The document discusses obsessive compulsive disorder (OCD), detailing its diagnostic criteria from DSM-IV, where individuals must experience obsessions and/or compulsions that are time-consuming or cause significant distress. It describes common obsessions, compulsions, prevalence rates, and associated comorbidities, as well as diagnosis and treatment options such as cognitive behavioral therapy and medications. Additionally, it highlights the effectiveness of various drugs, potential side effects, and recommendations for treatment during pregnancy.

1. Obsessive compulsive
disorder
Vipul Sharma
M.Pharm (pharmacy practice)
Manipal college of pharmaceutical
sciences (MAHE), MANIPAL

2. DSM IV criteria
• To be diagnosed with OCD, a person must
have obsessions and/or compulsions,
according to the DSM-IV-TR diagnostic
criteria.
• Moreover, the obsessions or compulsions
must be time-consuming (taking up more
than one hour per day), cause distress, or
cause impairment in social, occupational,
or school functioning

3. Obsession
• An obsession is a recurrent, persistent
idea, thought, impulse, or image that is
experienced as intrusive and inappropriate
and produces marked anxiety or distress
• Common obsessions involve thoughts
about contamination (e.g., concern with
germs, dirt, or toxic chemicals), repeated
doubts, and needing to have things in a
particular order

4. Obsessions
• The thoughts, impulses, or images are not
simply excessive worries of real-life problems.
• The person attempts to ignore or suppress 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 or her own mind, and are not based in
reality.
• Excessive or unreasonable worry about real life
situations

5. Compulsion
• A compulsion is defined as a repetitive
behavior or mental act generally
performed in response to an obsession.
• The most common compulsions involve
washing and cleaning, counting, checking,
and requesting or demanding assurances

6. Compulsions
• Repetitive behaviors or mental acts that the
person feels driven to perform in response to an
obsession, or according to rules that must be
applied rigidly.
• Behaviors or mental acts are not pleasurable -
aimed at preventing or reducing distress or
• preventing some dreaded event or situation;
• Not actually connected to the issue, or they are
excessive

7. • typical OCD sufferer performs tasks (or
compulsions) to seek relief from obsession-
related anxiety
• To others, these tasks may appear odd and
unnecessary.
• But for the sufferer, such tasks can feel critically
important, and must be performed in particular
ways to ward off dire consequences and to stop
the stress from building up.

8. Compulsive actions
• Repeatedly checking that one's parked car
has been locked before leaving it,
• Turning lights on and off a set number of
times before exiting a room,
• Repeatedly washing hands at regular
intervals throughout the day,
• Touching objects a certain number of
times before leaving a room,
• Walking in a certain routine way

9. • Repetitive activities (e.g., hand washing,
checking, ordering, need to ask, need to
confess)
• Repetitive mental acts (e.g., counting,
repeating words silently praying)

10. Prevalence
• prevalence between one and three
percent, although the prevalence of
clinically recognized OCD is much lower
• many individuals with the disorder may not
be diagnosed
• Patients may be secretive about
symptoms and purposefully refuse to
report or deny symptoms.

11. Screening questions
• Do you have repetitive thoughts that make
you anxious and that
• you cannot get rid of?
• Do you check things excessively?
• Do you feel the need to wash your hands
frequently?
• Do you keep things exceptionally clean?

12. Diagnosis
• The diagnostic criteria for OCD requires
the presence of either
• obsessions and/or compulsions (although
most patients have both)
• that are severe enough to cause marked
distress, to be time-consuming
• (occupy more than 1 hour per day), or
• to cause significant impairment in social
or occupational functioning

13. Diagnosis tools
• Rating scales may be used to measure
symptom severity, and a baseline
determination is indicated if these tools are
used
• The most widely used scale is the Yale-
Brown Obsessive Compulsive Scale
(YBOCS).

14. Other comorbid illness related to
OCD
• Patients often have comorbid depression,
anxiety disorders, and alcohol abuse or
dependence.
• Generalized anxiety disorder, Social anxiety
disorder,
• Anorexia nervosa, (decreased eating followed
by anxiety and even ISH)
• Bulimia nervosa (repeated eating within 2 hours
and anxiety and even ISH)

15. Other illness associated
• Tourette syndrome (Repeated body activities)
blinking head shoulder jerking Simple
vocalizations might include repetitive throat-
clearing, sniffing, or grunting sounds
• Asperger syndrome, (difficulty in understanding
body behaviour) Impaired social behaviour,
social impairment with extreme obtuseness,
limited interests and/or unusual preoccupations,
repetitive routines or rituals, speech and
language peculiarities, and non-verbal
communication problems

16. Contd…
• Compulsive skin picking,
• Body dysmorphic disorder, Being preoccupied
with minor or imaginary physical flaws, usually of
the skin, hair, and nose, such as acne, scarring,
facial lines, marks, pale skin, thinning hair,
excessive body hair, large nose, or crooked
nose, excessive checking in Mirror
• Having a lot of anxiety and stress about the
perceived flaw and spending a lot of time
focusing on it,
• Trichotillomania – pull out their own hair, Nail-
biting, skin-picking, and thumb-sucking

17. Obsessive-compulsive personality
disorder
• A pervasive pattern of preoccupation with
orderliness, perfectionism, and mental and
interpersonal control, at the expense of
flexibility, openness, and efficiency,
beginning by early adulthood and present
in a variety of contexts,
• Overconscious
• Miserly saving money
• stubern

18. Goal
• Reduction in the frequency of obsessive
thoughts
• Time spent performing compulsive acts
• Reduction in the degree of anxiety
• Provide optimal level of psychosocial
occupational functioning and an overall
improved QOL.

19. In adolescents and adults
• Cognitive Behavioral Therapy (CBT)
generally selected first for mild OCD,
• CBT + SSRI (e.g., fluoxetine, fluvoxamine,
sertraline, or paroxetine) are used for
more severe OCD
• In adults, CBT is the initial choice for mild
OCD, and CBT plus an SSRI or an SSRI
alone is selected for more severe OCD

20. Drugs approved by FDA
• Five antidepressants
• clomipramine,- TCA
• fluoxetine,- SSRI
• fluvoxamine,
• paroxetine,
• sertraline

22. Clinical trials on TCA and SSRI
• TCA like Clomipramine-
• SSRIs fluoxetine, fluvoxamine, paroxetine,
and sertraline.
• 65-75% response
• consistently demonstrated efficacy 25-
60% in controlled trials
• Obsessive-compulsive symptoms improve
over a 4- to 10-week treatment period

23. SSRIs
• Inhibiting reuptake of 5-HT makes more 5-HT
available to postsynaptic receptors
• Reduces formation of the 5-HT metabolite 5-
hydroxyindoleacetic acid
• Prolonged exposure to increased amounts of 5-
HT after chronic antidepressant treatment (2 to 3
weeks) leads to
• Altered responsiveness of postsynaptic 5-HT
receptors or presynaptic autoregulatory
receptors that govern 5-HT release in specific
brain regions

24. Side effects of SSRIs
• nausea, headache, tremor, gastrointestinal
complaints, drowsiness, akathisia, insomnia,
disinhibition, and agitation
• Akathisia- unpleasant sensations of "inner"
restlessness that manifests itself with an inability
to sit still or remain motionless
• Extensively metabolized in the liver,
• liver disease - prescribe cautiously
• in lower doses than in healthy subjects.

25. Pregnancy
• during pregnancy is required, fluoxetine appears
to be the safest choice
• Clomipramine should be avoided during
pregnancy.
• Clonazepam can be considered for OCD
symptoms in pregnant women with disabling
anxiety,
• but with higher doses (2 to 5 mg/day), hypotonia,
apnea, and failure to feed have been observed
in newborns.

26. Alternatives
• Venlafaxine, which acts as a serotonin and
norepinephrine reuptake inhibitor, may be
effective for OCD.
• Intensive CBT augmentation with another drug
and more intensive CBT can be tried
• Buspirone is used as augmentation therapy, the
initial dose is 5 mg three times daily, and the
target dose should be 60 to 90 mg/day.
• In RCT citalopram (40 mg/day) + clomipramine
(150 mg/day) was effective in refractory pts

27. Thank you!