Obsessive

Compulsive
Disorder
HUSNA NAJIHAH DZULKARNAIN
1213828
 Outline
Introduction
Aetiolog
y
Obsessions
Compulsions
DSM V
Managements
Prognosis
Introduction
OCD : a common, chronic and disabling disorder marked by obsession and/or compulsions that
cause severe distress to the patient and families and interfere his social or individual
functioning.
It is a chronic condition, often associated with marked anxiety and depression
A patient with OCD may have obsession, a compulsion or both
A patient with OCD realizes the irrationality of the obsession and experiences both obsession
and compulsion as ego-dystonic (unwanted behaviour that is perceived as coming from within)
Epidemiology
Prevalence 2-3% of general population

The fourth most common psychiatric diagnosis after phobias, substance-related disorders,
and major depressive disorder.
Among adults, male and female are equally affected

Among adolescents, boys > female

Age onset : late adolescent and early adulthood (mean age 20 years)
Single > married
Aetiology
Neurochemical Abnormalities in serotonergic signaling and/or dopamine signaling

Infection (PANDAS)
Environment Hormonal level
Stress
First degree relatives; 3-7%
Genetics Monozygotic twin 50-80%
Dizygotic twin 25%

Psychological Defective arousal system and/or inability to control unpleasant internal states

Psychoanalytical Freud s term of obsessional neurosis : the result of regression from oedipal stage to pre-genital anal-
erotic stage of development as a defense against aggressive or sexual (unconscious) impulses.

Obsessions are conditioned stimuli

Behavioral
Compulsions: person discovers that a certain action reduces anxiety, he or she develops active avoidance
strategies in the form of compulsions to control the anxiety.
 Possible link between a subset of OCD cases with certain types of motor tic syndrome (eg;
Tourettes disorder and chronic motor tic).
Tic disorder higher rate of OCD, Tourettes disorder, chronic motor tics
OCD increase rate of OCD, Tourettes disorder, chronic motor tics.

Neuroimaging studies increase activity in frontal lobes, basal ganglia, and cingulate of
patient with OCD.
Obsession
1 . D efi n e d a s re c u r re nt a n d p e rs i ste nt t h o u g ht s ,
i m a g e s , fe e l i n g s o r i m p u l s e s t h at a re ex p e r i e n c e d , at
s o m e ti m e d u r i n g t h e d i st u r b a n c e , a s i nt r u s i ve a n d
u nwa nte d , a n d t h at i n m o st i n d i v i d u a l s ca u s e m a r ke d
a nx i et y o r d i st re s s .
2 . T h e i n d i v i d u a l att e m p t s to i g n o re o r s u p p re s s s u c h
t h o u g ht s , u rge s , o r i m a ge s , o r to n e u t ra l i ze t h e m w i t h
s o m e o t h e r t h o u g ht o r a c ti o n ( e . g : by p e r fo r m i n g a
compulsion).
Forms of obsession
Repeated and intrusive words, ideas or phrases which are upsetting
Obsessional thought the patient

Internal debates in which argument for and against even the

Obsessional ruminations simplest everyday actions are reviewed endlessly

Repeated themes expressing uncertainty about previous actions

Obsessional doubts (eg: whether or not the person turned off the electrical appliances)

Repeated urges to carry out actions, usually of a violent or

Obsessional impulses embarassing kind

Repeated vividly imagined scenes, often of a violent or disgusting

Obsessional images kind, involving abnormal sexual practices for example
Contents of obsession
Contamination the most common obsession

Pathological doubts 2nd most common (concerned with safety)

Intrusive thoughts, images of sexual acts, 3rd common

Concern or need for symmetry, order or exactness, 4th common

Repeated intrusive aggressive thought (hurting a child)

Religious obsession
 Compulsion
1. D e fi n e d a s r e p e ti ti v e b e h a v i o r s o r m e n t a l
acts that the individual feels driven to
perform in response to an obsession or
according to rules that must be applied
r i g i d l y.

2. The behaviors or mental acts are aimed at

p r e v e n ti n g o r r e d u c i n g a n x i e t y o r d i s t r e s s , o r
p r e v e n ti n g s o m e d r e a d e d s i t u a ti o n s , h o w e v e r
t h e y a r e n o t c o n n e c t e d i n a r e a l i s ti c w a y w i t h
what they are designed to neutralize or
p reve nt , or are c l e ar ly exc e ss i ve.
Types of Compulsion acts
Cleaning rituals repeated hand washing or household cleaning

Counting rituals may be spoken aloud or rehearsed silently

Checking rituals mainly concerned with safety

Dressing rituals doubting thoughts that lead to repetition

Ordering rituals has to put his/her belongings in a special order

DSM V Criteria
A. Presence of obsessions, compulsions, or both.
B. The obsessions or compulsions are time consuming (e.g: take more than 1 hour per day) or
cause clinically significant distress or impairment in social ,occupational, or
other important areas of functioning.
C. The o-c symptoms are not attributable to physiological effects of substance or
another medical condition
D. The disturbance is not better explained by the symptoms of another mental
disorder;
 Excessive worries GAD
Preoccupation with appearance Body
dysmorphic disorder
Difficulty discarding or parting with possessions Sexual urges or fantasies paraphilic disorder
hoarding disorder
Hair pulling trichotillomania
Skin picking excoriation disorder
Stereotypies Stereotypic movement disorder
Ritualized eating behaviour Eating disorder
Preoccupation with substances or gambling
substance-related and addictive disorders
Preoccupation in having an illness illness anxiety
disorder
Impulses distruptive, impulse control, conduct
disorder
Guilty ruminations MDD
Thought insertion or delusional preoocupations
Schizophrenia spectrum, other psychiatric disorder
Repetitive patterns of behaviour autism spectrum
disorder
Specifier
Good/Fair: recognized that OCD
belief is either
definitely/probably not true of
may or may not be true

Poor : thinks OCD beliefs are

Insight
probably true

Absent insight/ delusional belief :

Specify if convinced that OCD beliefs are
true

Individu has current or

Tic-related past history of a tic
disorder
Clinical features
Common symptoms pattern:

Contamination Obsession of contamination compulsive washing or avoidance of presumably

contaminated objects

Pathological Obsession of doubt compulsion of checking

thought
Intrusive Intrusive obsessional thought without a compulsion thoughts of aggressive or
thought sexual acts report themselves to police or confess to priest, or suicidal ideation

Symmetry Need for symmetry or precision compulsion of slowness.

Often take their complaints to physician rather than psychiatrist.

MSE : symptoms of depressive disorders, some have character traits suggesting OCD (excessive needs for neatness)
 Differential diagnosis
Tics disorders (esp. Tourettes syndrome)
Temporal lobe epilepsy
Medical ddx Trauma
Postencephalitic disorder

Obsessive concerns for details,perfectionism.

OCPD If there is no true obsessions and compulsions

Distinguished from OCD obsessive symptoms only found in the

Major depression presence of major depression period, whereas true OCD persist
despite remission of depression.

Distinguished from OCD schizo is associated with delusions and hallucination

Schizophrenia and disorganized speech
Patient with OCD can always know the unreasonable nature of their symptoms
 Managements
Biological (Pharmacotherapy )
Effective for obsessions rather than compulsions
SSRIs antidepressant can treat dysregulation of serotonergic (5HT) system and treat depression
Eg: Fluoxetine (20-60mg/day), Paroxetine (40-60mg/day), sertraline (150mg/day) and fluvoxamine (100-300mg/day).
Initial effects 4-6 weeks , maximal therapeutic effects 8-16 weeks
Continue medication for at least 6 months or longer if relapses
Anxiolytic drugs-give some short term symptomatic relief, but shouldnt prescribed for more than about 3 weeks at a time.
if treatment are ineffective, can consider to add Valproate or Lithium or Carbamazepine

Psychosocial treatment
Effective for compulsion
BT/CBT using specific technique; exposure and ritual/response prevention (ERP)
ERP gradually learn to tolerate the anxiety associated with not performing the ritual behavior
Psychoeducation-patient, family members
Managements cont..
Physical
1) ECT-consider if patient suicidal or severely incapacitated
2)Psychosurgery
Done in a few very severe cases in severe, incapacitating, intractable cases (treatment resistant)
Most common operation involves removing a section of the brain called cingulate cortex
Serious side effects; seizures, personality changes and less ability to plan

3) Deep brain stimulation- for severe refractory cases

Course and prognosis
OCD typically starts in childhood or adolescence, persists throughout a persons life, and
produces substantial impairment in functioning due to the severe and chronic nature of the
illness.
20-30% show significant improvement, 40-50% show moderate improvement, but 20-40% have
chronic or worsening symptoms

Relapse rates are high after stopping medication

1/3 patients with OCD have major depressive disorder and suicide is a risk for all patients with
OCD
 Prognosis
GOOD POOR

- Longer duration
- Good premorbid - Early onset (childhood)
social and -Male
occupational - Bizarre
adjustment compulsion,hoarding,
symmetry
- Comorbid depression
- A precipitating event - Presence of over valued
idea (some acceptance of
obsession and compulsion
- Episodic symptoms - Presence of personality
disorder (esp. schizotypal)
-Less avoidance - Presence of tics
Thank you.