This document summarizes a seminar on obsessive-compulsive disorder (OCD). The seminar was held at Hind Institute of Medical Sciences and chaired by Dr. Abhishek Pathak, with Dr. Manish Singh presenting. Key points from the document include: OCD is a chronic neuropsychiatric disorder characterized by recurrent obsessions and compulsions; it has a prevalence of 2-3% and is equally common in males and females; treatment involves serotonin reuptake inhibitors (SRIs) and/or cognitive behavioral therapy (CBT). The seminar covered etiology, phenomenology, diagnosis, differential diagnosis, comorbidities, and treatment of OCD.

1. SEMINAR TOPIC- OCD
Venue : HIND INSTITUTE OF MEDICAL SCIENCES
DEPARTMENT OF PSYCHIATRY
Date-31/05/2022
Chairperson:- Dr. ABHISHEK PATHAK
(Associate Professor Department Of Psychiatry, HIMS, Ataria)
Presenter:- Dr. MANISH SINGH(PG JR1)
•

2. INTRODUCTION
OCD is a chronic, waxing and waning neuropsychiatric
disorder characterized by recurrent obsessional thoughts
and/or compulsive acts

3. -According to WHO, OCD is among the 10 most
disabling medical condition worldwide
-OCD is twice as prevalent as schizophrenia and
bipolar disorder
-Fourth most common psychiatric disorder
(Karno et al 1988)
-2to3 percent life time prevalence
-OCD being labelled as “hidden epidemic”
(Hollander et al 1997)

4. -Equally common in both male and female
-Onset is usually childhood or early adult life

5. Etiology
• Cortico–striatal–thalamic–cortical (CSTC) pathway plays a
particularly important role in mediating the cognitive-affective
impairments seen in OCD
• A range of neurotransmitter systems contribute to OCD,
including serotonergic, dopaminergic, glutamatergic, and
GABAergic systems

7. OCD
Obsessions
Own thoughts but no
voluntary control
Repetitive
Intrusive, Unwanted,
Senseless
Time Consuming
Must not be pleasurable
Anxiety/Distressing
Thoughts, Images, Impulses
Compulsions
Motor acts/rituals
Repetitive
Stereotyped
Excessive
Intrusive
Time Consuming
Reduce anxiety

8. Common Obsessions
Contamination
Pathological doubts
Somatic
Need for symmetry
Aggressive
Religious Obsessions/ Blasphemous Obsessions
Sexual obsessions
Multiple obsessions

9. Common Compulsions
Checking
Washing
Counting
Need to ask or confess
Symmetry and precision
Hoarding
Compulsive rituals/repeating
Multiple Compulsions

10. Phenomenology
Symptoms differ patient to patient
Also dynamic in same patient
Mixed OCD> Pred. O> Pred. C

11. Phenomenology
Obsessions –
Thoughts, Images, Impulses
Avoidance needs to be explored

12. Phenomenology
Compulsions- Yielding/ Non Yielding
Self/ Proxy
Ritual- Rigid set of rules, start and end
Avoidance need to be explored

13. Insight
• Insight is the acknowledgement of the
irrational nature of OCD symptoms
• Recognizing that their experience are
“excessive or unreasonable”
• Interference to work
• Insight- good, fluctuating, poor, overvalued
ideas, delusion

14. Y-BOCS item 11
0=Excellent insight: fully rational in thinking
1=Good insight: readily acknowledges absurdity
but some lingering doubts
2=Fair insight: reluctantly admits absurdity but
no fixed conviction
3=Poor insight: Overvalued ideas present
4=Lack of insight: Delusional conviction

15. Comorbidity
• Up to two-third of pt. with OCD have comorbid
psychiatric disorders
(Kaplan and Hollander 2003)
Depression
Panic disorder
Social phobia
GAD
Tic disorder
Bipolar disorder
Personality disorder(Borderline, Schizotypal disorder, OCPD, AAPD
Paranoid PD)

16. OCD in other psychiatric disorders
• BPAD
• Schizophrenia
• Depression
• OC Spectrum Disorders
• Neurological conditions(eg. Parkinsonism,
Dementia, Epilepsy)

17. OC Spectrum Disorders
• OCSD are related disorders, that may overlap with OCD in terms of clinical
symptoms, associated features, presumed etiology, familial transmission
and response to selective pharmacological or behavioural treatment.
(Hollander et al 1997)

18. OCD
Neurological disorders
Tourette’s Syndrome
Tic disorder
Autism
Sydenham’s Chorea
Preoccupation with bodily
sensation/appearance
BDD
Hypochondriasis
Anorexia Nervosa
Impulse Disorders
Trichotillomania
Pathological gambling
Kleptomania
Self injurious behaviour

19. PANDAS
Paediatric Autoimmune Neuropsychiatric Disorders
Associated with Streptococcal infection
Diagnostic criteria
1.Presence of OCD, Tic disorder or both
2. Paediatric onset of symptoms(3years to puberty)
3. Abrupt onset, Episodic course, worsening of symptoms
4. Positive throat culture for group A beta hemolytic
streptococcus or history of scarlet fever
5. Association with neurological abnormalities( physical
hyperactivity, jerky movements)

20. Differential Diagnosis
• Depressive Rumination
• GAD
• Hypochondriasis
• BDD
• OCPD

21. OCD TREATMENT

22. Psychoeducation
• OCD is an illness(Brain disorder)
• Not a reflection of one’s character
• Myths and facts on OCD
• Biological basis of symptoms
• Course and outcome
• Need for treatment
• Duration and dose
• Role of family
• Regular follow-up

23. First line of treatment
Serotonin Reuptake Inhibitors- SRIs
OR
Cognitive Behavioral Therapy- CBT

24. Treatment of OCD
In the current scenario SRIs are first-line
agents in the treatment of OCD

25. Choice of Medication
-Most of the SRIs are almost equally effective in treating OCD
-Only clomipramine is found to have edge over others in its efficacy in treating OCD
-Anticholinergic side effects of clomipramine limits its use as a first line of treatment in
OCD
-Selective Serotonin Reuptake Inhibitors(SSRIs) are not only effective in the treatment
of OCD, but also have better safety and tolerability profile than does clomipramine

26. Choice of medication is based upon-
1)Side effect profile
2)The co-morbid conditions
3)Affordability and Pt’s choice
- Many of the OCD pts will not respond to first SRI but
will respond to another SRI
- Hence, sequential trial of SRIs are considered

27. Initiation of treatment
• Educating the pts about the possible side effect. This will
reduce the drop rates
• OCD doesn’t respond to usual antidepressant dose, OCD
responds at higher dosage
• Starting at the lowest possible dose, titrating the dose
slowly to effective dose within 4-6 weeks and
continuation in the same dose for another 6-8 weeks.
• For judging efficacy continue maximally tolerated
effective dose of SSRI for at least 12 weeks

28. Drug Suggested Dose
Escitalopram 20-30 mg
Fluoxetine 60-80mg
Fluvoxamine 200-300mg
Paroxetine 40-60mg
Sertraline 150-200mg
Citalopram 40-60mg
Clomipramine 150-225mg
Venlafaxine 225-300mg

29. Onset of response
• Initial response to medications starts around
6-8 weeks and maximum benefit occurs only
at 10-12 weeks
• Hence, don’t change the medication
prematurely without adequate dose and
duration of treatment

30. Duration of treatment
-90% of the pts do relapse when an effective pharmacotherapy
is discontinued.
-Reinstatement of the treatment after relapse can be associated
with poorer response
-Continue effective pharmacotherapy for atleast 1-2 years
-Long term or lifelong medication should be considered after 2 or
more relapses

31. Maintenance treatment and dose
• The long term maintenance treatment of OCD following
response to acute treatment is to prevent relapse.
• Medications are generally recommended to be continued at
the same dose that resulted in improvement.

32. Augmentation
Drug Suggested dosage
Aripiprazole 5-10 mg
Risperidone 1-3 mg
Haloperidol 2.5-10 mg
Memantine 10-20 mg
Lamotrigine 100 mg
Ondansetron 2-4 mg twice a day
Granisetron 1 mg twice a day
Topiramate, Riluzole, N-acetylcystein, Mirtazapine,
Clomipramine

33. Role of ERP(CBT)
-CBT/ERP monotherapy may be recommended as first line of
treatment in mild to moderately ill patients
-In severely ill patients a combination of CBT and SSRI is
recommended.
-When facilities for CBT are available, CBT / BT is recommended
as the first line augmenting strategy in partial/non-responders
to SSRI treatment.
-CBT alone are in combination with SRI can reduce frequent
relapses.

34. • In ERP, pts are exposed repeatedly to the source of their
obsessions and prevented from performing the rituals, until
the obsessions lose their compelling quality.
• In behavioural term, it is called as “Habituation”

35. Treatment outcome OCD
TREATMENT
RESPONSE
A ≥35% reduction in Y-BOCS scores plus CGI-I rating of 1 (‘very much
improved’) or 2 (‘much improved’), lasting for at least one week
PARTIAL
RESPONSE
A ≥25% but <35% reduction in Y-BOCS scores plus CGI-I rating of at least
3 (‘minimally improved’), lasting for at least one week
REMISSION ≤12 on the Y-BOCS plus CGI-S rating of 1 (‘normal, not at all ill’) or 2
(‘borderline mentally ill’), lasting for at least one week
RECOVERY ≤12 on the Y-BOCS plus CGI-S rating of 1 (‘normal, not at all ill’) or 2
(‘borderline mentally ill’), lasting for at least one year
RELAPSE For responders: The person no longer meets the definition of ≥35%
reduction on Y-BOCS scores plus CGI-I rating of 6 (‘much worse’) or
higher for at least one month
For remitters/recovered: the person again scores 13 or above on the
Y-BOCS plus CGI-I rating of 6 (‘much worse’) or higher for at least one
month
Refractory No change or worsening of symptoms

37. II THANK YOU II