This ppt consists of OCD diagnosis and treatment presentation with good examples and photo collection for a better explanation. MBBS Presentation

1. Presenter - EPURI MAHESWARI
Moderator - Dr. KEYA

3. Definitions
Obsessions
1. An idea ,impulse or image which intrudes into the conscious
awareness repeatedly
2. It is recognized as one's own idea ,impulse/image but is perceived as
ego-alien(foreign to one's personality)
3. It is recognized as irrational and absured (insight is present)
4. Patient tries to resist against it but is unable to
5. Failure to resist ,leads to marked distress
Ref : Niraj Ahuja 7th edition

4. Compulsion
1. A form of behaviour which usually follows obsessions
2. It is aimed at either preventing or neutralising the distress or fear
arising out of obsession
3. The behaviour is not realistic and is either irrational or excessive
4. Insight is present ,so the patient realizes the irrationality of compulsion
5. The behaviour is performed with absence of subjective compulsion
(urge or impulse to act )
Compulsion may diminish the anxiety associated with obsessions ref: Niraj
Ahuja 7th edition

5. •Anxiety: Anxiety can be conceptualised as normal and adaptive
response to treat that prepares the organism for flight / fight
•Ref (Kaplan and saddock 11th edition)
•Delusion: one's idea but is not recognised as ego-alien
•In fact, it is strongly believed
•Hence it is thought to be irrational and is never resisted
•Thought insertion : not thought as one's idea but is instead somebody
else's thought being forcibly inserted into one's mind
Ref : Niraj Ahuja 7 th edision

6. Epidemiology
•It is fourth most common psychiatric diagnosis after phobia, Substance
related disorder, Major depressive disorder
•Among adults ;men and women are equally likely to be affected but
among adolescents boys are more commonly affected than girls
•Overall symptoms of about 2/3rd of affected persons have an onset
before age 25 and the symptoms of fewer than 15%have an onset at
age 35
•Onset of disorder can occur in adolescents/ childhood ,in some cases as
early as 2 years of age

7. •Single persons are more frequently affected with OCD than married
persons( ref Kaplan and sadocks 11th edition)
•OCD occurs less often among blacks than among whites
•More common in persons from upper socioeconomic strata and with high
intelligence
•Life time prevalence of OCD is 2-3 % though IndianA data shows a lower
prevalence rate (Niraj Ahuja 7th edition )
•Some researches have estimated that the disorder is found in as many as
10% of outpatient in psychiatric clinics

8. Comorbidity
•Persons with OCD are commonly affected by other mental disorders
•The life time prevalence for major depressive disorder in persons with
OCD is about 67%
•For social phobia -25%
•Other common comorbid psychiatric diagnosis in patients with OCD
are alcohol use disorder , generalized anxiety disorder, specific
phobias , panic disorders, eating disorders, personality disorders
•Incidence of Tourette disorder in patients with OCD is 5%-7% and 20%-
30% of patients with OCD have a history of tics

10. Etiopathogenesis
Genetics :
•1.Available genetic data on OCD support the hypothesis that the
disorder has significant gangetic component
•2.Relatives of probands with OCD consistently have a 3 fold to 5 fold
higher propability of having OCD or obsessive compulsive features
than families of control probands
•3.higher concordance rate for monozygotic twins rather than for
dizygotic twins
•4.The data however do not distinguish the heritable factors from the
influence of cultural and behavioural effects on transmission of the
disorder

11. Biological factors
1. Obsessive compulsive symptoms can occur secondary to many illnesses
such as voneconomo's encephalitis,basal ganglion lesions, Tourette
syndrome and hypothalamic and 3rd ventricle lesions
2. Seratonergic system : many clinical drug trials that have been
conducted support the hypothesis that dysregulation of seratonin is
involved in the symptom formation of obsession and compulsions in
disorder
•Data also shows that seratonergic drugs are more effective in treating
OCD than drugs that affect other neurotransmitter system but whether
seratonin is involved in the cause of OCD is not clear

12. •In one study ,the CSF concentration of 5 HIAA decrease after treatment
with clomipramine focusing attention on seratonergic system.
•Clinical studies have assayed CSF concentration of seratonin metabolites (
5- HIAA)and affinities and number of platelet binding sites of titrating
imipramine (tofranil) which binds to seratonin reuptake sites & have
reported variable findings of then measures in patients with OCD .

14. Nor adrenergic system
1. Currently less evidence exists for dysfunction in nor adrenergic
system in OCD
2. Anecdotal reports show some improvement in OCD symptoms with
use of oral clonidine (catapres) , a drug that lowers the amount of NE
released from presynaptic nerve terminals
•Neuroimmunology : some interest exists in positive link between
streptococcal infections and OCD (pandas)
•Group A beta hemolytic streptococcal infection can cause rheumatic
fever and approximately 10% to 30% of patients develop syndenhams
chorea and show obsessive compulsive symptoms

16. Behavioral factors
•This is not able to explain the causation of OCD
but is very useful in treatment of OCD
•The behavioral theory explains obsessions
as conditioned stimuli to anxiety ( similar to phobias )
•Compulsions as learned behavior which decrease
the anxiety associated with obsessions
•The decrease in anxiety positively reinforces
the compulsive acts and they become stable

17. Psychosocial factors
•Personality factors : OCD differs from obsessive compulsive personality
disorder which is associated with an obsessive concern for details
,perfectionism and other similar personality traits
•Most persons with OCD do not have premorbid compulsive symptoms
and such personality traits are neither necessary nor sufficient for
development of OCD
•Only about 15 to 35% of patients with OCD have had premorbid
obsessional traits

18. Psychodynamic factors

23. Defence Mechanism
•Isolation of Affect: By this defence mechanism, Ego removes the affect
(isolates the affect) from the anxiety-causing idea.
•The idea is thus weakened, but Remains still in the consciousness.
•The affect however becomes free and attaches itself to other neutral
idea(s) by symbolic associations.
•Thus, these neutral ideas become anxiety-provoking and turn into
obsessions.
• This happens only when isolation of affect is not fully successful
(incomplete isolation of affect).

24. •When it is fully successful, both the idea and affect are repressed and
there are no obsessions.
• Undoing : This defence mechanism leads to compulsions, which
prevent or undo the feared conssequences of obsessions.
• Reaction formation :results in the formation of obsessive compulsive
personality traits rather than contributing to obsessive compulsive
symptoms while displacement leads to formation of phobic symptoms

25. ICD 10

29. DSM 5 ( diagnostic and statistical manual
of mental disorders )
•This criteria allows clinicians to indicate whether the patients with OCD are
characterized by good / fair insight ,poor insight ,fair insight
•Good insight - OCD beliefs are definitely or probably not true / may /may
not be true
•Poor insight- OCD beliefs are probably true
•Absent insight - convinced that their beliefs are true

31. Clinical features

34. •Contamination. The most common pattern is
an obsession of contamination, followed by
washing or accompanied by compulsive
avoidance of the presumably contaminated
object.
•The feared object is often hard to avoid (e.g.,
feces, urine, dust, or germs).
• Patients may literally rub the skin off their
hands by excessive hand washing or may be
unable to leave their homes because of fear
of germs.

35. •Although anxiety is the most common emotional response to the feared
object, obsessive shame and disgust are also common. Patients with
contamination obsessions usually believe that the contamination is
spread from object to object or person to person by slightest contact
•Pathological Doubt. The second most common pattern is an obsession
of doubt, followed by a compulsion of checking.
•The obsession often implies some danger of violence (e.g., forgetting to
turn off the stove or not locking a door).
•The checking may involve multiple trips back into the house to check
the stove, for example.

36. •These patients have an obsessional self-doubt and always feel guilty
about having forgotten or committed something.

37. •Symmetry. The fourth most common pattern is the need for symmetry
or precision, which can lead to a compulsion of slowness.
•Patients can literally take hours to eat a meal or shave their faces.

38. •Other Symptom Patterns. Religious obsessions and compulsive hoarding
are common in patients with OCD.
•Compulsive hair pulling and nail biting are behavioural patterns related
to OCD.
•Masturbation may also be compulsive.

42. Differential Diagnosis
•Medical Conditions
1. Bosal Ganglion disorders such as syndenham’s chorea and
Huntington’s disease.
2. Neurological signs of such basal ganglion pathology must be
assessed when considering the diagnostic of OCD in a patient
presenting for psychiatric treatment
•OCD develops before age of 30 years and new onset OCD in older individual
should rise questions about potential neurological contributions to the
disorder.

43. Tourettes Disease
•OCD is closely related to Tourettes disease as 2 conditions frequently
co-occur, both in individual overtime and within families.
•About 90% of persons with Tourettes disorder have compulsive
symptom and as many as 2/3rd meets the diagnostic criteria for OCD.
•In classical form, Tourettes disorder is associated with a pattern of
recurrent vocal and motor tics that bear only a slight resemblance to
OCD

44. •The premonitory urges that precede tics often strikingly resemble
obsessions, however and many of the more complicated motor tics are
very similar to compulsion.

45. Other Psychiatric Conditions
•The keys to distinguishing OCD from psychosis are
1. Patients with OCD can almost always acknowledge the
unreasonable nature of their symptoms.
2. Psychotic illness are typically associated with a host of other
features that are not characteristics of OCD.
•OCD is difficult to distinguish from depression because 2 disorders often
occur comorbidly and major depression is often associated with
obsessive thoughts.

46. •The two are best distinguished by their courses obsessive
symptoms associated with depression are only found in presence
of a depressive episode, where as true OCD persist despite
remission depression.

47. Course
1. More than half of patients with OCD have a sudden onset of
symptoms
2. The onset of symptoms for about 50%-70% of patients occur after a
stressful event such as a pregnancy ,sexual problem ,death of relative
3. Because many persons manage to keep their symptoms secret ,they
often delay 5 to 10 years before coming to psychiatric attention
4. Course is usually long but variable
5.some experience fluctuating course and others experience a constant
one

48. Prognosis
1 .About 20%-30% of patients have significant improvement of their
symptoms
2.About 40%-50% have moderate improvement
3.Remaining 20%-40% of patients either remain ill or their symptoms
worsen About 1/3rd of patients with OCD have major depressive disorder
and suicide is risk for all patients with OCD
Poor prognosis -> is indicated by yielding to compulsions, childhood onset,
bizzare compulsion, a coexisting major depressive disorder, delusional
beliefs
Good prognosis -> is indicated by good social and occupational adjustment
, presence of precipitating event and episodic nature of symptoms

49. Treatment
Psychotherapy
1. Psychoanalytic psychotherapy is used in certain selected patients,
who are psycho logically oriented.
2. Supportive psychotherapy is an important adjunct to other
modes of treatment. Supportive psychotherapy is also needed by
the family members.

50. Behaviour Therapy &
Cognitive Behaviour Therapy
•Behaviour modification is an effective mode of therapy, with a success
rate as high as 80%, especially for the compulsive acts. It is customary
these days to combine CBT with BT at most centres.
•The techniques used are listed below
i. Thought-stopping (and its modifications)
ii. Response prevention.
iii. Systematic desensitisation.
iv. Modelling.

51. Drug Treatment
1. Benzodiazepines (e.g. alprazolam, clonazepam) have a limited role in
controlling anxiety as adjuncts and should be used very sparingly.
2. Antidepressants: Some patients may improve dramatically with specific
serotonin reuptake inhibitors (SSRIs).
• Clomipramine (75-300 mg/day), a nonspecific serotonin reuptake inhibitor
(SRI), was the first drug used effectively in the treatment of OCD.
•The response is better in the presence of depressive symptoms, but many
patients with pure OCD also improve substantially.
• Fluoxetine (20-80 mg/day) is a good alternative to clomipramine and often
preferred these days for its better side-effect profile.

52. •Fluvoxamine (50-200 mg/day) is marketed as a specific anti-obsessional
SSRI drug
•Paroxetine (20-40 mg/day) and sertraline (50-200 mg/day) are also
effective in some patients
3. Antipsychotics: These are occasionally used in low doses (e.g.
haloperidol, risperi done, olanzapine, aripiprazole, pimozide) in the
treatment of severe, disabling anxiety
4. Buspirone has also been used beneficially as an adjunct for
augmentation of SSRIs, in some patients..

53. Electroconvulsive Therapy
•In presence of severe depression with OCD, ECT may be needed.
•ECT is particularly indicated when there is a risk of suicide and/or when
there is a poor response to the other modes of treatment.
•However, ECT is not the treatment of first choice in OCD.

58. Psychosurgery
•Psychosurgery can be used in treatment of OCD that has become
intractable, and is not responding to other methods of treatment.
•It is worth mentioning that psychosurgery is only available as a
treatment choice at a very few centres throughout the world.
•He best responders are usually those who have significant associated
depression, although pure obsessives also do respond.

59. •The main benefit is the marked reduction in associated distress and
severe anxiety.
The procedures which can be employed are:
i. Stereotactic limbic leucotomy.
ii. Stereotactic subcaudate tractotomy.
• Psychosurgery is usually followed by intensive behaviour therapy aimed
at rehabilitation.
•However, with the easy availability of SSRIs, and a good response of
OCD symptoms to SSRIs and other pharmacological measures,
psychosurgery is very rarely used in the treatment of OCD.

60. •Very often, a comprehensive treatment of OCD requires that multiple
treatment modalities (e.g. drug treatment and BT/CBT) be combined in
a specific manner, suitable to the particular patient being treated at the
time.

62. Thank
You