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
 OCD Pre/Post SSRI

Baseline

After
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

80
70
Stereotypy

60
50
Placebo
40
30 Fluoxetine
20
10
0

Weeks (0-8)
“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:
0
Pharmacotherapy
PBO
PAR40
ESC10
ESC20

-5
Estimate

**
** *
* *
-10
*
** ****
* **
** **

-15
0 2 4 6 8 10 12 14 16 18 20 22 24
Week

* p<0.05 vs PBO, ** p<0.01 vs PBO

(Stein et al, 2007)
 Treatment Resources

• MRC Unit Anxiety Disorders (cl2@sun.ac.za)

• GSH OCD Evaluations (dan.stein@uct.ac.za)
• 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