This document provides information on obsessive compulsive disorder (OCD) and obsessive compulsive spectrum disorder. It discusses the definitions of obsessions and compulsions according to DSM-5. It also covers the epidemiology, comorbidities, neurobiological causes, diagnostic criteria, and treatment options for OCD which include psychotherapy such as exposure and response prevention, and pharmacotherapy with medications like SSRIs, TCAs, and augmentation agents.

1. Obsessive Compulsive
Spectrum Disorder
Presenter :- Dr. Vijay Saini
(Resident)
Guide :- Dr. Anant Rathi

2. Obsessions
• Repetitive and constants thoughts, images or
impulses that cause anxiety or distress.
– not about real-life problems.
– Try to ignore or counter act
– recognized as a product of one’s own mind and not
imposed from without.

3. Compulsions
• Repetitive behaviors or mental acts person does
in reaction to obsessions.
– done to avoid or decrease distress.
– acts are clearly excessive or not realistic.

4. According to DSM – 5
• Obsessions are defined by the following
features.
• 1. Recurrent or Persistent thoughts, urge or
images that are experienced at some time
during the disturbance as intrusive and
unwanted and that causes marked anxiety and
distress.
• 2. Attempt to ignore or suppress such
thoughts ,urge or image to neutralize them
with some other thought or action.

5. • Compulsions are defined as follows :
1. Repetitive behaviours or mental act that the
person feels driven to perfrom in response to an
obsession or according to rules that must be
rigidly applied.
2. Behaviours or mental act aimed at preventing
or reducing anxiety or distress, or preventing
some dreaded events or situations; Those
behaviours or mental acts are either unconnected
realistically with what they are designed to
neutralize or prevent or clearly excessive.

6. DSM-5 &OCD
• DSM-5 has a separate chapter for OCD and
related disorders
• They are no longer considered anxiety disorders.
• Disorders in this chapter include
– Obsessive-compulsive disorder,
– Body dysmorphic disorder and
– Trichotillomania (hair-pulling disorder),

7. - Hoarding disorder
- Excoriation (skin-picking) disorder.
• Obsessive-compulsive and related disorders can
include
– body-focused repetitive behavior disorder and
– obsessional jealousy, or unspecified obsessive-
compulsive and related disorder.
Specifier:-
- Insight- Good/fair, Poor and absent/Delusional
- Tic related

8. EPIDEMIOLOGY
• Lifetime prevalence - 2 to 3 percent.
• 10 percent of outpatients in psychiatric clinics.
• Among adults, men and women are equally likely
to be affected, but among adolescents, boys are
more commonly affected than girls.
• mean age of onset is about 20 yr, although men
have a slightly earlier age of onset (mean about 19
years) than women (mean about 22 years).

9. CO-MORBIDITIES
• Lifetime prevalence for major depressive disorder
in persons with OCD is about 67 percent and for
social phobia, about 25 percent.
• The incidence of Tourette's disorder in patients
with OCD is 5 to 7 percent, and 20 to 30 percent
of patients with OCD have a history of tics.
• Other common comorbid psychiatric diagnoses in
patients with OCD include alcohol use disorders,
generalized anxiety disorder, specific phobia,
panic disorder, eating disorders, and personality
disorders.

10. Diagnostic Criteria (ICD-10)
• For a definite diagnosis obsessional symptoms or compulsive acts, or both,
must 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 characteristic :-
(a) They must be recognised as the individual's own thoughts or impulses.
(b) There must be at least one thought or act that is still resisted
unsucessfully, even though others may be present which sufferer no
longer resist.
(c) The thought of carrying out the act must not in itself be pleasurable.
(d) The thoughts, images or impulses must be unpleasantly repetitive.

11. Neurobiological
PsychologicalEnvironmental
Neurobiological
PsychologicalEnvironmental
Causes of OCD in short
Causes of OCD in short

12. Neurobiological factors
Neurotransmitter Levels
Serotonin
“ocd.jpg”“normal.jpg”
CSF
Platelets
Low
5HT
5HIAA
DA – Hyper functioning in PFC
5HT – Hypo functioning in basal ganglia
Dysfunction of the so-called 'cortico-striato-thalamic' loops

13. Cortico-striatal-thalamocortical loop
• The orbitofrontal cortex has a circuit that sends information to the
thalamus such as aggression, sexuality and bodily excretions.
• When these parts of the brain are activated we are bound to act upon
those certain behaviors or actions.
• These impulses are brought to ones conscience and after brain has sent
the information and have acted upon that information the impulse
eventually decreases and you move on to your daily routine.
• Within people who have OCD, some certain impulses cannot be turned off
or ignored by that part of the brain, which causes them to repeat the
same action over and over again.
• Eventually they become obsessed with these actions and they have
become integrated into their routine and they have no control over it.

14. Brain Imaging Studies
CT/MRI: Decrease size of caudate nuclei
PET: Increased activity in frontal lobe (OFC) & basal
ganglia(caudate), Thalamus

15. Genetic factor
OCD has significant genetic component .
Three to five times higher probability of OCD
in relatives of probands with OCD.
Concordance for OCD in twins is significantly
higher for monozygotic twins than for
dizygotic twins

16. Environmental factors
Early childhood conflicts:
• This is an early theory that suggests conflicts or
problems during childhood are the roots of OCD.
• This is specifically looking at either permissive or
mainly unengaged parenting techniques.

17. Psychological - COGNITIVE THEORY OF OCD
• Obsessional thoughts:
– It’s not the thought itself that is disturbing, but
rather the interpretation of the thought.
– The issue of responsibility is believed to be a core
belief or cognitive distortion of people with OCD.

18. Compulsive behaviors:
– Neutralizing, either through compulsive behaviors or
mental strategies, is aimed at preventing terrible
consequences, or averts the possibility of being
responsible
– Seeking reassurance is another form of neutralizing, as it
can serve to spread responsibility to others, thus diluting
that of the individual
– Avoidance, though not an overt neutralizing behavior, is
often used to prevent contact with particular stimuli

19. OCD Cycle –Learning Theory
OBSESSIONS
COMPULSIONS
RELIEF ANXIETY

20. PSYCHODYNAMIC FACTORS
ISOLATION
It protects an individual from anxiety provoking affects
and impulses.
isolation less effective
Patient experience a partial awareness of the impulse
without fully recognizing its meaning
Impulse is displaced from the true object to other people
or object.

21. PSYCHODYNAMIC FACTORS (CONTD.)
UNDOING
When impulse`s constant threat escape primary defense of
isolation
Secondary defensive operations is started
Compulsive act that is performed in an attempt to prevent or
undo the consequences that the patient irrationally
anticipates from a frightening obsessional thought or impulse.

22. PSYCHODYNAMIC FACTORS (CONTD.)
REACTION FORMATION
 Manifest patterns of behaviour and consciously
experienced attitudes that are exactly the opposite of the
underlying impulses
 Reaction formation results into formation of character
traits of OCD.

23. PSYCHOANALYTIC FACTORS
AMBIVALENCE
 Present in normal children during the anal sadistic
development phase.
 Children feel both love and murderous hate towards the
same object.
 Patients with OCD often consciously experience both love
and hate toward an object.
 Conflict of opposing emotions is evident in a patient` doing
and undoing patterns of behaviour and in paralyzing doubt
in the face of choice.

24. PSYCHOANALYTIC FACTORS (CONTD.)
MAGICAL THINKING
Inherent in magical thinking is omnipotence of thought.
An event can occur merely by thinking without
intermediate physical actions.
This feeling causes them to fear having an aggressive
thought.

25. Contamination 45 %
Pathological doubt 42 %
Somatic 36 %
Need for symmetry 31 %
Aggressiveness 28 %
Sexual 26 %
Obsessions Percentage

26. Checking 63 %
Washing 50 %
Counting 36 %
Symmetry & precision 28 %
Compulsions Percentage

27. • In children-
Obsession :-
-concern or disgust with bodily waste or
secretion, dirt, germs, environmental toxins and
-fear something terrible may happen
Compulsion :-
-Excessive or ritualized hand washing,bathing,tooth
brushing or grooming
- Repeating rituals (going in and out of door, up and
down from chair)

28. Disease Differential diagnosis
OCD and delusional disorder Not a fixed belief , ego-dystonic , not
accompanied by hallucination
Idiopathic OCD And OCD-like associated
disorder
Basal ganglia mostly involved and another
symptomatic pattern are present such as
sydenhams chorea .
OCD and Tourettes Disoder Must present before 18 yr , at least 1 year
pattern of multiple motor and one or more
vocal tics , never tics free of 3 months or more
.
OCD and obsessive-compulsive personality
disorder
Personality traits are ego-syntonic , present
before 18 yr , no true syndrome of obsession
and compulsion .
OCD and obsessive thoughts in psychosis Patient have insight to there symptoms , no
other features of psychosis (delusion ,
hallucination )
OCD and depression Obsessive thoughts present during depression
episode , while in OCD they persist .

29. TREATMENT

31. Psychotherapy

32. Behaviour therapy
• Many clinician consider behaviour therapy
treatment of choice.
• The principal behavioural approach in OCD is
exposure and response prevention.
• Others are desensitization, thought stopping,
flooding ,implosion therapy etc. They are less
useful.
• Supportive psychotherapy and family therapy
also useful.

33. Pharmacotherapy
1. TCA/Clomipramine
2. SSRI
3. Venlafaxine, mirtazepine, tianeptine
4. Augmentation agents:-
• Antipsychotics:- Preferably Aripiprazole, Risperidone
Haloperidol, Olanzapine, Qutiapine
• Glutaminergic agents:- Memantine, lamotrigene,
Topiramate, Riluzole, N-Acetyl cysteine
• 5-HT Antagonist:- Ondensetron, Granisetron
• Others:- Buspirone, Li, Clonazepam, Opioids,
IV Clomipramine, Pimozide

34. Dose of Anti OCD Drugs
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF OBSESSIVE COMPULSIVE
DISORDER (IPS Guideline committee)
Drug Usual starting
dose(mg)
Usual target
dose(mg)
Usual
max.dose(mg)
Fluvoxamine 50 200 300
Fluxotine 20 40-60 60
Sertraline 50 150 225
Citalopram 20 40-60 60
Clomipramine 25-50 100-250 250
Paroxetine 20 50 60

35. Unique proprties of Fluvoxamine
• No active metabolite and Action on sigma1 receptor
• Lesser droping out of treatment as compared to others.
• Its efficacy in OCD has been firmly established by both
placebo-controlled (Jenike et al, Goodman et al ,Hollander E
et al) and active-comparison studies.( Freeman CP et
al,Mundo et al, zoher et al)
• Among the SSRIs, fluvoxamine is one of the weakest inhibitors
of norepinephrine and dopamine reuptake. it has relatively
few and mild cardiovascular and anticholinergic effects.
• Better tolareted so lesser drop out from treatment.

36. Repetitive Transcranial Magnetic Stimulation (rTMS)
• Possible Hypothesis-it has been postulated that low
frequency rTMS can have therapeutic benefits in patient
with OCD by inhibiting the hyper-excitable CSTC circuit.
• Explorations of rTMS to the DLPFC, OFC, or SMA in a total of
10 studies have demonstrated only acute efficacy for
obsessive-compulsive symptoms of rTMS.( Riannee M. Bloom et al.Update
on Repetitive Transcranial Magnetic Stimulation in Obsessive-Compulsive Disorder: Different Targets.
Curr Psychiatry Rep. 2011 Aug; 13(4): 289–294)
• Both NICE and APA practice guideline for t/t of OCD
conclude “currently rTMS cannot be recommended as a t/t
option

37. Electroconvulsive Therapy
• Can be used in resistant cases
• Although 60 % of review shows some positive
response to ECT, but it can not be stated that this
provide evidence that ECT is indeed effective for
OCD.(Fontelle et al)
• ECT, as currently administered, should be
reserved for selected cases of patients with OCD
displaying severe mood disorders.(Martines et al)
• The American Psychological Association (APA)
task force on ECT in 1990 stated that ECT is an
effective treatment option for patients suffering
from OCD with severe depression. However this
is not evidenced by RCTs.

38. 40

39. Treatment resistant OCD
• Term Treatment resistant is generally applied to
those patients who have not shown a satisfactory
response to adequate trials to at least two SRIs .
• The term treatment refractory or intractable
connote greater degree of treatment resistance,
as reflected in failure to respond to a variety of
anti OCD treatment strategies (including
combination of agents) as well as behaviour
therapy .
• Dan, J. Stein, Eric Hollander (2002). The American Psychiatric Publishing Textbook of Anxiety
Disorders

40. OCD in Bipolar disorder
• Treatment of comorbid BD with OCD is huge
challenge for clinicians as management of one
can worsen other and researchers into treatment
aspects of this entity is sparse.
• Mood stabilizer along with adjuvant topiramate
or with olanzapine-SSRI/ Clomipramine
combination can be used. Use of other
conventional agents is limited to case reports.
Management of obsessive-compulsive disorder comorbid with bipolar disorder.Firoz Kazhungil,
E.Mohandas. IJP 2016;58(3).259-269

43. Body Dysmorphic Disorder
A. Preoccupation with an imagined defect in
appearance. If a slight physical anomaly is
present, the person’s concern is markedly
excessive.
B.The preoccupation causes clinically significant
distress or impairment in functioning.
C. The preoccupation is not better accounted for by
another mental disorder (e.g., dissatisfaction with
body shape and size in anorexia nervosa).

44. • Most common age of onset b/w 15 and 30 years
• Women affected more
ETIOLOGY:-
-Similarity to OCD, comorbidity with depression
and higher family history of mood disorder S/O
role of serotonin.
- Psychodynamic model- it reflecting the
displacement of sexual and emotional conflict
onto nonrelated part.

45. CLINICAL FEATURES:-
-Affected area- facial flaws followed by breasts,
genitalia.
- Ideas or delusion of reference
-Can result either excessive mirror imaging or
avoidance
- Person may be housebound

46. Differential Diagnosis
 Anorexia Nervosa-restricted to concern about
being fat
 Avoidant personality disorder and Social
phobia – may worry about being embrassed
by imagined or real defect but concern is not
prominent, persisting ,distressing or impairing.
 Delusional disorder

47. HOARDING DISORDER
• The disorder characterized by acquiring and
not discarding things that are deemed to be
little or no value resulting in excessive clutter
of living space
• Commonly driven by obsessive fear of losing
important items.
• Distorted belief about importance of
possession and by extreme emotional
emotional attachment to possession.

48. • 2-5 per. Prevelance, equally among male and
female and associated with social anxiety,
withdrawl and dependent personality traits.
• ETIOLOGY:-
- 80 per of hoarders reporting at least one first
degree relative with hoarding.
- Lower metabolism in posterior cingulate cortex
and occipital cortex which account for attention
and decision making deficits.
- Link b/w hoarding and markers on chromosomes
4q,5q, 17q and COMT gene on ch 22q.

49. Clinical features
• Most pts do not perceive their behaviour
problematic i.e.ego syntonic
• Overemphasize the importance of recall
information and possession
• Avoid making decision about discarding items.
• Other problems-Pest infestations, Fire in
collected items
• Social, Occupational and functional
impairement

50. Co-morbidities
• 30 per of OCD pts have hoarding.
• Symptoms in OCD are ego-dystonic whereas in
hoarding they are ego syntonic
• 20 per met criteria for ADHD.
• Hoarding behaviour noted in dementia,
surgery in prefrontal and orbitofrontal cortex
and schizophrenia.

51. • It is very difficult to treat. SSRI having mixed
results.
• The most effective treatment is cognitive
model that include training in decision making
and categorizing; exposure and habituation to
discarding ;and cognitive restructuring.

52. TRICHOTILLOMANIA
• Term coined by Francois Hallopeau in 1889
• There is increased tension prior to hair pulling
and a sense of relief after pulling
• All the areas of body may affect but mostly
scalp
• 2 types- Focused and automatic
• Hair loss is characterized by short, broken
strands appearing together with long, normal
hairs in affected areas

53. • Hair pulling may associated with trichophagy (35-
40 %)
• Patient usually deny that and hide alopecia.
EPIDEMIOLOGY:-
 Lifetime prevalence ranging from 0.6 to 3.4 %
with F:M is 10:1, Begin in early to mid
adolescence age
 Childhood type occur approx equal in both sex
 Patient is likely to be only or oldest child in family.

54. ETIOLOGY
• It is multi determined, although its onset may
linked with stressful situations i.e. disturbed
mother-child relation, fear of being left alone.
• Family members of d/o have history of tic,
impulse control disorder ,OCD suggestive of
genetic predisposition.
• Smaller volume of left putamen and left lenticular
areas.
• Relationship b/w serotonin receptor gene
polymorphism and trichotillomania.

55. Course and treatment
• Early onset(before 6 yr) tend to remit rapidly and
respond well to t/t while late onset( after 13 yr) is
associated with chronicity and poor prognosis.
• Treatment usually involve psychiatrist,
psychologist and dermatologist.
• Topical steroid with hydroxyzine along with SSRI.
• Poor response to SSRI can be augmented with
lithium, pimozide, venalafexine, naltrexone,
buspirone and trazadone.
• Biofeedback, densensitization ,habit reversal and
insight oriented psychotheraphy are sucessful
behavioral treatment.

56. EXCORIATION (SKIN
PICKING)DISORDER
• Another names – skin picking syndrome,
emotional excoriation, nervous scratching
artifact, epidermotillomania and para artificial
excoriation.
• DSM 5 criteria requires recurrent skin picking
resulting in skin lesion and repeated attempts
to decrease or stop picking.
• The skin picking must cause clinically relevant
distress or impairement in functioning.

57. Epidemiology and etiology
• Lifetime prevalence 1-5 % in general population,
approx 12 % in adolescent psychiatric population
and 2% with other skin disorders. Women more
affected.
• Some theorists speculate that skin picking is a
manifestation of repressed rage at authoritarian
parents.
• According to psychoanalytic theories skin is erotic
organ. Picking having masturbatory equivalance
and source of erotic pleasure.
• Many pts start picking at onset of skin dz and
continue to pick after skin dz cleared.

58. • Abnormalities in serotonin,dopamine and
glutamate have been hypothesized.
• Pt may pick as a means to relieve stress i.e.
marital conflicts, loss of loved one ,unwanted
pregnancy etc.

59. Clinical features
• Face is most common site. Other are legs,
arms, hand, fingers and scalp.
• In severe case , picking leads to disfigurement
require surgical intervention.
• Pt may feel tension before picking which
relieved after picking. Many pt often feel guit
and negative feeling after act.
• Many pt avoid social situations and may
attempt suicide.

60. Diiferential diagnosis
1. OCD- equal in both sex, Compulsion of skin
picking less likely. Skin picking if present
associated with obsession of contamination.
2. Body dysmorphic disorder- Skin picking is
centered on removing believed imperfection.
3.Substance like coccaine and amphetamine
can result in skin picking due to formication.

61. 4. Factitious Dermatitis-
a) self inflicted injury.
b) It can present as aggravation of dermatosis
targeting variety of lesion including blisters,
ulcers, erthyma, edema and sinuses.
c) The morphology of lesion is bizzare with
clearcut, angulated or geometric edges.
Presence of normal unaffected skin adjacent to
horrible skin lesion is diagnostic clue.
d) Pt ‘s description of history of lesion is vague
and lacks detais about appearance and
evolution of lesion.

62. Treatment
• Usual onset at adolescent age (mean age 12
to16) but may be in adulthood. Lag phase b/w
onset and diagnosis.
• Difficult to treat. SSRI have some efficacy
specially fluxotine as compared to placebo.
• Naltrexone reduce urge to pick. Glutaminergic
agent and lamotrigene have shown efficacy.
• Nonpharamacological treatment include habit
reversal and CBT.

63. REFERENCES
• The ICD-10 classification of mental and behavioural disorders. Clinical
descriptive and diagnostic guidelines,WHO
• The Synopsis of Psychiatry,11th edition. Benjamin James Sadock, Virginia
Alcott Sadock, Pedro Ruiz.
• Diagnostic and statistical manual of mental disorders DSM-5 Fifth Edition.
American Psychiatric Society.
• Management of obsessive-compulsive disorder comorbid with bipolar
disorder.Firoz Kazhungil, E.Mohandas. IJP 2016;58(3).259-269
• Dan, J. Stein, Eric Hollander (2002). The American Psychiatric Publishing
Textbook of Anxiety Disorders
• Textbook of psychiatry. Alan tassman
• The Comprehensive textbook of Psychiatry. Benjamin James Sadock,
Virginia Alcott Sadock, Pedro Ruiz
• Drug treatment of obsessive-compulsive disorder.Michael Kellner
Dialogues Clin Neurosci. 2010 Jun; 12(2): 187–197

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