Michael Ingram, MD ▪ Introduction to Obsessive Compulsive and Related Disorders ▪ Epidemiology of OCD ▪ Diagnosis of OCD ▪ Neurobiology of Impulsivity and Compulsivity ▪ Treatment ▪ Prognosis ▪ Brief tour of the other OCD spectrum disorders At the conclusion of this lecture, you should be able: ▪ To recognize the signs and symptoms of OCD and related disorders ▪ To review the basic neurobiology of impulsivity and compulsivity ▪ To recall the available treatment options for OCD and related disorders ▪ What is an obsession? ▪ A recurrent and intrusive thought, feeling, idea, or sensation ▪ An obsession is a mental event ▪ What is a compulsion? ▪ A compulsion is a conscious, standardized, recurrent behavior, such as counting, checking, or avoiding ▪ A compulsion is a behavior ▪ In OCD, obsessions and compulsions are ego-dystonic ▪ Compulsive acts are carried out in an attempt to relieve the associated with the obsession ▪ Sometimes it works, sometimes it doesn’t work ▪ Resisting a compulsive act increases anxiety ▪ Epidemiology ▪ 2-3% lifetime prevalence in general population ▪ 4th most common outpatient psychiatric diagnosis ▪ 10% of outpatients in psychiatric clinics ▪ Epidemiological studies in Europe, Asia, and Africa have confirmed these rates across cultural boundaries ▪ Estimated that 40% of patients do not achieve a clinical response from SSRIs1 ▪ Epidemiology (Continued…) ▪ Females slightly more than males in adulthood ▪ Boys 2-3 times more affected than girls in childhood ▪ Mean onset 19.5 years old, rarely onset after 35 ▪ Males earlier age of onset than females ▪ Mean age of onset: 20 years ▪ Boys: 19 years (mean) ▪ Girls: 22 years (mean) ▪ ~60% have onset of symptoms before 25yo ▪ <15% have onset of symptoms after 35yo ▪ Single persons > Married persons

▪ Possible Risk Factors ▪ Genetic factors (monozygotic concordance rate of 0.57) ▪ Environmental factors (trauma, abuse, perinatal, infectious) ▪ Psychosocial and developmental factors

▪ Controversy ▪ Childhood streptococcal infections increase risk of OCD (PANDAS)? ▪ Associated conditions ▪ 90% of patients with OCD have psychiatric ▪ 76% Anxiety disorders ▪ 63% Mood disorders ▪ 56% control disorders ▪ 39% Substance use disorders ▪ 30% of patients with OCD have accompanying disorder ▪ OCD in children and adolescents ▪ Comorbidities reported in up to 50% pediatric patients ▪ ADHD ▪ Separation ▪ Specific ▪ Anxiety disorders ▪ Tourette disorder ▪ DSM-5 Criteria A. Presence of obsession, 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 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 (ie., by performing a compulsion) ▪ DSM-5 Criteria A. Presence of obsessions, compulsions, or both ▪ Compulsions are defined by 1 and 2 1. Repetitive behaviors or mental acts 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 ▪ DSM-5 Criteria

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. Symptoms are not attributable to the physiological effects of a substance or another medication

D. The disturbance is not better explained by symptoms of another (e.g., GAD, hoarding do, do, excoriation do, eating do, etc)

Specifiers ▪ Insight: good, fair, poor, absent, delusional ▪ Tic-related: The individual has a current or past history of a Contamination Intrusive (hand washing, Thoughts cleaning)

Pathological Symmetry/Precision Doubt (Slowness) (Checking)

There is considerable overlap, but generally patients present with a predominant symptom pattern of an obsession-compulsion pair.

Compulsions in parenthesis YBOCS is often used in clinical research in an attempt to quantify OCD symptom severity and track progress over time Pauls, David L., Amitai Abramovitch, Scott L. Rauch, and Daniel A. Geller. "Obsessive–compulsive Disorder: An Integrative Genetic and Neurobiological Perspective." Nature Reviews Neuroscience Nat Rev Neurosci (2014): 410-24. Print. ▪ Neurotransmitters implicated in OCD pathophysiology ▪ Serotonin – supported by alleviation of symptoms with SSRIs ▪ Glutamate – glutamate modulating drugs showing promising results ▪ Dopamine ▪ Cortico-striato-thalamo-cortical circuit (CSTC) ▪ Hyperactivity in (OFC), anterior (ACC), and caudate nucleus ▪ Glutamate is the primary excitatory neurotransmitter in CSTC ▪ Increased Glutamate levels in CSF, caudate, and OFC in OCD pts Circuitry of impulsivity and reward. The Circuitry of compulsivity and motor response “bottom-up” circuit that drives impulsivity inhibition. The “bottom-up” circuit that drives (shown in pink) is a loop with projections from compulsivity (shown in pink) is a loop with the ventral to the thalamus, from the projections from the dorsal striatum to the thalamus to the ventromedial prefrontal cortex thalamus, from the thalamus to the orbitofrontal (VMPFC), and from the VMPFC back to the cortex (OFC), and from the OFC back to the dorsal ventral striatum. This circuit is usually striatum. This habit circuit can be modulated “top- modulated “top-down” from the prefrontal down” from the OFC, but if this top-down response cortex (PFC). If this top-down response inhibition system is inadequate or is overcome by inhibition system is inadequate or is overcome activity from the bottom-up dorsal striatum, by activity from the bottom-up ventral striatum, compulsive behaviors may result. impulsive behaviors may result.

Stahl’s Essential Psychopharmacology 4th ed ▪ Etiology & Pathophysiology – remains unclear ▪ Heterogeneous ▪ Biological Factors ▪ Genetic polymorphisms ▪ Autoimmune processes ▪ Infection ▪ Inflammatory and oxidative stress ▪ Abnormalities of neurotransmission ▪ Behavioral Factors ▪ Psychosocial Factors Pauls, David L., Amitai Abramovitch, Scott L. Rauch, and Daniel A. Geller. "Obsessive–compulsive Disorder: An Integrative Genetic and Neurobiological Perspective." Nature Reviews Neuroscience Nat Rev Neurosci (2014): 410-24. Print. Pauls, David L., Amitai Abramovitch, Scott L. Rauch, and Daniel A. Geller. "Obsessive–compulsive Disorder: An Integrative Genetic and Neurobiological Perspective." Nature Reviews Neuroscience Nat Rev Neurosci (2014): 410-24. Print. ▪ Current Treatment (pharmacotherapy + behavioral) ▪ SSRIs (typically requires higher doses compared to depression) ▪ ▪ ▪ ▪ ▪ ▪ ▪ TCA most selective for serotonin reuptake ▪ Other therapies ▪ ECT ▪ Surgery (Psychosurgery) ▪ Deep Brain Stimulation ▪ agents ▪ Problems with current treatment ▪ Only 20-30% of patients have significant improvement ▪ 40-50% of patients have moderate improvement ▪ 20-40% of patients do not respond or get worse! ▪ Higher doses of SSRIs required to alleviate symptoms in OCD ▪ Associated adverse effects lead to patient non-compliance • Obsessive-Compulsive or Related Disorder Due to another medical condition • PANDAS

• Substance induced Obsessive-Compulsive or related disorder

• Olfactory Reference Syndrome

•

• Hoarding Disorder

• Hair-Pulling Disorder (Trichotillomania)

• Excoriation (Skin-Picking) Disorder Hypothesis: Acute and rapid onset of OCD/ symptoms in a subset of children with group A beta hemolytic streptococcal infections.

Antibodies to GABHS cross react with neurons causing dysfunction

Controversial

https://www.healthynewbornnetwork.org/blog/have- you-got-data-on-follow-up-of-children-after-group-b- streptococcus-infection/ ▪ A false belief by the patient that he or she has a foul body odor that is not perceived by others ▪ Leads to excessive showering, changing clothes ▪ May rise to level of somatic ▪ () ▪ Rule out organic illness ▪ Temporal lobe epilepsy ▪ Pituitary tumors ▪ Sinusitis ▪ Preoccupation with an imagined defect in appearance that causes clinically significant distress ▪ If a slight physical anomaly is actually present, the person’s concern with the anomaly is excessive and bothersome ▪ Compulsions: ▪ Mirror checking ▪ Excessive grooming ▪ Comparing appearance to others ▪ Men: preoccupation with muscle mass and “bulking up”

▪ Women>Men; unmarried; AoO = 15-30years ▪ High with MDD, Anxiety, ▪ Body dysmorphic Disorder more often seen in ▪ Plastic Surgery Clinics ▪ Dermatology Clinics ▪ Internist/Primary Care Clinics

▪ Treatments ▪ Fluoxetine ▪ Clomipramine ▪ TCAs ▪ MAOIs https://en.wikipedia.org/wiki/Body_dysmor phic_disorder ▪ Psychotherapy ▪ Surgical/procedural interventions rarely benefit these patients ▪ Acquiring and not discarding unimportant possessions of little or no value ▪ Obsessive fear of losing important items that may be needed in the future ▪ Distorted beliefs about the importance of possessions ▪ Excessive emotional attachment to possessions ▪ Leads to http://www.thewowdecor.com/how-to-help- ▪ the-hoarder-in-your-house/ ▪ Unsanitary living conditions ▪ Health risks (falls, animal born diseases) ▪ Fire risks ▪ Commonly seen in single persons with or dependent personality traits ▪ Seen in , CVA, and (slightly different presentation) ▪ Begins in early adolescence, often persists over lifetime ▪ Most lack insight into their illness (ego-syntonic) ▪ Treatment ▪ Medications aren’t effective ▪ Cognitive behavioral interventions are most effective ▪ Trichotillomania coined by a French dermatologist Francois Hallopeau in 1889 ▪ Chronic disorder characterized by repetitive hair pulling ▪ Results in hair loss ▪ Increased tension prior to hair pulling and relief of tension or gratification after the hair pulling ▪ 0.6-3.4% lifetime prevalence ▪ Women:Men = 10:1 ▪ 35%-40% chew or swallow the hair ▪ Bezoars – hairballs in the GI tract → Obstruction

▪ Pharmacological Treatments ▪ SSRIs ▪ SNRIs ▪ Lithium ▪ ▪ Naltrexone https://www.cbc.ca/life/wellness/th ▪ Buspirone e-truth-about-trichotillomania-the- ▪ Clonazepam hair-pulling-disorder-1.3865541 ▪ Trazodone

▪ Behavioral Treatments ▪ Biofeedback ▪ Insight-oriented psychotherapy ▪ Hypnotherapy ▪ Compulsive and repetitive picking of the skin ▪ 1-5% lifetime prevalence ▪ Women>Men ▪ Rule out stimulant induced excoriation ▪ Face (most common) ▪ Also: Legs, Arms, Torso, Hands, Cuticles, Fingers, Scalp ▪ Embarrassment and avoidance/social withdrawal ▪ 12% of skin-picking patients have attempted suicide ▪ Pharmacological Treatments ▪ Fluoxetine ▪ Naltrexone ▪ Lamotrigine ▪ Behavioral Treatments ▪ Cognitive Behavioral Therapy ▪ Habit Reversal ▪ THE END ▪ Stay tuned for more Simply Psych EDU Lectures! ▪ www.simplypsychedu.com 1. Afshar, Hamid et al. "N-Acetylcysteine Add-On Treatment in Refractory Obsessive- Compulsive Disorder." Journal of Clinical Psychopharmacology (2012): 797-803. Print. 2. Pauls, David L., Amitai Abramovitch, Scott L. Rauch, and Daniel A. Geller. "Obsessive– compulsive Disorder: An Integrative Genetic and Neurobiological Perspective." Nature Reviews Neuroscience Nat Rev Neurosci (2014): 410-24. Print. 3. Oliver, Georgina, Olivia Dean, David Camfield, Scott Blair-West, Chee Ng, Michael Berk, and Jerome Sarris. "N-Acetyl Cysteine in the Treatment of Obsessive Compulsive and Related Disorders: A Systematic Review." Clin Psychopharmacol Neurosci Clinical Psychopharmacology and Neuroscience (2015): 12-24. Print. 4. "Obsessive Compulsive Disorder." Dynamed. 5. Sadock, Benjamin J., and Harold I. Kaplan. Kaplan & Sadock's Synopsis of : Behavioral Sciences/clinical Psychiatry. 10th ed. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print. 6. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association, 2013. Print. 7. Stahl’s Essential Psychopharmacology, 4th Edition. Cambridge University Press. 2013