OCD Obsessive Compulsive Disorder

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					                       Obsessive-Compulsive Disorder
                    Summary of the APA Practice Guideline

1. DSM IV Criteria
   A. Either obsessions or compulsions:

   Obsessions as defined by (1), (2), (3), and (4):

             (1) recurrent and persistent thoughts, impulses, or images that are
   experienced at some time during the disturbance, as intrusive and inappropriate
   and that cause marked anxiety or distress

             (2) the thoughts, impulses, or images are not simply excessive worries
   about real-life problems

            (3) the person attempts to ignore or suppress such thoughts, impulses,
   or images, or to neutralize them with some other thought or action

             (4) the person recognizes that the obsessional thoughts, impulses, or
   images are a product of his or her own mind (not imposed from without as in
   thought insertion)

   Compulsions as defined by (1) and (2):

              (1) repetitive behaviors (e.g., hand washing, ordering, checking) or
   mental acts (e.g., praying, counting, repeating words silently) that the person
   feels driven to perform in response to an obsession, or according to rules that
   must be applied rigidly

              (2) 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 designed to neutralize or prevent or are clearly excessive

        B. At some point during the course of the disorder, the person has
   recognized that the obsessions or compulsions are excessive or unreasonable.
   Note: This does not apply to children.

         C. The obsessions or compulsions cause marked distress, are time
   consuming (take more than 1 hour a day), or significantly interfere with the
   person’s normal routine, occupational (or academic) functioning, or usual social
   activities or relationships.

       D. If another Axis I disorder is present, the content of the obsessions or
   compulsions is not restricted to it (e.g., preoccupation with food in the presence
   of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern
   with appearance in the presence of Body Dysmorphic Disorder; preoccupation
   with drugs in the presence of a Substance Use Disorder; preoccupation with
   having a serious illness in the presence of Hypochondriasis; preoccupation with
   sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in
   the presence of Major Depressive Disorder).

       E. The disturbance is not due to the direct physiological effects of a
   substance (e.g., a drug of abuse, a medication) or a general medical condition.

2. Differential Diagnoses with major differentiators

      a. Depression – depressive ruminations are mood congruent, usually focus
         on the past, and do not elicit compulsions/rituals
      b. GAD– worries focus on real-life problems or vague sense of foreboding
         and do not elicit compulsions
      c. PTSD – intrusive thoughts related to past trauma not anticipated future
      d. Schizophrenia, Psychosis of Mania or Depression - will have other
         symptoms of these disorders. OCD obsessions of delusional intensity
         more likely to have typical OCD content versus in psychotic disorders
         where persecution, ideas of reference, grandiosity more likely
      e. Hypochondriasis – worries about health arise from misinterpreted body
         symptoms, and there is lack of insight
      f. Body Dysmorphic Disorder – recurrent, intrusive thoughts limited to fear of
         body defect
      g. Anorexia/Bulimia – thoughts and behaviors focus on body weight
      h. Paraphilias, Pedophilia - OCD sexual obsessions lead to avoidance
         behaviors, are morally abhorrent, and are resisted

3. Epidemiology
      a. 1-month prevalence: 0.6% in adults
      b. Lifetime prevalence: 1.6%
      c. Mean age of onset: 22-35yo, 1/3 of cases before 15yo, males earlier onset
      d. Slight predominance in females in adults
      e. Early-onset disease associated with increased severity, tic disorders,
         ADHD, multiple anxiety disorders
Coding System

1) Bold font and underline = Level I recommendation that also has FDA approval.
2) Bold font = Level I recommendation.
3) Italic and Bold Font = FDA approved, but not yet in guidelines or not level I (i.e., available after
      guidelines were published or were level II or III).
4) (GW) Recommended in Guideline Watch, but not FDA approved
5) (II) = Level II recommendation; (III) = Level III recommendation

    1. Evaluation

         For List of Screening Questions, see “Additional Notes”
            a. Rule out other diagnoses (psychiatric and general medical)
            b. Establish therapeutic alliance, establish goals for treatment, and
                understanding expectations will encourage treatment adherence
            c. Consider baseline scale [10-item Yale-Brown Obsessive Compulsive scale (Y-
                BOCS)], document time requirement of obsessions/compulsions, level of life
            d. Ensure safety of patient and patient’s dependants (II)
            e. Decide on appropriate treatment setting

    2.       Initiation (Step I): CBT, SRI, or combination of both [Consider complications such
         as depression, anxiety, or other illness, preference to not take medications, willingness to
         do work of CBT (II)]
             a. CBT
                       i. Exposure and Response Prevention (ERP) at least once weekly for 13-
                          20 weeks or daily for 3 weeks
                      ii. CBT focused on cognitive techniques (II), address interpersonal conflict
                          (II), address psychodynamic issues (III), motivational interviewing (III)
             b. SRI - Prior response to given drug (II), patient prefers SRI alone (II), may
                 consider as initial in severe OCD before CBT initiation (II)
                                Titrate weekly to effect (II), continue for at least 6 weeks at max
                                tolerable or effective dose (II), consider side effect profiles in
                       i. Fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram,
             c. Combination (CBT + SRI)
                       i. Co-occurring psychiatric conditions for which SRIs are effective
                      ii. Patient wishes to limit duration of SRI treatment (II)

    3. Step 2: Inadequate response Step 1- i.e. CBT after 13-20 weekly sessions, 3 weeks of
       daily CBT, or 8-12 weeks of SRI (4-6 at highest comfortably tolerated dose) with no
       interfering factor (II) then:
           a. Combine SRI with CBT (ERP) or vice versa if monotherapy (II)
           b. Moderate Response
                  i. Augment with a second-generation antipsychotic (none specifically
                      named, none FDA approved) (II)
                 ii. Add cognitive therapy to ERP or increase frequency of sessions (III)
          c. Little to No Response
                  i. Switch to different SSRI
                         1. Fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram,
                 ii. Switch to clomipramine
                iii. Augment with a second generation antipsychotic (II)
                iv. Switch to venlafaxine (II)
                 v. Switch to Mirtazapine (III)

   4. Step 3: Inadequate response to Step 2
         a. Moderate and for little or no response
                   i. Switch to different augmenting second generation antipsychotic (no rating
                  ii. Switch to different SRI (no rating provided)
                 iii. Augment with clomipramine (III)
                 iv. Augment with buspirone, pindolol, morphine sulfate, inositol, or
                      glutamate antagonists [riluzole, topirimate] (III)
         b. Little or no response
                   i. Switch to D-amphetamine monotherapy (III)
                  ii. Switch to tramadol monotherapy (III)
                 iii. Switch to ondansetron monotherapy (III)
                 iv. Switch to MAOI (III)
         c. Intensive partial hospitalization or residential treatment for severe treatment-
              resistance (II)

   5. Step 4: Failure of all above- Consider transcranial magnetic stimulation, deep brain
      stimulation and ablative neurosurgery

   6. Discontinuation of effective treatment
         a. For medications: continue 1-2 years, then consider gradual taper over
             several months or more
         b. For CBT: provide periodic booster sessions for 3-6 months after acute treatment

Additional Notes:

   1. Screening Questions
         a. Do you have unpleasant thoughts that you can’t get rid of?
         b. Do you worry about getting ill or contaminated from germs?
         c. Do you worry that you might impulsively harm someone?
         d. Do you ever count things, or wash your hands over and over?
         e. Do you worry a lot about whether you performed religious rituals correctly or
             have been amoral?
          f. Do you need things arranged symmetrically or in very exact order?
          g. Do you have trouble discarding things, so that your house is quite cluttered?
          h. Do these worries or behaviors interfere with your functioning at work, home, or in
             social activities?

Y-BOCS Symptom checklist:

Y-BOCS Score Sheet

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Description: OCD Obsessive Compulsive Disorder