2. “ . . . Continually tormented by an inner sense of
imperfection,
connected with the perception that actions or
intentions
have been incompletely achieved.”
—Pierre Janet
3. What is OCD?
• Is an anxiety disorder that effects 1-2% of the population
• They experience obsessions and compulsions
• Obsessions – unwanted thoughts, images or impulses that
cause a lot of stress and anxiety
• Compulsions – are behaviours or acts that are carried out to
reduce the anxiety
4. Epidemiology of OCD
• 2.5% lifetime prevalence.
• Prevalence is similar for men and women.
• Onset occurs typically during adolescence or early adulthood.
• Onset is earlier for males than females.
• Tends to be chronic without treatment with periods of waxing
and waning of symptoms.
5. Obsessions
• Obsessions are intrusive, distressing thoughts and mental
images which repeat over and over. They are ego-dystonic
(experienced as unpleasant).
• Common obsessions:
– Dirt and contamination
– Pathological doubt
– Need for symmetry
– Hoarding
– Sexual content (blasphemous religious thoughts.)
– Aggressive content
– Superstitious fears
6. Compulsions
• Compulsions are repetitive behaviors (hand washing,
cleaning) or mental acts (praying, counting) that the person
feels driven to perform in response to an obsession.
• Common compulsions:
– Cleaning and washing
– Arranging until things are “just right”
– Hoarding
– Checking
– Mental rituals (prayers, counting etc.)
7. Common Obsessions in OCD
Obsession % of Sample(N-200)
contamination 45
Pathological doubt 42
somatic 36
symmetry 31
aggressive 28
sexual 26
others 13
Multiple obsessions 60
8. Common Compulsions in OCD
Compulsion % of Sample (N = 200)
Checking 63
Washing and cleaning 50
Counting 36
Need to ask and confess 31
Symmetry and precision 28
Hoarding 18
Multiple compulsions 48
10. • The person must have recognized at some point that the
obsessions or compulsions are excessive or unreasonable.
• These recurrent obsessions or compulsions must be severe
enough to be time consuming (taking up more than 1 hour
per day).
• The obsessions/compulsions must cause a marked distress or
significantly interfere with the individuals normal routine,
occupational functioning, or usual social activities or
relationships with others.
General requirements
12. Neuroanatomical models of ocd
• Common areas include
– Orbito-frontal cortex
– Head of the caudate
– Anterior cingulate
– Thalamus
13. Imaging-Structural
Volumetric studies reveal involvement in the form of
– Decreased volumes of
• Orbito-frontal Cortex(OFC)
• Anterior Cingulate Cortex(ACC)
• Basal ganglia
– Increased volume of the thalamus
14. • PET studies reveal increased glucose metabolism in OFC and
caudate nuclei.
• Symptom provocation is associated with increase in blood
flow to OFC, ACC, caudate and thalamus.
• Treatment studies reveal that lower metabolism is associated
with better response to medication
15.
16. Assessment Techniques
• Office Visits
• The Anxiety Disorder Interview Schedule – Revised (ADIS-R)
• The Yale-Brown Obsessive-Compulsive Symptom Checklist (Y-
BOC)
• The Leyton Obsessional Inventory (Lol)
• The State Trait Anxiety Inventory of Children (STAIC)
17. Differential Diagnosis
• Anxiety disorder Due to a
General Medical Condition
• Substance induced Anxiety
Disorder
• Body Dysmorphic Disorder
• Specific or Social Phobias
(Trichotillomania)
• Major Depressive Episode
• Generalized Anxiety
Disorder
• Hypochondriasis
• Specific Phobia
• Delusional Disorder
• Psychotic Disorder Not
Otherwise Specified
21. Pharmacotherapy
• SSRI’s
– First line drug.
– Higher doses than for MDD (ex. 80 mg fluoxetine)
– 10-12 weeks before switching
• Clomipramine
– first FDA approved, most serotonin specific of TCA’s.
– Augmentation with Li / atypical antipsychotics, e.g.
risperidone .
22. Other Medications
• Monoamine Oxidase Inhibitors
– The monoamine oxidase inhibitors (MAOIs) are effective
antidepressants
– The two MAOIs available are phenelzine (Nardil) and
tranylcipramine (Parnate).
– The MAOIs are used to treat OCD only when SSRI
medications fail.
24. Exposure and Response Prevention
(ERP)
• The most widely practised behaviour therapy for OCD is called
exposure and response prevention.
• There are two components:
– Exposure Treatment
– Response Prevention Treatment
• Treatment starts with exposure to situations that cause the
least anxiety
• As the patient overcomes these, they move on to situations
that cause more anxiety
25. ERP
• Exposure Treatment
– Controlled exposure (direct or imagined) to objects or
situations that trigger obsessions while raising anxiety
levels
– Over time the exposure leads to less anxiety and over a
long period of time it leads to very little anxiety at all.
26. ERP
• Response Prevention Treatment
– The ritual behaviours that people with OCD engage in to
reduce anxiety.
– Patients learn to resist the compulsion to perform rituals
and are eventually able to stop engaging in these
behaviours
27. Common Difficulties During ERP
• Non-compliance with response prevention instructions.
• Continued passive avoidance.
• Arguing about exposure/response prevention requirements
• Emotional overload.
• Family reactions.
28. • Deep brain stimulation disrupts
action of cortico-thalamic
(hyperactive) circuit
• Electrode is placed in anterior
limb of internal capsule
• Modulation of OFC, ACC, striatum,
thalamus and globus pallidus
activation noted
29. Treatment Refractory
• Psychosurgery
– For patient’s who have failed medication and therapy
– Response rate approx. 50%
– Four surgical prodecures
• Cingulotomy, subcaudate tractotomy, limbic leukotomy,
capsulotomy
• Interrupt signals from OFC to basal ganglia
– Gamma Knife
• Anterior limb of internal capsule
31. Prognosis
• Chronic waxing and waning.
• The rule of thirds
– 20-30% “significant improvement”
– 40-50% “moderate improvement”
– Remaining 20-40% stay ill or get worse.
32. Poor Prognostic factors
1.Yielding rather than resisting compulsions
2.Childhood onset
3.Bizzare compulsions
4.Need for hospitalization
5.Co-existence with depression
6.Delusional beliefs and over valued ideas
7. Co-existence with personality disorders.
33. Good prognostic factors
1. Good social and occupational adjustment
2. Presence of precipitating events
3. Episodic nature of the illness
34. • Paediatric Autoimmune Neuropsychiatric Disorders
Associated with Streptococcus (PANDAS)
– First noticed as behavioural problem accompanying
Sydenham’s chorea in rheumatic fever
– Immune response to Group A β-Hemolytic Streptococci
with cross reactivity to basal ganglia antigen.
– No clear immune markers have been found differentiating
pts. with PANDAS and those with no PANDAS but OCD.
– Intravenous immunoglobulin and penicillin prophylaxis
have been tried for children satisfying the PANDAS criteria.
Swedo SE et al. Am J Psychiatry 1998;155:264–271.3.
35. OCD Experiences
OCD Not OCD
A man who washes his hands 100
times a day until they are red and
raw
A woman who unfailingly
washer her hands before every
meal
A women who locks and relocks her
door before going to work every day
– for half an hour
A woman who double-checks
that her apartment door and
windows are locked each night
before she goes to bed.
A college student who must tap on
the door frame of every classroom 14
times before entering
A musician who practices a
difficult passage over and over
again until its perfect
A man who stores 19 years of
newspapers “just in case” – with no
system for filling or retrieving
A woman who dedicates all her
spare time and money to
building her record collection
36. OCPD
• Pervasive pattern of preoccupation with orderliness,
perfectionism, and mental and interpersonal control, at the
expense of flexibility, openness and efficiency.
• Preoccupation with details, rules and lists, so that the point of
the activity is lost
• Perfectionism that interferes with task completion
• Excessively devoted to work so that leisure activities and
friendships suffer
37. OCD vs. OCPD
• OCD is ego dystonic, personality disorders are ego syntonic
• OCPD lacks true obsessions or compulsions.
• OCD patients are found in clinics, people with OCPD go to
medical school.
38. Conclusion
• In conclusion, OCD is a tough disorder to live with. We all may
think that OCD can have an easy fix, and that it really isn’t that
hard to live with. But, the reality is that it is not, as it affects
almost every aspect of the persons life, whether it be
interactions with family or friends, or simple everyday tasks
that we all take for granted.
