. DEVELOPMENTAL,PSYCHOSOCIAL AND
SOCIO-CULTURAL HISTORY
i)Developmental transitions in childhood
and adulthood
ii)The patients capacity to achieve stable
and gratifying familial and social
relationships.
iii)Sexual History
iv)Educational & Occupational History
v)Primary and socio-cultural support group
vi)Assessment of psychosocial stressors
Management
Psychiatric management consists of an
include:
Less than 1 hour per day spent obsessing
and performing compulsive behaviors
No more than mild OCD-related anxiety;
An ability to live with uncertainty;
Little or no interference of OCD with the
tasks of ordinary living.
FOR TREATMENT
In general, patients should be cared for in the
least restrictive setting that is likely to be safe
and to allow for effective treatment.
Consequently, the appropriate treatment
setting will depend on a number of factors:
a.Hospital treatment: may be indicated by:
i)suicide risk,
ii)an inability to provide adequate self-care,
danger to others
support,
iv) An inability to tolerate outpatient
medication trials because of side effects,
v)need for intensive CBT,
vi)the presence of medical conditions that
necessitate hospital observation while
medications are initiated, or by cooccurring conditions that themselves
require hospital treatment, such as severe
or suicidal depression, schizophrenia, or
mania.
4.ENHANCEMENT OF TREATMENT
ADHERENCE
To enhance treatment adherence, the
psychiatrist should consider factors related
to the illness, the patient, the physician,
the patient-physician relationship, the
treatment, and the social or environmental
milieu.
The patients beliefs about the nature of
the illness and its treatments will influence
adherence, providing patient and family
education may enhance adherence.
6.MANAGEMENT OF
ACUTE PHASE
A. Choosing an Initial Treatment Modality
CBT and SRIs are recommended on the
medical conditions.
a.IMPLEMENTING PHARMACOTHERAPY
SRI(mg/d)
STARTING
USUAL
TARGET
USUAL
MAXIMA
L
OCCASIONALLY
PRESCRIBED
MAXM
CLOMIPRAMI
NE
25
100-250
250
Pl.level>5OOng/
ml SEIZURES &
CONDUCTION
DELAY
CITALOPRAM
20
40-60
80
120
ESCITALOPRA 10
M
20
40
60
FLUOXETINE
20
40-60
80
120
FLUOXAMINE
50
200
300
450
SETRALINE
50
200
200
400
PAROXETINE
20
40-60
60
100
disorders.
Elderly
Most patients will not experience
substantial improvement until 46 weeks
after starting medication.
Some patients, such as those who have had
little response to previous treatments and
are tolerating the medication well, may
benefit from even higher doses
CLOMIPRAMINE
Clomipramine ,the 3-chloro analogue of the
tricyclic imipramine, is unique among the
tricyclics in its marked potency for blocking
serotonin reuptake.
Clomipramine was the first FDA approved
drug for OCD(1989).
Desmethylclomipramine, a major
metabolite of clomipramine, potently
blocks reuptake of both 5-HT and
norepinephrine.
FLUOXETINE
Initially, on the basis of fluoxetines
FLUOXAMINE
It is a unicyclic agent that differs from the
SERTRALINE
Sertraline is a naphthalenamine derivative
with an active metabolite, n
desmethylsertraline.
Approved by FDA in 1997.
CITALOPRAM/ESCITALOPRAM
Citalopram is a cyclic phthalin derivative
Technique
a.Behavioural Assessment
The therapist helps the patient to identify
b.Education
Patients need an understanding of OCD , an
exposure to triggers.
At the beginning of therapy, therefore, short term
Cognitive therapy
individuals with OCD hide their rituals because they
Prognostic factors
Good Prognosis
Poor Prognosis
Precipitating event
Episodic nature of
symptoms
Good premorbid
adjustment
Childhood onset
Yielding to compulsions
Bizarre compulsions
Overvalued ideas
Coexisting major depression
Personality disorders
Poor compliance
Poor insight
Obsessive slowness
Cognitive impairment
Need for IP treatment
CRITERIA
STAGE 1 RECOVERY/NOT AT
ALL ILL
YBOCS<8
STAGE II REMISSION
YBOCS<16
STAGE V NONRESPONSE
STAGE VI RELAPSE
6.Fenfluramine
7.L-Tryptophan
8.Trazodone
9.Pindolol
Combination therapy:
1.Clomipramine with SSRIs
2.Clomipramine with MAOI.
Switching antidepressants:
SNRI- venlafaxine
MAOI-B
Nefazodone
Novel strategies:
1.Intravenous clomipramine.
2.MAOIs
3.Clonidine
4.Flutamide
5.Inositol
6.D-cycloserine
7.Non-pharmacological Biological
C.DISCONTINUATION OF ACTIVE
TREATMENT
Successful medication treatment should be
1996) also reported significantly higher 6month, 1-year, and 2-year relapse rates for
the patients whose SRI treatment was
discontinued
Thus, rates of relapse appear to be
increased after discontinuation of SRI
treatment but cannot be precisely
specified.
A.PSYCHIATRIC FEATURES
1. Chronic Motor Tics
2.Tourettes syndrome
3.Major Depression
4.Bipolar disorder
5.Panic disorder
6.Social Phobia
7.Schizophrenia
8.Substance use disorders
9.Autism & Aspergers disorder.
10.Personality Disorders
11.Neurological conditions
Conclusion
For many patients with OCD the illness is