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Vimali. M,
Pharm.D(PB),
13425T0010
 Introduction
 Definition
 Aetiology
 Patho physiology
 Clinical presentation
 Signs and symptoms
 Differential diagnosis
 Diagnosis
 Treatment
 Non-pharmacological
 Pharmacological
 Psychological
 Co-morbid conditions
 Relapse
 Therapeutic outcomes
 Conclusion
 Obsessive compulsive disorder(OCD)
 Characterized by obsessional thoughts and
compulsive rituals.
 Secondary to both depressive illness and Gilles
de la Tourette syndrome.
 OCD is an anxiety disorder characterized by
intrusive thoughts that produce uneasiness,
apprehension, fear or worry; by repetitive
behaviours aimed at reducing the associated
anxiety; or by a combination of such obsessions
and compulsions
 OCD is characterized by anxiety-provoking
ideas, images or impulses(obsessions) and by
urges-compulsions to do something hat will
lessen their anxiety.
 Obsession:
 Repetitive, intrusive thoughts, ideas or impulses that
are recognized as a foreign or repugnant to the
individual.
 They are involuntary, seemingly uncontrollable
thoughts, images or impulses that occur over and
over again in the mind.
 Compulsion:
 Repetitive, stereotyped behaviors that are
senseless and are not connected un a realistic
way with what they are meant to produce or
prevent.
 The individuals usually recognizes the
senselessness of the behaviors, although they
do relieve tension.
 80% cases: before the age of 18.
 Higher in males than females
 But age of onset is younger in females than
males
 It is common in Latin America, Africa, Europe
at 2-3 times than those in Asia and Oceania.
 Psychological:
may have high amount of predisposing
genes.
 Biological
 neuro=-transmitter’s role
 Genetic-hSERT mutation
 Basal ganglia dysfunction
 Stress
 Life style modification- new job, puberty, etc.
 5-7% of the first degree relatives.
 Twin studies showed 80-90%concordance in
monozygotic twins and about 50%in dizygotic
twins.
 Basal ganglia dysfunction:
 Associated with a number of neurological
disorders involving dysfunction of the
striatum, including parkinsonism disease,
Sydenham’s and Huntington's disease.
 Fear of being contaminated by germs or dirt or
contaminated others.
 Fear of causing harm
 Intrusive sexually explicit or violent thoughts and
images.
 Excessive focus on religious or moral ideas.
 Fear of losing or not having things that you might
need.
 Superstitions, excessive attention to something
considered lucky or unlucky.
 Order and symmetry: just right
 Double checking of things such as locks,
appliances and switches.
 Repeatedly checking in on loved ones to make
sure they are safe.
 Spending a lot of time in cleaning or washing.
 Counting, tapping, repeating certain words or
doing other senseless things to reduce anxiety.
 Ordering or arranging things, “just so”.
 Cognitive deficits regarding:
 Spatial memory loss
 Verbal memory
 Fluency
 Auditory attention was not significantly affected
Over-valued ideas:
The patient will be uncertain whether the fears
that cause them to perform their compulsions are
irrational or not.
 Washers: afraid of contamination.
 Checkers: repeatedly check things associated
with harm or danger.
 Doubters or sinners: everything isn’t perfect or
done just right something terrible will happen
or they will be punished.
 Counters and arrangers: obsessed with order
and symmetry.
 Hoarders; something bad will happen if they
throw anything away.
 Seretonergic probes
 Dopamine model
 Brain imaging studies
 Probe: m- chloro phenyl piperazine(m-CPP)
 Non-specific postsynaptic 5-HT agonist and
metabolite of antidepressant Trazadone, m-
CPP Produced very limited behavioural
effects in normal volunteers.
 Other drugs which have been studied as 5-HT
probes:
 Metergoline
 Ipsapirone
 L-Tryptophan
 Fenfluramine.
 To assess the biochemical and physiologic
function of the brain using single- photon
emission computed tomography and positron
emission tomography have produced
consistent findings that identify 3 areas of
increased or abnormal metabolic activity:
 The orbito-frontal areas-cortex
 Cingulate cortex
 Head of the caudate nucleus.
 Tourette’s syndrome: a disorder of dopamine(DA)
dysfunction, DA dysregulation may contribute to
come forms of OCD.
 Multiple tics(motor and speech) with behavioural
problems including Affection Deficit Hyperactivity
Disorder(ADHD) and OCD.
 More common in childhood or adolescence, males
and is lifelong.
 Sometimes explosive barking and grunting of
obscenities and gestures.
 Cause: Disorder of synaptic transmission.
 OCPD
 Major depressive
disorder
 Bipolar disorder
 Generalized anxiety
disorder
 Anorexia nervosa
 Social anxiety disorder
 Bulimia nervosa
 Tourette syndrome
 Asperger syndrome
 Attention deficit
hyperactivity disorder
 Dermatillomania
 Body dysmorphic
disorder
 Trichotillomania
 Delayed sleep phase
syndrome
 autism spectrum
disorder
 Patients with OCD are aware of the irrationality of
their symptoms, are often ashamed to admit their
symptoms and are skilled at hiding them.
 OCPD patients do not view behaviour as irrational
and do not wish to change, as they consider these
personality features to be beneficial.
 OCD patients often initially seek treatment from
primary care physicians/dermatologists because
of severe dermatitis from excessive washing
 Only trained therapists can perform OCD
diagnosis. They look for three things.
 The patient has obsessions.
 The patient does compulsive behaviours and
 The obsessions and compulsions take a lot of time and
get in the way of important activities the person values,
such as working, going to school, or spending time
with friends.
 To achieve a great level of symptom reduction
as possible while recognizing that a complete
cure or elimination of all symptoms is unlikely.
 To minimize adverse consequences on quality
of life.
 To restore the patient to an optimal level of
psycho-social and occupational functioning.
 In adolescents with OCD, CBT-generally
selected for milder cases.
 For more severe OCD, CBT+SSRI-fluoxetine,
fluoxamine, sertraline or paroxetine(or SSRI
alone).
 Clomipramine-selected after 2 or 3 failed SSRI
trials.
 Exposure with response prevention is
particularly helpful for contamination or other
fears, symmetry rituals, counting or repeating,
hoarding and aggressive urges.
 Cognitive therapy is especially helpful for
scrupulosity, more guilt and pathologic doubts.
13 to 20 sessions are typically required to treat
uncomplicated OCD and an adequate trial is
considered to be atleast 20 hours.
 Anti-depressants approved by the Food and
Drug Administration:
 Clomipramine(anafranil)
 Fluvoxamine(Luvox)
 Flouxetine(Prozac)
 Paroxetine(Paxil, Pexeva)
 Sertraline(Zolofit)
S.N
o.
Generic name Initial dose Maintanence
dose
Actual daily
target dose
1 CITALOPRAM 20 20-60 40
2 CLOMIPRAMINE 10 100-250 150-200
3 FLUOXETINE 20 20-80 40-60
4 FLUOXAMINE 50 100-300 200
5 PAROXETINE 20 20-60 40
6 SERTRALINE 50 75-200 150
 Diarrhoea
 Nausea
 Imsomnia
 Akathisia
 Sedation
 Diminished libido
and/or orgasm.
 Anxiety
 Insomnia
 Restlessness
 Anti-cholinergic side
effects than to
akathisia
 Tolerance to adverse
effects develop over 6-
8 weeks of treatment.
 Hepatic and renal disorders
 Elderly
 Pregnancy and lactating women
 Children and adolescence
 Benzodiazepines
 Buspirone, 5HT1A partial agonist
 St. John’s wort(450 mg of Hypericin 0.3%)
Co-morbid condition Treatment
Pregnancy CBT alone
Cardiac or renal disease CBT alone or with an SSRI
Tourette’s syndrome CBT+conventional anti-psychotic +SRI
Attention deficit hyperactivity
disorder
CBT+SSRI+Psycho-stimulant
Panic disorder or social phobia CBT+SSRI
Major depression CBT+SRI
Bipolar disorder CBT+Mood stabiliser
schizophrenia SRI+anti-psychotic
 Psychiatric hospitalization
 Residential treatment
 Electroconvulsant therapy(ECT)
 Transcranial magnetic stimulation
 Deep brain stimulation.
 Modelling
 Thought stopping
 Cognitive behaviour therapy
 OCD patients should be monitored for
symptom response, adverse effects and drug
interactions.
 Y-BOCS- monitors symptom severity-periodic
assessment.
 Ellingrod’s review-rating scale
 Changes in social and occupational functioning
should be assessed.
 Patients older than 40years-receive a
pretreatment ECG before starting
clomipramine.
 Periodic liver function tests in liver disease
patients if clomipramine is used.
 White blood counts to evaluate for
agranulocytosis.
 89% chronically treated with clomiprmine-
recurrence of symptoms after a 7 week placebo
period.
 2years after discontinuation of therapy with
clomipramine, fluoxamine or fluoxetine,
relapse rate were 77-80%
 Behaviour therapy increases the persistance of
improvement after drug therapy is
discontinued.
 http://www.ocfondation.org.aspx, accessed on
November 17,2013.
 http://www.helpguide.org/mental/obsessive_co
mpulsive_disorder_ocd.htm, accessed on
November 17,2013.
 http://www.mayoclinic.com/health/mental-
illness-in-
children/MY01915/NSECTIONGROUP=2,
accessed on December 6,2013.
 http://www.medicinenet.com/obsessive
_compulsive_disorder_ocd/article.htm, accessed
on December 6,2013.

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Ocd

  • 2.  Introduction  Definition  Aetiology  Patho physiology  Clinical presentation  Signs and symptoms  Differential diagnosis  Diagnosis  Treatment  Non-pharmacological  Pharmacological  Psychological  Co-morbid conditions  Relapse  Therapeutic outcomes  Conclusion
  • 3.  Obsessive compulsive disorder(OCD)  Characterized by obsessional thoughts and compulsive rituals.  Secondary to both depressive illness and Gilles de la Tourette syndrome.
  • 4.  OCD is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear or worry; by repetitive behaviours aimed at reducing the associated anxiety; or by a combination of such obsessions and compulsions
  • 5.  OCD is characterized by anxiety-provoking ideas, images or impulses(obsessions) and by urges-compulsions to do something hat will lessen their anxiety.  Obsession:  Repetitive, intrusive thoughts, ideas or impulses that are recognized as a foreign or repugnant to the individual.  They are involuntary, seemingly uncontrollable thoughts, images or impulses that occur over and over again in the mind.
  • 6.  Compulsion:  Repetitive, stereotyped behaviors that are senseless and are not connected un a realistic way with what they are meant to produce or prevent.  The individuals usually recognizes the senselessness of the behaviors, although they do relieve tension.
  • 7.
  • 8.
  • 9.  80% cases: before the age of 18.  Higher in males than females  But age of onset is younger in females than males  It is common in Latin America, Africa, Europe at 2-3 times than those in Asia and Oceania.
  • 10.  Psychological: may have high amount of predisposing genes.  Biological  neuro=-transmitter’s role  Genetic-hSERT mutation  Basal ganglia dysfunction  Stress  Life style modification- new job, puberty, etc.
  • 11.  5-7% of the first degree relatives.  Twin studies showed 80-90%concordance in monozygotic twins and about 50%in dizygotic twins.  Basal ganglia dysfunction:  Associated with a number of neurological disorders involving dysfunction of the striatum, including parkinsonism disease, Sydenham’s and Huntington's disease.
  • 12.  Fear of being contaminated by germs or dirt or contaminated others.  Fear of causing harm  Intrusive sexually explicit or violent thoughts and images.  Excessive focus on religious or moral ideas.  Fear of losing or not having things that you might need.  Superstitions, excessive attention to something considered lucky or unlucky.  Order and symmetry: just right
  • 13.  Double checking of things such as locks, appliances and switches.  Repeatedly checking in on loved ones to make sure they are safe.  Spending a lot of time in cleaning or washing.  Counting, tapping, repeating certain words or doing other senseless things to reduce anxiety.  Ordering or arranging things, “just so”.
  • 14.  Cognitive deficits regarding:  Spatial memory loss  Verbal memory  Fluency  Auditory attention was not significantly affected Over-valued ideas: The patient will be uncertain whether the fears that cause them to perform their compulsions are irrational or not.
  • 15.  Washers: afraid of contamination.  Checkers: repeatedly check things associated with harm or danger.  Doubters or sinners: everything isn’t perfect or done just right something terrible will happen or they will be punished.  Counters and arrangers: obsessed with order and symmetry.  Hoarders; something bad will happen if they throw anything away.
  • 16.  Seretonergic probes  Dopamine model  Brain imaging studies
  • 17.
  • 18.  Probe: m- chloro phenyl piperazine(m-CPP)  Non-specific postsynaptic 5-HT agonist and metabolite of antidepressant Trazadone, m- CPP Produced very limited behavioural effects in normal volunteers.  Other drugs which have been studied as 5-HT probes:  Metergoline  Ipsapirone  L-Tryptophan  Fenfluramine.
  • 19.  To assess the biochemical and physiologic function of the brain using single- photon emission computed tomography and positron emission tomography have produced consistent findings that identify 3 areas of increased or abnormal metabolic activity:  The orbito-frontal areas-cortex  Cingulate cortex  Head of the caudate nucleus.
  • 20.  Tourette’s syndrome: a disorder of dopamine(DA) dysfunction, DA dysregulation may contribute to come forms of OCD.  Multiple tics(motor and speech) with behavioural problems including Affection Deficit Hyperactivity Disorder(ADHD) and OCD.  More common in childhood or adolescence, males and is lifelong.  Sometimes explosive barking and grunting of obscenities and gestures.  Cause: Disorder of synaptic transmission.
  • 21.
  • 22.  OCPD  Major depressive disorder  Bipolar disorder  Generalized anxiety disorder  Anorexia nervosa  Social anxiety disorder  Bulimia nervosa  Tourette syndrome  Asperger syndrome  Attention deficit hyperactivity disorder  Dermatillomania  Body dysmorphic disorder  Trichotillomania  Delayed sleep phase syndrome  autism spectrum disorder
  • 23.
  • 24.
  • 25.  Patients with OCD are aware of the irrationality of their symptoms, are often ashamed to admit their symptoms and are skilled at hiding them.  OCPD patients do not view behaviour as irrational and do not wish to change, as they consider these personality features to be beneficial.  OCD patients often initially seek treatment from primary care physicians/dermatologists because of severe dermatitis from excessive washing
  • 26.  Only trained therapists can perform OCD diagnosis. They look for three things.  The patient has obsessions.  The patient does compulsive behaviours and  The obsessions and compulsions take a lot of time and get in the way of important activities the person values, such as working, going to school, or spending time with friends.
  • 27.  To achieve a great level of symptom reduction as possible while recognizing that a complete cure or elimination of all symptoms is unlikely.  To minimize adverse consequences on quality of life.  To restore the patient to an optimal level of psycho-social and occupational functioning.
  • 28.  In adolescents with OCD, CBT-generally selected for milder cases.  For more severe OCD, CBT+SSRI-fluoxetine, fluoxamine, sertraline or paroxetine(or SSRI alone).  Clomipramine-selected after 2 or 3 failed SSRI trials.
  • 29.
  • 30.  Exposure with response prevention is particularly helpful for contamination or other fears, symmetry rituals, counting or repeating, hoarding and aggressive urges.  Cognitive therapy is especially helpful for scrupulosity, more guilt and pathologic doubts. 13 to 20 sessions are typically required to treat uncomplicated OCD and an adequate trial is considered to be atleast 20 hours.
  • 31.  Anti-depressants approved by the Food and Drug Administration:  Clomipramine(anafranil)  Fluvoxamine(Luvox)  Flouxetine(Prozac)  Paroxetine(Paxil, Pexeva)  Sertraline(Zolofit)
  • 32. S.N o. Generic name Initial dose Maintanence dose Actual daily target dose 1 CITALOPRAM 20 20-60 40 2 CLOMIPRAMINE 10 100-250 150-200 3 FLUOXETINE 20 20-80 40-60 4 FLUOXAMINE 50 100-300 200 5 PAROXETINE 20 20-60 40 6 SERTRALINE 50 75-200 150
  • 33.  Diarrhoea  Nausea  Imsomnia  Akathisia  Sedation  Diminished libido and/or orgasm.  Anxiety  Insomnia  Restlessness  Anti-cholinergic side effects than to akathisia  Tolerance to adverse effects develop over 6- 8 weeks of treatment.
  • 34.  Hepatic and renal disorders  Elderly  Pregnancy and lactating women  Children and adolescence
  • 35.  Benzodiazepines  Buspirone, 5HT1A partial agonist  St. John’s wort(450 mg of Hypericin 0.3%)
  • 36. Co-morbid condition Treatment Pregnancy CBT alone Cardiac or renal disease CBT alone or with an SSRI Tourette’s syndrome CBT+conventional anti-psychotic +SRI Attention deficit hyperactivity disorder CBT+SSRI+Psycho-stimulant Panic disorder or social phobia CBT+SSRI Major depression CBT+SRI Bipolar disorder CBT+Mood stabiliser schizophrenia SRI+anti-psychotic
  • 37.  Psychiatric hospitalization  Residential treatment  Electroconvulsant therapy(ECT)  Transcranial magnetic stimulation  Deep brain stimulation.
  • 38.
  • 39.  Modelling  Thought stopping  Cognitive behaviour therapy
  • 40.  OCD patients should be monitored for symptom response, adverse effects and drug interactions.  Y-BOCS- monitors symptom severity-periodic assessment.  Ellingrod’s review-rating scale  Changes in social and occupational functioning should be assessed.
  • 41.  Patients older than 40years-receive a pretreatment ECG before starting clomipramine.  Periodic liver function tests in liver disease patients if clomipramine is used.  White blood counts to evaluate for agranulocytosis.
  • 42.  89% chronically treated with clomiprmine- recurrence of symptoms after a 7 week placebo period.  2years after discontinuation of therapy with clomipramine, fluoxamine or fluoxetine, relapse rate were 77-80%  Behaviour therapy increases the persistance of improvement after drug therapy is discontinued.
  • 43.
  • 44.  http://www.ocfondation.org.aspx, accessed on November 17,2013.  http://www.helpguide.org/mental/obsessive_co mpulsive_disorder_ocd.htm, accessed on November 17,2013.  http://www.mayoclinic.com/health/mental- illness-in- children/MY01915/NSECTIONGROUP=2, accessed on December 6,2013.  http://www.medicinenet.com/obsessive _compulsive_disorder_ocd/article.htm, accessed on December 6,2013.