Post by Mel on Jan 6, 2006 13:59:22 GMT -5
Obsessive-Compulsive Disorder
Background: Obsessive-compulsive disorder (OCD) is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as an anxiety disorder. It is characterized by distressing intrusive thoughts and/or repetitive actions that interfere with the individual's daily functioning. The DSM-IV criteria for OCD are as follows:
The individual expresses either obsessions or compulsions. Obsessions are defined by the following 4 criteria:
Recurrent and persistent thoughts, impulses, or images are experienced at some time during the disturbance as intrusive and inappropriate and cause marked anxiety and distress.
The thoughts, impulses, or images are not simply worries about real-life problems.
The person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action.
The person recognizes that the obsessional thoughts, impulses, or images are a product of his/her own mind (not imposed from without as in thought insertion).
Compulsions are defined by the following 2 criteria:
The person feels driven to perform repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) in response to an obsession or according to rules that must be applied rigidly.
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are meant to neutralize or prevent or they are clearly excessive.
At some point during the course of the disorder, the person recognizes that the obsessions or compulsions are excessive or unreasonable. This does not apply to children.
The obsessions or compulsions cause marked distress; are time consuming (take >1 h/d); or significantly interfere with the person's normal routine, occupational or academic functioning, or usual social activities or relationships.
If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it, such as preoccupation with food and weight in the presence of an eating disorder, hair pulling in the presence of trichotillomania, concern with appearance in body dysmorphic disorder, preoccupation with drugs in substance use disorder, preoccupation with having a serious illness in hypochondriasis, preoccupation with sexual urges in paraphilia, or guilty ruminations in the presence of major depressive disorder.
The disorder is not due to the direct physiologic effects of a substance or a general medical condition.
Specify with poor insight if, for most of the current episode, the person does not recognize that the symptoms are excessive or unreasonable.
Pathophysiology: The exact pathophysiologic process that underlies OCD has not been established. Research and treatment trials suggest that abnormalities in serotonin (5-HT) transmission in the central nervous system are central to this disorder. This is strongly supported by the efficacy of specific serotonin reuptake inhibitors (SSRIs) in the treatment of OCD.
Evidence also suggests a role for abnormalities in dopaminergic transmission in cases of OCD. In some cohorts, Tourette syndrome and multiple chronic tics genetically co-vary with OCD in an autosomal dominant pattern. OCD symptoms in this group of patients show a preferential response to a combination of SSRIs and neuroleptics.
Functional and anatomic studies in OCD have demonstrated some reproducible patterns of abnormality. Specifically, MRI and positron emission tomography (PET) scanning have shown increases in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus, with a trend toward right-sided predominance. In some studies, these areas of overactivity have been shown to normalize following successful treatment with either SSRIs or cognitive-behavioral therapy (CBT). These findings suggest the hypothesis that the symptoms of OCD are driven by impaired intracortical inhibition of a para-limbic circuit that mediates strong emotions and the autonomic responses to those emotions. Cingulotomy, a neurosurgical intervention in OCD, interrupts this circuit (see Treatment).
Similar abnormalities of inhibition are observed in Tourette syndrome, with a postulated abnormal modulation of basal ganglia activation.
Frequency:
In the US: Once believed to be rare, OCD appears to have an overall prevalence of 1.7-4%. Discovery of effective treatments and education of patients and health care providers have significantly increased the identification of individuals with OCD over the past decade.
Internationally: International studies have shown a similar incidence and prevalence of OCD worldwide.
Mortality/Morbidity:
OCD is a chronic disorder. Without treatment, symptoms may wax and wane in intensity but rarely remit spontaneously. While many patients experience moderate symptoms, OCD can potentially be a severe and disabling illness.
Persons with OCD often do not seek treatment. Many persons with OCD delay for years before obtaining an evaluation for obsessive-compulsive (OC) symptoms. Patients with OCD often feel shame regarding their symptoms and put great effort into concealing them from family, friends, and health care providers.
Sex: The overall prevalence of OCD is equal in males and females. Childhood-onset OCD is more common in males and more likely to be linked genetically with attention deficit hyperactivity disorder (ADHD) and Tourette syndrome.
Age: Symptoms usually begin in individuals aged 10-24 years. Childhood-onset OCD may have a higher rate of comorbidity with Tourette syndrome and ADHD.
CLINICAL Section 3 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography
History: OCD is diagnosed primarily by history. Once the diagnosis is suspected, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) is an important tool in defining the range and severity of symptoms and monitoring the response to treatment. Elements that should be covered when obtaining the history, including suggestions for typical interview questions, include the following:
Nature and severity of obsessive symptoms
Have you ever been bothered by thoughts that do not make any sense and keep coming back to you even when you try not to have them?
When you had these thoughts, did you try to get them out of your head? What would you try to do?
Where do you think these thoughts are coming from?
Nature and severity of compulsive symptoms
Has there ever been anything that you had to do over and over again and could not resist doing, such as repeatedly washing your hands, counting up to a certain number, or checking something several times to make sure you have done it right?
What behavior did you have to do?
Why did you have to do the repetitive behavior?
How many times would you do it and how long would it take?
Do these thoughts or actions take more time than you think makes sense?
What effect do they have on your life?
Age of onset
History of tics, either current or past
Psychiatric review of systems
Mood and anxiety symptoms
Somatoform disorders, especially hypochondriasis and body dysmorphic disorder
Eating disorders
Impulse control disorders, especially kleptomania and trichotillomania
ADHD
Family history of OCD, Tourette syndrome, tics, ADHD, and other psychiatric diagnoses
Current or past substance abuse or dependence
Antecedent infections, especially streptococcal and herpetic infections
Common obsessions include the following:
Contamination
Safety
Doubting one's memory or perception
Scrupulosity (need to do the right thing, fear of committing a transgression, often religious)
Need for order or symmetry
Sexual/aggressive thoughts
Common compulsions include the following:
Cleaning/washing
Checking (checking locks, stove, iron, safety of children)
Counting/repeating actions a certain number of times or until it feels right
Arranging objects
Touching/tapping objects
Hoarding
Confessing/seeking reassurance
List making
Physical:
Evaluate all patients with OCD for the presence of Tourette syndrome or other tic disorders because this can be a comorbid diagnosis that may influence the treatment strategy. The findings on neurologic and cognitive examination should otherwise be normal. Focal neurologic signs or evidence of cognitive impairment should prompt evaluation for other diagnoses.
Skin findings in OCD may include the following:
Eczematous eruptions related to excessive washing
Hair loss related to trichotillomania or compulsive hair pulling
Excoriations related to neurodermatitis or compulsive skin picking
Causes: The cause of OCD is not known; however, the following elements may play a role.
Genetic: In some cohorts, OCD, ADHD, and Tourette syndrome/tic disorders co-vary in an autosomal dominant fashion with variable penetrance.
Infectious
Case reports of OCD with and without tics arising in children and young adults following acute group A streptococcal infections have been published. Fewer reports cite herpes simplex virus as the precipitating infectious event.
The hypothesis holds that these infections trigger a CNS immune response that produces neuropsychiatric symptoms (ie, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections [PANDAS]). A number of the poststreptococcal cases improved following treatment with antibiotics.
Stress: OCD symptoms can worsen with stress; however, this does not appear to be an etiologic factor.
Interpersonal relationships
OCD symptoms can interact negatively with interpersonal relationships, and families can become involved with the illness in a counterproductive way.
Parenting style or upbringing does not appear to be a causative factor in OCD.
Background: Obsessive-compulsive disorder (OCD) is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as an anxiety disorder. It is characterized by distressing intrusive thoughts and/or repetitive actions that interfere with the individual's daily functioning. The DSM-IV criteria for OCD are as follows:
The individual expresses either obsessions or compulsions. Obsessions are defined by the following 4 criteria:
Recurrent and persistent thoughts, impulses, or images are experienced at some time during the disturbance as intrusive and inappropriate and cause marked anxiety and distress.
The thoughts, impulses, or images are not simply worries about real-life problems.
The person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action.
The person recognizes that the obsessional thoughts, impulses, or images are a product of his/her own mind (not imposed from without as in thought insertion).
Compulsions are defined by the following 2 criteria:
The person feels driven to perform repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) in response to an obsession or according to rules that must be applied rigidly.
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are meant to neutralize or prevent or they are clearly excessive.
At some point during the course of the disorder, the person recognizes that the obsessions or compulsions are excessive or unreasonable. This does not apply to children.
The obsessions or compulsions cause marked distress; are time consuming (take >1 h/d); or significantly interfere with the person's normal routine, occupational or academic functioning, or usual social activities or relationships.
If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it, such as preoccupation with food and weight in the presence of an eating disorder, hair pulling in the presence of trichotillomania, concern with appearance in body dysmorphic disorder, preoccupation with drugs in substance use disorder, preoccupation with having a serious illness in hypochondriasis, preoccupation with sexual urges in paraphilia, or guilty ruminations in the presence of major depressive disorder.
The disorder is not due to the direct physiologic effects of a substance or a general medical condition.
Specify with poor insight if, for most of the current episode, the person does not recognize that the symptoms are excessive or unreasonable.
Pathophysiology: The exact pathophysiologic process that underlies OCD has not been established. Research and treatment trials suggest that abnormalities in serotonin (5-HT) transmission in the central nervous system are central to this disorder. This is strongly supported by the efficacy of specific serotonin reuptake inhibitors (SSRIs) in the treatment of OCD.
Evidence also suggests a role for abnormalities in dopaminergic transmission in cases of OCD. In some cohorts, Tourette syndrome and multiple chronic tics genetically co-vary with OCD in an autosomal dominant pattern. OCD symptoms in this group of patients show a preferential response to a combination of SSRIs and neuroleptics.
Functional and anatomic studies in OCD have demonstrated some reproducible patterns of abnormality. Specifically, MRI and positron emission tomography (PET) scanning have shown increases in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus, with a trend toward right-sided predominance. In some studies, these areas of overactivity have been shown to normalize following successful treatment with either SSRIs or cognitive-behavioral therapy (CBT). These findings suggest the hypothesis that the symptoms of OCD are driven by impaired intracortical inhibition of a para-limbic circuit that mediates strong emotions and the autonomic responses to those emotions. Cingulotomy, a neurosurgical intervention in OCD, interrupts this circuit (see Treatment).
Similar abnormalities of inhibition are observed in Tourette syndrome, with a postulated abnormal modulation of basal ganglia activation.
Frequency:
In the US: Once believed to be rare, OCD appears to have an overall prevalence of 1.7-4%. Discovery of effective treatments and education of patients and health care providers have significantly increased the identification of individuals with OCD over the past decade.
Internationally: International studies have shown a similar incidence and prevalence of OCD worldwide.
Mortality/Morbidity:
OCD is a chronic disorder. Without treatment, symptoms may wax and wane in intensity but rarely remit spontaneously. While many patients experience moderate symptoms, OCD can potentially be a severe and disabling illness.
Persons with OCD often do not seek treatment. Many persons with OCD delay for years before obtaining an evaluation for obsessive-compulsive (OC) symptoms. Patients with OCD often feel shame regarding their symptoms and put great effort into concealing them from family, friends, and health care providers.
Sex: The overall prevalence of OCD is equal in males and females. Childhood-onset OCD is more common in males and more likely to be linked genetically with attention deficit hyperactivity disorder (ADHD) and Tourette syndrome.
Age: Symptoms usually begin in individuals aged 10-24 years. Childhood-onset OCD may have a higher rate of comorbidity with Tourette syndrome and ADHD.
CLINICAL Section 3 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography
History: OCD is diagnosed primarily by history. Once the diagnosis is suspected, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) is an important tool in defining the range and severity of symptoms and monitoring the response to treatment. Elements that should be covered when obtaining the history, including suggestions for typical interview questions, include the following:
Nature and severity of obsessive symptoms
Have you ever been bothered by thoughts that do not make any sense and keep coming back to you even when you try not to have them?
When you had these thoughts, did you try to get them out of your head? What would you try to do?
Where do you think these thoughts are coming from?
Nature and severity of compulsive symptoms
Has there ever been anything that you had to do over and over again and could not resist doing, such as repeatedly washing your hands, counting up to a certain number, or checking something several times to make sure you have done it right?
What behavior did you have to do?
Why did you have to do the repetitive behavior?
How many times would you do it and how long would it take?
Do these thoughts or actions take more time than you think makes sense?
What effect do they have on your life?
Age of onset
History of tics, either current or past
Psychiatric review of systems
Mood and anxiety symptoms
Somatoform disorders, especially hypochondriasis and body dysmorphic disorder
Eating disorders
Impulse control disorders, especially kleptomania and trichotillomania
ADHD
Family history of OCD, Tourette syndrome, tics, ADHD, and other psychiatric diagnoses
Current or past substance abuse or dependence
Antecedent infections, especially streptococcal and herpetic infections
Common obsessions include the following:
Contamination
Safety
Doubting one's memory or perception
Scrupulosity (need to do the right thing, fear of committing a transgression, often religious)
Need for order or symmetry
Sexual/aggressive thoughts
Common compulsions include the following:
Cleaning/washing
Checking (checking locks, stove, iron, safety of children)
Counting/repeating actions a certain number of times or until it feels right
Arranging objects
Touching/tapping objects
Hoarding
Confessing/seeking reassurance
List making
Physical:
Evaluate all patients with OCD for the presence of Tourette syndrome or other tic disorders because this can be a comorbid diagnosis that may influence the treatment strategy. The findings on neurologic and cognitive examination should otherwise be normal. Focal neurologic signs or evidence of cognitive impairment should prompt evaluation for other diagnoses.
Skin findings in OCD may include the following:
Eczematous eruptions related to excessive washing
Hair loss related to trichotillomania or compulsive hair pulling
Excoriations related to neurodermatitis or compulsive skin picking
Causes: The cause of OCD is not known; however, the following elements may play a role.
Genetic: In some cohorts, OCD, ADHD, and Tourette syndrome/tic disorders co-vary in an autosomal dominant fashion with variable penetrance.
Infectious
Case reports of OCD with and without tics arising in children and young adults following acute group A streptococcal infections have been published. Fewer reports cite herpes simplex virus as the precipitating infectious event.
The hypothesis holds that these infections trigger a CNS immune response that produces neuropsychiatric symptoms (ie, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections [PANDAS]). A number of the poststreptococcal cases improved following treatment with antibiotics.
Stress: OCD symptoms can worsen with stress; however, this does not appear to be an etiologic factor.
Interpersonal relationships
OCD symptoms can interact negatively with interpersonal relationships, and families can become involved with the illness in a counterproductive way.
Parenting style or upbringing does not appear to be a causative factor in OCD.
