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Obsessive Compulsive Disorder OCD


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Title: Obsessive Compulsive Disorder OCD

Obsessive Compulsive Disorder(OCD)
  • Dr. Bob Carey
  • Regional Support Associates

As Good as It Gets
What is OCD?
  • Disorder causing worries, doubts, and
    superstitious beliefs during everyday life.
  • Described by some as mental hiccups that wont
    go away.

Obsessions? Compulsions?
  • Obsessions repetitive and unwelcome thoughts,
    images, or impulses that are difficult to dismiss
    or control.
  • Compulsions repetitive behavioral responses
    can be resisted only with great difficulty.
  • Recent studies have found lifetime prevalence of
    OCD in North America to be about 2.5/100 people.

  • Thoughts, images, or impulses that repetitively
    occur to become out of ones own control.
  • Person suffering from these obsessions finds them
    intrusive and disturbing recognizes they dont
    make sense.

Obsessions - continued
  • Obsessions often accompanied by uncomfortable
    feelings such as fear, disgust, or doubt.
  • For example, people with OCD may worry
    excessively about dirt and germs, and obsessed
    with the idea that they are contaminated or may
    contaminate others

  • These are acts that are continually performed to
    provide relief from discomfort caused by
  • OCD compulsions do not give the person pleasure
    (unlike drinking, gambling, etc.).
  • For example, a person may repeatedly check to see
    if their stove was left on in fear of burning the
    house down.

Most people with OCD have multiple OCD symptoms
Multiple Compulsions
Common Symptoms
OCD time spent thinking about the act and
performing the act
Ordering Compulsion
Most Common Symptoms
  • Sets of common obsessions and compulsions are
    observed in developmentally disabled individuals
    with OCD. Typically, these sets are described
    best as just so behaviors, in which certain
    things have to be arranged or performed in a
    particular way to relieve the anxiety.
  • The most clinically useful and detailed symptoms
    checklist is included in the Yale-Brown
    Obsessive-Compulsive Scale.

OCD and Developmental Disability
  • may not to be able to identify obsessions
  • may not recognize that obsessions dont make
  • diagnosis often based on compulsions
  • misdiagnosis is common both inaccurate
    diagnosis of OCD or misdiagnosis of another

Common Themes
  • The most common theme of obsessions are
    contamination themes, and the related compulsive
    behavior is washing, usually compulsive
    handwashing. Along with contamination themes,
    problems with aggressive obsessions, sexual
    obsessions, the need for symmetry and order,
    obsessions about harm to oneself or others, and
    the need to confess exist. These excessive
    thoughts result in the common compulsive
    behaviors of washing, repeating, checking,
    touching, counting, arranging, hoarding, or

Misdiagnosis is Common
  • Because the behaviors observed in persons with
    OCD often are stereotypical and repetitive, 2
    other disorders, both in the developmental
    disability spectrum, commonly are confused with
  • First, children with mild autism or Asperger
    disorder also may have repetitive thoughts and
    specific stereotypic compulsive behaviors. While
    disorders in the autistic spectrum are considered
    to be pervasive developmental disorders (PPD) and
    quite different than OCD, at times the
    differential diagnosis between the 2 sets of
    disorders is somewhat difficult to make.

How to Tell the Difference
  • Remember - Social difficulties and communication
    problems are key intrinsic features of Asperger
    disorder on the PDD spectrum.

Co-Morbid Disorders Differential Diagnosis
Diagnostic Issues in DD
  • Difficult to distinguish with personality traits
    in persons with DH that engage in repetitive
    questions (repetitive speech, echolalia) that can
    occur in anxious individuals with limited verbal
    skills or in autistic spectrum disorders.
  • Compulsive behaviours are common in adults with
    intellectual disability stereotyped behaviour
    and movement disorders from underlying brain

When does OCD begin?
  • Begin anywhere from preschool age to adulthood
    (40 years).
  • Obsessive-compulsive behavior affects both males
    and females equally but is more common among
    adolescent boys than adolescent girls. The mean
    age of onset is about 20 years (2,10), but cases
    have been reported in children as young as 2
    years (10-12).
  • On average, people with OCD see 3-4 doctors and
    spend over 9 years seeking treatment before they
    receive a correct diagnosis.
  • OCD tends to go under-diagnosed and under-treated
    because people with the illness often act
    secretive about their symptoms.

(No Transcript)
Epidemiology of OCD
  • The majority of patients with obsessive-compulsive
    disorder have both obsessions and compulsions,
    some have only one or the other.
  • Most patients realize the irrational nature of
    their thoughts and rituals but feel helpless and
    hopeless about controlling them.
  • In one epidemiologic survey, 18 children were
    found to have OCD, and only 4 were receiving any
    professional mental health care. Not one of these
    4 was diagnosed properly.

Gender Culture
  • Boys are more likely to have a prepubertal onset
    and a family member with OCD or Tourette
  • Girls are more likely to have onset of OCD during
  • OCD is more common in whites than African
    American children in clinical samples. However,
    epidemiologic data suggest no differences in
    prevalence as a function of ethnic group or
    geographic region.

Prevalence of OCD
  • The World Health Organization lists
    obsessive-compulsive disorder as one of the five
    major causes of disability throughout the world.
  • It is considered the fourth most common
    psychiatric condition, ranking after phobias,
    substance abuse disorders, and major depressive
    mood disorder.

Prevalence Underestimated
  • Prevalence of OCD is underestimated why?
  • 60 of all persons with a diagnosable anxiety
    disorder never see a mental health professional
    they may turn to their family physician,
    religious leader or another family member for

Prevalence with Intellectual Disability
  • In the general population, the prevalence is
    estimated to be around 1
  • In populations with intellectual disability, the
    prevalence has been estimated to be between 1 and

What Causes OCD?
  • The probable biologic explanations of
    obsessive-compulsive disorder include heredity,
    brain lesions, abnormal brain glucose metabolism,
    and serotonergic dysfunction.
  • No specific gene associated with OCD however,
    when a parent has OCD there is an increased risk
    that the child will also develop the illness.
  • Problems in the front part of brain (orbital
    cortex) and deeper structures (basal ganglia).

Brain Differences persons with OCD use
different brain circuitry in performing a
cognitive task than people without the disorder
(Rauch et al. J. of Neuropsychiatry, 1997)
Genetic Link?
  • If one twin has OCD, the other twin is more
    likely to have OCD if the children are identical
    twins rather than fraternal twin pairs.
  • OCD is increased among first-degree relatives of
    children with OCD, particularly among fathers
    (Lenane et al., 1990). It does not appear that
    the child is simply imitating the relatives
    behavior, because children who develop OCD tend
    to have symptoms different from those of
    relatives with the disease (Leonard et al.,

Role of Serotonin
  • Studies showing that serotonin plays a role in
    the pathophysiology of obsessive-compulsive
    disorder have led to new and highly effective

Infection Causes?
  • Recent research suggests that some children with
    OCD develop the condition after experiencing one
    type of streptococcal infection (Swedo et al.,
    1995). This condition is referred to by the
    acronym PANDAS, which stands for Pediatric
    Autoimmune Neuropsychiatric Disorders Associated
    with Streptococcal infections. Its hallmark is a
    sudden and abrupt exacerbation of OCD symptoms
    after a strep infection.
  • The cause of this form of OCD appears to be
    antibodies directed against the infection
    mistakenly attacking a region of the brain and
    setting off an inflammatory reaction.

OCD Cause Summary
  • Although a definitive cause of obsessive-compulsiv
    e disorder has not yet been found, it is
    considered the product of interactions between
    biologic predisposition and various developmental
    and psychosocial influences

OCD Assessment
  • For adults with intellectual disability
    Compulsive Behavior Checklist (Gedye, 1996)
  • This list uses 25 types of compulsions done by
    adults with developmental disabilities grouped
    into 5 categories ordering, completeness,
    cleaning, checking/touching, deviant grooming.
  • Ratings are done by caregiver who has familiarity
    with person.

OCD Assessment
  • Also we can use the Obsessive Speech Checklist
    designed for use only with developmentally
    disabled people who talk in sentences and use
    meaningful speech
  • This is used to help determine if they meet the
    criteria for OCD

  • During last 20 years, two effective methods for
    treating OCD have been developed
  • Cognitive-Behavioural Psychotherapy (CBT)
  • Medication with a serotonin reuptake inhibitor

Stages of Treatment
  • Acute Treatment Phase Treatment is aimed at
    ending the current episode of OCD.
  • Maintenance Treatment Treatment is aimed at
    preventing future episodes of OCD.

Components of Treatment
  • Education Educate family and patients on how to
    manage OCD and prevent complications.
  • Psychotherapy Cognitive-Behavioural Therapy
    (CBT) is the key element of treatment for most
    patients with OCD.
  • Medication Medication with a serotonin reuptake
    inhibitor is helpful for many OCD patients.

Treatment Considerations
  • Use of both medication and psychotherapy results
    in a better outcome than use of either alone.
  • Many patients with obsessive-compulsive disorder
    are very secretive about their illness.
    Therefore, a detailed review of symptoms may be
  • Many patients have somatic complaints (eg,
    fatigue, pain, hypochondriacal symptoms,
    excessive worrying, chronic sadness). Thus, a
    comprehensive medical evaluation is essential to
    rule out any preexisting medical and psychiatric

More Treatment Considerations
  • The impact of obsessive-compulsive disorder on
    interpersonal relationships, employment,
    marriage, and academic performance needs to be
    evaluated early in the diagnostic process.
  • Coexisting psychiatric conditions (eg, major
    depression, panic disorder, phobias, eating
    disorders) should be treated along with
    obsessive-compulsive disorder. Similarly,
    obsessive-compulsive patients with ongoing
    alcohol or drug abuse problems should be treated
    for these before medication is considered.
  • Although obsessive symptoms can be reduced with
    medications, the interpersonal relationships,
    social skills, work habits, and ability to resist
    compulsions require a comprehensive treatment
    plan that involves several aspects of each
    patient's life.

Cognitive Behavioural Psychotherapy (CBT)
  • Exposure and response intervention.
  • Exposure person remains in contact with
    something they usually fear until their anxiety
    is diminished.
  • Response intervention persons rituals or
    avoidance behaviours are blocked (those afraid of
    germs are not only exposed to germs but refrained
    from ritualized washing).
  • Exposure is usually more helpful in decreasing
    anxiety and obsessions, while response
    intervention is better at decreasing compulsive

CBT (Contd)
  • Patients who complete CBT report a 50-80
    reduction in OCD symptoms after 11-20 sessions.
  • Using CBT on a weekly basis, can take 2 months or
    longer to show full effects.
  • Practiced in the therapists office, and do daily
    E/RP homework.
  • When the OCD is very severe, it is sometimes
    better to practice CBT in a hospital setting.

Treatment Effectiveness
  • Behavioural techniques are most effective for
    certain types of OCD symptoms particularly
    cleaning or checking rituals.
  • Best approaches are DRO in combination with in
    vivo exposure Relaxation Training Stimulus
    Control techniques.

Medications First-line drug treatment
  • In a primary care setting with appropriate
    psychiatric consultation, pharmacotherapy for
    obsessive-compulsive disorder and comorbid
    psychiatric conditions can be quite successful.
    Between 50 and 70 of patients respond well to
  • The tricyclic antidepressant clomipramine
    hydrochloride (Anafranil) and various selective
    serotonin reuptake inhibitors (SSRIs) have been
    approved by the US Food and Drug Administration
    (FDA) for treatment of obsessive-compulsive
  • The approved SSRIs include fluvoxamine maleate
    (Luvox), paroxetine hydrochloride (Paxil),
    sertraline hydrochloride (Zoloft), and fluoxetine
    hydrochloride (Prozac).

Medication Efficacy Studies
  • Double Blind studies have shown the effectiveness
  • Clomipramine (may be the best but has the most
    adverse side effects)
  • Fluvoxamine
  • Fluoxetine
  • Sertraline
  • They inhibit the reuptake of serotonin into
    synaptic nerve terminals

Side Effects to Watch for
  • Teratogenetic concerns avoid all medications
    during pregnancy unless symptoms are disabling .
    All SSRIs are excreted in breast milk and
    therefore should not be used by nursing mothers.
  • Hepatic disease and hepatic metabolism SSRIs
    should be used cautiously in patients with
    chronic hepatic diseases. Clinical monitoring and
    dose reductions are recommended to prevent drug
    interactions and undesirable side effects.
  • Sexual dysfunction Although most side effects
    associated with SSRIs are well tolerated over
    time, sexual dysfunction is perhaps the most
    troubling adverse effect and can lead to
    discontinuation of or noncompliance with drug
  • Cessation of therapy Abrupt discontinuation of
    SSRIs can lead to development of the
    "interruption-discontinuation syndrome." This is
    manifested by emergence of adverse effects and
    worsening of obsessive-compulsive symptoms.
    Therefore, gradual tapering of doses or shifting
    among various SSRIs is recommended (17).

Adjunctive drug therapy
  • Buspirone hydrochloride (BuSpar), a specific
    nonbenzodiazepine anxiolytic medication, has been
    shown to benefit some obsessive-compulsive
    patients with comorbid anxiety.
  • Mood stabilizers (eg, lithium, carbamazepine,
    valproic acid Depakene, Depakote) can be used
    to augment the efficacy of SSRIs or to treat
    obsessive-compulsive patients with comorbid
    bipolar disorder .

Med. Treatment Issues
  • Clomipramine and SSRIs as anti-compulsive agents
    have the potential to precipitate hypomania and
  • Risperidone is useful as an acute hypomanic
    agent, has mood stabilizing properties.

When insight is poor
  • Motivation is necessary for CBT to be effective
  • OCD behaviour is of itself reinforcing
  • When insight is poor, behavioural techniques may
  • If you block one compulsion, usually another is

Behavioural Techniques
  • Behavioural techniques are most effective for
    certain types of OCD symptoms particularly
    cleaning or checking rituals.
  • Best approaches are Differential Reinforcement
    in combination with Relaxation Training and
    Stimulus Control techniques.

Differential Reinforcement
  • Very effective and efficient but difficult to do
    on a consistent basis
  • Reinforce behaviours that are appropriate
  • Ignore behaviours that are not appropriate
  • Redirect

Relaxation Techniques
  • Identify anxiety behaviours
  • Relaxation Deep breathing, muscle relaxation
  • Guided Imagery
  • Provide concrete visual cues
  • Quiet place

Stimulus Control
  • Set up person for success
  • Identify triggers /stimulus
  • Instigating conditions
  • Vulnerability conditions
  • Maintaining (reinforcing) conditions
  • Reduce the internal triggers - medication
  • Modify environment
  • Teach coping skills

Is this the hill you want to die on?
  • Restricting behaviour will escalate behaviour
  • Compromise
  • Allow behaviour within defined limits
  • E.g., defined space for hoarding

Best Treatment Approach
  • Multi-Modal that considers the
    Bio-Psycho-Social aspects of the person
  • OCD may improve with habilitative changes, person
    centred planning, specific behavioural
    intervention plans and appropriate medication
    treatment and ongoing monitoring of

Difficulties in Producing Change
Case History
  • Story of Alaa Severe OCD

  • Diagnostic uncertainty English is not first
    language possible High Functioning Autism or
    Aspergers syndrome

Ritualistic Behaviours
  • Will perform ritualistic behaviours all day long
    cleaning, repetitive questions, routine and
  • Will become agitated during performance of
    rituals can become very aggressive at these

Case Alaa
  • Severe Aggression led to placement in
    Institutional setting where he was given 31
    staffing ratio (Alaa 3 staff)
  • He was not allowed out

Alaa environment
  • He was kept in a locked room most of day (TV room
    with locked half door)
  • He was moved (e.g. to bathroom) with 3 staff
    encircling him and having him keep his hands in

Case Alaa
  • CTO was used for extreme aggression
  • He would also engage in SIB hundreds of times
    per day
  • He would also engage in Property Destruction
    holes in walls, broken toilets, etc

Case Alaa Treatment Plan
  • Use of DRO Contingency Management Token
    Economy absence of target behaviours
  • Greatly improving the quality of his time and
    interactions with staff doing fun activities
  • Eliminate locked areas in house but reserving use
    of CTO for extreme aggression
  • Develop prompting strategy so as not to
    inadvertently reinforce repetitive questions (one
    reminder prompt and withdraw attention)

Alaa Treatment
  • Expose him to many other reinforcing activities
    to lessen his obsessions around specific video
    movies, food, cleaning
  • New Psychiatrist new medications with use of
    SSRIs .
  • Propranolol Nozinan seem to be helping

Ontario OCD Resources
  • The Ontario OCD Network.Contact Details for
    Resource DirectoryCorinna de Beer120 Lombard
    St., Suite 301, Toronto, Ontario, M5C 3H5Ph
    416-970-2611Fax 416-703-7151eMail

OCD Network
  • Ontario Obsessive Compulsive Disorder NetworkPO
    Box 151Markham, OntL3P 3J7tel
    416-410-4772fax 905-472-4473web site    
    http//home.interhop.net/oocdnEmail is
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