Symptoms of Obsessive-compulsive Disorder

OCD Wednesday, September 11, 2024 9:50 AM • Epidemiology • Female>male • Avg age of onset: 24-35 y/o • Onset earlier in males • Etiology • Genetic + environmental factors • 1st degree relatives Probable OCD Panic disorder Eating disorders Obsessive-compusilve personality disorder • DSM-5 Criteria Obsessions • Repetitive thoughts, images, impulses • • 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. • 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) Compulsions • Repetitive activities, mental acts • 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. • The disturbance is not better explained by the symptoms of another mental disorder, for examples: • GAD (Generalized Anxiety Disorder) • Excoriation – Skin picking disorder • Eating disorder • Substances related and addictive disorders • 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 • • Suggested: A successful treatment response is a YBOCS score reduction of 35% or more • YBOCS – Yale Brown OCD Scale • Treatment • Non-pharmacological 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) • Pharmacological 1st-line: SSRIs (off-label: citalopram, escitalopram) Drugs with consistent efficacy (40-75% of patients respond to first SSRI) • Fluoxetine • Fluvoxamine • Sertraline • Paroxetine: dose adjustment in severe renal or hepatic impairment better tolerated than clomipramine Sx improve over 4-10 week period ADR: GI/diarrhea, sexual disfunction, restlessness 2nd-line: Clomipramine (Anafranil) 25-100 mg daily (MAX 250 mg/d) TCA Issues with tolerability and safety ADR: weight gain, anticholinergic side effect, sedation Monitor drug level & ECG Dose adjust in CrCl < 30 or severe renal impairment 2nd-line/alternatives: Venlafaxine, duloxetine, mirtazapine, other TCAs • Approach + Response to Treatment • 8–12 weeks remain as the optimal duration of an initial trial in OCD 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 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 If no response by week 4 → dose/medication should be optimized 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 • OCD dosing may go over FDA approved dosing • Onset of effect can take up to 6-8 weeks or even longer • Augmentation Strategy • Wait for 3 month trial of antidepressant before augmenting w/ 2nd gen antidepressant Evidence supports: • Risperidone • Aripiprazole • Olanzapine • Quetiapine