Psychiatry

1. By
Jini P. Abraham

2. Obsession
Recurrent, intrusive, and
distressing thoughts, images,
or impulses
Irrational and absurd
Failure to resist, leads to
marked distress
Unpleasant
Increases a person’s anxiety
Compulsion
Repetitive, seemingly
purposeful, behaviours that a
person feels driven to perform
Usually follows obsession
Behaviour not realistic and
is either irrational or
excessive
Carrying out compulsions
reduces anxiety

3.  Common, chronic, and disabling disorder marked by
obsessions and/or compulsions that are egodystonic
and cause significant distress to the patients and their
families.

4. Epidemiology
 Prevalence – 2 to 3 %
 Children and adolescents = Adults
 Men and women equally affected
 Adolescence – Boys > Girls
 Mean age of onset – 20 years

5.  Depression
 Social phobia
 Specific phobia
 Panic disorder
 Alcohol – use disorders
 Eating disorders
 PTSD
 Anxiety disorders
 Personality disorders
 Schizophrenia
Co morbidities

6.  Predominantly obsessive thoughts or ruminations
 Predominantly compulsive acts (compulsive rituals)
 Mixed obsessional thoughts and acts
Clinical syndromes

7.  Biological factors
 Behavioural factors
 Psychological factors
Etiology

8.  SEROTONIN
 Dysregulation of
serotonin
 Abnormality of the
serotonergic system
and particularly the
hypersensitivity of
postsynaptic 5-HT
receptors
Neurotransmitters

9.  NORADRENALINE
 Clonidine lowers the amount of norepinephrine
released from the presynaptic nerve terminals.
 DOPAMINE
 Presence of OCD symptoms in Tourette’s syndrome,
Sydenham’s chorea and postencephalitic parkinsonism

11. Genetics
 High concordance rate among monozygotic twins
 First degree relatives – 5 to 7%

12.  PET scan – Increased activity in frontal lobes, basal
ganglia and cingulum
 CT and MRI studies – Decreased sizes of caudate
bilaterally
 EEG abnormality marked over temporal lobes
Brain imaging studies

13. Brain regions involved

14.  Obsessions considered as conditioned stimuli
 When a relatively neutral stimulus is coupled with an
anxiety – provoking stimulus, through conditioning, it
will produce anxiety even when presented alone.
 Compulsions are learnt as a way to reduce anxiety.
 Once relief of anxiety is produced, the relief serves as
reinforce to the compulsion, which are then being
repeated by the patient.
Behavioural factors

16.  Sigmund Freud – Obsessional neurosis
 Obsessive symptoms result from unconscious impulses
of an aggressive or sexual nature.
 These impulses cause extreme anxiety, which is
avoided by the defence mechanisms.
Psychological factors

17. Phobias
Reaction
Formation
New defences
Isolation of
affect
Displacement
Obsessive
thoughts
Anal sadistic
phase
Anxiety related
to oedipal
conflicts
Regression
Obsessional
personality
traits
Undoing
Fixation in
development
Compulsive
acts
Early childhood
Disturbed development in
At present In presence of fixation at anal sadistic phase
Reinforcement of Anal/Aggressive impulses
Normally disguised in

18.  Obsessions –
o Contamination
o Pathological doubt
o Need for symmetry
o Aggressive
o Sexual
 Compulsions –
o Checking
o Washing
o Counting
o Need to ask or confess
o Symmetry and precision
o Hoarding
Clinical Presentation

19.  Sydenham’s chorea
 Huntington’s disease
 Tourette’s syndrome
 Tic disorders
 Temporal lobe epilepsy
 Trauma
 Psychiatric diagnoses, including phobias and major
depressive disorder
Differential Diagnosis

20.  Onset of symptoms after a stressful event
 Obsessive compulsive activities take up > 1 hour per
day and are undertaken to relieve the anxiety
 Course – usually long, but variable,
fluctuating/chronic
 More prone to depression and sometimes, suicide
Course and prognosis

21.  Pharmacotherapy
 Behavioural therapy
 Psychotherapy
 Other approaches
Treatment

22. Pharmacotherapy
 Clomipramine – TCA
 SSRI’s –
 Fluoxetine
 Fluvoxamine
 Paroxetine
 Sertraline
 Citalopram
 Anti – Psychotics, buspirone, clonidine, MAO
inhibitors

23.  Effective mode of therapy, with success rate as high as
80%
 Exposure and response prevention
 Desensitization
 Thought stopping
 Flooding
 Implosion therapy
 Patients must be truly committed to improvement
Behavioural therapy

24.  Attention of family members through provision of
emotional support, reassurance, explanation, and
advice on how to manage and respond to patient.
 Family therapy can build a treatment alliance as well as
help in the resistance of compulsions.
 Group therapy
Psychotherapy

25.  Electroconvulsive therapy – Severe depression with
OCD
 Psychosurgery, followed by intensive behaviour
therapy aimed at rehabilitation
Other approaches