OBSESSIVE –COMPULSIVE AND
RELATED DISORDERS
by Dr. Noor Abdulamir
• Obsessive-compulsive disorder (OCD) is represented
by a diverse group of symptoms that include intrusive
thoughts, rituals, preoccupations, and compulsions.
• These recurrent obsessions or compulsions cause
severe distress to the person.
• The obsessions or compulsions are time-consuming
and interfere significantly with the person's normal
routine, occupational functioning, usual social
activities, or relationships.
• A patient with OCD may have an obsession, a
compulsion, or both.
• An obsession is a recurrent and intrusive thought, feeling,
idea, or sensation. In contrast to an obsession, which is a
mental event, a compulsion is a behavior.
• Specifically, a compulsion is a conscious, standardized,
recurrent behavior, such as counting, checking, or avoiding.
• A patient with OCD realizes the irrationality of the obsession
and experiences both the obsession and the compulsion as
ego-dystonic (i.e., unwanted behavior).
• Although the compulsive act may be carried out in an
attempt to reduce the anxiety associated with the obsession,
it does not always succeed in doing so.
• The completion of the compulsive act may not affect the
anxiety, and it may even increase the anxiety. Anxiety is also
increased when a person resists carrying out a compulsion.
Epidemiology
● OCD is the fourth most common psychiatric
disorder.
● Lifetime prevalence is 2-3% among adults.
● Male and Female are equally affected.
● In adolescents boys are more commonly
affected than girls.
● Mean age of onset is 20 years.
Etiology
Causes can be divided into three groups: biological,
behavioral and psycho-social :
A- Biological factors:
1. Neurotransmitters: serotonin. The many clinical drug
trials that have been conducted support the hypothesis
that dysregulation of serotonin is involved in the symptom
formation of obsessions and compulsions in the disorder.
2. Brain imaging studies: increased activity in frontal
lobes, basal ganglia( especially the caudate), and the
cingulum.
3. Genetics:
higher concordance rate for monozygotic twins than for
dizygotic twins.
Family studies :35%of first degree relatives of OCD
patients are also affected.
B- Behavioral factors:
1.Conditioned stimuli
2.Avoidance strategies
C- Psychosocial factors:
1. Personality factors:
15-35% of OCD patients have premorbid obsessional traits.
Most patients with OCD do not have premorbid compulsions.
2. Psychodynamic factors:
Obsessive compulsive neurosis: regression from the oedipal
phase of psychosexual development.
DSM5 criteria for Diagnosis
• Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
1. recurrent and persistent thoughts, impulses, or images that are
experienced, at some time during the disturbance, as intrusive
and inappropriate and that cause marked anxiety or distress
2. the thoughts, impulses, or images are not simply excessive
worries about real-life problems
3. the person attempts to ignore or suppress such thoughts,
impulses, or images, or to neutralize them with some other
thought or action
4. the person recognizes that the obsessional thoughts, impulses,
or images are a product of his or her own mind (not imposed
from without as in thought insertion)
• Compulsions as defined by (1) and (2):
1. repetitive behaviors (e.g., hand washing, ordering,
checking) or mental acts (e.g., praying, counting, repeating
words silently) that the person 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 distress or preventing some dreaded event or
situation; however, these behaviors or mental acts either
are not connected in a realistic way with what they are
designed to neutralize or prevent or are clearly excessive
• At some point during the course of the disorder, the person has
recognized that the obsessions or compulsions are excessive or
unreasonable.
• The obsessions or compulsions cause marked distress, are time-
consuming (take more than 1 hour a day), or significantly interfere with
the person's normal routine, occupational (or academic) functioning, or
usual social activities or relationships.
• If another Axis I disorder is present, the content of the obsessions or
compulsions is not restricted to it (e.g., preoccupation with food in the
presence of an eating disorder; hair pulling in the presence of
trichotillomania; concern with appearance in the presence of body
dysmorphic disorder; preoccupation with drugs in the presence of a
substance use disorder; preoccupation with having a serious illness in
the presence of hypochondriasis; preoccupation with sexual urges or
fantasies in the presence of a paraphilia; or guilty ruminations in the
presence of major depressive disorder).
• The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition
Course and prognosis of OCD
● Sudden onset ( in one half of patients).
● Precipitating factors are present in(50-70%) of cases.
● There is often a delay of 5-10 years before patient comes to
psychiatric attention.
● Presentation is heterogeneous; but there are certain patterns
which are the major patterns:
1- contamination.
2- pathological doubt.
3- intrusive thoughts (mostly aggressive or sexual )-no
compulsions
4- symmetry or precision : leads to compulsion of slowness.
5-other symptoms :religious obsessions, compulsive
hoarding , …etc
Course is long (fluctuating or constant).
• 20 - 30% -significant improvement.
• 40 - 50% -moderate improvement.
• 20 - 40% -worsening course.
• 1/3 have a major depressive disorder.
• Suicide is a risk for all patients with OCD.
DDx
1. Medical conditions:
● Tourette disorder and other tic disorders.
● Temporal lobe epilepsy( complex partial epilepsy).
● Head trauma.
● Post-encephalitic complications.
2. Psychiatric disorders:
● Schizophrenia.
● Obsessive-Compulsive personality disorder.
● Phobias.
● Depressive disorders.
Treatment
• Pharmacotherapy, behavioral therapy ,or combination of both is effective in
significantly reducing the symptoms of OCD.
1. Pharmacotherapy:
First-line:Serotonin-specific reuptake inhibitors (SSRIs):,effective with low
side effect profile
Example : fluoxetine ,sertraline, paroxetine, fluvoxamine, citalopram .
-Side effects: headache ,GI upset, insomnia, sexual dysfunction.
Tricyclic antidepressant (derivative of imipramine)
Used when:
1. There is an adequate trial of at least one SSRI found to be ineffective
2. SSRI is poorly tolerated
3. The patient prefers clomipramine
4. There has been a previous good response to clomipramine
- ECG and blood pressure measurement necessary before prescribing
because they have arrythmogenic effect
Example ; Clomipramine
- Other drugs: SNRIs , MAOIs, augmentation drugs( like antipsychotic) .
2. Psychotherapy
o Behavioral therapy (exposure response-prevention
therapy): treatment of choice for limiting dysfunction
resulting from obsessions and compulsions
o Cognitive therapy: anxiety management, keeping a
diary, cognitive restructuring, coping strategies
3. Other therapies :
● electroconvulsive therapy (ECT), Deep brain
stimulation (DBS) ,Psychosurgery .
● These treatments are used in resistant cases.
Obsessive–Compulsive or Related Disorder Due to
Another Medical Condition
Many medical conditions can result in obsessive–
compulsive symptoms (i.e., hair pulling, skin picking).
OCD-like symptoms have been reported in children
following group A β-hemolytic streptococcal
infection and have been called pediatric
autoimmune neuropsychiatric disorders
associated with streptococcus (PANDAS). They
are believed to result from an autoimmune process
that leads to inflammation of the basal ganglia that
disrupts cortical–striatal–thalamic axis functioning
Substance-Induced Obsessive–Compulsive or Related
Disorder
Substance-induced obsessive–compulsive or
related disorder is characterized by the emergence
of obsessive–compulsive or related symptoms as
a result of a substance, including drugs,
medications, and
alcohol.
Other Specified Obsessive–
Compulsive or Related Disorder
A. Olfactory reference syndrome
People with olfactory reference syndrome have a false belief
that they have a foul body odor that is not perceived by
others. The preoccupation leads to repetitive behaviors such
as washing the body or changing clothes. Patients with the
disorder may have good, fair, poor, or absent insight into the
behavior. The syndrome is predominant in males and
single persons. The mean age of onset is 25 years of age.
The belief of a subjective sense of smell that does not exist
externally may rise to the level of a somatic delusion, in which
a diagnosis of a delusional disorder may be more appropriate.
In assessing a patient with olfactory reference syndrome, it is
essential to exclude other medical causes.
Body dysmorphic disorder (BDD)
is a distinct mental disorder in which a person is preoccupied with an imagined
physical defect or a minor defect that others often cannot see. As a result,
people with this disorder see themselves as "ugly" and often avoid social
exposure or turn to plastic surgery to try to improve their appearance.
BDD shares some features with eating disorders and obsessive-compulsive
disorder. BDD is similar to eating disorders in that both involve a concern
with body image. However, a person with an eating disorder worries about
weight and the shape of the entire body, while a person with BDD is concerned
about a specific body part.
People with obsessive compulsive disorder (OCD) have recurring and distressing
thoughts, fears, or images (obsessions) that they cannot control. The anxiety
(nervousness) produced by these thoughts leads to an urgent need to perform
certain rituals or routines (compulsions). With BDD, a person's preoccupation with
the defect often leads to ritualistic behaviors, such as constantly looking in a
mirror or picking at the skin..
The person with BDD eventually becomes so obsessed with the
defect that their social, work, and home functioning suffers.
BDD is a chronic (long-term) disorder that affects men and
women equally.
The most common areas of concern for people with BDD
include:
Skin imperfections: These include wrinkles, scars, acne, and
blemishes.
Hair: This might include head or body hair or absence of hair.
Facial features: Very often this involves the nose, but it also
might involve the shape and size of any feature.
Body weight: Sufferers may obsess about their weight or muscle
tone
Some of the warning signs that a
person may have BDD include
-Engaging in repetitive and time-consuming behaviors, such as looking
in a mirror, picking at the skin, and trying to hide or cover up the
perceived defect
-Constantly asking for reassurance that the defect is not visible or too
obvious
-Repeatedly measuring or touching the perceived defect
-Experiencing problems at work or school, or in relationships due to the
inability to stop focusing about the perceived defect
-Feeling self-conscious and not wanting to go out in public, or feeling
anxious when around other people
-Repeatedly consulting with medical specialists, such as plastic
surgeons or dermatologists, to find ways to improve their appearance
Hoarding Disorder
Compulsive hoarding is characterized by acquiring
and not discarding
things that are deemed to be of little or no value
resulting in excessive
clutter of living spaces. Hoarding may result in health
with impairment in
such functions as eating, sleeping, and grooming.
The disorder was
originally considered a subtype of OCD, but is now
considered to be a separate diagnostic entity.
Hair-Pulling Disorder (Trichotillomania)
Hair-pulling disorder is a chronic disorder characterized by
repetitive hair pulling that leads to variable hair loss that
may be visible to others. It is also known as
trichotillomania.
-The disorder is similar to OCD and impulse control
disorders
-Female to male ratio as high as 10 to 1.
-An estimated 35% to 40% of patients with hair-pulling
disorder chew or swallow the hair that they pull out at one
time or another.
-All areas of the body may be affected, most commonly the
scalp.
Excoriation (Skin-Picking) Disorder
Excoriation or skin-picking disorder is characterized
by the compulsive and repetitive picking of the skin.
It can lead to severe tissue damage and result in the
need for various dermatologic treatments.
It is more prevalent in women than in men.
Thank you
