1 Obsessive-Compulsive and Related Disorders
2 OC & Related Disorders (DSM 5):Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder (DSM5) Trichotillomania Excoriation Disorder (DSM5) Substance/Med-Induced OC & Related Disorder(DSM5) OC & Related Disorder Due to Another Medical Condition(DSM5) Other Specified OC & Related Disorder Unspecified OC & Related Disorder
3 An Obsession is a recurrent and intrusive thought,feeling,or idea that is egodystonic.A compulsion is a concious repetitive behavior linked to an obsession that when performed,functions to relieve anxiety caused by the obsession. patients with OCD are generally aware that their obsessions and compulsions are senseless or unrealistic, but they cannot stop them.
4 COMMON PATTERNS OF OBSESSIONS & COMPULSIONS1. Obsessions about contamination followed by excessive washing or compulsive avoidance of the feared contaminant 2. Obsessions of doubt (forgetting to turn off the stove, lock the door, Water taps,House alarm,House lights,Wallet etc.) followed by repeated checking to avoid potential danger 3. Obsessions about symmetry followed by compulsively slow performance of a task (such as eating, showering,lining items exactly in place etc.) 4. Intrusive thoughts with no compulsion. Thoughts are often sexual or violent.
5 DIAGNOSIS AND DSM-5 CRITERIAA.Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are 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 individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder
6 Specifiers With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true. With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true. Tic-related: The individual has a current or past history of a tic disorder
7 EPIDEMIOLOGY Lifetime population prevalence: Around 3%Onset is usually in early adulthood (Mean:19.5yo) Men are equally likely to be affected as women. OCD is associated with major depressive disorder, eating disorders, other anxiety disorders, and obsessive–compulsive personality disorder. The rate of OCD is higher in patients with first-degree relatives who have Tourette’s disorder.
8 Shows rigidity and stubbornness.OCD vs OCPD Obsessive-Compulsive Personality Disorder : an extensive pattern of preoccupation with perfectionism, orderliness, and interpersonal and mental control, at the cost of efficiency, flexibility and openness Symptoms must appear by early adulthood and in multiple contexts,At least four of the following should be present: Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met). Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). Is unable to discard worn-out or worthless objects even when they have no sentimental value. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. Shows rigidity and stubbornness.
9 OCD vs OCPD OCPD is a personality disorder.symptoms are ego-syntonic, and patients lack insight.they will usually seek treatment because of the conflict caused between them and their family and friends related to their need to have others conform to their way of doing things. Obsessions and compulsions are not present in OCPD OCD patients are usually distressed by having to carry out these tasks or rituals. In contrast, people with OCPD view activities such as excessive list making or organization of items around the home as necessary and even beneficial. OCD patient uses these tasks to reduce anxiety caused by obsessional thoughts;might make a list over and over again to prevent the death of a loved one. In contrast,OCPD patient might justify list-making as a good strategy to improve efficiency.
10 Etiology of OCD: Genetic: Rates of OCD are higher in first-degree relatives and monozygotic twins than in the general population .However, it is possible the behavior is learnt as a result of witnessing other family members with the condition. Neurochemical: people with the condition appear to have decreased levels of serotonin in their brain.
11 Life events: OCD may be more common in people with a history of having experienced emotional, physical or sexual abuse, neglect, social isolation or bullying. Personality: if you are a neat, meticulous, methodical person with high standards – a "perfectionist" – you may be more likely to develop the condition.
12 Prognosis & comorbidities:About 70% of people experience a chronic and lifelong course, with worsening and improving. About 5% have episodic symptoms with partial or complete remission between episodes. 30% of patients have significant improvement, 20-40% experience worsening of symptoms. relapses are common in the course of OCD intervention but with proper preparation, they can usually be caught and treated before blossoming into another full blown OCD episode.
13 Patients with OCD are at high risk of having comorbid:major depression (31%) social phobia (11%) eating disorder (8%) panic disorder (6%) and Tourette's syndrome (5%)
14 Management Psychotherapy (exposure and response prevention): this involves gradually learning to tolerate the anxiety associated with not performing the ritual behavior. Medication: SSRI,TCAs Procedures: electroconvulsive therapy was found effective in some severe refractory cases. Surgery as a last resort in patients that do not improve with other treatments.
15 Body Dysmorphic DisorderBDD is a body-image disorder characterized by persistent and intrusive preoccupations with an imagined or slight defect in one's appearance. Believes body part is abnormal, misshapen or defective. Sees self as ugly when normal in appearance. Preoccupation disrupts day-to-day life. Not accounted for by other disorder (anorexia nervosa)
16 BDD most often develops in adolescents and teens, and research shows that it affects men and women almost equally. About one percent of the U.S. population has BDD. The causes of BDD are unclear, but certain biological and environmental factors may contribute to its development, including genetic predisposition, neurobiological factors such as malfunctioning of serotonin in the brain, personality traits, and life experiences.
17 Symptoms: BDD sufferers may perform some type of compulsive or repetitive behavior to try to hide or improve their flaws although these behaviors usually give only temporary relief: camouflaging (with body position, clothing, makeup, hair, hats, etc.) comparing body part to others' appearance seeking surgery Checking/avoiding in a mirror skin picking excessive grooming excessive exercise changing clothes excessively
18 BDD and other mental disorders:People with BDD commonly also suffer from the anxiety disorders like social anxiety disorder, depression and eating disorders. Effective treatments are available to help BDD sufferers live full, productive lives: CBT teaches patients to recognize irrational thoughts and change negative thinking patterns. Patients learn to identify unhealthy ways of thinking and behaving and replace them with positive ones. Antidepressants including SSRI can help relieve obsessive and compulsive symptoms of BDD
19 Hoarding Disorder Hoarding is the persistent difficulty discarding or parting with possessions, regardless of their actual value. Commonly hoarded items may be newspapers, magazines, paper and plastic bags, flyers, bills, cardboard boxes, photographs, household supplies, food, and clothing.
20 Difference between hoarding and collecting:Many people collect items such as books or stamps and this isn’t considered a problem. The difference between a "hoard" and a "collection" is how these items are organised. A collection is usually well-ordered and the items are easily accessible. A hoard is usually very disorganised, takes up a lot of room and the items are largely inaccessible.
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22 I’ve always had trouble throwing things awayI’ve always had trouble throwing things away. Magazines, newspapers, old clothes… What if I need them one day? I don’t want to risk throwing something out that might be valuable. The large piles of stuff in our house keep growing so it’s difficult to move around and sit or eat together as a family. My husband is upset and embarrassed, and we get into horrible fights. I’m scared when he threatens to leave me. My children won’t invite friends over, and I feel guilty that the clutter makes them cry. But I get so anxious when I try to throw anything away. I don’t know what’s wrong with me, and I don’t know what to do. This example is typical of someone who suffers from hoarding.
23 Symptoms Patient may exhibit any or all of the following:Inability to throw away possessions Severe anxiety when attempting to discard items Great difficulty categorizing or organizing possessions Indecision about what to keep or where to put things The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Suspicion of other people touching items Obsessive thoughts and actions: fear of running out of an item or of needing it in the future; checking the trash for accidentally discarded objects. The hoarding should not be attributable to another medical condition (e.g.,schizophrenia, brain injury, cerebrovascular disease, Prader-Willi syndrome). May lead to functional impairments, including loss of living space, social isolation, family or marital discord, financial difficulties, health hazards
24 Hoarding can be related to compulsive buying (such as never passing up a bargain), the compulsive acquisition of free items (such as collecting flyers), or the compulsive search for perfect or unique items (which may not appear to others as unique, such as an old container). Management: Antidepressants (SSRI,TCAs) &CBT
25 Trichotillamania excessive pulling of one’s own hair, resulting in noticeable hair loss. Scalp is the most common area then eyelashes and eyebrows. peak prevalence between the ages of 4 and 17 years. Female: Male = 10:1 more common in OCD and OCPD patients.
26 DSM-5 Recurrent pulling out of one’s hair, resulting in hair lossRepeated attempts to decrease or stop the hair-pulling behavior The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning The hair pulling or hair loss cannot be attributed to another medical condition. The hair pulling cannot be better explained by the symptoms of another mental disorder as body dysmorphic disorder, OCD. **Only for a better understanding** Medical condition that leads to alpecia: 1- dermatologic as Tinea Capitis – look for erythmatous papules in scalp- 2- Inherited: Minotherix – hair thinning and fragilty- 3- medication as chemootherapy * to differentiate from OCD: In trichotillomania patients USUALLY are not aware of pulling hair .
27 Individuals with Trichotillomania often attempt to cover up the hair loss that occurs because of the disorder. They try to prevent others from seeing the hair loss by using camouflage techniques that include the use of hats, scarves, and false eyelashes. Some may even resort to having false eyebrows permanently tattooed onto their skin. They also tend to pull out the hair in secret places.
28 Before the sufferer pulls their hair there is a high level of tension and a strong urge to pull.Pleasure, gratification, or relief when pulling out the hair. After done: feel depressed and ashamed from hair loss and usually tend to avoid social relationships.
29 Hypnosis, relaxation technique Behavioral therapyChronic course of the disease and needs to stay on TT. More difficult to treat in adults ONSET. Treatment: SSRI, antipsychotic, lithium Hypnosis, relaxation technique Behavioral therapy Hypnosis: learn how to gain gain focus on the illness to gain a better control of the behaviour. Relaxation: deep breathing behavioral: do something in particular when the patient feels an urge to pull the hair out.
30 Excoriation characterized by the repeated urge to pick, scratch one's own skin, often to the extent that damage is caused. Sometimes an inciting incident is the cause but a minor one (e.g: insect bite), and sometimes no inciting incident is present Epidemiology 1.4% in adults ¾ are females Adolescence onset (puberty
31 DSM-5 Recurrent skin-picking, resulting in lesionsRepeated attempts to decrease or stop skin picking The skin picking causes clinically significant distress or impairment in important areas of functioning The skin picking cannot be attributed to the physiologic effects of a substance (cocaine) or another medical condition (scabies, obstructive biliary disease) The skin picking cannot be better explained by the symptoms of another mental disorder (Body dysmorphic disorder, stereotypies and intentional harming of self)
32 Chronic disorder. If not treated, the intensity fluctuates but never disappear.
33 Substance induced OCRDDiagnostic Criteria: Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of the obsessive-compulsive and related disorders predominate in the clinical picture. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2): The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. The involved substance/medication is capable of producing the symptoms in Criterion A.
34 Not better explained by an obsessive-compulsive and related disorder that is not substance/medication-induced. Such evidence of an independent obsessive-compulsive and related disorder could include the following: The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non-substance/medication-induced obsessive-compulsive and related disorder (e.g., a history of recurrent non-substance/medication- related episodes). The disturbance does not occur exclusively during the course of a delirium. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning
35 Exampels: Sedative drugs anti-anxiety amphetamine cocaine Marijuana Caffiene and Alcohol
36 General medical condition induced OCRDDiagnostic Criteria: Obsessions, compulsions, preoccupations with appearance, hoarding, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of obsessive-compulsive and related disorder predominate in the clinical picture. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. The disturbance is not better explained by another mental disorder. The disturbance does not occur exclusively during the course of a delirium. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
37 Examples: Infection and anemia >> CBC Brain trauma carbon monoxide poisoning hepatic diseases dermatologic conditios Tawdeee7: Case reports have been published of OCD with and without tics arising in children and young adults following acute group A streptococcal infections.
38 Other SPECIFIED OCRD Body dysmorphic-like disorder with actual flawsBody dysmorphic-like disorder without repetitive behavior Body-focused repetitive behavior disorder (e.g. nail biting) Obsessional jealousy Shubo-Kyofu: Excessive fear of having bodily deformity Koro: an episode of sudden and intense anxiety that the penis (or the vulva and nipples in females) will recede into the body, possibly leading to death.
39 What are the UNSPECIFIED OCRD?Symptoms characteristic of an obsessive-compulsive and related disorder Cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate BUT do not meet the full criteria for any of the disorders
40 Case study a colleague asks to talk about his younger brother, a graduate student in his early 30s. His brother recently moved into town and currently staying with the colleague. The colleague tells you that he is going crazy because his brother refuses to use the dishwasher, his brother insists on washing dishes in an elaborate way taking several hours. As they are both employed and busy people, dishes have piled up in the sink and on the counter because the brother doesn’t have the time to clean them properly. The colleague also reported that his brother has been always in troubles with all his roommates. Their relationship becomes weaker after this.
41 History an physical examinationAnalyze obsessive nature and severity: Have you ever been bothered by thoughts that do not make any sense and keep coming back to you even when you try not to have them? Tried to get them out? Where do you think they came from? Analyze compulsive nature and severity: What behavior did you have to do in a repitive manner? How many times? Time spent on it? Effect on your life? ask about mood disorder? (highly associated with OCD. History of tics. Medication intake or withdrawal history to determine physical illness history of tics (Tics related OCD) past history of OCD family history of OCD On physical examination: Eczematous eruptions related to excessive washing .
42 DONE