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Teaching 30 july

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Teaching 30 july

  1. 1. MRCPsych General Adult Psychiatry (Eating Disorders, OCD and PTSD) By: Yasir Hameed (MRCPsych) Specialist Registrar Norfolk and Suffolk NHS Trust 30 July 2014
  2. 2. Disclaimer • SPMM and Birmingham notes • BMJ learning • Various MCQs from previous papers and online courses
  3. 3. Eating disorders 1. Anorexia nervosa 2. Bulimia nervosa 3. EDNOS – atypical ED or ED not otherwise specified
  4. 4. Important to note • Binge eating disorders • Amenorrhoea in Anorexia • Food intake during binges • Bulimia vs anorexia patients’ engagement • Stability of the diagnosis
  5. 5. Epidemiology of bulimia and anorexia (adapted from Fairburn & Harrison, 2003)
  6. 6. Genetics
  7. 7. Risk factors (adapted from Fairburn & Harrison, 2003) • Female sex • Adolescence and early adulthood • Western cultural adaptation • Family history of ED, depression • Family history of substance misuse, especially alcoholism (bulimia nervosa) • Family history of obesity (bulimia nervosa) • Adverse parenting (especially low contact, high expectations, parental discord)
  8. 8. Risk factors (cont’d) • Childhood sexual abuse • Critical comments about eating, shape, or weight from family and others • Occupational and recreational pressure to be slim • Low self-esteem • Perfectionism (anorexia nervosa more than bulimia nervosa) • Past history of being obese (bulimia nervosa) • Early menarche (bulimia nervosa)
  9. 9. Binge eating disorder (BED) • Recurrent episodes of binge eating in the absence of extreme weight-control behaviour • Association with obesity • Patients typically present in their 40s, more males (25%) • High spontaneous remission • Stress associated overeating common phenomenon • Self help, behavioural weight loss programmes and CBT/IPT can help
  10. 10. Diagnostic features of bulimia nervosa The core diagnostic symptoms include : • Extreme concerns about weight • Regular binge eating • Preoccupation with food and diet • Extreme measures of weight control • If there is also severe self maintained weight loss (for example with a body mass index <18) a diagnosis of anorexia nervosa of the “binge eating and purging” type will apply.
  11. 11. Physical symptoms of EDs (adapted from Fairburn & Harrison, 2003) • Increased sensitivity to cold • Gastrointestinal symptoms • Dizziness and syncope • Amenorrhoea • Poor sleep with early morning wakening
  12. 12. Physical signs of EDs • Emaciation; stunted growth and failure of breast development (if pre-pubertal onset) • Dry skin; fine downy hair (lanugo) on the back, forearms, and side of the face; in patients with • Hyper carotenaemia, orange discolouration of the skin • Russell's sign – calluses in knuckles due to repeated vomit induction • Swelling of parotid and submandibular glands (especially in bulimic patients)
  13. 13. Signs (cont’d) • Erosion of inner surface of front teeth (peri-mylolysis) in those who vomit frequently • Cold hands and feet; hypothermia • Bradycardia; orthostatic hypotension; cardiac arrhythmias (especially in underweight patients and those with electrolyte abnormalities) • Dependent oedema (complicating assessment of bodyweight) • Weak proximal muscles (elicited as difficulty rising from a squatting position)
  14. 14. Abnormalities on physical investigation Endocrine • Low concentrations of LH, FSH and and oestradiol • Low T3, T4 in low normal range, normal concentrations of TSH (low T3 syndrome) • Mild increase in plasma cortisol • Raised GH • Severe hypoglycaemia (rare) • Low leptin
  15. 15. Investigations (cont’d) Cardiovascular • ECG abnormalities • Myopathy and fatal cardiomyopathy Gastrointestinal • Delayed gastric emptying • Decreased colonic motility • Acute gastric dilatation
  16. 16. Investigations (cont’d) Haematological • Moderate normocytic normochromic anaemia • Mild leucopenia with relative lymphocytosis • Thrombocytopenia Other metabolic abnormalities • Hypercholesterolaemia • Raised serum carotene • Hypophosphataemia • Dehydration
  17. 17. Electrolyte disturbance • metabolic alkalosis and hypokalaemia (vomiting) • metabolic acidosis, hyponatraemia, hypokalaemia (laxative abuse) Other abnormalities • Osteopenia and osteoporosis (with heightened fracture risk) • Enlarged cerebral ventricles and external cerebrospinal fluid spaces (pseudo atrophy)
  18. 18. Effects on pregnancy (Human Reproduction Update 2006 12(3):193-207) • Decreased fertility • May have more abortions • Higher rates of hyperemesis gravidarum, anaemia, impaired weight gain • Compromised intrauterine foetal growth • Premature delivery is more likely • Rates of caesarean delivery is high • Post-natal complications and post-partum depression are higher • Associated with low birth weight, microcephaly, low APGAR scores. • In actively anorexic mother, the neonate may have hypoglycaemia
  19. 19. Managing bulimia Cognitive behaviour therapy • Typically involves about 20 individual treatment sessions over 5 months • 33-50% make a complete and lasting recovery • Antidepressants • Have an anti-bulimic effect • Produce a rapid decline in the frequency of binge eating and purging, and an improvement in mood.
  20. 20. Managing anorexia Major therapeutic goals: 1. Engagement 2. weight restoration 3. psychological therapy 4. if needed use of compulsion
  21. 21. Outpatient therapy for anorexia has best chance if a. Illness is present for less than 6 months b. No bingeing or vomiting c. Have parents who cooperate and are willing to participate in family therapy
  22. 22. Summary of NICE guidelines Anorexia: ▫ Drugs should not be used as sole or primary treatment for anorexia nervosa ▫ Consider Psychological therapies ▫ Individual and family interventions ▫ Dietary counselling should not be provided as sole treatment for anorexia nervosa
  23. 23. Summary of NICE guidelines Bulimia: ▫ Evidence-based self-help programme and/or antidepressants ▫ SSRIs (specifically fluoxetine) are drugs of first choice for bulimia nervosa ▫ Specifically adapted CBT ▫ Interpersonal psychotherapy should be considered as alternative to CBT
  24. 24. What's the outlook? (BN) • Up to 70% or more are in full or partial remission • What do patients want to know? • Patients want to know where to go for help and “what will work.”
  25. 25. Case vignette • A 23 year old woman presents to your practice with dizziness. On questioning you find out that she exercises for two to three hours each day at a gym. You suspect that she has bulimia nervosa. To confirm your suspicion what should you ask her? A. Are you sleeping badly and do you have a poor appetite? B. Do you have panic attacks? C. Have you suffered from abuse? D. Have you been binge eating? E. Have you recently been dieting?
  26. 26. Case vignette 1 • A 23 year old woman presents to your practice with dizziness. On questioning you find out that she exercises for two to three hours each day at a gym. You suspect that she has bulimia nervosa. To confirm your suspicion what should you ask her? A. Are you sleeping badly and do you have a poor appetite? B. Do you have panic attacks? C. Have you suffered from abuse? D. Have you been binge eating? E. Have you recently been dieting?
  27. 27. • The woman tells you that as well as exercising she is taking 40 Senokot (laxative) tablets a day and vomiting twice a day after binge eating. What tests should you order? A. Liver function tests B. Urea, creatinine, and potassium levels C. A full blood count D. Thyroid function tests E. Serum calcium level
  28. 28. • The woman tells you that as well as exercising she is taking 40 Senokot (laxative) tablets a day and vomiting twice a day after binge eating. What tests should you order? A. Liver function tests B. Urea, creatinine, and potassium levels C. A full blood count D. Thyroid function tests E. Serum calcium level
  29. 29. • You arrange an electrocardiogram. What is this most likely to show? A. Peaked T and flat P waves B. Bradycardia C. ST depression and tall U waves D. QRS widening and QT prolongation E. ST elevation and inverted T waves
  30. 30. • You arrange an electrocardiogram. What is this most likely to show? A. Peaked T and flat P waves B. Bradycardia C. ST depression and tall U waves D. QRS widening and QT prolongation E. ST elevation and inverted T waves
  31. 31. • She asks you which treatments can best help people with bulimia nervosa. What should you tell her? A. No treatment has been found to be really effective B. Most people improve without specific help after about six months C. There is good evidence supporting the use of cognitive behavioural therapy, which is a form of psychotherapy D. An antidepressant is best because bulimia nervosa is a masked form of depression E. She needs an analytic form of psychotherapy to find out what is underlying her problems
  32. 32. • She asks you which treatments can best help people with bulimia nervosa. What should you tell her? A. No treatment has been found to be really effective B. Most people improve without specific help after about six months C. There is good evidence supporting the use of cognitive behavioural therapy, which is a form of psychotherapy D. An antidepressant is best because bulimia nervosa is a masked form of depression E. She needs an analytic form of psychotherapy to find out what is underlying her problems
  33. 33. • Your patient says she has heard that there is an "epidemic of eating disorders." Which one of the following should you advise her? A. Although eating disorders are at epidemic levels there is no need for alarm B. The incidence of eating disorders is decreasing C. There may have been an increase in the incidence of eating disorders, but it is not large D. It is only anorexia nervosa that is at epidemic levels E. Eating disorders are increasing at the same rate as weight disorders and obesity
  34. 34. • Your patient says she has heard that there is an "epidemic of eating disorders." Which one of the following should you advise her? A. Although eating disorders are at epidemic levels there is no need for alarm B. The incidence of eating disorders is decreasing C. There may have been an increase in the incidence of eating disorders, but it is not large D. It is only anorexia nervosa that is at epidemic levels E. Eating disorders are increasing at the same rate as weight disorders and obesity
  35. 35. • You advise her that cognitive behavioural therapy will involve keeping a food diary. She says this won't be necessary because she knows exactly what she eats and can tell a therapist from memory at each session. What would you reply? A. OK, I'm sure that will work just as well B. Keeping the diary is an important and essential first step in the therapy C. She could skip that part and come back to it later D. Perhaps cognitive behavioural therapy isn't right for her E. If she takes antidepressants she will find it easier to keep the diary
  36. 36. • You advise her that cognitive behavioural therapy will involve keeping a food diary. She says this won't be necessary because she knows exactly what she eats and can tell a therapist from memory at each session. What would you reply? A. OK, I'm sure that will work just as well B. Keeping the diary is an important and essential first step in the therapy C. She could skip that part and come back to it later D. Perhaps cognitive behavioural therapy isn't right for her E. If she takes antidepressants she will find it easier to keep the diary
  37. 37. • She is worried that the cognitive behavioural therapy will make her gain weight. What should you tell her? A. She is likely to gain weight with cognitive behavioural therapy, but it's better to be fat than to have bulimia nervosa B. She will definitely lose weight with cognitive behavioural therapy C. She might gain weight with cognitive behavioural therapy, but you can prescribe her some tablets to help D. Most people lose or gain only a few kilograms at most E. She shouldn't gain weight with cognitive behavioural therapy because it incorporates weight loss strategies, such as restrictive dieting
  38. 38. • She is worried that the cognitive behavioural therapy will make her gain weight. What should you tell her? A. She is likely to gain weight with cognitive behavioural therapy, but it's better to be fat than to have bulimia nervosa B. She will definitely lose weight with cognitive behavioural therapy C. She might gain weight with cognitive behavioural therapy, but you can prescribe her some tablets to help D. Most people lose or gain only a few kilograms at most E. She shouldn't gain weight with cognitive behavioural therapy because it incorporates weight loss strategies, such as restrictive dieting
  39. 39. • She confides that as well as binge eating and abusing laxatives, she used to cut herself to relieve psychological distress, she drinks heavily (more than eight standard drinks daily at her local pub, mostly with friends), and her moods go "up and down" all the time to the extent that she can't remember ever feeling happy or relaxed over a sustained period. What diagnosis should you now consider? A. Major depression B. Borderline personality disorder C. Social phobia D. Bipolar disorder E. A factitious disorder
  40. 40. • She confides that as well as binge eating and abusing laxatives, she used to cut herself to relieve psychological distress, she drinks heavily (more than eight standard drinks daily at her local pub, mostly with friends), and her moods go "up and down" all the time to the extent that she can't remember ever feeling happy or relaxed over a sustained period. What diagnosis should you now consider? A. Major depression B. Borderline personality disorder C. Social phobia D. Bipolar disorder E. A factitious disorder
  41. 41. Various MCQs • A 30 year old man has bulimia nervosa. If he does have a family history then which one of the following conditions is one or both of his parents likely to have? A. Schizophrenia B. Pica C. Obesity D. Psychopathy E. Depression F. Bipolar disorder
  42. 42. Case vignette 2 • A 30 year old man has bulimia nervosa. If he does have a family history then which one of the following conditions is one or both of his parents likely to have? A. Schizophrenia B. Pica C. Obesity D. Psychopathy E. Depression F. Bipolar disorder
  43. 43. • The man says he is puzzled that he has an eating disorder as he thought they only occurred in women. Which one of the following should you advise him? A. Eating disorders are extremely rare in men and are usually secondary to some other problem B. He's partly right - the only men who have eating disorders are those who are also homosexual C. About one in 10 people with bulimia nervosa is male, and the presentation is similar to bulimia in females, although excessive exercising is more common in men than purging D. Eating disorders are as common in men as in women, it is just that they are not asked about them E. Eating disorders are increasing in men at an alarming rate
  44. 44. • The man says he is puzzled that he has an eating disorder as he thought they only occurred in women. Which one of the following should you advise him? A. Eating disorders are extremely rare in men and are usually secondary to some other problem B. He's partly right - the only men who have eating disorders are those who are also homosexual C. About one in 10 people with bulimia nervosa is male, and the presentation is similar to bulimia in females, although excessive exercising is more common in men than purging D. Eating disorders are as common in men as in women, it is just that they are not asked about them E. Eating disorders are increasing in men at an alarming rate
  45. 45. Case vignette 3 A 22-year-old man attends A&E department accompanied by very worried parents. They claim that their son has lately become increasingly aggressive and unusually suspicious of them. He is convinced that the neighbours are after him because they hate him. His parents are convinced that these symptoms may be due to a very strict diet he is doing in order to take part in a sport competition. The patient is oriented to time, place and person. His past medical history is unremarkable and he denies taking any medication. On examination, the patient is well built with no abnormal findings except for nodulocystic acne on his face and back. What is the most likely cause of this patient’s abnormal behaviour? A. Anorexia nervosa B. Paranoid schizophrenia C. Bipolar disorder D. Exogenous androgens E. Corticosteroid abuse
  46. 46. Case vignette 3 A 22-year-old man attends A&E department accompanied by very worried parents. They claim that their son has lately become increasingly aggressive and unusually suspicious of them. He is convinced that the neighbours are after him because they hate him. His parents are convinced that these symptoms may be due to a very strict diet he is doing in order to take part in a sport competition. The patient is oriented to time, place and person. His past medical history is unremarkable and he denies taking any medication. On examination, the patient is well built with no abnormal findings except for nodulocystic acne on his face and back. What is the most likely cause of this patient’s abnormal behaviour? A. Anorexia nervosa B. Paranoid schizophrenia C. Bipolar disorder D. Exogenous androgens E. Corticosteroid abuse
  47. 47. Case vignette 4 • A15year old girl is admitted as an inpatient with anorexia nervosa. She suddenly develops dizziness and shortness of breath with chest pain. Which of the following is the most likely complication that can explain her symptoms? (Jan 2009) A. Pulmonary embolism B. First degree heart block C. Sinus tachycardia D. Cardiomyopathy E. Myocarditis
  48. 48. Case vignette 4 • A15year old girl is admitted as an inpatient with anorexia nervosa. She suddenly develops dizziness and shortness of breath with chest pain. Which of the following is the most likely complication that can explain her symptoms? (Jan 2009) A. Pulmonary embolism B. First degree heart block C. Sinus tachycardia D. Cardiomyopathy E. Myocarditis
  49. 49. Various MCQs • With respect to epidemiological differences between bulimia and anorexia, choose an incorrect statement: A. Bulimia starts later than anorexia B. Anorexia is excessively represented in lower social classes C. The prevalence of anorexia is around 0.5% to 1% D. The prevalence of bulimia is around 2% E. Stability of individual diagnoses of various eating disorders is poor.
  50. 50. Various MCQs • With respect to epidemiological differences between bulimia and anorexia, choose an incorrect statement: A. Bulimia starts later than anorexia B. Anorexia is excessively represented in lower social classes C. The prevalence of anorexia is around 0.5% to 1% D. The prevalence of bulimia is around 2% E. Stability of individual diagnoses of various eating disorders is poor.
  51. 51. • Risk factors specific for bulimia rather than anorexia include A. Family history of obesity B. Family history of alcoholism C. Impulsivity D. Early menarche E. All of the above
  52. 52. • Risk factors specific for bulimia rather than anorexia include A. Family history of obesity B. Family history of alcoholism C. Impulsivity D. Early menarche E. All of the above
  53. 53. • Which of the following is true with regard to the diagnosis of eating disorders? A. Anorexia is more prevalent than bulimia B. Binge episodes are characteristic of anorexia C. A typical binge can include 1000-2000 Cal D. Anorexic patients seek treatment more often than bulimic patients E. Most patients with anorexia have a past history of bulimia
  54. 54. • Which of the following is true with regard to the diagnosis of eating disorders? A. Anorexia is more prevalent than bulimia B. Binge episodes are characteristic of anorexia C. A typical binge can include 1000-2000 KCal D. Anorexic patients seek treatment more often than bulimic patients E. Most patients with anorexia have a past history of bulimia
  55. 55. • With respect to epidemiological differences between bulimia and anorexia, choose an incorrect statement: A. Bulimia starts later than anorexia B. Anorexia is excessively represented in lower social classes C. The prevalence of anorexia is around 0.5% to 1% D. The prevalence of bulimia is around 2% E. Stability of individual diagnoses of various eating disorders is poor.
  56. 56. • With respect to epidemiological differences between bulimia and anorexia, choose an incorrect statement: A. Bulimia starts later than anorexia B. Anorexia is excessively represented in lower social classes C. The prevalence of anorexia is around 0.5% to 1% D. The prevalence of bulimia is around 2% E. Stability of individual diagnoses of various eating disorders is poor.
  57. 57. • Monozygotic concordance rate in anorexia is estimated to be around A. 25% B. 35% C. 15% D. 5% E. 55%
  58. 58. • Monozygotic concordance rate in anorexia is estimated to be around A. 25% B. 35% C. 15% D. 5% E. 55%
  59. 59. • A 34 year old lady presents with recurrent episodes of binge eating but has no weight control behaviour. She has a general tendency to overeat and looks overweight. Which of the following is correct regarding this presentation? A. Nearly a quarter of those suffering from this problem are males B. She has bulimia nervosa C. She has anorexia nervosa D. Her condition will not remit spontaneously E. Stressful periods are associated with decline in binges
  60. 60. • A 34 year old lady presents with recurrent episodes of binge eating but has no weight control behaviour. She has a general tendency to overeat and looks overweight. Which of the following is correct regarding this presentation? A. Nearly a quarter of those suffering from this problem are males B. She has bulimia nervosa C. She has anorexia nervosa D. Her condition will not remit spontaneously E. Stressful periods are associated with decline in binges
  61. 61. • Which of the following is a laboratory abnormality seen in anorexia? A. High oestrogen B. Low cortisol C. Hyperphosphataemia D. Low tri-iodothyronine E. Hyperkalaemia
  62. 62. • Which of the following is a laboratory abnormality seen in anorexia? A. High oestrogen B. Low cortisol C. Hyperphosphataemia D. Low tri-iodothyronine E. Hyperkalaemia
  63. 63. • The babies of anorexic mothers A. Are large for dates B. Have lower APGAR scores C. Are born post-term D. Have a larger head circumference E. Have diabetes
  64. 64. • The babies of anorexic mothers A. Are large for dates B. Have lower APGAR scores C. Are born post-term D. Have a larger head circumference E. Have diabetes
  65. 65. • Which of the following is not commonly associated with bulimia? A. Oesophageal tears B. Dental decay C. Peptic ulcer D. Seizures E. Parotid gland enlargement
  66. 66. • Which of the following is not commonly associated with bulimia? A. Oesophageal tears B. Dental decay C. Peptic ulcer D. Seizures E. Parotid gland enlargement
  67. 67. • Which of the following modes of treatments is not endorsed by evidence based guidelines for managing anorexia? A. Antidepressants B. Cognitive analytical therapy C. Cognitive behavioural therapy D. Dialectic behavioural therapy E. Family based interventions
  68. 68. • Which of the following modes of treatments is not endorsed by evidence based guidelines for managing anorexia? A. Antidepressants B. Cognitive analytical therapy C. Cognitive behavioural therapy D. Dialectic behavioural therapy E. Family based interventions
  69. 69. • Which of the following is true with regard to use of antidepressants in eating disorders? A. Antidepressants do not have specific antibulimic effects B. Antidepressants act slower in eating disorders than in depression C. Antidepressants are more effective than CBT in anorexia D. Antidepressant effects are often sustained even after stopping the medications E. Medications should not be used as sole treatment for anorexia
  70. 70. • Which of the following is true with regard to use of antidepressants in eating disorders? A. Antidepressants do not have specific antibulimic effects B. Antidepressants act slower in eating disorders than in depression C. Antidepressants are more effective than CBT in anorexia D. Antidepressant effects are often sustained even after stopping the medications E. Medications should not be used as sole treatment for anorexia
  71. 71. • Focused family interventions are particularly useful in which of the following subgroups with eating disorders? A. Late onset anorexia B. Adolescents with bulimia C. Adolescents with anorexia nervosa D. Adults with co-morbid physical illnesses E. Binge eating disorder
  72. 72. • Focused family interventions are particularly useful in which of the following subgroups with eating disorders? A. Late onset anorexia B. Adolescents with bulimia C. Adolescents with anorexia nervosa D. Adults with co-morbid physical illnesses E. Binge eating disorder
  73. 73. Further reading • The Royal College of Psychiatrists information site for eating disorders • Includes leaflets, factsheets, books, and reports on eating disorders, a primary care protocol for managing adults with eating disorders, and information about the eating disorders special interest group and relevant events. • https://www.rcpsych.ac.uk/members/sections/e atingdisorders.aspx
  74. 74. OCD • Introduction • Obsessive-compulsive disorder is a prevalent and disabling condition. Epidemiological surveys have repeatedly shown a high lifetime prevalence, amounting to 2-3% of the population worldwide. [ 2 ] [ 3 ] A recent European study suggested a lower estimate, with a 12 month prevalence of 0.7% and a lifetime estimate of 0.8%. [ 4 ] • Nevertheless, only a fraction of people with obsessive- compulsive disorder present for treatment and the diagnosis is often missed. • The lifetime prevalence of obsessive-compulsive disorder relative to other major mental disorders is given in Table 1.
  75. 75. Table 1. Lifetime prevalence of major mental disorders Major depressive episode 6.7% Obsessive-compulsive disorder 2.6% Schizophrenia 1.9%
  76. 76. • The illness is more common in women than in men (ratio 1.5:1). The mean age of onset is reported as 20 years, with bimodal peaks at ages 12-14 years and 20-22 years. [ 5 ] • Untreated obsessive-compulsive disorder usually runs a chronic, lifelong course: it fluctuates in intensity but rarely disappears. In a seminal follow up study spanning several decades, Skoog and Skoog reported only a minority of patients had become free from symptoms. [ 6 ]
  77. 77. How do I diagnose it? • The International Classification of Diseases (10th revision, ICD-10) and the Diagnostic Statistical Manual (4th edition, DSM-IV) recognise obsessions or compulsions (or both) as core symptoms of obsessive-compulsive disorder. [ 7 ] [ 8 ] • To make the diagnosis: • Obsessions or compulsions (or both) must be present on most days for at least two weeks • Obsessions and compulsions must share the following features, all of which must be present: ▫ They must originate in the mind of the individual ▫ They must be repetitive and unpleasant ▫ At least one must be unsuccessfully resisted ▫ Carrying out the obsessive thought or compulsive act is not intrinsically pleasurable.
  78. 78. • Obsessions are unwanted ideas, images, or impulses that repeatedly enter a person's mind. Although recognised to be generated by the person (unlike "made thoughts" that characterise schizophrenic delusions) they are out of character, unwanted, and distressing. • Compulsions are repetitive stereotyped behaviours or mental acts that are driven by rules that must be applied rigidly. They are not inherently enjoyable and do not result in the completion of any useful task. To qualify for the diagnosis the symptoms must be experienced as disabling.
  79. 79. Table 2. Common symptoms of obsessive-compulsive disorder Common obsessions Common compulsions •Fear of causing harm to someone else •Fear of self harm •Fear of behaving unacceptably •Fear of contamination •Fear of making a mistake •Need for symmetry or exactness A. Behaviours •Cleaning •Hand washing •Ordering and arranging •Checking •Asking for reassurance B. Mental acts •Making mental lists •Counting •Repeating words silently
  80. 80. • Most people with obsessive-compulsive disorder endure a mixture of obsessions and compulsions. • Common obsessions include unrealistic worries about harm, such as being responsible for an accident or the fear of contamination, accompanied by avoidance of situations in which harm or contamination may occur. These obsessions generate compulsive behaviours aimed at avoiding the feared event, such as excessive checking or cleaning rituals. Other frequently occurring obsessions include a need for symmetry or orderliness and unwarranted fears and images about committing aggressive or sexual acts.
  81. 81. • Other common compulsions include counting, ordering, and arranging things. Symptoms are distressing and embarrassing and patients may be unwilling to discuss them for fear of censure. They may involve family members in their compulsions or persistently demand reassurance.
  82. 82. • Excessive doubt, the need for completeness, shame, and abnormal assessment of risk are thought to underlie most obsessions. • You need to be able to differentiate aggressive obsessions from other forms of psychopathology, such as urges to commit suicide or violence that occur in depression or psychopathic disorder, respectively. People with pure obsessive-compulsive disorder almost never carry out the feared act and spend an excessive amount of time and energy resisting and controlling their behaviour to avoid the risk of harm. But people with obsessive- compulsive disorder are not immune from the influences of other complicating disorders that may occur in addition, such as depression or personality disorder.
  83. 83. • OCD in children and young people • OCD frequently commences in childhood or adolescence, with a prevalence of 1% being quoted from population studies. [ 9 ] Undetected OCD in children not only causes marked psychological distress, but also can lead to an increased risk of morbidity and comorbidity in adulthood. [ 5 ]Interestingly, some studies suggest that the juvenile onset form of OCD seems more strongly related to a positive family history and may be more associated with tic disorders. [ 10 ] • You should consider guided self help for children and young people with OCD with mild functional impairment, in conjunction with support and information for the family or carers. Children and young people with OCD with moderate to severe functional impairment, and those with OCD with mild functional impairment for whom guided self help has been ineffective or refused, should be offered CBT (including Exposure and Response Prevention) involving the family or carers and adapted to suit the developmental age of the child as the treatment of choice. Group or individual formats should be offered depending upon the preference of the child or young person and their family or carers.
  84. 84. • If psychological treatment is declined by children or young people with OCD and their families or carers, or they are unable to engage in treatment, an SSRI may be considered with specific arrangements for careful monitoring for adverse events. The coexistence of comorbid conditions, learning disorders, persisting psychosocial risk factors such as family discord, or the presence of parental mental health problems, may be factors if the child or young person’s OCD is not responding to any treatment. • Additional or alternative interventions for these aspects should be considered. However, the child or young person will still require evidence based treatments for his or her OCD.
  85. 85. Comorbidity and the obsessive- compulsive disorder spectrum • A substantial lifetime comorbidity with other disorders has been identified, including [ 11 ] : • Depression (66%) • Simple phobia (22%) • Social phobia (18%) • Eating disorder (17%) • Alcohol dependence (14%) • Panic disorder (12%) • Tourette's syndrome (7%).
  86. 86. • There are also reports of an increased rate of obsessive- compulsive disorder in people with schizophrenia. Poyurovsky et al found a rate of 14% in 50 people hospitalised with first episode schizophrenia. [ 12 ] • Several disorders appear to be related to obsessive- compulsive disorder by: • The nature of their symptoms, which show similarities to obsessions or compulsions, or • Their frequent co-occurrence with obsessive-compulsive disorder, or both. • They have been termed obsessive-compulsive disorder spectrum disorders. [ 13 ] Examples are listed in Table 3.
  87. 87. Table 3. Obsessive-compulsive disorder related disorders •Autistic spectrum disorders •Body dysmorphic disorder (dysmorphophobia) •Trichotillomania •Hypochondriasis •Paraphilias •Compulsive gambling •Anorexia nervosa •Gilles de la Tourette syndrome
  88. 88. • Hypochondriasis involving a preoccupation with health related fears can be indistinguishable from obsessive-compulsive disorder. Body dysmorphic disorder, which involves obsessional thoughts relating to imagined or slight defects in appearance and frequent checking in the mirror, can also be difficult to distinguish from obsessive- compulsive disorder. However, in pure hypochondriasis and body dysmorphic disorder obsessions and compulsions are restricted to specific body related themes, unlike obsessive-compulsive disorder in which a broader range of obsessive-compulsive symptoms are usually manifested. Those with hypochondriasis do not regard their preoccupations as senseless and try little to resist them. • Tourette's syndrome, Huntington's disease, and Sydenham's chorea are neurological disorders that are commonly associated with obsessive-compulsive behaviours.
  89. 89. Non-psychiatric presentations of obsessive-compulsive disorder • Patients may present in a wide variety of ways. They may present with: • Chapped hands, eczema, or trichotillomania • Fear of cancer • Fear of HIV • Vaginal discomfort from douching. • People with obsessive-compulsive disorder frequently present to nonpsychiatrists for treatment and there is a need for greater awareness of obsessive-compulsive disorder in nonpsychiatric healthcare settings. • Patients with hypochondriacal obsessions, falsely believing themselves to be unwell, often present to GPs or hospital services seeking medical reassurance where their obsessive- compulsive disorder may escape notice.
  90. 90. • A recent survey of 92 patients attending the dermatology clinic at a general hospital revealed approximately 20% screened positive either for obsessive-compulsive disorder or a clinically relevant obsessive-compulsive disorder related disorder. In most cases the obsessional symptoms had not been previously diagnosed. Patients had a variety of dermatological problems, not simply sore hands from excessive washing, most notably eczema and acne. [ 14 ] • People with obsessive-compulsive disorder may also present to the genitourinary clinic with obsessions concerning venereal disease; previously syphilis, nowadays mainly HIV infection. • Women may develop obsessive-compulsive disorder in pregnancy or the puerperium. [ 15 ] Their illness may be mistaken for postnatal depression. It is important to differentiate between severely depressed women who may threaten the safety of their children through infanticide and women with postnatal obsessive- compulsive disorder, who obsessively worry about harming their children but are most unlikely to do so.
  91. 91. Raising the profile of obsessive- compulsive disorder • Obsessive-compulsive disorder is a chronic condition, which, if untreated, causes substantial social and emotional impairment. It is responsible for people failing to achieve their academic or occupational potential, and cripples personal relationships. The celibacy rate associated with obsessive- compulsive disorder is unusually high. [ 16 ] • Many patients hide their symptoms because they fear they are going mad or because of the stigma attached to the illness. It can therefore take some people many years before they are able to discuss their problems with a professional. • The diagnosis and treatment of obsessive-compulsive disorder by healthcare practitioners is also less than satisfactory. Patients are reported to wait roughly 17 years before receiving appropriate treatment, despite surveys indicating that the time between the onset of symptoms and correct diagnosis is shortening. [ 16 ] [ 17 ] Better recognition of obsessive- compulsive disorder is important because the illness readily responds to psychological or pharmacological treatments.
  92. 92. Table 4. The Zohar-Fineberg obsessive-compulsive screen 1.Do you wash or clean a lot? 2.Do you check things a lot? 3.Is there any thought that keeps bothering you that you would like to get rid of but can't? 4.Do your daily activities take a long time to finish? 5.Are you concerned about orderliness or symmetry?
  93. 93. • Measuring obsessive-compulsive disorder • People with obsessive-compulsive disorder are notoriously poor at gauging their level of impairment, particularly during treatment when they may have difficulty recognising signs of improvement. It can be helpful to ask a family member to corroborate the patient's history.
  94. 94. • Psychological treatment • Behavioural therapy • Prolonged "graded exposure" to the feared situation combined with self imposed "response prevention" has been shown to be effective for patients with obsessions and overt compulsions. • Graded exposure is based on the observation that an obsessional patient who has an intense fear of a situation, such as contamination with dirt, when confronted with the feared situation may escape or perform activities (washing) to reduce or prevent the harm they fear might result. Escape and compulsions reduce the unpleasant anxiety associated with their obsessions. Consequently, these behaviours are reinforced and worsen after each episode of brief exposure and escape. • The reduction in anxiety produced by a compulsive ritual such as washing tends to be small and the effect temporary. The aim of graded exposure treatment is to produce prolonged periods of contact with the feared situation until anxiety naturally reduces (habituation), producing more long lasting remediation.
  95. 95. • During treatment the patient may be asked to dirty their hand and remain in that situation until their anxiety has decreased significantly. This can take one or two hours. Patients are taught techniques to help them endure and overcome the anxiety associated with exposure. • Although this appears to be a simple technique, the therapist's skill is essential in accurately identifying the appropriate fear provoking cues, educating the patient about the therapy, and agreeing a level of exposure that will cause a degree of anxiety that can be tolerated.
  96. 96. • Response prevention - prevention of mental or physical compulsions (in this example by not washing the dirt away) - is the essential second step following exposure. This can usually be achieved by demonstrating to the patient how compulsions interfere with exposure. • Exposure tasks are repeated by the patient at least daily (preferably three times a day) until there is little anxiety even at the start of exposure. More difficult situations can then be tackled when the patient has completed all the tasks on their individual hierarchy of anxiety. • For exposure to be most effective, it should be: • Prolonged rather than of short duration [ 18 ] • In real life rather than in fantasy [ 19 ] • Practised regularly with homework tasks. [ 20 ] • Graded exposure and response prevention has been shown to be a quick and cost effective treatment. The technique can be easily learnt through supervision from a trained therapist or from appropriate reading material (for example Hawton et al and Stern and Drummond [ 21 ] [ 22 ] ). • Some patients need 10 to 15 hours of therapist aided exposure time, while others need no more than simple instruction in self exposure techniques. • There are now several self help manuals (for example Veale [ 23 ] ). Computerised treatment packages such as BT Steps (Marks et al) have also become popular. [ 24 ] But unless the disorder is mild, few patients are able to complete self help programmes without some guidance from a • professional.
  97. 97. • Cognitive behavioural therapy • Cognitive behavioural therapy involves supplementing graded exposure and response prevention with talking treatments aimed at remedying faulty reasoning that may have developed with the disorder. • For example, people may be encouraged to re-evaluate overvalued beliefs about risk or personal responsibility to regain a more realistic perspective. [ 25 ] [ 26 ] Although there is no clear evidence that cognitive therapy produces better results than simple exposure and response prevention, there is evidence in favour of using targeted cognitive techniques to overcome specific problems with exposure and facilitate patient engagement and concordance. [ 27 ] [ 28 ] [ 29 ] [ 30 ] • In contrast to simple behavioural therapy, cognitive behavioural therapy requires a greater level of therapist expertise. This is because poorly applied cognitive therapy may make obsessive-compulsive disorder worse as the patient can incorporate the process of looking for evidence to confirm or refute obsessions into their rituals.
  98. 98. • Outcome of behavioural therapy and cognitive behavioural therapy • Controlled trials indicated that graded exposure and response prevention was effective in many patients who completed treatment, with success rates varying from 75% to 85%. [ 31 ] [ 32 ]However, these studies lacked intention to treat data. • Family involvement in treatment may improve outcome. [ 33 ] According to an uncontrolled follow up survey, the improvements made during graded exposure and response prevention can be maintained for at least four years. [ 34 ] • However, some patients are reluctant to engage in exposure treatments even when accompanied by cognitive therapy, while others need booster sessions because their symptoms return. Patients with compulsions appear to respond better to behavioural therapy than patients with obsessions. [ 35 ] Patients with psychiatric comorbidity, in particular depression of more than moderate intensity, tend not to respond well to cognitive behavioural therapy unless medication is added. [ 36 ]
  99. 99. • Other forms of psychotherapy • There is no evidence to support psychodynamic psychotherapy for patients with obsessional disorders. [ 37 ] Indeed, there is a perception that insight oriented therapy can make obsessive-compulsive disorder worse by encouraging introspection. For this reason this form of psychotherapy is not recommended for most patients (see the NICE website at:http://www.nice.org.uk). Moreover, there is no convincing evidence for the use of psychoanalysis, transactional analysis, hypnosis, or marital or couple therapy for treating obsessive- compulsive disorder.
  100. 100. • Pharmacological treatment • The weight of evidence shows that obsessive-compulsive disorder responds preferentially to drugs that powerfully inhibit the synaptic reuptake of serotonin. These are the: • Tricyclic antidepressant clomipramine • More highly selective serotonin reuptake inhibitors (SSRIs). • Meta-analyses of randomised controlled trials have shown that these drugs are effective in obsessive-compulsive disorder, both in the presence and absence of comorbid depression. [ 38 ] • Clomipramine • Building on several small, positive trials, two seminal multicentre studies of clomipramine, which included 238 and 263 nondepressed patients with obsessive-compulsive disorder, were performed.[ 39 ] [ 40 ] Significant differences between drug and placebo emerged in favour of clomipramine as early as the first and second weeks of treatment. The benefits of clomipramine, given in flexible doses, increased slowly and gradually up to around 45% improvement by the 10 week endpoint of the studies.
  101. 101. • Clomipramine is associated with potentially dangerous side effects such as cardiotoxicity and cognitive impairment, which occur substantially more with clomipramine than with SSRIs. There is also an increased risk of convulsions in patients taking clomipramine (up to 2%). • The recommended maximum daily dose of clomipramine in the UK is 250 mg. • Selective serotonin reuptake inhibitors • The efficacy of fluvoxamine, sertraline, fluoxetine, paroxetine, and citalopram in the treatment of obsessive-compulsive disorder has been demonstrated in large scale studies. [ 41 ] [ 42 ] [ 43 ] [ 44 ] [ 45 ] [ 46 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] Like clomipramine the effect appears early but takes several weeks to develop fully. Dose finding studies have suggested that higher doses (60 mg citalopram, fluoxetine, paroxetine; 200 mg sertraline) are more effective, although the evidence for higher doses of sertraline and citalopram was less clear cut. [ 45 ] [ 47 ] [ 48 ] [ 51 ] [ 52 ]
  102. 102. • Which drug is the most clinically effective? • Head to head studies show equivalent efficacy and better tolerability for SSRIs compared with clomipramine. [ 50 ] [ 53 ] Not only is the risk of dangerous side effects such as convulsions, cardiotoxicity, and cognitive impairment substantially lower with SSRIs, but clomipramine is also associated with greater impairment of sexual performance (up to 80% of patients) compared with SSRIs (up to 30% of patients) and troublesome anticholinergic effects. [ 54 ] • On the other hand, SSRIs are associated with initially increased nausea, nervousness, and insomnia.[ 55 ]
  103. 103. • Slow, gradual improvement characterises the response to medication • The treatment effect of SSRIs or clomipramine emerges within days after treatment is started, and increases slowly and almost imperceptibly for weeks and months. Gains continue to accrue for at least six months and probably longer. Sometimes progress seems remarkably slow, and people with obsessive-compulsive disorder may find it difficult to acknowledge changes are occurring. • Meanwhile, side effects such as nausea and agitation tend to emerge early, before signs of improvement are consolidated, but usually abate over time. [ 45 ] For these people it is important to allow enough time for the treatment effect to develop and not to discontinue or change the drug prematurely. A trial of at least 12 weeks at the maximum tolerated dose and careful assessment is advisable before judging its effectiveness.
  104. 104. • Long term drug treatment • Obsessive-compulsive disorder is a chronic illness and so treatment needs to be tested to see whether it remains effective in the longer term. A small number of double blind studies lasting up to 12 months have shown that those who responded to acute treatment benefited from continuing with medication with no evidence of tolerance developing. [ 45 ] [ 56 ] [ 57 ] • In contrast, studies looking at the effects of discontinuing clomipramine or SSRIs under double blind, placebo controlled conditions showed a relatively rapid and incremental worsening of symptoms in people who switched to placebo. • This emphasises the importance of maintaining treatment with medication long term, that is for at least 12 months (see the NICE website at: http://www.nice.org.uk), and argues against discontinuation of treatment even after one year. You should discuss the option of long term medication with the patient. If medication is to be stopped, this may best be done gradually over weeks and months to mitigate possible withdrawal effects.
  105. 105. • Comparison of pharmacological and psychological treatments • From available evidence, psychological and pharmacological treatments appear equally effective and it is not clear whether the two forms of treatment combined is superior to psychological or pharmacological monotherapy. • The lack of availability of psychological therapies, relative to pharmacotherapy, means that drug treatment is started first for most people. • Treatment resistant obsessive-compulsive disorder • Residual symptoms remain despite prolonged treatment in about 30% of patients. If the patient has been receiving monotherapy with either treatment as a first line strategy it may be appropriate to combine the two forms. • The evidence base for the management of treatment resistant obsessive- compulsive disorder is slim, but a few treatment strategies are available (Table 5).
  106. 106. Table 5. Evidence based strategies for resistant obsessive- compulsive disorder •Increase the dose •Switch to another SSRI •Change administration to intravenous (citalopram, clomipramine) •Change to a selective noradrenaline reuptake inhibitor •Add clomipramine and an SSRI •Add an antipsychotic
  107. 107. • Some of these can be managed by the GP. Alternatively, it would be reasonable to refer patients with refractory illness to the local psychiatry service. • Before changing from first line treatments it is important to check concordance and review the diagnosis. In particular you should look for evidence of Tourette's syndrome, which can easily masquerade as obsessive-compulsive disorder and which responds preferentially to the addition of antipsychotic agents. • Increase the dose • Uncontrolled case studies suggest that for some patients increasing doses of SSRIs above formulary limits may produce a better effect. [ 58 ] Doses of clomipramine up to 300 mg have been systematically investigated in the US in large scale trials and found to be safe. However, doses exceeding 250 mg should be prescribed with caution because of the risk of seizures and cardiotoxicity.
  108. 108. • Switch to another SSRI • Some people may be helped by switching drug. [ 59 ] [ 60 ] • Change administration to intravenous (citalopram, clomipramine) • Although a single double blind study investigating refractory obsessive- compulsive disorder has shown intravenous clomipramine to be more effective than placebo, changing the mode of drug delivery from oral to intravenous is impractical in many patients. [ 61 ] • Change to a selective noradrenaline reuptake inhibitor • Venlafaxine acts rather like SSRIs at higher dose levels. The evidence supporting switching from SSRIs to venlafaxine is not strong. [ 62 ] • Add clomipramine and an SSRI • The combination of an SSRI with clomipramine has been suggested, although controlled studies are lacking. Such a procedure may best be managed by a clinician experienced in treating resistant obsessive- compulsive disorder. It is advisable to monitor the patient's ECG and clomipramine plasma level.
  109. 109. • Combining SSRIs and antipsychotic properties • Obsessive-compulsive disorder does not respond to antipsychotics given as monotherapy. • Although evidence for adding antipsychotics is inconsistent, placebo controlled studies suggest that atypical antipsychotics added in may have a role in treatment resistant obsessive-compulsive disorder, particularly risperidone, quetiapine, olanzapine, and haloperidol. [ 63 ] • Doses used in these studies were at the lower range to minimise side effects. Recent studies have been of short duration and small sample size, and were therefore prone to type II errors. [ 64 ] [ 65 ]There is insufficient evidence to prefer one antipsychotic over another. • Other strategies for refractory obsessive-compulsive disorder • The efficacy of several other treatments is not yet proved. • Immune system modulating drugs, such as intravenous immunoglobulin and plasmapheresis, may have a role in obsessive-compulsive disorder, for example following streptococcal infections in children. [ 66 ] • Electroconvulsive therapy may help treat comorbid depression but is not thought to be effective for treating obsessive-compulsive disorder alone.
  110. 110. • Invasive treatments such as capsulotomy and cingulotomy produce an effect in difficult to treat obsessive-compulsive disorder, but the evidence is limited. Stereotactic neurosurgery is recommended only as a last option. • Deep brain stimulation involves less intracerebral neuronal damage and holds promise for future investigation in highly specialised centres. • NICE guidelines for obsessive-compulsive disorder • The NICE guidelines for obsessive-compulsive disorder are summarised in Figure 1. [ 1 ]
  111. 111. • Mild functional impairment or patient preference for low intensity approach • Offer cognitive behavioural therapy (including exposure and response prevention)
  112. 112. • If the patient cannot engage in cognitive behavioural therapy (including exposure and response prevention) or if cognitive behavioural therapy (including exposure and response prevention) is inadequate, or if the person has mild functional impairment, offer a choice of either Treatment with an SSRI alone (12 weeks) or cognitive behavioural therapy (including exposure and response prevention) alone (>10 therapist hours)
  113. 113. • Inadequate response or severe functional impairment • Offer SSRI and cognitive behavioural therapy (including exposure and response prevention) combined
  114. 114. • Inadequate response after 12 weeks or no response to SSRI alone, or patient has not engaged in CBT (including exposure and response prevention) • Offer either a different SSRI or clomipramine
  115. 115. • No response to a full trial of at least one SSRI alone, a full trial of combined SSRI + cognitive behavioural therapy (including exposure and response prevention), or a full trial of clomipramine alone
  116. 116. • Refer to multidisciplinary mental health team with specialist expertise in obsessive-compulsive disorder • Still no response
  117. 117. • Consider: • Additional cognitive behavioural therapy (including exposure and response prevention) or cognitive therapy • Adding an antipsychotic to an SSRI or clomipramine • The combination of clomipramine and citalopram.
  118. 118. • What is the lifetime prevalence of obsessive-compulsive disorder? • 2% • 5% • 10% • 15%
  119. 119. • Which one of the following statements about obsessions in obsessive-compulsive disorder is correct? • They are enjoyable • They are recognised to be generated by someone else • They are out of character, unwanted, and distressing • They are never sexual in nature
  120. 120. • What is the mean age of onset of obsessive-compulsive disorder? • 10 years • 20 years • 30 years • 40 years
  121. 121. • In response prevention, when is exposure most effective? • When it is of short duration • When undertaken in reality rather than in fantasy • When undertaken only in therapy sessions
  122. 122. • Which one of the following statements about behavioural therapy is correct? • Compulsions appear to respond better than obsessions • Patients with psychiatric morbidity respond better than those without • It is less effective than psychodynamic psychotherapy in obsessive-compulsive disorder • Comorbid depression has no effect on outcome
  123. 123. • Which one of the following statements about the use of SSRIs in obsessive-compulsive disorder is correct? • They are more likely to cause seizures than clomipramine • A trial of at least 12 weeks is advisable before judging response • Signs of improvement appear before side effects appear • They are associated with a greater prevalence of sexual side effects than clomipramine
  124. 124. • Which one of the following is an evidence based strategy for people with obsessive- compulsive disorder that is resistant to treatment? • Changing from SSRIs to venlafaxine • Adding inositol as augmentation • Combining SSRIs and an antipsychotic • Electroconvulsive therapy
  125. 125. • Which one of the following statements about antipsychotics in treatment resistant obsessive-compulsive disorder is correct? • They are effective as monotherapy • Evidence for their use as add on treatment is very strong • Clozapine has been shown to be effective as add on treatment • Haloperidol has been shown to be effective as add on treatment
  126. 126. • Which one of the following forms of psychotherapy is recommended for treating obsessive-compulsive disorder? • Psychoanalysis • Transactional analysis • Marital or couple therapy • Graded exposure and response prevention
  127. 127. • The lifetime prevalence of OCD is around (August 2008) • A. 10 - 20% • B. 0.5 – 1% • C. 2 – 3% • D. 8 – 10% • E. 1 to 2 in 1000
  128. 128. • Which of the following neuroimaging findings is most consistent with OCD? (August 2008) • A. Decreased metabolism at orbitocingulate region • B. Increased metabolism of orbitocingulate region • C. Decreased metabolism at dorsal prefrontal cortex • D. Increased metabolism at amygdala • E. Decreased metabolism at amygdala
  129. 129. • Which of the following statements is true regarding anorexia nervosa? • choice. • A. • Amenorrhoea precedes weight loss in 50% of patients • B. • Lack of sexual interest is usual • C. • High levels of T3 and T4 with low levels of thyroid-stimulating hormone (TSH) are a usual biochemical finding • D. • Decreased growth hormone concentration occurs • E. • 25% of patients eventually develop schizophrenia • The answer is: B • Amenorrhoea precedes weight loss in 20% of patients; low levels of T3 and low normal T4 with normal TSH is a usual biochemical finding; raised growth hormone concentration is seen. Anorexia does not evolve into shizophrenia.#
  130. 130. • Which of the following statements is true regarding restoration of weight in anorexia nervosa? • choice. • A. • It is usually done as an outpatient • B. • The aim is to increase body weight by 0.5 kg a week • C. • It requires an extra 500–1000 calories per day • D. • The usual target weight is between a healthy weight and a weight the patient thinks is ideal • E. • All of the above
  131. 131. • OCD (neuroimaging) • • • Studies utilizing 18Fluorodeoxyglucose PET (FDG-PET) report increased glucose metabolism in the orbitofrontal cortex (OFC), caudate, thalamus, prefrontal cortex, and anterior cingulate among patients with OCD as compared with nonpatients. • Studies utilizing Technetium-99m (99mTc )- hexamethylpropyleneamine- • oxime SPECT (HMPAO-SPECT) have found both increased and decreased blood flow to various brain regions including the OFC, caudate, various areas of the cortex, and thalamus in OCD patients as compared with normal controls.Odd speech without being incoherent
  132. 132. • All of the following are licenced for obsessive compulsive disorder except. A. Paroxetine • B. Sertraline • C. Escitalopram • D. Citalopram • E. Fluoxetine
  133. 133. • What would you do for a patient with OCD and no improvement after two months on 50mg of • sertraline? (March 2008) • A. Increase the sertraline • B. Change to a different SSRI • C. Add an antipsychotic • D. Switch to venlafaxine • E. Add sodium valproate
  134. 134. • A. The dose required to treat OCD is higher than dose required for depression and initial response • can take 10-12 weeks. (Maudsley.2007). If there is no response to initial starting doses of SSRIs, dose • should be gradually increased. (NICE.2005) Venlafaxine and valproate are not indicated at this stage • for OCD. Antipsychotics may be used as second line augmenting agents. • Maudsley prescribing guidelines, 9th edition, page 252 • NICE Guidelines. Obsessive-compulsive disorder: Core interventions in the treatment of • obsessive-compulsive disorder and body dysmorphic disorder.2005
  135. 135. • A community health worker regularly sees a patient with OCD. She wants to use a scale to • screen for depression before asking the patient to attend your clinic for an evaluation. Which scale would you choose? (Jan 2009) • a. Edinburgh depression scale • b. Beck’s depression inventory • c. Montgomery Asberg Rating Scale • d. Calgary depression scale • e. Schedule for clinical assessment in Neuropsychiatry
  136. 136. • Ans:B. A community health worker can screen for depression in a high risk group by using self • rated Beck’s depression inventory. Other scales mentioned here may not be useful for the given • clinical scenario. A trained clinician could use Hamilton Depression Rating Scale in OCD patients • to assess severity and presence of depression
  137. 137. • In OCD which of the following symptoms may be specifically resistant to treatment? • A. Washing • B. Checking • C. Hoarding • D. Sexual obsessions • E. Religious obsessions
  138. 138. • Which of the following is associated with PANDAS? • A. Panic disorder • B. Agoraphobia • C. Psychosis • D. OCD • E. Hypochondriasis
  139. 139. • The first line treatment in an adult with severe OCD is • A. SSRIs only • B. Clomipramine • C. CBT only • D. A choice of either SSRI or CBT • E. Antipsychotic augmentation
  140. 140. • Which of the following outcomes is often used as treatment response in OCD trials? • A. 35% reduction in YBOCS • B. YBOCS scores fall below detectable levels • C. 50% reduction in YBOCS • D. 75% reduction in YBOCS • E. 20% reduction in YBOCS
  141. 141. • In PANDAS which of the following tests is most likely to be positive? • A. Anti DNAse B • B. Anti nuclear antibodies • C. pANCA • D. cANCA • E. Anti Basal Ganglia antibodies
  142. 142. PANDAS • Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection—PANDAS is thought • to be secondary to streptococcal infection and mediated by autoantibodies binding to basal ganglia. This produces • tics, fluctuating obsessive compulsive symptoms and anxiety.
  143. 143. • National Institute of Mental Health Clinical Diagnostic Criteria for PANDAS • 1. Presence of OCD or a tic disorder. • 2. Onset between 3 years of age and the beginning of puberty. • 3. Abrupt onset of symptoms or a course characterized by dramatic exacerbations of symptoms. • 4. The onset or the exacerbations of symptoms is temporally related to infection with GABHS. • 5. Abnormal results of neurologic examination (hyperactivity, choreiform movements, and/or tics) during an • exacerbation.
  144. 144. • Note that the neuropsychiatric symptoms need not have onset during streptococcal (group A beta hemolytic) • infection; exacerbation correlated temporally is also acceptable for a diagnosis. • AntiDNAseB or Antistreptolysin O titres are likely to be elevated in most with recent streptococcal infection. A • fraction of these may have auto antibodies to neurons in basal ganglia called anti basal ganglia antibodies. These • are not established as diagnostic of PANDAS though initial studies are encouraging.
  145. 145. OCD spectrum • OCD spectrum disorders can be classified as • 1. Those associated with somatic preoccupation e.g.body dysmorphic disorder or anorexia nervosa. • 2. Those associated with neurological disorders (repetitive behaviours) e.g. Tourette syndrome, Sydenham's • chorea and autism. • 3. Those associated with impulse control disorders or with rousing or pleasurable repetitive behaviours e.g. • paraphilias, kleptomania, trichotillomania, and pathological gambling. (Castle & Phillips, 2006)
  146. 146. • Various OCD spectrum disorders are • 1. Anankastic personality • 2. Anorexia nervosa • 3. Asperger’s • 4. Body dysmorphic disorder • 5. Hypochondriasis • 6. Kleptomania • 7. Sydenham’s chorea • 8. Tourette’s syndrome. • 9. Trichotillomania
  147. 147. Obsessive compulsive disorder in young people (NICE Guidelines) • NICE suggest the following on the management of OCD in young people • Mild - Guided self help, if no improvement try CBT with ERP • Moderate / severe - CBT with ERP (first), then SSRI's • NICE recommend using sertraline and fluvoxamine for OCD in young people. If the child also has depression then fluoxetine is suggested. Clomipramine is suggested as second line. Treatment should be continued for at least 6 months from the beginning of remission.
  148. 148. Post Traumatic Stress Disorder • Factors associated with post-traumatic stress disorder (from Bisson, 2007): • Pretraumatic factors • • Previous psychiatric disorder • • Sex (more prevalent in female patients than in male patients) • • Personality (external locus of control greater than internal locus of control) • • Lower socioeconomic status • • Lack of education • • Race (minority status) • • Previous trauma including childhood unresolved trauma • • Family history of psychiatric disorders • • Insecure childhood attachment • • Personality disorders including ASPD, Borderline.
  149. 149. • Peritraumatic factors • • Severity of trauma • • Perceived threat to life • • Peritraumatic emotions • • Peritraumatic dissociation • • Chronic pain • Post-traumatic factors • • Perceived lack of social support • • Subsequent life stress • Protective factors: • ı High IQ • ı High social class • ı Viewing the dead body of friend/relative after trauma • ı Male • ı Psychopath
  150. 150. • The incidence varies across the world. Resilience to trauma is a dynamic factor and so individuals who may not • develop PTSD after one trauma may develop after another. • Females suffer from more PTSD than males. It is unclear if this is due to higher exposure to trauma or greater • vulnerability to develop PTSD. Molestation is more common in females than males. Mugging is more common in • males than females. But in both instances women develop more PTSD. The only trauma where men develop more • PTSD may be rape. • Hippocampus and amygdala show neuroimaging abnormalities. Hypocortisolaemia is reported in PTSD. Strong • avoidance features may predict chronicity in PTSD.
  151. 151. NICE guidelines for PTSD - summary • Encourages primary care diagnosis and screening – it is probably • underdiagnosed. • Up to 30% of people exposed to trauma may develop PTSD. • PTSD can also develop in children. • Watchful waiting if symptoms are mild and present for less than 4 weeks after • trauma. • Trauma-focussed CBT - individual basis as outpatients to be offered to all with • severe symptoms present for less than 3 months • If present for more than 3 months (chronic) offer trauma focussed CBT or • EMDR. • If no improvement consider pharmacological treatment. • Paroxetine, mirtazapine for general use; amitriptyline or phenelzine for • specialist use.
  152. 152. • Few questions appeared in March 2008 paper 3 from Bisson, 2007 review in APT. Please see the summary of this • paper in the following table:
  153. 153. • Drug Evidence • Paroxetine Good RCT evidence. NICE second line. • Licenced for PTSD in UK • Sertraline RCT evidence; but NICE appraisal did not show • significance. Licensed for females not males with • PTSD in UK!! • Fluoxetine 1 RCT but not significant • Imipramine & • Amitriptyline • Poor quality of evidence; but statistically • significant result for Amitriptyline; not so for • imipramine. • Phenelzine Poor quality of evidence; but statistically • significant result • Mirtazapine One small strongly positive RCT. NICE second • line. • Venlafaxine One large RCT no benefit • Olanzapine Monotherapy RCT negative; augmentation of • SSRIs positive • Risperidone Tested only as adjunct – no effect
  154. 154. Prevention of PTSD • What are the effects of interventions to prevent post- traumatic stress disorder (Bisson, Clinical evidence • 2004)? • Likely to be beneficial Multiple-session CBT to prevent PTSD in people with acute stress • disorder (reduced PTSD compared with supportive counselling) • Unknown effectiveness Multiple-session CBT to prevent PTSD in all people exposed to a • traumatic event • Propranolol to prevent PTSD • Single-session group debriefing to prevent PTSD • Temazepam to prevent PTSD • Unlikely to be beneficial Single-session individual debriefing to prevent PTSD • Supportive counselling to prevent PTSD
  155. 155. Psychological treatments • Categories: • ı Individual trauma focussed: • Trauma-focused cognitive–behavioural therapy (TFCBT). • Eye movement desensitisation and reprocessing (EMDR). • ı Individual non trauma focussed: • Stress management and relaxation. • Other therapies (including supportive therapy/non- directive non-directive counselling, • psychodynamic therapies and hypnotherapy). • ı Treatments delivered in groups: • Group cognitive–behavioural therapy.
  156. 156. Trauma focused CBT • May include exposure therapy wherein repeated confrontation of traumatic memories and • repeated exposure to avoided situations take place together with relaxation and anxiety reduction. In trauma • focused cognitive component modification of misinterpretations that lead to overestimation of current threat and • modification of other beliefs related to the traumatic experience and the individual's behaviour during the trauma • (for example, guilt and shame) are attempted via cognitive restructuring process. Trauma focused psychological • treatment should usually be given for eight to 12 sessions
  157. 157. Eye movement desensitisation and reprocessing • This was serendipitously discovered by a psychologist called • Shapiro when she first applied it to herself. It is based on the theory that bilateral stimulation, in the form of eye • movements, allows the processing of traumatic memories. While the patient focuses on specific images, negative • sensations and associated cognitions, bilateral stimulation is applied to desensitise the individual to these • memories and more positive sensations and cognitions are introduced.
  158. 158. Post traumatic stress disorder • Post traumatic stress disorder (PTSD) is an emotional reaction to a traumatic event. The ICD-10 diagnostic criteria are as follows:- • Exposure to a traumatic event which would be likely to cause pervasive distress in almost anyone. • The event must be persistently remembered or relived, as evidenced by flashbacks, vivid memories, or nightmares. • The patient must actively avoid situations which remind them of the event. • In addition it stipulates that either of the following must be present Partial amnesia for part of the event • Persistent symptoms of psychological arousal such as, poor sleep, poor concentration, hypervigilance, exaggerated startle response, irritability.
  159. 159. • The above symptoms must occur within 6 months of the event. NICE guidelines make the following recommendations about the treatment of PTSD • Debriefing should not be offered • Where symptoms are mild and have been present for less than 4 weeks watchful waiting should be considered (follow up given within 1 month) • All people with PTSD should be offered a course trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR). • Drug treatments for PTSD should not be used as a routine first-line treatment for adults in preference to a trauma-focused psychological therapy. • Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or phenelzine for initiation only by mental health specialists) should be considered for the treatment of PTSD in adults who express a preference not to engage in trauma-focused psychological treatment.
  160. 160. • With regard to PTSD which of the following is true? • A. it is overdiagnosed • B. resilience is not a dynamic quality • C. prevalence of PTSD is the same all over the world • D. prior trauma does not increase susceptibility to PTSD • E. Chronic pain is associated with PTSD.
  161. 161. • In PTSD which of the following statement is true? • A. refugees are at no more risk than the indigenous population • B. avoidance is associated with chronicity • C. misdiagnosis as refractory depression does not occur • D. cortisol levels are high • E. Securely attached individuals exhibit more symptoms.
  162. 162. • In the aetiology of PTSD choose one correct option: • A. the hippocampus has no role • B. locus of control has no role • C. the sympathetic nervous system is not involved • D. lower level of education is protective • E. Unresolved childhood trauma increases the risk.
  163. 163. • Vulnerability factors for PTSD include: • A. male gender • B. middle age • C. internal locus of control • D. Personality disorders. • E. good impulse control
  164. 164. • In PTSD there is confirmed effectiveness for all of the following treatments except: • A. EMDR • B. Hypnotherapy • C. Antidepressant • D. Stress management • E. Trauma focused therapy
  165. 165. • With respect to the recommended treatments for PTSD which of the following are endorsed by NICE guidelines for use in primary care settings? • A. Sertraline and fluoxetine • B. Sertraline and paroxetine • C. Mirtazapine and paroxetine • D. Amitriptyline and phenelzine • E. Mirtazapine and fluoxetine

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