In this presentation I review Obsessive Compulsive Disorder and related disorders.

1. Michael Ingram, MD

2.  Introduction to Obsessive Compulsive and Related Disorders
 Epidemiology of OCD
 Diagnosis of OCD
 Neurobiology of Impulsivity and Compulsivity
 Treatment
 Prognosis
 Brief tour of the other OCD spectrum disorders

3. At the conclusion of this lecture, you should be able:
 To recognize the signs and symptoms of OCD and related disorders
 To review the basic neurobiology of impulsivity and compulsivity
 To recall the available treatment options for OCD and related disorders

4.  What is an obsession?
 A recurrent and intrusive thought, feeling, idea, or sensation
 An obsession is a mental event
 What is a compulsion?
 A compulsion is a conscious, standardized, recurrent behavior, such
as counting, checking, or avoiding
 A compulsion is a behavior
 In OCD, obsessions and compulsions are ego-dystonic
 Compulsive acts are carried out in an attempt to relieve the
anxiety associated with the obsession
 Sometimes it works, sometimes it doesn’t work
 Resisting a compulsive act increases anxiety

5.  Epidemiology
 2-3% lifetime prevalence in general population
 4th most common outpatient psychiatric diagnosis
 10% of outpatients in psychiatric clinics
 Epidemiological studies in Europe, Asia, and Africa have confirmed
these rates across cultural boundaries
 Estimated that 40% of patients do not achieve a clinical response
from SSRIs1

6.  Epidemiology (Continued…)
 Females slightly more than males in adulthood
 Boys 2-3 times more affected than girls in childhood
 Mean onset 19.5 years old, rarely onset after 35
 Males earlier age of onset than females
 Mean age of onset: 20 years
 Boys: 19 years (mean)
 Girls: 22 years (mean)
 ~60% have onset of symptoms before 25yo
 <15% have onset of symptoms after 35yo
 Single persons > Married persons
 Possible Risk Factors
 Genetic factors (monozygotic concordance rate of 0.57)
 Environmental factors (trauma, abuse, perinatal, infectious)
 Psychosocial and developmental factors
 Controversy
 Childhood streptococcal infections increase risk of OCD (PANDAS)?

7.  Associated conditions
 90% of patients with OCD have psychiatric comorbidities
 76% Anxiety disorders
 63% Mood disorders
 56% Impulse control disorders
 39% Substance use disorders
 30% of patients with OCD have accompanying tic disorder
 OCD in children and adolescents
 Comorbidities reported in up to 50% pediatric patients
 ADHD
 Separation anxiety disorder
 Specific phobias
 Anxiety disorders
 Tourette disorder

8.  DSM-5 Criteria
A. Presence of obsession, compulsions, or both
 Obsessions are defined by 1 and 2
1. Recurrent and persistent thoughts, urges, or images that are
experienced, at some time during the disturbance, as intrusive and
unwanted, and that cause marked anxiety or distress
2. The individual attempts to ignore or suppress such thoughts, urges,
or images, or to neutralize them with some other thought or action (ie.,
by performing a compulsion)

9.  DSM-5 Criteria
A. Presence of obsessions, compulsions, or both
 Compulsions are defined by 1 and 2
1. Repetitive behaviors or mental acts that the individual feels driven
to perform in response to an obsession or according to rules that must
be applied rigidly
2. The behaviors or mental acts are aimed at preventing or reducing
anxiety or distress, or preventing some dreaded event or situation;
however, these behaviors or mental acts are not connected in a realistic
way with what they are designed to neutralize or prevent, or are
clearly excessive

10.  DSM-5 Criteria
B. The obsessions or compulsions are time-consuming (e.g., take more
than 1 hour per day) or cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning
C. Symptoms are not attributable to the physiological effects of a
substance or another medication
D. The disturbance is not better explained by symptoms of another
mental disorder (e.g., GAD, hoarding do, trichotillomania do, excoriation
do, eating do, etc)
Specifiers
 Insight: good, fair, poor, absent, delusional
 Tic-related: The individual has a current or past history of a tic disorder

11. Contamination
(hand washing,
cleaning)
Symmetry/Precision
(Slowness)
Intrusive Thoughts
Pathological
Doubt
(Checking)
There is considerable overlap, but generally patients present with a
predominant symptom pattern of an obsession-compulsion pair.
Compulsions in parenthesis

12. YBOCS is often used in clinical research in an attempt to
quantify OCD symptom severity and track progress over time

13. Pauls, David L., Amitai Abramovitch, Scott L. Rauch,
and Daniel A. Geller. "Obsessive–compulsive Disorder:
An Integrative Genetic and Neurobiological
Perspective." Nature Reviews Neuroscience Nat Rev
Neurosci (2014): 410-24. Print.

14.  Neurotransmitters implicated in OCD pathophysiology
 Serotonin – supported by alleviation of symptoms with SSRIs
 Glutamate – glutamate modulating drugs showing promising results
 Dopamine
 Cortico-striato-thalamo-cortical circuit (CSTC)
 Hyperactivity in orbitofrontal cortex (OFC), anterior cingulate cortex
(ACC), and caudate nucleus
 Glutamate is the primary excitatory neurotransmitter in CSTC
 Increased Glutamate levels in CSF, caudate, and OFC in OCD pts

15. Circuitry of impulsivity and reward. The
“bottom-up” circuit that drives impulsivity
(shown in pink) is a loop with projections from
the ventral striatum to the thalamus, from the
thalamus to the ventromedial prefrontal cortex
(VMPFC), and from the VMPFC back to the
ventral striatum. This circuit is usually
modulated “top-down” from the prefrontal
cortex (PFC). If this top-down response
inhibition system is inadequate or is overcome
by activity from the bottom-up ventral
striatum, impulsive behaviors may result.
Circuitry of compulsivity and motor response
inhibition. The “bottom-up” circuit that drives
compulsivity (shown in pink) is a loop with
projections from the dorsal striatum to the
thalamus, from the thalamus to the orbitofrontal
cortex (OFC), and from the OFC back to the dorsal
striatum. This habit circuit can be modulated “top-
down” from the OFC, but if this top-down response
inhibition system is inadequate or is overcome by
activity from the bottom-up dorsal striatum,
compulsive behaviors may result.
Stahl’s Essential Psychopharmacology 4th ed

16.  Etiology & Pathophysiology – remains unclear
 Heterogeneous
 Biological Factors
 Genetic polymorphisms
 Autoimmune processes
 Infection
 Inflammatory and oxidative stress
 Abnormalities of neurotransmission
 Behavioral Factors
 Psychosocial Factors

17. Pauls, David L., Amitai Abramovitch, Scott L. Rauch,
and Daniel A. Geller. "Obsessive–compulsive Disorder:
An Integrative Genetic and Neurobiological
Perspective." Nature Reviews Neuroscience Nat Rev
Neurosci (2014): 410-24. Print.

18. Pauls, David L., Amitai Abramovitch, Scott L. Rauch,
and Daniel A. Geller. "Obsessive–compulsive Disorder:
An Integrative Genetic and Neurobiological
Perspective." Nature Reviews Neuroscience Nat Rev
Neurosci (2014): 410-24. Print.

19.  Current Treatment (pharmacotherapy + behavioral)
 SSRIs (typically requires higher doses compared to depression)
 Fluoxetine
 Fluvoxamine
 Paroxetine
 Sertraline
 Citalopram
 Clomipramine
 TCA most selective for serotonin reuptake
 Other therapies
 ECT
 Surgery (Psychosurgery)
 Deep Brain Stimulation
 Glutamatergic agents

20.  Problems with current treatment
 Only 20-30% of patients have significant improvement
 40-50% of patients have moderate improvement
 20-40% of patients do not respond or get worse!
 Higher doses of SSRIs required to alleviate symptoms in OCD
 Associated adverse effects lead to patient non-compliance

21. • Obsessive-Compulsive or Related Disorder Due to another medical condition
• PANDAS
• Substance induced Obsessive-Compulsive or related disorder
• Olfactory Reference Syndrome
• Body Dysmorphic Disorder
• Hoarding Disorder
• Hair-Pulling Disorder (Trichotillomania)
• Excoriation (Skin-Picking) Disorder

22. Hypothesis: Acute and rapid onset of
OCD/Tics symptoms in a subset of children
with group A beta hemolytic streptococcal
infections.
Antibodies to GABHS cross react with
basal ganglia neurons causing dysfunction
Controversial
https://www.healthynewbornnetwork.org/blog/have-
you-got-data-on-follow-up-of-children-after-group-b-
streptococcus-infection/

23.  A false belief by the patient that he or she has a foul body odor
that is not perceived by others
 Leads to excessive showering, changing clothes
 May rise to level of somatic delusion
 (Delusional Disorder)
 Rule out organic illness
 Temporal lobe epilepsy
 Pituitary tumors
 Sinusitis

24.  Preoccupation with an imagined defect in appearance that causes clinically significant distress
 If a slight physical anomaly is actually present, the person’s concern with the anomaly is excessive and
bothersome
 Compulsions:
 Mirror checking
 Excessive grooming
 Comparing appearance to others
 Men: preoccupation with muscle mass and “bulking up”
 Women>Men; unmarried; AoO = 15-30years
 High comorbidity with MDD, Anxiety, Psychosis
 Body dysmorphic Disorder more often seen in
 Plastic Surgery Clinics
 Dermatology Clinics
 Internist/Primary Care Clinics
 Treatments
 Fluoxetine
 Clomipramine
 TCAs
 MAOIs
 Psychotherapy
 Surgical/procedural interventions rarely benefit these patients
https://en.wikipedia.org/wiki/Body_dysmorp
hic_disorder

25.  Acquiring and not discarding unimportant possessions
of little or no value
 Obsessive fear of losing important items that may be
needed in the future
 Distorted beliefs about the importance of possessions
 Excessive emotional attachment to possessions
 Leads to
 Cluttering
 Unsanitary living conditions
 Health risks (falls, animal born diseases)
 Fire risks
 Commonly seen in single persons with social anxiety
or dependent personality traits
 Seen in dementia, CVA, and schizophrenia (slightly
different presentation)
 Begins in early adolescence, often persists over
lifetime
 Most lack insight into their illness (ego-syntonic)
 Treatment
 Medications aren’t effective
 Cognitive behavioral interventions are most effective
http://www.thewowdecor.com/how-to-help-the-
hoarder-in-your-house/

26.  Trichotillomania coined by a French dermatologist Francois Hallopeau in 1889
 Chronic disorder characterized by repetitive hair pulling
 Results in hair loss
 Increased tension prior to hair pulling and relief of tension or gratification after the hair pulling
 0.6-3.4% lifetime prevalence
 Women:Men = 10:1
 35%-40% chew or swallow the hair
 Bezoars – hairballs in the GI tract  Obstruction
 Pharmacological Treatments
 SSRIs
 SNRIs
 Lithium
 Pimozide
 Naltrexone
 Buspirone
 Clonazepam
 Trazodone
 Behavioral Treatments
 Biofeedback
 Insight-oriented psychotherapy
 Hypnotherapy
https://www.cbc.ca/life/wellness/the-
truth-about-trichotillomania-the-
hair-pulling-disorder-1.3865541

27.  Compulsive and repetitive picking of the skin
 1-5% lifetime prevalence
 Women>Men
 Rule out stimulant induced excoriation
 Face (most common)
 Also: Legs, Arms, Torso, Hands, Cuticles, Fingers, Scalp
 Embarrassment and avoidance/social withdrawal
 12% of skin-picking patients have attempted suicide
 Pharmacological Treatments
 Fluoxetine
 Naltrexone
 Lamotrigine
 Behavioral Treatments
 Cognitive Behavioral Therapy
 Habit Reversal

28.  THE END
 Stay tuned for more Simply Psych EDU Lectures!
 www.simplypsychedu.com

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"Obsessive–compulsive Disorder: An Integrative Genetic and Neurobiological
Perspective." Nature Reviews Neuroscience Nat Rev Neurosci (2014): 410-24. Print.
3. Oliver, Georgina, Olivia Dean, David Camfield, Scott Blair-West, Chee Ng, Michael
Berk, and Jerome Sarris. "N-Acetyl Cysteine in the Treatment of Obsessive
Compulsive and Related Disorders: A Systematic Review." Clin Psychopharmacol
Neurosci Clinical Psychopharmacology and Neuroscience (2015): 12-24. Print.
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Kluwer/Lippincott Williams & Wilkins, 2007. Print.
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D.C.: American Psychiatric Association, 2013. Print.
7. Stahl’s Essential Psychopharmacology, 4th Edition. Cambridge University Press. 2013