OBSESSIVE-COMPULSIVE AND RELATED DISORDERS Dan J. Stein University of Cape Town.

OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Dan J. Stein

University of Cape Town

OCD

• OBSESSIONS:Recurrent and persistent thoughts

• COMPULSIONS:Repetitive behaviors or mental acts

• Distress/Dysfunction

OCD

• Contamination concerns hand-washing

• Possible harm concerns checking

• Symmetry concerns symmetry behaviours

NOT OCD

• Obsessive-compulsive personality disorder

• Pathological or problem gambling, compulsive sexual disorder, problematic internet use

• Hoarding concerns hoarding behaviors

• Being a meticulous professional or student

OCD

• 4th most common psychiatric disorder in one USA study

• 10th most disabling of all medical disorders in WHO BoD study

• Subclinical washing, checking, symmetry, symptoms are common

(Ruscio et al, 2008)

OCD Spectrum

• Range of disorders with intrusive thoughts and repetitive behaviors

• - Tourette’s syndrome• - Body Dysmorphic Disorder • - Hypochondriasis• - Hoarding Disorder• - Trichotillomania • - Skin Picking Disorder

Psychodynamic Approach

Character Neurosis Psychosis

• Similarity in central unconscious conflicts

• Differences in certain psychodynamics

Cognitive-Behavioral Approach

OCDS OCD OCDS

• Similarity in cognitive-behavioral function

• Differences in particular contents

Psychobiological Approach

OCDS OCD OCDS

• Similarity in central psychobiol mechanisms

• Differences in certain psychobiol processes

Baseline

After SSRI

OCD Pre/Post SSRI

So: Range of Presentations

• Dermatologist: Dermatitis, Loss of Hair

• Neurologist: Tics

• Plastic Surgeon: Somatic concerns

• Internist: Hypochondriacal concerns

• Pediatrician: Early onset

• Obstetrician: Pregnancy

But: Overlapping Neurobiology

• OCD OCD+Tics Tics

• 5-HT genes DA genes??

• Good evidence that OCD and TS have a genetic relationship

And: Overlapping Pharmacology

SRIs more effective than NRIs:

• OCD• Body Dysmorphic Disorder, Hypochondriasis?• Hoarding Disorder?• Trichotillomania, Skin Picking Disorder?• O-C symptoms in Tourette’s, in autism, in

intellectual disability

Animal Stereotypy

Pre-SSRI Post-SSRI

Animal Stereotypy

Animal Stereotypy

01020304050607080

Weeks (0-8)

Ster

eoty

py

PlaceboFluoxetine

“From Bench to Bedside”

(Harvey et al, 2008)

Somatic Preoccupations

Somatic Preoccupations

OCD BDD/ORS/HYP anorexia

(with or without insight)

• BDD is in DSM-5 OCRD section

• ORS likely in ICD-11 OCRD section

• HYP likely in ICD-11 OCRD section

Somatic Preoccupations

OCD BDD/ORS/HYP anorexia

(with or without insight)

• First line Rx of BDD/ORS/HYP is SSRI / CBT

Hoarding Behaviours

Hoarding Behaviours

(Saxena et al, 2004)

Hoarding Behaviours

OCD Hoarding OCPD hoarding

• Hoarding Disorder is in DSM-5 OCRD

• Criteria do not overlap with Collecting!

• Neuroanatomy slightly different from OCD

Hoarding Behaviours

OCD Hoarding OCPD hoarding

• First line Rx of Hoarding Disorder is SSRI / CBT

Stereotypies/Grooming

“From Bench to Bedside”

Stereotypies/Grooming

OCD TTM/SPD SMD/SIB

• TTM/SPD are in DSM-5 OCRD

• Partly due to consumer advocacy!

Stereotypies/Grooming

OCD TTM/SPD SMD/SIB

• First line Rx of TTM/SPD is CBT

• Growing interest in N-acetylcysteine

Tics/Involuntary Movements

Tics/Involuntary Movements

OCD/soft signs OCD/tics TS

• OCD has a tic specifier in DSM-5• TS likely in ICD-11 OCDR section• Some evidence of overlapping

neuroimmunology

PANDAS

“From Bench to Bedside”

“From Bench to Bedside”

(Harvey et al, 2008)

Tics/Involuntary Movements

OCD/soft signs OCD/tics TS

• Rx options in Tourette’s Disorder include DA blockers / CBT

Treatment-Resistant OCD

• 27 short-term trials of Rx-resistant anxiety

• 19 investigated augmentation in OCD

• Similar design features eg low doses of antipsychotic agents in SRI non-responders

• Overall symptom severity reduced to a larger extent with these agents

(Ipser et al, 2006)

OCD Treatment Principles

• Useful to screen for intrusive thoughts and repetitive behaviours

• Patients with one OCRD may well have another, or MDD / etc

OCD Treatment Principles

• Range of standardized OCS symptom severity measures available eg YBOCS

• Range of accurate information available on internet eg OCF, TLC

OCD Treatment Principles

• Exposure and response prevention is a highly effective form of Rx

• Many resources available eg OCF, www.stoppulling.com

• Important to involve partners and/or family

OCD Treatment Principles

• SSRIs are effective for OCD and for several OCRD

• Higher dose and longer duration than in MDD

• Consider referral after 2 different 12 week trials of SSRIs fail

Psychobiology:Pharmacotherapy

**

* *** **

* **

* *** **

** **

-15

-10

-5

0

0 2 4 6 8 10 12 14 16 18 20 22 24

Week

Est

imat

e

PBO

PAR40

ESC10

ESC20

* p<0.05 vs PBO, ** p<0.01 vs PBO (Stein et al, 2007)

Treatment Resources

• MRC Unit Anxiety Disorders ([email protected])

• GSH OCD Evaluations ([email protected])

• Internet:– SADAG Support Groups– Obsessive-Compulsive Foundation (OCF)– Trichotillomania Learning Centre (TLC)

CONCLUSION

• OCRD are seen universally (and indeed DSM-5 field surveys were from RSA)

• The psychobiology and treatment of OCD is increasingly understood

CONCLUSION

• Provides the basis for the DSM-5 / ICD-11 construct of OC and Related Disorders

• Aims to help recognize and Rx some key prevalent, overlooked, disabling conditions

CONCLUSION

• Initial Rx of these disorders should be initiated in primary care

• Referral resources are available in more refractory cases