Name
OBSESSIVE COMPULSIVE DISORDER
DESCRIPTION
DETAIL
CAUSES Dysregulation of neurotransmitter, serotonin -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS • Impulse control disorders: Compulsive gambling, sex or substance abuse - the compulsive behavior is not in response to obsessive thought and patient derives pleasure from the activity, unlike OCD where obsessions and compulsions are ego dystonic • Depression: Can see brooding, but ideas not perceived as senseless as in OCD • Schizophrenia: Patient perceives thought to be true and from an external source • Obsessive compulsive personality disorder: Not to be confused with OCD. In personality disorder, traits are ego-syntonic. Traits include perfectionism, preoccupation with detail, trivia or procedure and regulation. Patient tends to be rigid, moralistic and stingy. Often traits are rewarded in patient‘s job as desirable traits. • Generalized anxiety, phobic disorders, separation anxiety: Similar response of heightened anxiety, but presence of obsessions or rituals clarifi es OCD diagnosis • Anxiety disorder due to a general medical condition: may be obsessions or compulsions, are assessed to be a direct physiological consequence of a general medical conditionSPECIAL TESTS • Yale Brown obsessive-compulsive scale (Y-BOCS) • Maudsley obsessive-compulsive inventory (MOCI) • Children’s Yale Brown obsessive-compulsive scale (CY-BOCS) IMAGING PET scan - abnormal metabolism in frontal cortex and caudate nuclei (not generally available other than in research centers) DIAGNOSTIC PROCEDURES Psychiatric interview
TYPENOTES
RISK FACTORS Greater concordance in monozygotic twins family history as aboveGENERAL MEASURES • Combine medications and cognitive behavior therapy • Psychiatric referral for therapy (in vivo exposure and response prevention) • Family psycho-education • Parent behavior management training if OCD patient child/adolescent SURGICAL MEASURES Psychosurgery (last resort) ACTIVITY No restriction DIET With use of phenelzine must have tyraminefree diet to prevent precipitation of hypertensive crisis DRUG(S) OF CHOICE . Serotonin reuptake inhibitor, fluoxetine (Prozac) . Adults: begin with 20 mg/day q morning and increase every 4-6 weeks to obtain maximal clinical response. Dose range: 20-60 mg/day. Doses >20 mg/day should be divided. . Children: safety and effi cacy has not been established for OCD . Sertraline (Zoloft) . Adults: begin with 50 mg per day and increase every week until clinical response. Dose range: 50-200 mg per day. Doses > 100 mg/day should be divided. . Children: Begin with 25 mg per day, increase in 25 mg increments until clinical response . Paroxetine (Paxil) . Adults: begin with 20 mg/day, increase weekly in 10 mg increments until maximal clinical response . Children: safety and effi cacy has not been established for OCD . Fluvoxamine (Luvox) . Adult - begin with 100 mg/day and increase every week until clinical response (dosage range 200-300 mg) . Children (8-17) - begin with 25 mg/day, increase in small increments (25-50 mg) until clinical response . Clomipramine (Anafranil) . Adults - beginning at 25 mg/day and increased gradually to 100 mg over fi rst 2 weeks. Then to 250 mg over next several weeks, as tolerated. . Children - beginning at 25 mg /day over fi rst two weeks as in adults. Then titrated up to 3 mg/kg or 200 mg/day (which ever is smaller) over the next several weeks. Contraindications: . Absolute fluoxetine, paroxetine, and sertraline contraindications : . Hypersensitivity to the selective serotonin re-uptake inhibitors . Within 14 days of MAO inhibitor . Relative fluoxetine and sertraline contraindications: . Severe liver impairment . Seizure disorders (lowers seizure threshold) . Clomipramine is of the tricyclic antidepressant class, so carries same contraindications as drugs in that class . Absolute clomipramine contraindications: . Within 6 months of myocardial infarction . Narrow angle glaucoma . 3rd degree AV block . Within 14 days of MAO inhibitor . Relative clomipramine contraindications: . Prostatic hypertrophy (urinary retention) . Seizure disorder (lower seizure threshold ) . 1st, 2nd degree AV block, bundle branch block and CHF (pro-arrhythmic effect) Precautions: • Drug should to be taken for a minimum of 10 weeks before considering it a treatment failure; could be several months before peak effi cacy • Because patients with OCD may have concomitant depression, suicide potential must be assessed • Long half-life may be troublesome if patient has an adverse reaction • May cause drowsiness and dizziness when therapy is initiated - warn patients about driving and heavy equipment hazards • May alter glucose control by lowering blood glucose levels while on the medication and increase blood glucose after stopping the medication • Tricyclic class of antidepressants dangerous in overdose PATIENT MONITORING • Y-BOCS • MOCI POSSIBLE COMPLICATIONS • Depression in 1/3 of OCD patients • Avoidant behavior (phobic avoidance) • Anxiety and panic-like episodes associated with obsessions EXPECTED COURSE/PROGNOSIS • Chronic waxing and waning course in majority • 24-33% fl uctuating course • 11-14% phasic with periods of remission • 54-61% chronic progressive course • Early onset a poor outcome predictor
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
PET ( POSITRON EMMISION TOMOGRAPHY ) IMAGING BRAIN