Jen's mother called you in the clinic telling you that her 18 years old son is mentally ill.

she ask for your opinion regarding his odd behavior and thoughts , she add that jens stop going to school because of his illness.

Obsessive-Compulsive Disorder

By:dr. A.fattah Alsaud

Obsessive-Compulsive DisorderObsessive-Compulsive Disorder

• obsessive-compulsive disorder is described as recurring obsessions or compulsions severe enough to be time consuming or cause marked distress or significant impairment

• An obsession is a recurrent and intrusive thought, feeling, idea, or sensation

• A compulsion is a conscious, standardized, recurring pattern of behavior, such as counting, checking, or avoiding.

Criteria:

•Subjective (from inside)

•Silly (pt. recog. That It is untrue)

•Unpleasant,

•Desire to resist

• Some thing in the mind which is repetitive & keeps coming, usu. Unpleasant & distressing,Pt. try hard to resist them but they keeps coming.

Some thing in the mind can be:

•Idea (thoughts)

•Image (e.g. someone naked, not halluc. )

•Impulse (urge) to do some thing.

EPIDEMIOLOGYEPIDEMIOLOGY

• The lifetime prevalence estimated at 2 to 3 %.

• 10 % of outpatients in psychiatric clinics.

• Among adults, men and women are equally likely to be affected, but among adolescents, boys are more commonly affected than are girls.

• Age of onset : 2/3 below age of 25 yrs.

common co morbid psychiatric diagnoses: common co morbid psychiatric diagnoses:

• major depressive disorder about 67 %,

• social phobia about 25 %,

• alcohol use disorders,

• specific phobia,

• panic disorder,

• eating disorders

ETIOLOGYETIOLOGY

• Biological Factors– Neurotransmitters

• serotenergic drugs ( decrease serotonin )

• Neuroimmunology (PANDAS)

– Brain-Imaging Studies (PET SCAN, MRI study)

– Genetics (twin study, runs in family)

• Behavioral Factors– learning theory

• Personality Factors (personality Dx.)

• Psychodynamic Factors

Obsess ional personality feature :

•Exx. Doubt & cautions

•Perfectionism

•Over consciousness

•Inflexibility & stubbornness

Diagnostic Criteria for Obsessive-Compulsive DisorderDiagnostic Criteria for Obsessive-Compulsive Disorder

A. 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 (eg, handwashing, ordering, checking) or mental

acts (eg, 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.

• B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: this does not apply to children.

• C. The obsessions or compulsions cause marked distress; are time-consuming (take more than an hour a day); or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.

• D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (eg, 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).

• E. The disturbance is not due to the direct effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.

CLINICAL FEATURESCLINICAL FEATURES

• many people manage to keep their symptoms secret

• Patients with obsessive-compulsive disorder often go to physicians other than psychiatrists (e.g. pt. visit derma clinic for complication of exx cleaning).

• Precipitance: about 50 to 70 percent of patients occurs after a stressful event ( puperty, menstruation, marriage, examination, death of close relative)

• Course: (episodic or chronic)

• Usu. Compulsions is 2ry to obsessions.

• The most common pattern is an obsession of contamination, followed by washing or accompanied by compulsive avoidance of the presumably contaminated object.

• The second most common pattern is an obsession of doubt, followed by a compulsion of checking.

• the third is intrusive obsessional thoughts without a compulsion.

• The fourth is the need for symmetry or precision, which can lead to a compulsion of slowness.

ObsessionsObsessions

(N = 200)

• Contamination 45%

• Pathological doubt 42%

• Need for symmetry 31%

• Aggressive 28%

• Sexual 26%

• Other 13%

• Multiple obsessions 60%

CompulsionsCompulsions

(N = 200)

• Checking 63%

• Washing 50%

• Counting 36%

• Need to ask or confess 31%

• Symmetry and precision 28%

• Hoarding 18%

• Multiple comparisons 48%

prognosisprognosis

• About 20 to 30 percent of patients have significant improvement in their symptoms,

• 40 to 50 percent have moderate improvement,

• The remaining 20 to 40 percent of patients either remain ill or have a worsening of their symptoms.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

• Nl. Preoccupation : e.g. one preoccupied about exams.

• Depression • SCZ (e.g.: delusion, well be accepted by the

pt. with out resistence).• Tic Dx. : (involuntary movement )here there is

no resistance to it,• Obsessional personality: here the one is not

distressed by his acts & will not try to resist them.

Treatment Treatment

• Psychotherapy : – Supportive : let the pt. talk about his problem, reassure,

explain & advice .– CBT– Behavioral therapy: exposure & response prevention.

• Pharmacotherapy:– Minor tranquilizer (anxioletics)– Antidepressants :

• TCA ( clomepramine)• SSRI ( paroxetin)

• ECT ( for depression )• Psychosurgery: cingulotomy ( disconnect fronto-

thalamic connection to decrease distress & anxiety with obsessions )

Thank You

Case: Case:

• Jens is German and 18 years old. He stopped going to high school because of his illness.

ProblemProblem

• When he was almost 15 years old, Jen's parents noticed that after his newspaper and magazine delivery rounds, Jens would wash his hands more and more often and for a longer and longer time. Eventually he ended up spending more than an hour under the shower. When asked about it, Jens told his parents that he felt as if he were being contaminated by a popular women's magazine.

• He also feared that through contact with boys from less academic schools, he might become like them—"common, slimy, impulsive, aggressive, and stupid." Because he was afraid that he might be touched by such schoolboys in the bus, he insisted that his mother take him to school every day by car.

• Jens soon came to regard the walls, furniture, and other objects in his parents' home as contaminated by their less educated visitors. Only his own room, where no one else was allowed, seemed uninfected. He soon came to regard entire streets, buildings, shops, and playgrounds as contaminated, and he often went out of his way to avoid passing these places.

• He gave up his beloved tennis and also stopped playing on the football team. He spent almost all of his spare time in his room with the blinds down, sitting for hours in his chair doing nothing. He even refused to put on his washed and ironed clothing unless his mother had washed and ironed it under his supervision. In the end he could no longer read newspapers and magazines and could no longer touch his school books. He soon became a complete failure at school because he could no longer follow the lessons and no longer did any school work.

• Worst of all were his evening rituals in the shower, where he spent hours using several bottles of shower gel. He would clean his fingernails until they bled, and his skin became chapped and sore. When his parents tried to prevent him from showering excessively, he became aggressive.

• To their desperate attempts to make him realize that his fear of contamination and his endless washing were devoid of any realistic foundation, he constantly responded, "I know it's nonsense, but I just have to do it; I can't help it." He was often quite desperate and unhappy about his situation and kept crying about it.

History.History.

• Jens grew up as the second of four children. The father was an architect, and the mother worked as a librarian. His birth and childhood were quite normal. From infancy Jens was always very well behaved, orderly, and helpful. At school he was ambitious, and his grades were above average. He always kept his room clean and tidy and did not want playmates to come and make it untidy. At about the age of 13 he grew a lot in height, and at the age of 14 he was already more than 1.8 m tall, with the physical appearance of a young man. Before his illness he was very keen on sports, especially tennis, football, and cycling.

• His 49-year-old father came from a family of professional soldiers, with a very strict and efficiency-oriented upbringing, and his 50-year-old mother came from a similar family and had always made very high demands on herself. A cousin of the father was reported to suffer from a severe compulsion neurosis, but otherwise there was no information about psychiatric disorders in the family.

FindingsFindings

• On referral Jens appeared shy and reticent, with apparent difficulties in talking about himself and particularly about his emotions. He was aware that his obsessions and compulsions were his own ideas or impulses and that they were nonsensical. Initially he had tried to resist them, but eventually he realized that he simply could not do it.

• In the beginning giving in to the impulses relieved his tensions, but later on it became a torture. There was no evidence of hallucinatory experiences or delusional ideas. His speech was normal, and no catatonic features were observed. Throughout the interview he appeared mildly depressed. No cognitive deficiencies were detected, and he was fully oriented in all respects.

DISCUSSIONDISCUSSION

• Jens meets the criteria for an obsessive-compulsive disorder with mixed obsessional thoughts and acts. For several years he experienced obsessions of contamination and compulsions of washing that were repetitive and unpleasant, causing severe distress and interference with social and individual functioning. He acknowledged that the obsessions and compulsions originated from his own mind and that they were unreasonable. He had initially tried to resist his compulsions, but eventually he had to give in to them. There is no evidence of primary schizophrenic or affective disorders.

• A few depressive symptoms are mentioned, but not enough to meet the criteria of a depressive episode, and such symptoms obviously appear secondary to his obsessive-compulsive disorder. Exaggerated personality traits of an anancastic nature are described, but they are not sufficient to meet the criteria for a personality disorder, which his young age will also hardly allow.

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