Obsession An idea, impulse or image which intrudes into conscious awareness repeatedly Recognized as one’s own idea, impulse, image but is perceived as ego alien (foreign to one’s personality Recognized as irrational and absurd (insight is present) One’s tries to resist against it but unable to Failure to resist leads to marked distress
Compulsion A form of behavior which usually follows obsession The aim preventing or neutralizing the distress or fear arising out of obsession The behavior is not realistic and is either irrational or excessive Insight is present, so the patient realizes the irrationality of compulsion
Epidemiology Childhood onset 10 – 14 yo (Childhood-onset OCD may have a higher rate of comorbidity with Tourette Disorder and ADHD.) Sex : Equal in both sexes although the disorder more commonly presents in males in childhood or adolescence, and in females in their twenties. Prevalence : 0.5% General population 2-3% Lifetime- prevalence 17% Minor OCD Age : 2/3 individual onset early 20 - 25
Diagnosis and Clinical Symptoms The thoughts, impulses, or images are not simply excessive worries about real-life problems. The person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action. The person recognizes that the obsessional thoughts, impulses, or images are a product of his/her own mind (not imposed from without, as in thought insertion). DSM –IV-TR: Obsessions are defined by the following 4 criteria. Recurrent and persistent thoughts, impulses, or images are experienced at some time during the disturbance as intrusive and inappropriate and cause marked anxiety and distress. Those with this disorder recognize the craziness of these unwanted thoughts (such as fears of hurting their children) and would not act on them, but the thoughts are very disturbing and difficult to tell others about.
Compulsions are defined by the following 2 criteria: The person performs repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) in response to an obsession or according to rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are meant to neutralize or prevent or they are clearly excessive. At some point during the course of the disorder, the person recognizes that the obsessions or compulsions are excessive or unreasonable. This does not apply to children. The obsessions or compulsions cause marked distress; are time consuming (take >1 h/d); or significantly interfere with the person's normal routine, occupational or academic functioning, or usual social activities or relationships.
If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it, such as preoccupation with food and weight in the presence of an eating disorder, hair pulling in the presence of trichotillomania, concern with appearance in body dysmorphic disorder, preoccupation with drugs in substance use disorder, preoccupation with having a serious illness in hypochondriasis, preoccupation with sexual urges in paraphilia, or guilty ruminations in the presence of major depressive disorder. The disorder is not due to the direct physiologic effects of a substance or a general medical condition. The additional specification of "with poor insight" is made if, for most of the current episode, the person does not recognize that the symptoms are excessive or unreasonable
ICD- 10 Predominantly obsessive thought or ruminations Predominantly compulsive acts (compulsive rituals) Mixed obsessional thoughts and acts
Major Clinical Syndromes of Obsession and Compulsion
Major Clinical Syndromes of Obsession and Compulsion Pure obsession Repetitive intrusive thought , impulse, image which are not associated with compulsive acts (sexual/ aggressive) Dealt by counter- thoughts Ruminated the pros and cons of the thought concerned Primary obsessive slowness Rare syndromes Severe Obsession ideas and/ or extensive compulsive rituals. Marked slowness in daily activity
Behavioral Theory Not able to explain the causation of OCD adequately but is very useful in treatment
3. Biological Theory Occur 2ndary to illness such as encephalitis, syphilis, Tourette’s syndrome, hypothalamic and 3rd ventricle lesion 20% OCD Pt (patient) have tics which is suggestive to basal ganglia disorder Head injury Abnormalities in serotonin (5-HT) transmission in CNS 5-7% of 1st degree relatives of Pt with OCD and greater concordance between monozygotic than dizygotic twins
Treatment Psychotherapy Psychoanalytic psychotherapy :used in certain selected patient ( anankastic personalities) Supportive psychotherapy : important adjucts to ther modes of treatment, also needed by faily members
2. Behavior Therapy (BT) and Cognitive BT (CBT) Effective mode of therapy success rate 80% especially for the compulsive acts Techniques used : Thought stopping Exposure and Response prevention (ERT) Modeling Mass Practice
3. Drug Treatment Antidepressant Selective Serotonin Reuptake Inhibitor (SSRI)Fluvoxamine (Luvox) 100-300 mg/d PO Tricyclic antidepressant Clomipramine;75-250 mg /d PO