Obsessive Compulsive DisorderPresenter :- Dr. Anant (Resident)Guide :- Dr. D. K. Sharma (Prof. & Head)
OBSESSIVE COMPULSIVE DISORDEROCD is an anxiety disorder distinguished byrecurring thoughts that cause anxiety and theimpulse to perform certain actions in order torelieve the anxiety.(Obsessions and Compulsion)
Obsession• Recurrent persistent thoughts, impulses, images that – Enters the mind – Can’t be eliminated by consciousness by logic/reasoning – Involuntary – Ego-dystonic
Obsession - Characteristic features• Subjective sense of struggle• Conviction that to think is to make it more likely to happen• Recognized as own• Regarded as untrue and senseless• Generally about matters that are distressing• Often accompanied by compulsion
Compulsion• Pathological need to act on an impulse that if restricted produce anxiety• Repetitive behavior in response to an obsession, performed according to certain rules with no true end in itself
The obsessions or compulsions are asignificant source of distress to theindividual.
Causes of OCD in shortCauses of OCD in short Neurobiological Neurobiological Environmental Psychological Environmental Psychological
Neurobiological factors Neurotransmitter Levels Serotonin Low CSF 5HT Platelets 5HIAA“normal.jpg” “ocd.jpg” DA – Hyper functioning in PFC 5HT – Hypo functioning in basal ganglia Dysfunction of the so-called cortico-striato-thalamic loops
Brain Imaging StudiesCT/MRI: Decrease size of caudate nucleiPET: Increased activity in frontal lobe (OFC) & basal ganglia(caudate), Thalamus
BIOLOGICAL• The orbitofrontal cortex has a circuit that sends information to the thalamus such as aggression, sexuality and bodily excretions.• When these parts of the brain are activated you are bound to act upon those certain behaviors or actions. Causes• These impulses are brought to ones conscience and after your brain has sent you the information and have acted upon that information the impulse eventually decreases and you move on to your daily routine.• Within people who have OCD, some certain impulses cannot be turned off or ignored by that part of the brain, which causes them to repeat the same action over and over again.• Eventually they become obsessed with these actions and they have become integrated into their routine and they have no control over it.
GENETIC FACTORSOCD has significant genetic component .Three to five times higher probability of OCD in relatives ofprobands with OCD.Concordance for OCD in twins is significantly higher formonozygotic twins than for dizygotic twins .
Environmental factorsEarly childhood conflicts:• This is an early theory that suggests conflicts or problems during childhood are the roots of OCD.• This is specifically looking at either permissive or mainly unengaged parenting techniques.
Psychological - COGNITIVE THEORY OF OCD• Obsessional thoughts: – It’s not the thought itself that is disturbing, but rather the interpretation of the thought. – The issue of responsibility is believed to be a core belief or cognitive distortion of people with OCD.
Compulsive behaviors:– Neutralizing, either through compulsive behaviors or mental strategies, is aimed at preventing terrible consequences, or averts the possibility of being responsible– Seeking reassurance is another form of neutralizing, as it can serve to spread responsibility to others, thus diluting that of the individual– Avoidance, though not an overt neutralizing behavior, is often used to prevent contact with particular stimuli
• Model: – Stimuli in the form of unpleasant intrusive thoughts, of either external or internal origins are experienced – The thought is ego-dystonic, that is, it is inconsistent with the individual’s belief system – It usually involves an element of blame, responsibility, or control, which interacts with the content of the intrusive thought – Disturbances in mood and anxiety follow, which in turn lead to neutralizing behavior
Main consequences of neutralizing behavior It results in reduced discomfort, which leads to the development of compulsive behavior as a tool for dealing with stress. This reinforcing behavior may result in a generalization of this strategy Neutralizing will be followed by non-punishment, and can lead to an effect on the perceived validity of the beliefs The neutralizing behavior itself becomes a powerful and unavoidable triggering stimulus. The neutralizing behavior serves to reinforce the belief that something bad may happen
PSYCHODYNAMIC FACTORSISOLATION It protects an individual from anxiety provoking affects and impulses. isolation less effective Patient experience a partial awareness of the impulse without fully recognizing its meaning Impulse is displaced from the true object to other people or object.
PSYCHODYNAMIC FACTORS (CONTD.)UNDOING When impulse`s constant threat escape primary defense of isolation Secondary defensive operations is started Compulsive act that is performed in an attempt to prevent or undo the consequences that the patient irrationally anticipates from a frightening obsessional thought or impulse.
PSYCHODYNAMIC FACTORS (CONTD.)REACTION FORMATION Manifest patterns of behaviour and consciously experienced attitudes that are exactly the opposite of the underlying impulses Reaction formation results into formation of character traits of OCD.
PSYCHOANALYTIC FACTORSAMBIVALENCE Present in normal children during the anal sadistic development phase. Children feel both love and murderous hate towards the same object. Patients with OCD often consciously experience both love and hate toward an object. Conflict of opposing emotions is evident in a patient` doing and undoing patterns of behaviour and in paralyzing doubt in the face of choice.
PSYCHOANALYTIC FACTORS (CONTD.)MAGICAL THINKING Inherent in magical thinking is omnipotence of thought. An event can occur merely by thinking without intermediate physical actions. This feeling causes them to fear having an aggressive thought.
With OCD I feel…• Misunderstood, nobody seems to get me, they can’t understand why I am the way I am.
Depressed…• I feel depressed because I get stuck in my ways and nobody gets them or can help me.
CRAZY!• My obsessions drive me crazy. I wish they would stop.
Repetitive• I repeat myself and actions, over and over and over and over and over and over and over and over again….
Out of Control• I cant control my thoughts, actions, or myself. Its like I am a character in a video game.
Hyper• OCD makes me also feel hyper and wild sometimes, when its not ruining my life.
Introverted• I find that I am very unfond of others even my closest friends, when my compulsions are really bad.
Lazy • I don’t enjoy doing things or leaving my house because of the anxiety it causes. I’d rather just sit and wait.
Nervous• Not knowing what is going to happen makes me super nervous. Everything has to be planned out and go exactly according to plan.
Anxious• I get anxious when I have compulsions and I obsess over the little things, it’s a feeling that never goes away for me.
Scared• I get scared when people don’t understand me and judge me and when things don’t go according to plan, I get afraid something will happen to me.
OCD- Prevalence• Is chronic psychiatric disorder and is one of the 10 most disabling medical conditions worldwide• 4th most common psychiatric disorder• OCD is not received due attention and with its high prevalence it is being labeled as the ‘hidden epidemic’
ECT- Anti obsessional property?• APA task force on ECT- unless severe depression is prominent ECT is not an effective treatment option.• Reports and efficacy of ECT treatment in refractory OCD is sparse in literature.• Study- retrospective review 32 patients OC and depressive symptoms baseline survey ECT improvement in refractory OCD and depressive symptoms Fallacy- Retrospective study ECT conditions and parameters frequency & number criteria/reasons of stopping ECT were not specified
• Study- Open label 11 patients Maintenance ECT for refractory OCD- 2or3 per week for ten sessions. Significant improvement in initial 3-4 wks Maintained till 4 months Pre-treatment state within 6 months
Research Question• Is ECT is more beneficial in patients of OCD having co-morbid psychosis/Schizophrenia?
Repetitive Transcranial Magnetic Stimulation (rTMS)• In rTMS pulsed magnetic field is applied to the scalp induces electric currents that depolarizes underlying cortical neurons influencing their function• Possible Hypothesis- directly altering the hyper functioning of PFC with rTMS ameliorate symptoms of OCD• Speed of Stimulation > 1Hz- high frequency - activates stimulated areas• Speed of stimulation < 1Hz- low frequency - inhibit cortical stimulation
Study-• Crossover randomized investigator blind study• 12 right handed pts having current or past depression• Single session of rTMS at 80% of RMT(resting motor threshold) at 20Hz/2 second per minute for 20 minutes• On right lateral pre-frontal, left lateral pre-frontal and mid- occipital(control) site• Result- Compulsions decreased significantly for 8hrs after Rt lateral PFC stimulation with modest increase in positive mood• Non-significant reduction in compulsion urges 30 minutes after left lateral PFC stimulation• Non-significant increase in compulsive urges after mid- occipital stimulation• Obsession did not change significantly
Study-• Open label 12 Rt handed OCD refractory pts none having depression• Randomly assigned to 10 sessions of Rt or Lt pre-frontal rTMS of 10Hz, 110% RMT, 30 trains of 5 second each• Site- in relation to activating 1st dorsal interosseous muscle• Result- 33% of either group showed clinically significant improvement (40% reduction in YBOCS)• No significant differences b/w Rt & Lt sided rTMS• No difference b/w obsessions & compulsions score
Study (Alonso et al)• Double blind randomized placebo controlled parallel group design• 18 Rt handed pts with no other psychiatric co-morbidity• 10 pts assigned to thrice weekly sessions for 6wk at 1Hz on Rt pre- frontal at 110% of RMT- 2 pts showed 40% reduction in YBOCS• 8 pts assigned to placebo group- 1 responded• Improvement appeared following 5th wk of t/t• Real rTMS receivers had non-significant greater reduction in obsessions
Study (Sachdev et al)• Double blind randomized placebo controlled parallel group design• 18 pts without depression• 10 pts received real rTMS over Lt DLPFC• 8 pts received placebo rTMS• After 2 wks t/t status were informed to the pts with option of further 2 wks of rTMS to real rTMS receiver & 4 wks of rTMS to placebo receivers• Improvement in 1st 2 wks was not different among both groups• 6 pts had clinically significant improvement• Result- study did not support efficacy of high frequency DLPFC rTMS given over 2 wks in OCD
Study-• Double blind randomized placebo controlled parallel group design• To assess whether rTMS facilitates effect of anti- depressants in OCD• In 33 t/t resistant OCD pts• Study failed to find any difference in either group
Study-• Double blind randomized placebo controlled parallel group design• Aimed to enhance efficacy of rTMS by combining two forms of stimulation sequentially over Rt DLPFC & supplementary motor areas• 21 t/t resistant pts with coexistent depression• 2 pts in either group had a 25% reduction in YBOCS score• 1 pt in active group had clinically significant reduction in MADRS• Result- study did not find any clinically significant difference b/w two groups
Study-• Open label study from India• 42 Rt handed pts• 10Hz rTMS, 110% RMT over Rt DLPFC• Both active & placebo groups evinced significant improvement in obsession and compulsion• However active rTMS was not superior to placebo• Result- no significant effect of rTMS in t/t of OCD but modest effect on co-morbid depression
Limitations of above mentioned studies• Very small no. of subjects• Pt selection was not uniform• Definition of t/t resistant was not clear• No consistency in symptoms subtypes• Criteria for response were not very consistent• Technical parameters of rTMS as exact site of stimulation, side, method of site selection, strength and duration of sessions have no consensus• Presence of co-morbid depression makes it difficult to dissociate improvement in YBOCS from that due to improvement in depression
• With the information from current trials for rTMS in OCD- negligible evidence as none of the randomized controlled studies was able to find any difference b/w real and placebo group• Both NICE and APA practice guideline for t/t of OCD conclude “currently rTMS cannot be recommended as a t/t option”
Research Need• For larger double blind placebo controlled rTMS studies in co-morbidity free OCD pts with comparison across different stimulation sites• For longer follow up periods to assess if the beneficial effects are enduring