University:
West Coast University
Course:
PHAR 835 | IPC Neurology/Psychiatry
Academic year:

2024
Views:

427

Pages:

23
Author:

Asal A.

lineisWEBI gait Parna Haghparast, Pharm.D, BCPS Associate Professor West Coast University School of Pharmacy ACKNOWLEDGEMENT: PART OF THE SLIDES WERE ADOPTED FROM DR. MICHAEL PONDROM’S and Dr. Carol Yuan SLIDES Allen Allen, a 22-year old man, came to a mental health clinic for treatment of anxiety. He worked full-time as a janitor and engaged in a very few activities outside of work. When asked about anxiety, Allen said he was worried about contracting diseases such as HIV. Aware of a strong disinfectant smell, the mental health care provider asked Allen if he had any special cleaning behaviors linked to his concern about getting HIV. Allen said that he avoided touching almost anything outside of his home. He said that if he even came close to things that he thought might have been in contact with the virus, he had to wash his hands many times with bleach. He often washed his hands up to 30 times a day, spending hours on this routine. Physical contact was quite difficult. Shopping for groceries and taking the subway were big problems, and he had almost given up trying to go to social events or engage in romantic relationships. Allen When asked if he had other worries, Allen said that he was bothered by sudden images of hitting someone, fears that he would say things that might be offensive or wrong, and concerns about upsetting his neighbors. To ease the anxiety caused by these thoughts, he often replayed prior conversations in his mind, kept diaries to record what he said and often apologized for fear he might have sounded offensive. • When he showered, he made sure the water in the tub only reached a certain level. He was afraid that if he was not careful, he would flood his neighbors. This Photo by Unknown Author is licensed under CC BY Allen • Allen uses gloves at work and performed well. • He spent most of his free time at home. • Although he enjoyed the company of others, the fear of having to touch something if he was invited to a meal or to another person’s home was too much for him to handle. • He knew that his fears and urges were “kinda crazy,” but he felt they were out of his control. • Allen was diagnosed with OCD. He had many obsessions, including ones related to contamination (fear of contracting HIV), aggressions (intrusive image of hitting someone) and symmetry (exactness in the level of water). • These caused Allen to spend hours on his OCD routines and to avoid leaving his apartment, engaging in social relationships and performing basic errands. This Photo by Unknown Author is licensed under CC BY Allen • He also has many compulsions: • • • • excessive hand washing, checking (keeping diaries) repeating (often clarifying what he said) mental compulsions (replaying prior conversations in his mind). • The symptoms also got in the way of Allen’s normal daily tasks. Even though he was able to work, his job choice may have been swayed by his symptoms (few other jobs would allow him to always wear gloves and use bleach). • Not only did his symptoms consume much of his time, but he appeared to be lonely, isolated man whose quality of life had e orOCD. been greatly affected by his Epidemiology i Lifetime prevalence: ◦ 2.5% in general population ◦ 2-4% in pediatric population ◦ Female to male 1.5:1 Usually begins early in life (average age of onset= 24-35 YO) ◦ 20% in childhood ◦ 29% in adolescence ◦ 49% by age 20 Onset is earlier in males High rates of anxiety disorders in 1st degree relatives Risk of developing OCD is 11-12% if a first-degree relative has OCD Comorbidities In OCD Etiology and Pathophysiology • Genetic + environmental factors • First-degree relatives more likely to have ◦ Probable OCD ◦ Panic disorder ◦ Eating disorders in personality disorder ◦ Obsessive-compulsive • OCD is a problem of aberrant functioning of certain NT such as serotonin and glutamate, faulty interpretation of importance given to certain intrusions, resulting in manifestations of obsessions. DSM-5 Criteria Obsessions i 1. Recurrent and persistent thoughts, urges or images that are experienced, at some time during the disturbance, as intrusive, unwanted, and that in most individuals cause marked anxiety and distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some thought or action. (i.e., by performing a compulsion) 141 Compulsions 1. Time consuming (i.e., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 2. The disturbance is not better explained by the symptoms of another mental disorder, for examples: a. GAD (Generalized Anxiety Disorder) b. Excoriation – Skin picking disorder c. Eating disorder d. Substances related and addictive disorders e. Disruptive, impulse control and conduct disorders. Specifiers: •Insight: good or fair insight, poor insight, or absent insight/delusional beliefs •Related to a tic disorder Clinical Presentation Definitions Obsessions ◦ Repetitive thoughts ◦ Repetitive images ◦ Repetitive impulses Compulsions ◦ Repetitive activities ◦ Repetitive mental acts Common Symptoms in OCD Obsession Examples Associated Compulsive Behaviors Aggressive Fears of harming others, recurrent violent images Monitoring the news for reports of violent crimes, asking for reassurance about being a good person Contamination Fear of being contaminated or contaminating others; fear of being contaminated by germs, infections, or environmental factors; fear of being contaminated by bad or immoral persons Washing or cleaning rituals Pathologic doubt, completeness Recurrent worries about doing things incorrectly or incompletely, thereby negatively affecting the patient or others Checking excessively, performing actions in a particular order Religious Thoughts about being immoral and eternal damnation Asking forgiveness, praying, reassurance seeking Common Symptoms in OCD Obsession Examples Associated Compulsive Behaviors Self-control Fear of making inappropriate comments in public Avoiding being around others Sexual Recurrent thoughts about being a pedophile or sexually deviant; recurrent thoughts about acting sexually inappropriate toward others Avoiding situations that trigger the thoughts, performing mental rituals to counteract the thoughts Superstition Fears of certain “bad” numbers or colors Counting excessively Symmetry and exactness Recurrent thoughts of needing to do things in a balanced or exact fashion Ordering and arranging 065 it has been suggested that a successful treatment response is a YBOCS score reduction of 35% or more Treatment of OCD PHARMACOLOGIC THERAPY NONPHARMACOLOGIC THERAPY soUseSSRI Treatment Tx duration: 8–12 months to reduce the risk of relapse, and only after all, or almost all, symptoms have disappeared. 1. Non-Pharmacological Tx common initial nonpharmacologic treatment of choice  Psychotherapy (CBT) -Mild-moderate symptoms -For patients who prefer psychotherapy over meds -Adjunct to medications for severe symptoms -Preferred in motivated pts -Largely considered to be more efficacious than pharmacotherapy but well trained therapists/cost are barriers to access  Other options: ECT, deep brain stimulation (DBS), Trans magnetic stimulation (TMS) 2. Pharmacological Tx—Serotonin plays an important role  1st line: SSRIs (off-label: citalopram, escitalopram)—better tolerated than clomipramine -ADR: GI/diarrhea, sexual disfunction, restlessness -Paroxetine: dose adjustment in severe renal or hepatic impairment  2nd line: Clomipramine 25-100 mg daily (MAX 250 mg/d)—TCA -ADR: weight gain, anticholinergic side effect, sedation -Dose adjust in Crc< 30 or severe renal impairment nd  2 line/alternatives: Venlafaxine, duloxetine, mirtazapine, other TCAs Pharmacologic Therapy Antidepressant therapy (serotonergic)—equally efficacious • Drugs with consistent efficacy • Clomipramine (TCA class) • Fluoxetine • Fluvoxamine • Paroxetine • Sertraline • 40-75% of patients respond to SSRI treatment 40-75% of patients respond to first SSRI • Improvement often incomplete • Most patients have residual symptoms that limit functioning • Symptoms improve over 4-10 week period above goprotroth 4019 go Citalopram** (Celexa) Drugs Usual dose (mg/d) approve the fpa Occasional Off-label MAX Dose (mg/d) dEIS 20-40 80 Clomipramine (Anafranil) ^^ 75-250 Monitor drug level & ECG Escitalopram** (Lexapro) Fluoxetine (Prozac) 10-20 20-40 40 80-120 Fluvoxamine (Luvox) 100-300 450 Paroxetine (Paxil) 20-60 100 Sertraline (Zoloft) Venlafaxine (Effexor) 50-200 75-225 400 Duloxetine 60-120 Mirtazapine 30-60 60 ** Dose-related QTc prolongation ^^Clomipramine toxic level >900ng/ml seeit hand Yous atweekI to Approach and response to Treatment • 8–12 weeks remain as the optimal duration of an initial trial in OCD, o Two meta-analyses have demonstrated a significant improvement of OCD severity within the first 2 weeks of treatment with SSRIs, with the greatest incremental gains occurring early in the course of treatment o Likewise, an open-label trial of fluoxetine in treatment-naive patients indicated that a reduction of at least 20% of OCD symptom severity at week 4 was the best predictor of treatment response at 12 weeks o Altogether, these findings suggest that, in the absence of early improvement, modifications in the treatment plan may be considered before 8–12 week • For TCAs, initiate the drug at a low dose and increasing dose every 3–5 days. • The antidepressant dose should be increased to the highest recommended therapeutic level if initial treatment with a low or medium dose fails • For OCD, medium to high doses are recommended • Onset of effect can take up to 6-8 weeks or even longer 853 Augmentation Strategies Experts recommend waiting for a 3-month trial of antidepressant before augmenting with SGA Second Generation Antipsychotics •Evidence supports: •Risperidone •Aripiprazole •Olanzapine •Quetiapine Summary 1. OCD is characterized by obsessions and compulsions that are time consuming and cause disruption in daily functioning 2. CBT +/- SSRIs = FIRST-LINE therapy 3. Clomipramine may have greater efficacy and can be consider as alternative to SSRIs due to safety issues

OCD Obsessive-compulsive Disorder

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