Obsessive Compulsive Disorder Definition/description Characterised by recurrent thoughts or urges (obsessions) that often lead to repetitive behaviours or mental acts (compulsions) Epidemiology • • • Childhood: more common in males Adulthood: more common in females Average age onset: 20s Aetiology • • • • • Genetic Neurobiological - Abnormalities in cortico-striato-thalamo-cortical (CSTC) circuit ➔Include orbitofrontal cortex, anterior cingulate cortex and striatum Serotonin levels Infections - Paediatric autoimmune neuropsychiatric disorder associated with strep infections (PANDAS) Psychological trauma Clinical features • • Obsessions - Recurrent, intrusive and distressing thoughts or urges Compulsions - Repetitive behaviours or mental acts to provide relief from anxiety caused by obsessions ➔E.g. excessive handwashing for someone who fears contamination Diagnosis A. Presence of obsessions, 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 in most individuals 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 (i.e., by performing a compulsion). Compulsions are defined by (1) and (2): 1. Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviours or mental acts. 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. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder. Treatment and Management • • • • • First line treatment - CBT or SSRIs ➔E.g. sertraline, paroxetine, fluvoxamine Cognitive therapy and exposure response prevention Combination of CBT and SSRI if the initial treatment was monotherapy Consider switching to one of the following: - TCA with a serotonergic action e.g. clomipramine - An SNRI e.g. venlafaxine Combination of an antipsychotic agent (off label) - E.g. risperidone, quetiapine and SSRIs