Professional Documents
Culture Documents
Behavioral Medicine II
AY 2015-2016
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
Bookbased PPT/Lecturer
Obsession recurrent intrusive thought, feeling, idea, or sensation
Compulsion - conscious, standardized, recurrent, behavior, eg. Counting,
checking, avoiding motor, acting out an obsession
Diverse group of symptoms that are time-consuming and interfere significantly
with normal routine, occupational functioning, usual social activities, or
relationships
Patient realizes the irrationality of the disorder
Experiences the disorder as ego-dystonic (e.g unwanted-behavior), but he
cant help himself
Compulsive act carried out in an attempt to reduce anxiety form the
obsession may even increase the anxiety
Anxiety also increased when person resists carrying out compulsion
Epidemiology
Lifetime prevalence: 2 to 3%
Fourth most common pyschiatric dx (after phobia, substance related disorders,
2nd leading cause of morbidity by age 20
and major depression)
adolescent M > F
Women = men adults
Mean-age of onset:20 yrs
Single persons affected more frequently
Etiology
Biologic factors
o
Neurotransmitters
Serotonergic system
Dysregulation of serotonin
Reduction in 5-HT due to increased metabolism
Increased in CSF 5-HIAA metabolite of serotonin
makes serotonin more readily available = resolution of s/sx Success of serotonergic drugs e.g SSRIs
Noradrenergic system
Dysregulation of NE
Increased NE anxiety, OCD
NE antagonist --> lose OCD s/sx
Success of Clonidine in lowering NE
anti-HTN --> hypotension
release from presynaptic terminals
SSRI > clonidine
o
Neuroimmunology
?link between OCD and Group A-hemolytic
streptococcal infection increased antibodies
o
Brain Imaging
Dysfunctional
neurocircuitry between orbitofrontal
OCD is a basal ganglia dx
basal ganglia
cortex, caudate, and thalamus
particularly the caudate
nucleus
PET: increased activity in frontal lobes, basal ganglia,
and cingulum affecting amygdale
CT/MRI, smaller caudate bilaterally
o
Genetics
Relatives have three to fivefold higher probability of
OCD or OC features
o
Other biological data
EEG and neuroendocrine studies:
commonality with major depression,
tourettes disorder, and chronic motor tics
vocal and motor tics - jerky movements and bad words
Behavioral factors
o
Learning theory
Obsessions are conditioned stimuli
traumatic event in formative
Neutral stimulus becomes associated with fear or
years engrained in the mind so
when similar stimulus is
anxiety by being paired with events that are noxious
encountered, obsessions and
or anxiety producing
compulsions manifest
Person discovers an action that reduces anxiety
attached to an obsession, he develops active
avoidance strategies (compulsions or ritualistic
behavior) to control the anxiety
Because of the efficacy of reducing anxiety these
avoidance strategies decompulsion
Psychosocial factors
o
Personality factors no particular personality type is associated with OCD
OCD different from OC personality disorder
Diagnosis
D.
Co-morbidity
Major depressive disorder 67%
Social phobia 25%
Alcohol use disorders
Generalized anxiety disorder
Specific phobia
Panic disorder
Eating disorder
Personality disorders
Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive
disorder beliefs are definitely or probably not true or that they may or may not be
true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs
are probably true.
With absent insight/delusional beliefs: The individual is completely convinced
that obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder.
Symptom Pattern
CPISO
Contamination
Most common
Feeling of contamination
Excessive hand washing,
bathing
Avoidance of contaminated
object
Unable to leave home for fear
of contamination
They believe that even with the
slightest touch they will be
contaminated
Madikit lang ng konti,
handwashing na or even take a
bath
Commonly see: px uses
handkerchief or tissue to open
the doorknob, if the hand
touches the doorknob or door,
they immediately wash their
hands
They are unable to leave home
because of fear of
contamination
Intrusive thoughts e.g. LSS
Third most common
Intrusive obsessional thoughts
without compulsion
Repetitious thoughts of sexual
or aggressive act that is
reprehensible
If the patient would have these
aggressive thoughts,
sometimes he would report
himself to the police.
Natatakot ako baka pwede
akong makapatay
Sexual obsessions they
might even go to the priest and
confess
Pathological Doubt
Second most common
Intrusive obsessional thoughts
followed by compulsion of
checking
Lights, stove, doorlocks
Back-ups they even need to
go back home just to check
these things (nailock ko ba?
Napatay ko ba yung ilaw?)
Time consuming!
Natatkot sila baka manakawan
They fear that they might have
done something
o
Co-morbid personality disorder
Good prognosis
o
Good social and occupational adjustment
o
Presence of precipitating event
o
Episodic nature fleeting
**obsessional content has relation to the prognosis? -- NONE
Treatment
Pharmacotherapy:
o
SSRI
Related Disorders
Body dysmorphic disorder
Hoarding disorder
Hair-pulling disorder (trichotillomania)
Excoriation (skin picking) disorder
Symmetry
Need for symmetry, precision
Compulsion of slowness slow
because everything needs to
be done in exactly the same
way rigid system of doing things
Rituals
Everything to be done in
exactly the same way
Patients may walk in the
corridor, should be at the
middle to the point of
measuring it
Diagnosis
Acquiring and not discarding things that are deemed to be of little or no value,,
resulting in excessive clutter of living space
Obsessive fear of losing important items that a person believes may be of use
in the future
Distorted beliefs about the importance of possessions
Extreme emotional attachment to possessions back-ups
Epidemiology
2 to 5% of general population
Men = women
More common in single persons
Usually begins in early adolescence and persists throughout life
Co-morbidity
OCD
Compulsive buying kahit hindi kailangan (bags, shoes)
Personality disorders dependent, avoidant, schizotypal, paranoid types
Generalized anxiety disorder (27%)
ADHD
Social anxiety disorder (14%)
Schizophrenia
and may follow surgery resulting in
Dementia frontotemporal.
structural defects in prefrontal and orbitofrontal cortex
Eating disorders, depression, anxiety disorders, substance use disorders,
kleptomania, compulsive gambling
Etiology
80% have a first degree relative with hoarding behavior genetic
Lower metabolism in posterior cingulum and occipital cortex
Markers on chromosomes 4q, 5q, 17q
DDx: OCD, dementia, schizophrenia, bipolar mood disorder
Diagnosis
Acquiring and failure to discard a large amount of possessions that are
deemed useless or of little value
Greatly cluttered living areas precluding normal activities may be dangerous,
attract pest, fire, etc.
Significant distress and impairment in function due to hoarding
Diagnosis
Increase tension before hair pulliung; sense of release or gratification after hair
pulling
All areas of body affected, most commonly the scalp
Two types:
o
Focused pulling intentional act to control unpleasant personal
experiences, e.g. urge, bodily sensation (itching, burning) or thought
often during sedentary
o
Automatic pulling occurs outside awareness most
activities
Tricophagy eating the hair after pulling, may cause intestinal obstruction
Hair pulling is not reported as being painful but pruritus and tingling may occur in the involved area
Head banging, nail biting, scratching, gnawing, excoriation, and other acts of self-mutilation may be present
Treatment
Co-morbidity
target of self-inflicted injury, more
elaborate methods
OCD
OCD
Hair-pulling disorder
Body dysmorphism
Substance dependence
Major depression
Anxiety disorder
Body dysmorphic disorder
Borderline and obsessive-compulsive personality disorders
Clinical Features
Fear of losing items that patient believes will be needed later
Distorted belief about or an emotional attachment possessions
Hoarders do not perceive their behavior to be a problem, and is part of their
identity
Most commonly hoarded: Newspapers, magazines, old clothes, books, bags,
Etiology cause of skin picking is unknown
notes, photographs
Manifestation of repressed rage and authoritarian parents; self-assertion
Inability to organize possessions and avoidance to make a decision to discard
Relief of stress from marital conflicts, passing of loved-ones, unwanted
Course and Prognosis:
them
pregnancies
Chronic condition w/ a tx-resistant
goal in tx is to get rid of a significant amt of possessions
Treatment Tx studies using SSRIs have shown mixed results
course
Psychoanalytic theory skin is an erotic organ; masturbatory equivalent
Tx
seeking
does
not
usually
occur
Cognitive Behavior Therapy (CBT)
o
Skin picking is a source of erotic pleasure
until patients are in their 40s-50s,
o
Training in decision making and categorizing even if the hoarding began during
Serotonin, dopamine, glutamate dysregulation
o
Exposure and habituation to discarding
adolescence
Symptoms may fluctuate throughout Diagnosis
o
Cognitive restructuring
the course of the disorder but full
Recurring skin picking resulting in skin lesion
remission is rare
HAIR-PULLING DISORDER (TRICHOTOLLOMANIA)
Repeated attempts to decrease or stop picking
Clinical relevant distress or impairment in functioning
Chronic repetitive hair pulling
Clinical Findings
Trichotilomania (Francois Hallopeau)
Face most common site
Increased tension prior to hair pulling; relief of tension or gratification after hair
Legs, arms, torso, hands, cuticles, fingers, scalp
pulling
Tension prior to picking; relief and gratification after picking
Relief of stress and other negative feelings
Epidemiology
Patients often feel guilty and embarrassment at their behavior
Prevalence in underestimated because of underreporting
Two forms:
< 17 years
Treatmnent:
o
More serious, chronic form early to mid adolescence, Female >
SSRIs Fluoxetine
male; 10:1 only child or oldest child in the family
o
Childhood type girls = boys, less serious dermatologically and
Lamotrigine
psychologically resolves in adulthood
Habit reversal and brief cognitive-behavioral therapy (CBT)
Co-morbidity
Psychotherapy for underlying emotional factors
OCD
Course and Prognosis:
Mean age: early teens, <17 years
Anxiety disorders
The course of the disorder is not well known;
Tourettes disorder
both chronic and remitting forms occur
Depression
Eating disorder
Personality Disorder
Etiology
Disturbances in mother-child relationship
Fear of being left alone
HOARDING DISORDER