UNIVERSITY OF ZAGREB SCHOOL OF MEDICINE Veronika Nives Zoric Cognitive-Behavioural Therapy of Obsessive- Compulsive Disorder GRADUATE THESIS Zagreb, 2017. brought to you by CORE View metadata, citation and similar papers at core.ac.uk provided by University of Zagreb Repository
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UNIVERSITY OF ZAGREB SCHOOL OF MEDICINE
Veronika Nives Zoric
Cognitive-Behavioural Therapy of Obsessive-Compulsive Disorder
GRADUATE THESIS
Zagreb, 2017.
brought to you by COREView metadata, citation and similar papers at core.ac.uk
Title: Cognitive-Behavioural Therapy of Obsessive-Compulsive Disorder Author: Veronika Nives Zoric
Obsessive-Compulsive disorder is a severe and debilitating psychiatric disorder affecting more and more people worldwide. As the fourth most common psychiatric disorder, its history can be traced back to the 16th century. Although previously classified as an anxiety disorder in DSM-IV, it has recently been given its own chapter with related disorders in DSM-5. In ICD-10, OCD is grouped with neurotic, stress-related and somatoform disorders, and given the code F42. ICD-10 subdivides OCD into three types: predominantly obsessive type, predominantly compulsive type, and the most commonly found mixed type. Obsessions can be defined as repetitive and persistent thoughts or feelings that are viewed by the patient as intrusive and inappropriate and cause marked anxiety or distress. Typical obsessions include: fears of being contaminated by germs or poisons, fears of causing harm to oneself or others, and fears of committing some unacceptable action. Compulsions, on the other hand, are repetitive acts or behaviours that the patient deems necessary to perform as a response to an obsession, and which serve to reduce anxiety. Common compulsions include: excessive washing and cleaning, checking, seeking reassurance, hoarding objects, and insisting that things be put in a specific order or pattern. Based on the severity of symptoms OCD can be divided into mild, moderate and sever forms. Many theories exist on the etiology of OCD, but no theory is regarded as the sole etiologic factor. Comorbidity with other psychiatric disorders is common, with a lifetime history of major depression present in two thirds of OCD patients. An array of different psychiatric and neurologic disorders must be taken into account in the differential diagnosis of OCD such as: specific phobias, major depressive disorder, trichotillomania, hoarding disorder, tic disorders, and obsessive-compulsive personality disorder. The primary goal of treatment in the majority of OCD cases is to have the individual control the disorder rather than the obsessional disorder control the individual. Safe and effective first-line treatment for OCD includes cognitive-behavioural therapy (CBT) and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs). Severe and drug-resistant cases can be managed with electroconvulsive therapy and rarely, surgery. The course of the disease is chronic, and the quality of life largely depends on the severity of symptoms and the response to therapy.
Opsesivno-kompulzivni poremećaj (OKP) je teški i debilitativni psihijatrijski poremećaj koji utječe na sve više i više ljudi širom svijeta. Kao četvrti najčešći psihijatrijski poremećaj, njegova povijest se može pratiti do 16. stoljeća. Iako je prethodno klasificiran kao anksiozni poremećaj u DSM-IV, nedavno je dobio vlastito poglavlje s povezanim poremećajima u DSM-5. Kod ICD-10, OKP je grupiran s neurotskim, stresnim i somatoformnim poremećajima, te dodijeljen kod F42. ICD-10 dijeli OKP u tri tipa: pretežno opsesivno tip, pretežno kompulsivan tip i najčešće pronađen mješoviti tip. Opsesije se mogu definirati kao ponavljajuće i perzistentne misli ili osjećaje koje pacijent doživljava kao intruzivne i neprimjerene te koji uzrokuju ozbiljnu tjeskobu ili nelagodu. Tipične opsesije uključuju: strah od onečišćenja ili kontaminacije, strahovanja od nanoseći zla sebe ili drugima, i strah od počinjenja nekog neprihvatljivog djelovanja. S druge strane, Kompulzije ili prisile su ponavljajuća djela ili ponašanja koji pacijent smatra potrebnim za obavljanje kao odgovor na opsesiju, a koji služe za smanjenje anksioznosti. Uobičajene prisile uključuju: pretjerano pranje i čišćenje, provjeravanje, traženje sigurnosti, sakupljanje predmeta i inzistiranje na tome da se stvari stave u određeni red. Mnoge teorije postoje na etiologiji OKP, ali niti jedna teorija ne smatra se superiorna nad ostalim. Komorbiditet s drugim psihijatrijskim poremećajima je uobičajen, s dugotrajnom poviješću velike depresije prisutne u dvije trećine pacijenata s OKP. Različiti psihijatrijski i neurološki poremećaji moraju se uzeti u obzir u diferencijalnoj dijagnozi OKP-a, kao što su: specifične fobije, depresija, trichotilomania, patološko skupljanje, tic poremećaji i opsesivno-kompulzivni poremećaj ličnosti. Primarni cilj liječenja je da pojedinac kontrolira poremećaj, a ne da poremećaj kontrolira pojedinca. Sigurno i učinkovito prvoklasno liječenje OKP-a uključuje kognitivno-bihevioralnu terapiju (KBT) i farmakoterapiju sa selektivnim inhibitorima ponovne pohrane serotonina (SIPPS). Teški slučajevi otporni na lijekove mogu se liječiti elektrokonvulzivnom terapijom, a rijetko, kirurški. Tijek bolesti je kroničan, a kvaliteta života uvelike ovisi o težini simptoma i odgovoru na terapiju.
The initial dose is 50 mg daily. This is then increased by 25 mg every 4-7 days until the
maintenance dose of 100-300 mg is achieved. The FDA has added a black box warning for
this drug in reference to increased risks of suicidal thoughts and behaviour in young adults
and children. Fluvoxamine is not approved for use in all children.
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9.2.1.2. Clomipramine (Anafranil®)
Clomipramine is a tricyclic antidepressant that was discovered in 1964 and it is still being
used today. The maximal daily dosage for adults is 250 mg, while for children it is 200 mg. It
is a highly selective inhibitor of serotonin reuptake. It is also an antagonist/inverse agonist at
the histamine H1 receptor, the muscarinic acetylcholine receptors and the α1 adrenergic
receptor. These last three actions likely contribute to its adverse effects. Specifically,
clomipramine has substantial anticholinergic effects, such as dry mouth, blurred vision,
constipation, fatigue, tremor, and hyperhidrosis. Furthermore, clomipramine is associated
with increased risk of arrhythmia and seizures at doses greater than 200 mg daily, thus
requiring monitoring of serum concentration. Thus, clomipramine is most appropriate as a
second-line treatment for patients who do not respond to SSRIs.
9.2.1.3. Other Medication
In the case of ineffective treatment with SSRIs or TCA, the following drugs can be added to
therapy: Valproate (Depakine®), Lithium, or Carabamazepine (Tegretol®).
9.2.2. Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is not currently used as a first-line treatment for obsessive-
compulsive disorder (OCD). However, several studies have reported its effectiveness in
treating severe OCD, especially when first line therapies have failed. In one study by Liu
Xiaohui et al., three patients with severe OCD were treated by modified bifrontal ECT after
their first-line anti-OCD treatments (pharmacotherapy, behavioral therapy, and cognitive
behavioral therapy) failed. The resultls showed that in all three cases, the patients' depressive
symptoms improved considerably after the ECT procedures (Liu Xiaohui et al., 2014).
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9.2.3. Surgical Treatment
Surgery for OCD is reserved for patients with the most severe cases of the disease, refractory
to pharmacotherapy and psychotherapy. To be referred to surgery, certain requirements must
be met; the patient must have had adequate trials (at least 10 weeks at maximally tolerated
dose) of clomipramine, fluoxetine, fluvoxamine, sertraline, paroxetine, and a monoamine
oxidase inhibitor. Also all patients must have had extended trial of behaviour therapy
consisting of a minimum of 20 hours of ERP (Jenike et al., 1998). Contraindications must also
be taken into consideration such as: age below 18 or above 65, inability to comply with
treatment, and previous diagnosis or neurosurgical procedure. Two methods of surgery are
currently employed: one involves performing a lesion, and the other involves stimulation of
target areas using deep brain stimulation (DBS). In a lesion, a radiofrequency unit is used to
produce a thermal lesion of calculated volume. This is permanent and irreversible. In DBS an
electrode is implanted at the site of the target and current is delivered through a pacemaker to
alter the signals emanating from the target. Both this procedures are performed using
stereotactic techniques which offer a high degree of accuracy (within 1-2mm) (Doshi, 2009).
The four procedures currently being used are: anterior capsulotomy, cingulotomy, subcaudate
tractotomy and limbic leucotomy. Unfortunately there have been few comparison studies of
these operations, so no single procedure is classified as the best. The most commonly
performed surgical procedure is bilateral cingulotomy. In one study by Jung et al., the Y-
BOCS fell by 48% (Jung et al., 2006). Some patients with only limited response to surgery
report better response to pharmacotherapy and behavioural therapy post operatively (Spofford
et al., 2014). The most common complications following surgery include: infection,
haemorrhage, epileptic seizures, and weight gain. Some countries have abandoned
neurosurgery altogether, while in others it is only used in a few centers.
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9.3. Social Therapy
Social therapy is a particular kind of group therapy. The group consists of people of various
backgrounds, histories and ages. While traditional therapies typically focus on the individual,
social therapy focuses on the group and on being with others to grow and develop
emotionally.
9.3.1. Work Therapy
Work therapy is an excellent type of therapy that offers patients an opportunity to be
productive. Patients work together to accomplish various goals that are clearly outlined to
them in the beginning of the sessions. An activity program with adequate leadership and
personnel is established. Activities range from food preparation, landscaping, dressmaking,
carpentry etc…
9.3.2. Art Therapy
Art therapy is a prospective outlet for people who don’t know how to verbalize their feelings
during traditional psychotherapy sessions. It allows patients to set goals and create in a safe
space under the supervision of a professional. Various techniques are used such as painting,
drawing, sculpting or other types of artwork.
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10. COURSE AND PROGNOSIS
In more than half of patients, OCD begins with an abrupt appearance of symptoms. The
first symptoms usually begin after some stressful life event, such as the death of a loved one.
Diagnosis is not made right away since the majority of patients successfully hide their
disorder, especially those with the milder form. OCD is usually a chronic disorder with a
fluctuating course in most of patients. A study conducted by Rasmussen and Eisen in 1992
reported that 85 % of OCD patients had a continuous fluctuating course, 10 % had a
deteriorative course and 2 % were classified as episodic (Rasmussen and Eisen., 1992). More
recently in 1999, Skoog and Skoog, in a 40 to 50 year follow up of OCD patients, found that
overall clinical and subclinical symptoms were still evident in two-thirds of the sample at
follow-up, and 10 % of the sample showed a deteriorating course (Skoog and Skoog, 1999).
The majority of patients have both obsessions and compulsions as well as comorbidity with
other psychiatric disorders. Long-term complications of OCD have to do with the type of
obsessions or compulsions. For example, constant handwashing can cause skin breakdown.
OCD does not usually progress into another mental problem. Complete recovery to the point
of no longer requiring treatment is considered uncommon. However, if proper treatment is
started OCD can be managed and controlled and the patient can have an excellent quality of
life.
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11. ACKNOWLEDGMENTS
I would like to thank my mentor, prof. dr. sc. Dražen Begić, for his leadership and
professional guidance during the process of writing this graduate thesis.
I would also like to thank my critics, who found the time and will to comment on this
graduate thesis in a structured way.
Finally, I would like to thank my family for all of their support, understanding, and help
during my time at the Zagreb Medical School, as well as throughout my life.
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