the signs , symptoms ,etiology ,management of OCD as described in synopsis of psychiatry(11th edition)

1. OBSESSIVE COMPULSIVE DISORDER
Presented by :
Sakshi Maheshwari
M.Phil clinical psychology(2021-23)

2. Obsessions are persistent
thoughts,ideas,impulses or images that
seem to invade a person’s consciousness
Compulsions are repetitive and
rigid behaviors or mental acts that
people feel they must perform in
order to reduce or prevent anxiety

3. • Minor obsessions and compulsions can
play a helpful role in life.Little rituals often
calm us during times of stress.
• When obsessions and compulsions feel
excessive ,cause great distress and take up
too much time and interfere with daily
functions,become OCD

5. HISTORY
• Saint Ignatius of Loyola (1491–1556), spanish
saint, says “that devout people need to be sure
that they have pleased God and that they have
not sinned. If unable to convince themselves of
this, they may perform acts of penance. If these,
too, fail to allay their anxiety, then they will be
tormented by doubts and preoccupied by rituals.”

6. • Phlebotomy, draining blood to adjust body
humors, was used by doctors to treat unwanted
repetitive thoughts
• Morel(1851) first used the term ‘Obsessions’ and
described it as a disease of the emotions in order
to explain the accompanying anxiety
• Compulsions were distinguished from obsessions
• Esquirol, Dagonet and other French psychiatrists
termed it as monomania, impulsive insanity,
madness of doubt, etc. in psychiatric literature.

7. • Obsessive Compulsive Neurosis - 19th century; came to be
understood as a ‘neurosis’ and a neuropathology ( used till
4th edition of CTP)
• 20th century- ‘Obsessive Compulsive Disorder’given by Carl
Westphal(1877) from the english translation of the term
‘Zwangsneurose’ given by Freud
• 20th century - concepts of heredity, degeneration, cerebral
pathology
• Added in DSM-III For first time as anxious disorder

8. EPIDEMIOLOGY
• 1-2% of world population suffer from OCD in any year
• 3% develop disorder at some point in their life
• Women = men
• Adolescent boys > girls
• Mean age of onset = 20(can begin as early as 2yrs). In the
National Comorbidity Survey Replication (NCS-R) study, the odds
of onset are highest for individuals 18−29 years of age. Nearly a
quarter of males had onset before 10 years of age; In females,
onset often occurs during adolescence, although OCD can be
precipitated in the peripartum or postpartum period in some
women

9. COURSE
• More than half of patients have sudden onset of
symptoms
• 50-70% generally develop symptoms after
stressful life events(death,marriage,sexual
problems etc)
• Many people manage to live life with their
symptoms ,they often delay 5-10yrs before
coming to psychiatric attention

10. CLINICAL FEATURES
WISHES (eg.repeated wishes
that one’s spouse would die)
IMPULSES(repeated urges to
yell out bad things at work)
IMAGES(fleeting images of
forbidden sexual scenes)
IDEAS /DOUBTS(notions that
germs are lurking everywhere)
obsessions

11. • Compulsive behaviours are technically under
voluntary control,the people who feel they
must do them have little sense of choice in
this matter
• Most individuals recognise their behaviour is
unreasonable ,but they believe at the same
time something terrible will happen if they
don’t perform the compulsions.

13. • An individual with this disorder observed “ I can’t get to
sleep unless I am sure everything in the house is in its
proper place so that when I get up in the morning ,the
house is organized.I work like mad to set everything
straight before going to bed,but,when I get up in the
morning,I can think of a 1000 things I ought to do…..I
can’t stand to know something needs doing and I
haven’t done it” (McNeil,1967,pp 26-28)

14. COMMON THEMES
OBSESSIONS
• Dirt,contamination
• Violence
• aggression
• Orderliness
• Religion
• Sexuality
COMPULSIONS
• Cleaning
• Checking
• Order and balance
• Touching
• Verbal
• Counting

16. DSM-5
• A. presence of obsessions,compulsions,or both :
Obsessions are defined by (1) and (2) :
1. Recurrent and persistent thoughts,urges,or images that are experienced,at some time
during the disturbance ,as intrusive and unwanted,and that in most individuals cause
marked distress or anxiety
2. The individual attempts to ignore or suppress such thoughts,urges,or images,or to
neutralize them with some other thought or action
Compulsions are defined by (1) and (2) :
1. Repetitive behaviours(eg.checking,cleaning ) or mental acts(eg praying,counting) that
the individual feels driven to perform in response to an obsession or according to rules
that must be applied rigidly
NOTE : Young children may not be able to articulate the aims of these behaviours or mental acts

17. B. The obsessions and compulsions are time-consuming(eg .take more
than 1 hour per day) or cause clinically significant impairment in
social,occupational or important areas of functioning
C. The symptoms are not attributable to physiological effects of a
substance or another medical condition
D. The disturbance is not better explained by symptoms of another
mental disorder
• Excessive worries,as in GAD
• Preoccupation with appearance ,as in BDD
• Difficult discarding or parting with possessions,as in Hoarding
Disorder
• Hair pulling,as in trichotillomania
• Skin picking,as in excoriation

18. • Stereotypies,as in stereotypic movement disorder
• Ritualized eating behaviour ,as in eating disorder
• Preoccupation with substances or gambling,as in substance related and gambling
disorder
• Preoccupation with having an illness,as in illness anxiety disorder
• Sexual urges and fantasies,as in paraphilic disorder
• Impulses,as in disruptive ,impulse-control and conduct disorders
• Guilty ruminations ,as in MDD
• Thought insertion or delusional preoccupation ,as in schizophrenia spectrum
• Repetitive patterns of behaviour as in ASD
INSIGHT
Good/fair
poor
Absent/
delusional

19. ICD-10(F 42)
• Obsessional thoughts are ideas, images or impulses that
enter the individual's mind again and again in a stereotyped
form.
• They are almost invariably distressing (because they are
violent or obscene, or simply because they are perceived as
senseless) and the sufferer often tries, unsuccessfully, to
resist them.
• They are, however, recognized as the individual's own
thoughts, even though they are involuntary and often
repugnant

20. Diagnostic guidelines according to ICD 10
• For a definite diagnosis, obsessional symptoms or
compulsive acts, or both, must be present on most
days for at least 2 successive weeks and be a source of
distress or interference with activities. The obsessional
symptoms should have the following characteristics:
• a) they must be recognized as the individuals’ own
thoughts or impulses;

21. • b) there must be at least one thought or act that is still
resisted unsuccessfully, even though others may be
present which the sufferer no longer resists;
• c) the thought of carrying out the act must not in itself
be pleasurable (simple relief of anxiety is not regarded
as pleasure in this sense);
• d) the thoughts, images, or impulses must be
unpleasantly repetitive.

22. Specifiers
• F42.0 Predominantly obsessional thoughts or
ruminations
• F42.1 Predominantly compulsive acts [obsessional
rituals]
• F42.2 Mixed obsessional thoughts and acts
• F42.8 Other obsessive-compulsive disorders
• F42.9 Obsessive-compulsive disorder, unspecified

23. Comorbidity
MDD(lifeti
me
prevalence
67%)
Anxiety
disorder(
76%)
OCPD(23-
32%)
Tourette’s
disrorder(5-
7%)
Tics(20-30%)

25. DIFFERENTIAL DIAGNOSIS
• Aggressive,contamination,s
omatic
obsessions,checking,cleanin
g,repeating compulsions
• BASAL GANGLIA
Sydenham’s
chorea
•Basal ganglia
Huntington’s
disease
• In classical form,it is
associated with recurrent
vocal and motor tics
• Urges similar to
obsessions and tics to
compulsions
Tourette’s
Disorder

26. • Distinguished by course
• Obsessive symptoms in
depressions remain only during
episode
• True OCD persists despite
remissions
• Mood congruent thoughts
Depression
• Are anxious about
everyday things
• Apprehensions
about future
Generalized
anxiety disorder
• Obsessive concern
for
details,perfectionis
m
• Ego-syntonic
OC personality
disorder
• Less complex and not
aimed at neutralizing
obsessions
• Tics preceded by
premonitory sensory urges
Chronic
Tic disorder
• Autonomic symptoms are
very severe and significant
• Panic state stays for few
minutes
• Phobia directed for
particular object
Panic/
phobia
• OCD acknowledge the
unreasonable nature of
their symptoms
• Psychosis associated with
other features not typical
of OCD
Schizophrenia
(atypical
neuroleptic)

27. AETIOLOGY
PSYCHODYNAMIC
• In classic psychoanalytic,OCD termed as obsessive-
compulsive neurosis
• Considered to anal stage(disturbance in development
related to anal-sadistic phase) and develops anal-retentive
personality
• Often experience Ambivalence(love-hate feelings for same
object : patient’s doing and undoing behaviour)

28. • Here the battle b/w anxiety-provoking id
impulses(obsessions) and anxiety-reducing
defense mechanisms(compulsions)is not
buried in unconscious but played out in overt
thoughts and actions
• COMMON DEFENSE MECHANISMS: isolation,
undoing ,reaction formation

29. BEHAVIOURAL
• Concentrated on explaining and treating compulsions rather
than obsessions
• OBSESSIONS:
UCS + neutral stimulus = UCR
UCS+CS = CR
• COMPLUSIONS : certain action reduces anxiety related to
obsessional thoughts active avoidance strategy in form of
compulsions ..which become learned patterns of behaviour

31. COGNITIVE
• People blame themselves for repetitive,unwanted
thoughts and expect somehow that bad things will
happen
• To avoid such negative outcomes they try to neutralize
the thoughts by thinking or behaving in ways meant to
put matters right
• When a neutralizing effort brings temporary relief,it gets
reinforced and likely be repeated

32. BIOLOGICAL
• Neurotransmitter : low Serotonin activity( Serotonergic
hypothesis of OCD by Zohar (1987) -
Efficacy of SRIs where SRI = SSRI + Clomipramine + other
serotonergic medications)
• Brain Structures : orbitofrontal
cortex and caudate nuclei
additional : cingulate
cortex ,amygdala

33. THALAMUS
If impulses reach here person feels driven to think about them
CAUDATE NUCLEI
Impulses reach here,acts as filter ,Sends only most powerful impulses to thalamus
ORBITOFRONTAL CORTEX
Sexual,violent,other primitive Impulses normally arise

34. PET scans show increased activity(eg.metabolism and blood
flow)

35. •Family Studies : Relatives of probands
have 3-5 fold probability of having OCD
or OCD-like features
• Higher concordance rate for
monozygotic twins
•Family accommodation

36. TEMPERAMENTAL
• Greater internalizing symptoms,higher negative
emotionality and behavioural inhibition in childhood
are risk factors
ENVIRONMENTAL
• Abuse ,stressful and traumatic events are risk
factors.Sudden development in children can happen
post-infectious autoimmune syndrome
• DRUG-INDUCED OCD(atypical antipsychotics)

37. HOARDING
DISORDER
1. People are unable to give up or
throw out their possessions,even
worthless ones,because they feel a
need to save them and want to
avoid the discomfort of disposal
2. People accumulate an
extraordinary no. of possessions
that severely clutter and crowd
their homes(active living areas)

38. BODY
DYSMORPHIC
DISORDER
1. People are preoccupied with having
defect(s) or flaw(s) in their apperance
that seem at most trivial to others
2. In response to their concerns,they
repeatedly perform certain
behaviours(eg.check themselves in
mirror)or mental acts(eg.compare
themselves to others)
3. Ideas or delusions of reference
4. Most common age onset : 12-14yrs
(mean 16-17,median 15yrs)

39. Gender
dysphoria
Body
identity
integrity
disorder
Olfactory
reference
syndrome
Social
anxiety and
avoidance
Eating
disorder
Delusional
disorder

40. TRCHITILLOMA
NIA
1. Individuals repeatedly
pull out their hair
2. Despite attempts to
stop,they are unable to
stop this practise

41. EXCORIATION
1. People keep picking at their
skin,resulting in significant sores or
wounds
2. Despite attempts to stop,are unable
to do so
3. Most sufferers pick with their
fingers and center their picking on
one area,most often face

42. TREATMENT
Psychoeducation
• - “they have a relatively common disorder which is increasingly well
understood, and that the available treatments bring at least partial symptom
reduction and improved QOL”
• - Factors such as stigma, prejudice, and the role of the family and significant
others in aggravating or maintaining OCD
• - treatment should include the family whenever possible
• - Addressing reasons for this delay include a lack of knowledge about the
disorder, embarrassment about their symptoms, or anxiety about exposure
to feared stimuli

43. Cognitive-Behaviour Therapy

44. • Exposure and Response Prevention Therapy(Victor Meyer,1966)

45. •Desensitization
•Thought stopping
•Flooding
•Implosion therapy
•Aversive conditioning
•Habit reversal

46. •PSYCHODYNAMIC

49. Psychodynamic Therapy

50. Pharmacological
SSRIs
1. Fluoxetine(prozac)
2. Fluvoxamine(luvox)
3. Paroxetine(paxil)
4. Sertraline(zoloft)
5. Citalopram(celexa)
side effects : sleep
disturbance,nausea,diarrhea,headache,
anxiety,restlessness

51. Clomipramine
• most selective of all tri- and tetra- cyclic SSRIs.
• Side effects : significant sedation,anticholinergic
effects,including dry mouth and constipation
Other drugs
Valproate,Lithium,carbamazepine,MAOIs(phenelyzine)

52. Deep Brain Stimulation
• This is given when both medications and
therapy are not giving positive results.
• Done using MRI-guided stereotactic
techniques .Electrodes are implanted on
specific brain areas(basal ganglia)

53. PROGNOSTIC FACTORS
Sociodemographic variables, illness characteristics, and
comorbid disorders have all been identified as prognostic
factors,perhaps the most consistent of these include
• age at onset
• baseline illness severity and duration
• treatment response
• gender

54. • The prognosis is better when there has been a
precipitating event, social and occupational
adjustment is good, and the symptoms are episodic.
The prognosis is worse when there is a personality
disorder, and onset is in childhood. Male gender, tic-
related forms of OCD, and overvalued ideas about
the obsessions also predict a poor prognosis (Zohar
et al., 2009)

55. ASSESSMENT
• Structured diagnostic interviews for diagnosing OCD
include the Structured Clinical Interview for DSM-5
(SCID-5 Clinician or Research version) for adults and
the Anxiety Disorders Interview Schedule for DSM-5
(ADIS-5), which includes both an adult and a child or
parent version.

56. • The Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) and
the Children’s Y-BOC (CY-BOCS) are widely used, comprise a
symptom checklist and a severity scale, and are available in
self-report format
• Functional MRI and PET scanning have shown increases in
blood flow and metabolic activity in the orbitofrontal
cortex, limbic structures, caudate, and thalamus, with a
trend toward right-sided predominance.