Kembara Xtra - Medicine - Obsessive Compulsive Disorder
Not to be confused with obsessive-compulsive personality disorder, this anxiety disorder is marked by pathologic obsessions (recurrent intrusive thoughts, ideas, or images) and compulsions (repetitive, ritualistic behavioral or mental activities) that cause severe suffering. Epidemiology Incidence Predominant age: 19.5 years is the mean age of onset (1). - There are three subtypes: early onset in children and adolescents (18 years), adult onset (18–39 years), and late onset (40 years). In 50% of instances, the onset occurs in children or adolescents (often by age 18) (2). - Rarely diagnosed after the age of 50 - Predominant gender: females Obsessive-compulsive disorder (OCD) with a childhood onset (age 10 years) is more common in men, more likely to be heritable, and linked to a co-morbid tic disorder. - Although OCD can also be triggered in the peripartum or postpartum period, females are more likely to develop it during adolescence. Child Safety Considerations Insidious onset; evaluate brain injury in acute childhood OCD presentation. Aspects of Geriatrics Consider neurologic conditions in OCD with a recent onset. 2.3% lifetime frequency in adults; 1-2.3% prevalence in infants and adolescents Pathophysiology and Etiology Unknown exact pathophysiology and etiology. Possible function of: Dysregulation of serotonergic, catecholaminergic, and glutamatergic pathways; dysfunction of the orbitofrontal cortex (OFC) and anterior cingulate cortex (ACC) circuits of the cortico-striatal-thalamo-cortical (CSTC) system; and brain injury (physical trauma, stroke, etc.). Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS), an autoimmune injury to the basal ganglia, and contentious genetics Positive family history: incidence rates of 7-15% in first-degree relatives of children and adolescents with OCD Greater concordance in monozygotic twins Polygenic disorder with variations in serotonergic, catecholaminergic, and glutamatergic genes Risk Elements biological and environmental elements combined: OCD in the family; advanced mother and paternal ages; co-occurring mental illnesses, most frequently schizophrenia and anxiety disorders; Low serotonin levels have been linked to the emergence of OCD (antipsychotics with stronger antiserotoninergic mechanisms, like clozapine and olanzapine, have been connected with this). A history of childhood traumatic events, such as social exclusion and physical abuse, as well as brain injury, perinatal insults (birth difficulties), and encephalitis are some examples of brain injuries. Prevention Early detection and treatment can lessen the suffering and disability of the patient. Major depressive disorder, phobias, panic attacks, Tourette syndrome, tic disorders, substance misuse, eating disorders, and body dysmorphic disorder are all associated conditions. History Patients have obsessions, compulsions, or both, which are distressing, time-consuming (>1 hr/day), and significantly impede their ability to work and interact with others. Two criteria can be used to diagnose obsessions: - The person tries to ignore or neutralize these ideas with another thought or activity (for as by engaging in a compulsion). - The thoughts are recurrent, persistent, intrusive, and inappropriate. The following two criteria help to diagnose compulsions: - Repetitive, inflexible actions (such as hand washing) or mental activities (such as counting aloud) carried out in reaction to an obsession - Despite being intended to relieve stress, the response is either excessive or not really related to the fixation. Check for prior streptococcal infection in youngsters. clinical assessment Affected persons may have the following symptoms: chapped hands from excessive hand washing; hair loss from compulsive hair pulling or twisting; and weight loss from food restriction due to contamination fears. Differential Diagnosis: OCD (traits are pervasive, frequently ego-syntonic, and include perfectionism and obsession with detail, trivia, or procedure and regulation). Patients typically have rigid moral standards and are frugal.) Impulse-control problems, such as compulsive sex, gambling, or drug usage Major depressive disorder (depressive ruminations, without compulsive behavior, with themes of self-blame, guilt, failure, and regret) An eating disorder that only affects ritualized eating habits Tic disorder and stereotypic movement disorder (Tics are not intended to stop the preoccupation and are frequently preceded by premonitory sensations.) Schizophrenia disorder, phobic disorders, generalized anxiety disorder, and separation anxiety (excessive worry/anxious ruminating without compulsion) Hoarding disorder (difficulty getting rid of or giving up a possession; not related to an obsession) Body dysmorphic disorder (limited to concerns about appearance) Trichotillomania (exclusive to pulling out hair) Excoriation disorder (limited to overly plucking at the skin) Paraphilic disorder (limited to fantasies or cravings related to sexuality) Laboratory Results The following are the DSM-5's diagnostic standards for OCD: The existence of compulsions, obsessions, or both The following characteristics are used to define an obsession: - Recurrent or persistent urges, thoughts, or images that are felt as intrusive and unwanted and that significantly increase anxiety or distress - The person tries to ignore or suppress these urges, thoughts, or images or to neutralize them with other thoughts or behaviors (i.e., by engaging in compulsion). The following are the characteristics of compulsions: - Repetitive actions that an individual feels compelled to carry out as a result of an obsession or in accordance with norms that must be followed strictly, such as hand washing, ordering, checking, or silently repeating words. - The actions, whether physical or mental, are intended to avoid, lessen, or avoid some dreaded circumstance or event. These actions, however, are either obviously disproportionate or have no realistic connection to the thing they are intended to counteract or prevent. The obsessions or compulsions take up a lot of time (e.g., more than one hour per day), or they significantly hinder social, occupational, or other crucial areas of functioning. The physiologic consequences of a substance (such as an addictive substance, medication, or another medical condition) are not responsible for the OCD symptoms. Another mental condition's symptoms, such as excessive worrying like in generalized anxiety disorder or an obsession with appearance like in body dysmorphic disorder or skin picking, are not a better fit to explain the issue. Indicate whether the person has good or fair insight into whether their OCD beliefs are undoubtedly false, highly unlikely to be true, or uncertain. - Lack of insight: The person believes that their OCD-related beliefs are definitely real. - Lack of insight or delusional views: The person is utterly sure that their OCD beliefs are real. Indicate whether: - Tic related: The person has tic condition either now or in the past. Other/Diagnostic Procedures Standardized interviews are typically used to supplement assessment and management; free-form interviews are the most popular way for making an OCD diagnosis. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), which is used to gauge OCD severity and track recovery. Test Interpretation - Harm (i.e., being at fault for an accident) is a common obsessional theme - Uncertainty (i.e., whether the iron is off or the doors/windows are locked). - Blasphemous ideas (in a person who is fervently religious, for example) - Sexual obsessions (i.e., erroneous, impermissible thoughts) - Dirt, contamination, or illness - Symmetry/orderliness Customs or compulsions that are widespread - Cleaning and washing hands Both obsessions and compulsions are unrelated to another mental disease (such as food-related thoughts and the presence of an eating disorder), include checking, counting, ordering, and arranging, hoarding, and repeating. 80–90% of OCD sufferers engage in compulsive behaviors and obsessions. 10–19% of OCD patients are purely fixated. Management As a first line of treatment, cognitive-behavioral therapy (CBT), which combines exposure with response prevention and cognitive therapy, is advised. CBT has five stages of treatment: - Graded exposure and response training, family and individual psychoeducation, cognitive training, mapping OCD, relapse prevention, and generalization training. The best treatment for severe OCD involves a combination of medication and cognitive behavioral therapy. Other brain-modulation options for severe OCD include transcranial magnetic stimulation and electroconvulsive therapy. First Line of Medicine A sufficient antidepressant trial lasting at least 10 to 12 weeks. Doses that may be higher than those used to treat depression. The optimal time frame for pediatric patients is unknown, however a minimum maintenance course of treatment of 6 months is advised SSRIs are advised as first-line medications despite their variable levels of efficacy and the fact that no one SSRI is more effective than the others. Adults: 20 mg/day of fluoxetine (Prozac); increase by 10–20 mg every 4–6 weeks until response (20–80 mg/day). Children (7 to 17 years old): Start at 10 mg per day and gradually increase every 4 to 6 weeks until you see a response (20 to 60 mg per day). Sertraline, found in Zoloft Adults: range: 50 to 200 mg/day; increase by 50 mg every 4 to 7 days until response; may divide if >100 mg/day Children (6 to 17 years old): 25 mg/day, then 50 to 200 mg/day until response (25 mg/day increase every 7 days). Adults: 20 mg/day; increase by 10 mg every 4–7 days until response (40–60 mg/day). Paroxetine (Paxil). Children: It has not been proven to be safe or beneficial for kids under the age of 18. Citalopram (Celexa): Black box warning: maximum daily dose of 40 mg due to arrhythmia risk; not FDA-approved for use in OCD; absolute SSRI contraindications: concurrent use within 14 days of monoamine oxidase inhibitor (MAOI); relative SSRI contraindications: severe liver impairment; seizure disorder; precautions: watch for suicidal behavior/worsening depression during the first few months of therapy/after dosage changes - When therapy is started, it could make you feel sleepy and lightheaded. pregnant women's issues Except for paroxetine, which is a Category D drug, all SSRIs are Category C during pregnancy. Next Line Try switching to a different SSRI. - A trial of an SSRI produces a satisfactory response in 40–70% of patients, with a remission rate of 10%–40%. If there is no improvement, try tricyclic acid (TCA), clomipramine (Anafranil), an SSRI plus clomipramine, or citalopram or clomipramine IV therapy. Adults: 25 mg/day; increase progressively over two weeks to 100 mg/day, and then over several weeks to 250 mg/day (maximum dose), as tolerated. - Children (10 to 17 years old): 25 mg/day, titrated up to 3 mg/kg/day or 200 mg/day (whichever is less), tolerated. - Absolute contraindications to clomipramine Following a myocardial infarction (MI) by six months Relative clomipramine contraindications include: hypersensitivity to clomipramine or other TCA; concurrent use within 14 days of an MAOI; third-degree atrioventricular (AV) block. Narrow-angle glaucoma, prostatic hypertrophy, bundle branch block in the first or second degree, congestive heart failure, and narrow-angle glaucoma Precautions for Category C pregnancies Potential arrhythmia in individuals older than 40 years old receiving pretreatment ECG Watch for suicidal behavior/worsening depression during the first few months of therapy or after changing the dosage of antidepressants, especially in children, adolescents, and young adults. Referral for CBT (in vivo exposure and prevention of compulsions) and a psychiatric assessment are both appropriate in cases when obsessions and compulsions seriously impair the patient's ability to operate. Antipsychotic medications by themselves are ineffective for treating OCD. They can be used to supplement SSRI therapy for OCD that is resistant to treatment, but they can potentially make OCD symptoms worse. According to certain data, low-dose quetiapine or risperidone added to antidepressants will boost their efficacy. - Risperidone (Risperdal): 0.5 mg/day as a starting dose; 0.5 to 2.0 mg/day as a goal dose for at least 8 weeks Initial dose of aripiprazole (Abilify) is 5 mg/day; the target dose is 10 mg/day for at least 8 weeks. - Consider switching to venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), if there is still no improvement. Follow-up Y-BCOS survey to assess development ongoing treatment 1 to 2 years at maximum dosage, with a taper of 12–25% every 1-2 months. Patient Monitoring Watch for a reduction in obsessions and the amount of time spent engaging in compulsions. Chronic waxing and waning course in the majority of patients: - 54-61% chronic progressive course; - 24-33% variable course; - 11-14% phasic phases of remission - High risk of suicide; 50% of people have suicidal thoughts. Early onset is not a reliable indicator. Few studies have looked at how long pharmacotherapy should be administered, but it is typically advised to last for 1 to 2 years once remission is achieved. Patients who stop taking their medicine had a higher chance of relapsing (53% for those who switched to a placebo versus 23% for stable escitalopram). Complications include depression in one-third of OCD patients and avoidant behavior (which can lead to homeboundness in adults and school dropout in children). Panic-like and anxious episodes
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