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Obsessive-Compulsive Disorders

Subtypes of Obsessive-Compulsive Disorder

1. Washers

2. Checkers

3. Pure obsessions- 19%

4. Groomers - rare

5. Slowness - rare

6. Face pickers - young women

DSM-IV Criteria              

A. requires either obsessions or compulsions

B. the obsessions or compulsions cause significant distress or interfere with social or role functioning obsessive-compulsive disorder.

Characteristics        

 -Seem senseless, ego dystonic, no pleasure derived

 -If resisted increased tension yield to compulsion tension relief

Commonly Associated Features

Depression, anxiety, phobias, panic attacks

Prevalence

Old data: uncommon, 0.5 - 2.5% of psychiatric patients

New data: 2.5% of general population

OCD in Medical Practice

Infectious disease - fear of AIDS

OB-GYN - onset during and after pregnancy

Dermatologist - eczema, trichotillomania

GI - bowel obsessions

Urology - urinary obsessions

Plastic surgery - body dysmorphic disorder neurologist- Tourette's syndrome and OCD

Dentist - gum lesions from compulsive brushing 

Internist/GP - hypochondriasis

Screening Questions 

- Ask about repetitive actions such as checking, washing, etc

- Ask about repetitive intrusive thoughts

Sex

More common in females

Genetics 

- Family members of OCD probands have higher prevalence of OCD as well as other anxiety and affective disorders

- 20% of first-degree relatives have OCD, while another 15% have subclinical OCD

- Phenomenological subtypes do not run true in families (eg, mother washes, daughter checks)

- Genetic relationship between Tourette's syndrome, chronic motor tic disorder, and OCD has been proposed

Intelligence 

-Numerous studies document at least average intelligence

Relationship to Affective Illness

-Unclear, some gain and some lose obsessions during a depression

-Occasionally associated with bipolar illness

Relationship to Schizophrenia

Old Studies

- Only 3.5% of 843 schizophrenics had obsessional symptoms prior to psychosis

-1 of 150 obsessive-compulsive patients became schizophrenic

-2 of 88 became schizophrenic

- 12% became schizophrenic

New Data

-Although some schizophrenics also have obsessions & compulsions, OCD patients do not become schizophrenic

-"Schizobsessives," Axis II = schizotypal personality disorder

-Poor prognosis

Relationship to Personality

-Distinction between OCD and obsessive-compulsive personality disorder

-About 50% have obsessional premorbid personality traits (old data)

-Six percent of OCD patients also have DSM-III compulsive personality disorder -with modem structured interviews, over 50% meet criteria for a personality disorder when first presenting for treatment. When retested after effective treatment, many of the initially apparent personality disorders disappear.

-Personality features that predict poor treatment outcome include having:

a. Weak predictor = any PD

b. Strong predictors = Cluster A PD, more than one PD

c. Especially strong predictors = "odd speech," "ideas of reference," "paranoia"

Age of Onset 

One study: 88 patients

-Age 1-14 = 22%

-Age 15-24 = 42%

-Age 25-34 = 21%

-Over 35 = 15%

Another study: 816 patients

-65% before age 25

-15% after age 3

Newest data:

-Mean age of onset = age 20-22 years

-Males have earlier mean age of onset than females

-Checkers (and mixed cleaners & checkers) have earlier mean age of onset than cleaners or pure obsessionals

Precipitating Factors 

-Twenty-five percent - depression and/or anxiety accompanied the initial symptoms

-Fifty - 60% had stresses around time of onset: pregnancy, childbirth, sexual problems, death in family

Course and Prognosis (all old studies)

-88 patients - mean follow-up was 3.9 years

Theories of Etiology

1. Psychodynamic

3. Anatomic (rat model: inject amphetamine into ventro-lateral caudate area)

4. Organic/Neurologic

5. Serotonergic - most popular at this time

a. Clomipramine & fluoxetine (serotonergic agents) are effective treatments

b. Clomipramine (CMI) levels correlate with improved OCD symptoms

c. Improvement correlated (r=.75) with decreased post-rx CSF 5-HIAA d. serotonergic challenge studies

1. Pral mCPP (serotonergic agonist) given to 12 OCD pts & 20 controls. OCD pts increased OCD symptoms acutely compared to no change in controls.

2. Oral mCPP vs placebo given to 90CD pts. in a double-blind manner before and after rx with CMI

a. Before CMI rx: mCPP increased OCD & anxiety sx

b. After CMI rx: mCPP did not increase OCD or anxiety sx

Conclusion: this shows a possible association between OCD sx and increased serotonergic activity. Also, these results are consistent with down-regulation of the serotonergic system with clomipramine treatment.

3. Metergoline (serotonergic antagonist) has no effect on OCD patients who are untreated. When metergoline vs placebo was given for 4 days to 10 OCD pts while on clomipramine, it increased anxiety and OCD sx.

6. Developmental

Related Disorders (may respond to antiobsessional agents)

1. Eating Disorders

2. Dysmorphophobia (Body Dysmorphic Disorder)

3. Monosymptomatic Hypochondriasis

4. "Fear of AIDS"

5. Bowel & urinary obsessions

6. Tourette syndrome - about 50% have concomitant OCD & about 20% of OCD patients have tics. Genetic relationship between OCD and Tourette is likely.

7. Trichotillomania

"Organic" Causes (very unusual)

1. Epidemic Encephalitis

-1915-1926, no organism isolated, perhaps sporadic cases still appear

-Frequent neurologic sequelae

-Obsessions and compulsions common, often associated with

2. Neurologic Illness

a. 103 patients, 19.4% had a history of neurologic illness (by patient's report)

-6 patients -- severe CNS infections

-8 patients -- history of convulsive disorder

-6 patients -- history of Sydenham's Chorea

b. Huntington's disease - two patients reported with OCD that developed after the neurologic illness (one = cleaning compulsions, another = "smoking compulsions")

c. Tourette's syndrome - very strong association

3. Trauma

-415 cases of war-related head injured patients: 3.4% incidence of obsessive neurosis

-Case reports of OCD beginning after head trauma

4. Temporal Lobe Epilepsy -"involuntary forced thinking" is a tree seizure component

5. Brain Tumors -25 of 58 patients had functional psychiatric illness

-Only one had an obsessional illness (left frontal tumor)

6. Drugs: -phenmetrazine (Preludin) -clozapine

-Amphetamine psychosis -risperidone

-L -Dopa -benzodiazepine withdrawal

-Cocaine

7. Anti-caudate streptococcal antibodies

Treatment

1. Psychotherapy

-There is no evidence to suggest that psychodynamic psychotherapy alone is helpful for the alleviation of obsessions or compulsions. It is likely to help patients in other areas of 

2. Drugs

a. Antidepressants/novel agents

Documented to be Effective

1. Clomipramine - best studied, effective, dosage 100-250 my/day 

2. Fluoxetine - well studied, effective, dosage 40-80 mg/day 

3. Sertraline - well studied, effective dosage 100-200 mg/day

4. Fluvoxamine - well studied, effective dosage 100-300 mg/day

5. Paroxetine - well studied, effective dosage 40-60 mg/day

6. Citalopram - one European controlled trial, dosage 20-60 mg/day

Possibly Effective

7. venlafaxine (Effexor) - small uncontrolled series - maximum dosage375 mg/day

Experimental

8. Lamotrigine (Lamictal)

9. Gabapentin (Neurontin)

10. Phenytoin (Dilantin)

11. Pergolide (Permax)

12. Inositol

13. Naltrexone and Naloxone

14. Clonidine

b. monoamine oxidase inhibitors -- possibly effective when OCD patients have associated panic attacks or symmetry concerns. Wait at least 5 weeks between stopping fluoxetine and starting MAOI. Wait 2 weeks for

c. antipsychotics - rarely helpful, never use in uncomplicated cases, reportedly helpful as augmenting agent in OCD patients who also have tics. Newer antipsychotics like risperidone, clozapine, and olanzapine may be

d. Augmenting Strategies - drugs can be added to an antidepressant in an effort to

a. clonazepam* 

b. trazodone 

c. lithium* 

d. tryptophan 

e. buspirone* 

f. methylphenidate 

g. neuroleptics - helpful if OCD patient also has tics

e. If OCD improves, but depression persists: 

a. Bupropion (Wellbutrin) 

b. Cytomel 

c. Lithium 

d. Desipramine (Norpramin) 

e. Mirtazapine (Remeron) 

f. Pindolol (Visken)