Obsessive compulsive disorder

Obsessive compulsive disorder

OVERVIEW:

Psychiatric condition classified as an anxiety disorder in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and characterized by recurrent, intrusive thoughts (obsessions) and ritualistic behaviors (compulsions)
• Obsessions and compulsions consume more than an hour per day and cause occupational/social impairment
• Patients know thoughts (obsessions) come from their own minds and are not imposed from outside (as in thought insertion). Thoughts are not associated with another disorder (for example, thought of food if an eating disorder is present).
• Compulsions are ritualistic behaviors designed to relieve the anxiety of obsessions
• Common obsessive themes:
• Violence, such as harming a beloved child
• Doubt, such as whether doors or windows locked or iron turned off
• Blasphemous thoughts, such as in a devoutly religious person
• Contamination, dirt or disease
• Symmetry or orderliness
• Common rituals or compulsions:
• Hand washing
• Checking
• Counting
• Hoarding
• Repeaters - such as dressing rituals

System(s) affected: Nervous
Genetics: Positive family history in about 20% of cases, no mode of transmission identified
Incidence/Prevalence in USA: 2.5% lifetime prevalence, 1.5-2.1% one year prevalence
Predominant age: Mean age 20. 1/3 cases present by age 15, new cases after age 50 rare, 80% of cases before age 35
Predominant sex: Male = Female (males tend to present at a younger age)

SIGNS AND SYMPTOMS:

• Obsessions and/or compulsions that consume more than an hour a day and cause significant distress or impairment
• Obsessions (thoughts) are recurrent; patient attempts to ignore or neutralize thoughts with another thought or action
• Neither obsessions nor compulsions are related to another mental disorder
• Compulsions (actions) are repetitive, purposeful behaviors in response to thoughts in attempt to neutralize the thought - such as checking in response to doubt (locks, doors , windows or driving back over route to check for any possible damage inadvertently done while driving one's car)
• Repeated handwashing or ritualistic handwashing in response to fear of contamination
• 80-90% of patients have obsessions and compulsions
• 10-19% are pure obsessional
• 5% perform rituals until they feel right and may not have an identifiable obsession

CAUSES:

Dysregulation of neurotransmitter, serotonin

RISK FACTORS:

Greater concordance in monozygotic twins family history as above

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS:

• Impulse control disorders: Compulsive gambling, sex or substance abuse - the compulsive behavior is not in response to obsessive thought and patient derives pleasure from the activity, unlike OCD where obsessions and compulsions are ego dystonic
• Depression: Can see brooding, but ideas not perceived as senseless as in OCD
• Schizophrenia: Patient perceives thought to be true and from an external source
• Obsessive compulsive personality disorder: Not to be confused with OCD. In personality disorder, traits are ego-syntonic. Traits include perfectionism, preoccupation with detail, trivia or procedure and regulation. Patient tends to be rigid, moralistic and stingy. Often traits are rewarded in patient, s job as desirable traits.
• Generalized anxiety, phobic disorders, separation anxiety: Similar response of heightened anxiety, but presence of obsessions or rituals clarifies OCD diagnosis

LABORATORY:

N/A

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS:

N/A

SPECIAL TESTS:

• Yale Brown obsessive-compulsive scale (Y-BOCS)
• Maudsley obsessive-compulsive inventory (MOCI)

IMAGING:

PET scan - abnormal metabolism in frontal cortex and caudate nuclei (not generally available other than in research centers)

DIAGNOSTIC PROCEDURES:

Psychiatric interview

TREATMENT

APPROPRIATE HEALTH CARE:

Outpatient

GENERAL MEASURES:

• Combine medications and cognitive behavior therapy
• Psychiatric referral for therapy (in vivo exposure and response prevention)
• Family psycho-education
• Parent behavior management training if OCD patient child/adolescent

SURGICAL MEASURES:

Psychosurgery (last resort)

ACTIVITY:

No restriction

DIET:

With use of phenelzine must have tyramine-free diet to prevent precipitation of hypertensive crisis

PATIENT EDUCATION:

• Obsessive-Compulsive Foundation, P. O. Box 70, Milford, CT 06460-0070 (203) 878-5669 or (203) 874-3843 for recorded information
• Printed patient information available from: Obsessive-Compulsive Anonymous, P.O. Box 215, New Hyde Park, NY 11040, (516)741-4901

MEDICATIONS

DRUG(S) OF CHOICE:

• Serotonin reuptake inhibitor, fluoxetine (Prozac)
• Adults: begin with 20 mg/day q morning and increase every 4-6 weeks to obtain maximal clinical response. Dose range: 20-60 mg/day. Doses >20 mg/day should be divided.
• Children: safety and efficacy has not been established
• Sertraline (Zoloft)
• Adults: begin with 50 mg per day and increase every week until clinical response. Dose range: 50-200 mg per day. Doses > 100 mg/day should be divided.
• Children: safety and efficacy have not been established
• Paroxetine (Paxil)
• Adults: begin with 20 mg/day, increase weekly in 10 mg increments until maximal clinical response
• Children: begin with 20 mg/day, increase weekly in 10 mg increments until maximal clinical response
• Fluvoxamine (Luvox)
• Adult - begin with 100 mg/day and increase every week until clinical response (dosage range 200-300 mg)
• Children (8-17) - begin with 25 mg/day, increase in small increments (25-50 mg) until clinical response

Contraindications:
• Absolute fluoxetine, paroxetine, and sertraline contraindications
• Hypersensitivity to the selective serotonin re-uptake inhibitors
• Within 14 days of MAO inhibitor
• Relative fluoxetine and sertraline contraindications
• Severe liver impairment
• Seizure disorders (lowers seizure threshold)
• Clomipramine is of the tricyclic antidepressant class, so carries same contraindications as drugs in that class
• Absolute clomipramine contraindications:
• Within 6 months of myocardial infarction
• Narrow angle glaucoma
• 3rd degree AV block
• Within 14 days of MAO inhibitor
• Relative clomipramine contraindications:
• Prostatic hypertrophy (urinary retention)
• Seizure disorder (lower seizure threshold )
• 1st, 2nd degree AV block, bundle branch block and CHF (pro-arrhythmic effect)
Precautions:
• Drug should to be taken for a minimum of 10 weeks before considering it a treatment failure; could be several months before peak efficacy
• Because patients with OCD may have concomitant depression, suicide potential must be assessed
• Long half-life may be troublesome if patient has an adverse reaction
• May cause drowsiness and dizziness when therapy is initiated - warn patients about driving and heavy equipment hazards
• May alter glucose control by lowering blood glucose levels while on the medication and increase blood glucose after stopping the medication
• Tricyclic class of antidepressants dangerous in overdose
Significant possible interactions:
• Clomipramine
• Not yet fully elucidated
• May interfere with guanethidine, clonidine
• Serum level increased if used concomitantly with haloperidol
• Probable plasma increase if used with cimetidine, fluoxetine, methylphenidate
• Increases serum level of phenobarbital
• Fluoxetine and sertraline
• Causes increased concentrations of the following medications: warfarin, phenytoin, carbamazepine, diazepam, tricyclic antidepressants, and neuroleptics

ALTERNATIVE DRUGS:

• Clomipramine
• Adults - beginning at 25 mg/day and increased gradually to 100 mg over first 2 weeks. Then to 250 mg over next several weeks, as tolerated.
• Children - beginning at 25 mg /day over first two weeks as in adults. Then titrated up to 3 mg/kg or 200 mg/day (which ever is smaller) over the next several weeks.

FOLLOW UP

PATIENT MONITORING:

• Y-BOCS
• MOCI

PREVENTION/AVOIDANCE:

N/A

POSSIBLE COMPLICATIONS:

• Depression in 1/3 of OCD patients
• Avoidant behavior (phobic avoidance)
• Anxiety and panic-like episodes associated with obsessions

EXPECTED COURSE AND PROGNOSIS:

• Chronic waxing and waning course in majority
• 24-33% fluctuating course
• 11-14% phasic with periods of remission
• 54-61% chronic progressive course
• Early onset a poor outcome predictor

MISCELLANEOUS

ASSOCIATED CONDITIONS:

• Depression
• Panic disorder
• Social phobia
• Phobia
• Tourette's
• Alcoholism
• Substance abuse

AGE-RELATED FACTORS:

Pediatric: Child/adolescent onset in 33%. At this age males outnumber females 3:1.
Geriatric: Diagnosis not generally made after age 50
Others: N/A

PREGNANCY:

• Onset of OCD has been noted after delivery
• Safety of fluoxetine and clomipramine has not been established in pregnancy nor lactation

SYNONYMS:

Obsessive compulsive neurosis

ICD-9-CM:

300.3 Obsessive-compulsive disorders

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Medical Diagnosis » O » Obsessive compulsive disorder