OBSESSIVE-COMPULSIVE AND RELATED DISORDERS Dan J. Stein University of Cape Town
Jan 14, 2016
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