Management of OCD and treatment resistant OCD management, Slides of Psychiatry

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MANAGEMENT OF OBSESSIVE-COMPULSIVE

DISORDER AND TREATMENT RESISTANCE

Presenter: Dr. Bhavneesh Saini

Moderators: Dr. Arvind Sharma; Dr. Pir Dutt Bansal;

Dr. Mamta Bahetra; Dr. Prinka Arora

OBSESSIONS

These are recurrent and persistent ideas, thoughts,

urges or images that:

• Intrude into one’s mind;

• Are irrational, Ego-dystonic and time consuming;

• Person acknowledges them to be product of his own

mind;

• He attempts to ignore/ suppress/ neutralize them with

some other thought or action leading to marked anxiety

or distress.

DIFFERENTIATING TERMS

• Thought  Idea  Overvalued Idea 

Preoccupation  Rumination  Obsession 

Delusion

TYPE OF OBSESSIONS / COMPULSIONS

• (^) FORM OF OBSESSIONS:

1. Obsessive doubt (60-70%)

2. Obsessive thinking (30-50%)

3. Obsessive magical thinking (30-

4. Obsessive fear (25-40%)

5. Obsessive impulse (10-15%)

6. Obsessive image (4-5%)

• (^) FORM OF COMPULSIONS:

1. Yielding Compulsions (60%)

2. Controlling Compulsions (<10%)

• (^) CONTENT OF OBSESSIONS:

1. Dirt and contamination (40-50%)

2. Aggressive (30%)

3. Inanimate and impersonal (26%)

4. Sex (10%)

5. Religion

6. Miscellaneous

• (^) CONTENT OF COMPULSIONS:

1. Cleaning/ Washing

2. Checking

3. Ordering/ Rearranging

4. Repeating

5. Counting

6. Miscellaneous

DSM-5 CRITERIA FOR OCD OBSESSIVE-COMPULSIVE DISORDER (300.3) A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2):
3. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
4. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. 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 areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder

CHANGE FROM DSM-IV TO DSM-

• OCD shifted from Anxiety Disorders to a new

disorder class- Obsessive Compulsive and related

disorders; including Trichotillomania, Hoarding

disorder, Excoriation disorder, and BDD

• The point of ‘thoughts, impulses or images are not

simply excessive worries about real-life problems’

dropped.

• Specifier of Good/fair insight, poor insight and

absent insight included; specifier for tic-related also

included.

ETIOLOGY

• (^) BIOLOGICAL FACTORS :
  • (^) Neurotransmitters-
    • (^) 5-HT- CSF concentrations of 5-HIAA decreased by Clomipramine
    • (^) DA, GABA, Glutamate
  • (^) Neuroimmunology- Group A β-hemolytic Streptococcal infection
  • (^) Brain-Imaging studies:
    • (^) Altered functions in CSTC loops involving OFC, thalamus, Caudate Nucleus
    • (^) Gray matter volumetric and white matter tract changes in CSTC loops
    • (^) Increased activity in frontal lobe, BG, Cingulum on PET scans
    • (^) B/L smaller Caudate nuclei on CT/MRI scans
  • (^) Genetics:
    • (^) Family (3-5x) and twin studies (monozygotic) show susceptibility
    • (^) 5-HT and Catecholamine related polymorphisms
    • (^) Glutaminergic function genes
  • (^) EEG/ Neuroendocrine/ Others studies:
    • (^) Non-specific- decreases REM latency
    • (^) Non-suppression on Dexamethasone suppression test in 1/3rd^ patients
    • (^) Reduced Heart-rate variability.

PSYCHOANALYTICAL FACTORS

• (^) Psychogenesis of OCD lies in disturbances in psychosexual development

related to the anal phase.

• (^) Child is caught between libidinal desire to possess mother or father and

fear of punishment (from opposite parent). The anxiety thus generated by

the Oedipus complex is immense.

• (^) So, the development is inhibited and the child regresses to the earlier

stage of development characterised by sadistic and anal-erotic impulses.

• (^) Psychic conflicts at the anal stage represent another major predicament

for the child, as he or she needs to adapt to parental control of toilet

training (Ambivalency).

• (^) If parents are too harsh and make the child feel ashamed, the child may

deliberately soil his or her clothes as an act of rebellion.

• (^) This conflict over cleanliness can lead to OCD; since the ‘Superego’

represents the internalization of parental values and so develops to be

harsh and punitive.

• (^) PERSONALITY FACTORS:
  • (^) OCPD- 15-35% OCD patients have premorbid Anankastic personalities.
• (^) PSYCHODYNAMIC FACTORS:
  • (^) Unconscious wish for secondary gains
  • (^) Interpersonal and Family relations
    • (^) Family accommodation- leads to increase in symptoms and resulting rejecting attitude of family
    • (^) Expressed Emotions

DIFFERENTIAL DIAGNOSES

1. Other Anxiety disorders like GAD, SAD or Phobias
2. Body Dysmorphic disorder
3. Psychotic disorders (delusional preoccupations)
4. Kleptomania, Trichotillomania, Hoarding and Gambling disorder
5. Tourette disorder
6. Illness anxiety disorder
7. Impulse control disorder
8. Paraphilic disorders
9. OCD-like disorders associated with Basal Ganglia disease 10.Major Depressive disorder (guilty ruminations) 11.Obsessive-compulsive Personality disorder.

ASSESSMENT AND EVALUATION  (^) BASIC ASSESSMENT:

• (^) Comprehensive assessment of both patient and caregiver(s).
• (^) Complete history with information from all possible sources.
• (^) General Physical Examination including vitals like BP, weight and wherever indicated- BMI and waist circumference.
• (^) Mental Status Examination.
• (^) Establishing diagnosis according to ICD-10/ DSM-5 criteria.
• (^) Rule out Differential diagnoses (as described previously).
• (^) Detailed symptom evaluation, including:
  • (^) Identifying principal target symptoms (especially for CBT)
  • (^) Identify proxy compulsions, avoidance and safety behaviors
  • (^) Determine level of insight
  • (^) Assess family’s accommodation of patient’s rituals

CONTD..

• (^) Assessment of co-morbid psychiatric disorders (explained later).
• (^) Basic investigations: CBC, sugar and lipid levels, LFT, RFT, ECG (focus on QTc).
• (^) Assessment of caregivers: knowledge and understanding of illness, attitudes/ beliefs, impact of illness on them.
• (^) Ongoing assessments: Treatment response and adherence, side- effects, disability assessment.  (^) ADDITIONAL ASSESSMENTS:
• (^) Use of standardized rating scales to rate all aspects of illness- YBOCS (10-item scale for symptom severity and insight- score > significant; has target symptom list).
• (^) Neuroimaging especially in first episode OCD in elderly, onset after head trauma; non-response to treatment.

CHOICE OF TREATMENT SETTING OUTPATIENT TREATMENT:

• (^) Mild to Moderate severity
• (^) Those likely to be adherent to treatment - (^) Patients may follow-up initially once a month and subsequently at longer intervals depending upon response and tolerability INPATIENT TREATMENT:
• (^) High suicidal risk
• (^) Risk of harm to self or others
• (^) Severe/ extremely ill patients
• (^) Intolerance to side-effects
• (^) Treatment resistance (for intensive pharmacotherapy/ CBT/ ECT)
• (^) Co-morbid severe Depression or Psychosis

GOALS OF TREATMENT

SHORT TERM

• To achieve clinical response

and if possible, remission

• Remission of depression

• Deal with suicidal thoughts

and behavior

• Determine tolerability to

medication

• Identify and manage

adverse effects

LONG TERM

• Achieve recovery

• Restore psychosocial

functioning and

enhance quality of life

• Prevent relapses