Obsessive Compulsive

Spectrum Disorders

PRESENTER: DR. CAROLINE DIAS

CHAIRPERSON: DR. KRISHNAMURTHY

Concept of spectrum
To

indicate qualitative distinction arising

from a quantitative continuum
To identify a group of disorders
--Qualitatively distinct in appearance
but believed to be related from
pathogenetic point of view
Different meaning Broad areas of
psychiatric phenomena relating to a
single mental disorder

Concept of spectrum
Not

continuum
Manifestations vary widely in type and
severity
All kinds of combinations are possible
These combinations syndromes

OC spectrum disorders
model of medical classification where
various psychiatric, neurological and/or
medical conditions are described as existing
on a spectrum of conditions related to
obsessivecompulsive disorder (OCD)
The model suggests that many conditions
overlap with OCD in symptomatic profile,
demographics, family history, neurobiology,
comorbidity, clinical course and response to
various pharmacotherapies

Preoccupation with body

BDD
Hypochondriasis
Anorexia nervosa

Motor disorders

OCD
Impulse control
disorder
Trichotillomania
Pathological gambling
Compulsive sexual
disorder
Kleptomania

Tics
Tourettes disorder
Sydenhams chorea
PANDAS

OC spectrum disorders
MOTOR DISORDERS
Tourettes

disorder
Sydenhams chorea
Tics
PANDAS

OC spectrum disorders
IMPULSE CONTROL DISORDERS
Trichotillomania
Kleptomania
Pathological gambling
Pyromania
Intermittent explosive disorder
Compulsive sexual disorder
Compulsive buying
Skin picking (dermatillomania)
Nail biting (onychophagia)

OC spectrum disorders
PREOCCUPATION WITH BODY
Body dysmorphic disorder
Hypochondriasis
Anorexia nervosa
Bulimia nervosa

Controversial

Autism
Substance

use disorder
Self injurious behavior
Depersonalization
OCPD

COMORBIDITY

Patients

with OCSD have high rate of

comorbidity of OCD
Tourette syndrome 50%
Trichotillomania 34%
Pathological gamblers 7.2 times
relative risk
BDD 30%
Anorexia 18%

Family history
Among

first degree relatives of OCD

high prevalence of BDD,
hypochondriasis
Relatives of OCD pts. have higher
prevalence of tic disorder
Relative of tic disorder patients have
increased rate of OCD
Relatives of eating disorder patients
have higher prevalence of OCD
OCD is more prevalent in relatives of
autism

Animal studies
Hoxb8

gene mutations in mice

Excessive grooming
Excessive hair removal
Similar

to trichotillomania
If treated with SSRI there is no grooming

Animal studies
companion

and domestic animals

demonstrate repetitive nonfunctional
motoric behaviors
acral lick dermatitis (paw licking)
Rapoport and colleagues demonstrated
that acral lick dermatitis, like OCD, responds
more
robustly to clomipramine than to
desipramine
pharmacotherapeutic response of this
condition seems to mimic that of OCD

Is it possible that the OC spectrum of

disorders can be defined along neuroevolutionary considerations?
Horses-

stereotypies in locomotion
Cows and pigs - chewing stereotypies
Primates - grooming abnormalities
some

patients with OCD, body

dysmorphic disorder, trichotillomania,
and nail biting can be conceptualized as
suffering from abnormal grooming

NEUROCIRCUITRY
DISRUPTION OF CONTROL MECHANISMS:
Cortico-striatal neurocircuitry : mediate
the control of procedural strategies
Dysfunction

in the control of procedural

strategies with inappropriate release of
symptoms ranging from simple motoric
stereotypies to more complex behavioral
programs

neurologic

disorders characterized by
striatal lesions may be accompanied by
obsessive-compulsive symptoms
functional imaging studies demonstrate
that during implicit learning there is
striatal activation in healthy controls but
abnormal extra-striatal activity in OCD
successful treatment, whether using
medication, cognitive-behavioral
therapy, or neurosurgery, results in
decreased symptoms and altered activity
in cortico-striatal circuitry

DISRUPTION OF REWARD MECHANISMS

Cortico-striatal circuitry : mediate reward
processes - the ventral striatum
OCD

: absence of a feeling of goal completion

after an action is performed: people continue
with their compulsions repetitively until there is
finally the sense that things are now just
right.
Although OCD and drug addiction have
significant phenomenologic and psychobiologic
differences, both conditions may be
characterized by disruption of reward processes
and consequent compulsive behavior

NEUROCHEMISTRY
The Serotonin Hypothesis:
OCD
Higher levels of HIAA
Reduction in 5 HIAA after treatment with
clomipramine
Meta chloro phenyl piperazine (mCPP)
administation serotonin agonist
worsening of OCD
SSRI are effective in treatment

Rapoport and colleagues : clomipramine

was superior to desipramine in a range
of repetitive symptoms other than OCD
Eg: hair pulling , nail biting , stereotypic
behaviors , obsessive compulsive
symptoms in autistic disorder ,
symptoms of body dysmorphic disorder ,
self-injurious behavior in mental
retardation

Autism :
decreased capacity to synthesize
serotonin during development

Eating disorder: lower 5 HT moderate

dieting causes hypersensitivity of 5HT2c
exacerbation of eating disorder

The DopamineSerotonin Hypothesis:

There is growing evidence that
dopaminergic augmentation of serotonin
reuptake inhibitors may be useful in the
treatment of refractory OCD patients
particularly useful in patients with
comorbid
tics; so raising the question of the
relationship between OCD and Tourettes
syndrome

de

novo production or exacerbation of tics

with dopamine agonists, and dopamine
blockers have long been known to be effective
in TD
increased

striatal dopamine uptake sites in TD

Functional

imaging studies have confirmed

greater than normal striatal dopamine
transporter densities
Monozygotic

twins with TD-- increased

caudate D2 receptor binding was associated
with increased tic severity

NEUROANATOMIC:
SYDENHAMS CHOREA
Alterations to basal ganglia
Signal hyper intensity in caudate nucleus
PANDAS
Enlarged basal ganglia
TOURETTE SYNDROME
Volume of caudate nucleus was decreased

AUTISM
Enlargement of caudate
BDD
Caudate nuclear asymmetry
Increased white matter volume
TRICHOTILLOMANIA
Decreased left putamen and lenticular
nucleus

Basal Ganglia Hypothesis:

based

on data that OCD is mediated by

the striatum and leads to a concept of OC
spectrum disorders comprising those
conditions in which psychopathology of
the striatum leads to unwanted repetitive
behavior
Developmental

basal ganglia syndrome

(DBGS) - dysfunctional basal ganglia
development who present with tics, OCD,
and other symptoms

IMMUNE MECHANISMS:
patients may develop OC symptoms in the
aftermath of streptococcal infection -antinuclear antibodies
Anti basal ganglia antibodies found in OCD
Antiputamen antibodies in anorexia
nervosa
D8/17 expression appears increased in
childhood-onset OCD and TD and in autism
CSF type 1 cytokines, consistent with a
cell-mediated immune process
preponderance in OCD

PSYCHODYNAMIC FACTORS:
Freud : obsessive-compulsive neurosis,
and obsessive-compulsive psychosis lay
on a spectrum and were all characterized
by specific unconscious mechanisms (eg,
heightened anal
drive)
If

defenses against unconscious

mechanisms are penetrated, a neurosis
or even a psychosis may emerge

COMPULSIVITY vs IMPULSIVITY
OCD

spectrum : dimension of
compulsivity and impulsivity
compulsivity may reflect harm avoidance,
whereas impulsivity reflects risk seeking
OCD falls on the compulsive end of an
OCD spectrum, whereas impulsive
disorders fall on the impulsive end
disorders such as TD, trichotillomania,
and obsessive compulsive personality
disorder demonstrate both compulsive
and impulsive characteristics

IMPULSE CONTROL DISORDER

Inability

to resist actions that have

negative consequences
Impulses increase tension and provide
pleasure, gratification and release during
act
Also possess a compulsive component in
that behaviors become driven as
individual experiences guilt and disgust
and the goal of the behavior is to reduce
the anxiety

TRICHOTILLOMANIA
Epidemiology
Prevalence
0.6%
SexFemales> males
Age of onset- usually 18 years

TRICHOTILLOMANIA
Repetitive

hair pulling that results in significant

hair loss
There is an increasing level of tension
immediately before hair pulling or during
attempts to avoid pulling
There is a sensation of relief, pleasure or
gratification during hair pulling
The pulling is not explained by general medical
condition/other mental disorder
Significant distress or impairment in
occupational, social or other areas of
functioning is experienced as a result of pulling

TRICHOTILLOMANIA
Environmental factors- acts as triggering
events
Physical features of haircolor/shape/texture
Negative cognition- about appearance,
fear of being negatively evaluated,
shame related cognitions
Negative affective states-anxiety,
frustration, loneliness, fatigue
Specific settings- studying, watching TV,
driving, talking over phone

TRICHOTILLOMANIA

Possible subtypes
Focused hair pulling
Non focused hair pulling

TRICHOTILLOMANIA
Treatment
There is neither a universal nor a
complete response to any treatments for
TTM
Monotherapy with CBT or
pharmacotherapy is likely to produce
only partial symptom reduction in the
long run
Might yield superior improvement when
combined- but no evidence support

TRICHOTILLOMANIA
Pharmacotherapy
SSRI
Clomipramine
Psychotherapy
CBT/BT- Habit reversal, awareness
training, stimulus control

PATHOLOGICAL GAMBLING
Public

health issue

1980:

first recognized in DSM III

More

in men than women

PATHOLOGICAL GAMBLING

Recurrent gambling thoughts and

behaviors
Loss of control over gambling
behavior
Unable to resist the impulse to
gamble
Exhibit higher level of obsessionality
Obsessive thoughts about gambling
and compulsive behavior

PATHOLOGICAL GAMBLING
Treament:
Psychotherapeutic approaches:
Psychoanalysis
CBT
Pharmacotherapy:
SSRIs
Mood Stabilizers: carbamazepine, lithium
Opioid antagonists- naltrexone
Gamblers anonymous

INTERMITTENT EXPLOSIVE DISORDER:

Periodic episodes of aggression that

resulted in serious attacks on people or
property

The degree of aggression is grossly out of

proportion to the precipitating stressor
Treatment
Psychosocial:
Individual psychotherapies
Group psychotherapies
Meds
Mood stabilizers
Beta blockers
SSRIs

KLEPTOMANIA
Recurrent, impulsive pathological
stealing
Resistance to stealing is met with
anxiety and tension
COMPULSIVE BUYING
Uncontrollable buying which is markedly
distressing, time consuming and
resulting in socio occupational
dysfunction

NONPARAPHILIC SEXUAL COMPULSIONS:

Culturally acceptable
Increase in frequency and intensity which
interfere with sexual intimacy
Usually acted out (to differentiate from sexual
obsessions)
PYROMANIA

Recurrent purposeless [other than tension

relief] fire setting

Tension or affective arousal before setting

the fire

Attraction to the fire and its situational

context

Pleasure with setting the fire or its aftermath

HYPOCHONDRIASIS
Disorder

char by the fear or belief that

one has a severe illness based on signs
or symptoms
Typically, these pts. Experience a
reduction in anxiety after the physician
visit, but this reduction lasts only hours
or days
When another symptom returns the
anxiety resurfaces and the cycle of
hypochondriacal worry resumes

HYPOCHONDRIASIS
Phenomenology:
Rasmussen and Eisen: pts. With OCD who
have somatic or illness obsessions are
virtually indistinguishable from pts. With
hypochondriasis
Obsessions: intrusive, distressing and only
temporarily responsive to reassuarance
Compulsions: repetitive and performed to
reduce distress, manifesting primarily in
the form of checking ones body or checking
with others

HYPOCHONDRIASIS
Barsky

: can be distinguished based on

the presence of somatic sensations and
on the degree of insight
OCD: fears are unrealistic and try to
resist them
Hypochondriasis: high degree of
conviction
Fallon : fear of having an illness vs fear
of getting an illness

HYPOCHONDRIASIS
Course
Acute onset : good outcome
Improvement assc with shorter duration
of illness and less depression at baseline

HYPOCHONDRIASIS
Treatment:
Pharmacoterapy : SSRIs fluoxetine,
clomipramine, fluvoxamine
CBT

BODY DYSMORPHIC DISORDER

1987:

recognized as a distinct disorder

in DSM IIIR
Preoccupation

with imagined flaw in

appearance or excessive distress about
slight imperfection

BODY DYSMORPHIC DISORDER

Compulsive

mirror checking
Less insight than OCD patients
Chronic course and similar age at onset
High co morbidity with social phobia,
depression and trichotillomania
Pts with BDD conceptualized as varying
between a continuum of insight or
uncertainty--- ? two variants of the same
disorder

BODY DYSMORPHIC DISORDER

Treatment:
SSRIs: even when BDD concerns reach
delusional proportions
Refractory cases( delusional
component ):
Augmentation with low doses of atypical
anti neuroleptics such as risperidone
CBT

ANOREXIA NERVOSA
Obsessive fears about being fat
Compulsive attempts to reduce weight
BULIMIA NERVOSA
Preoccupied with body image
Leads to compulsive vomiting and
impulsive laxative abuse
Binge eating
Compulsive eating without efforts to
decrease weight

TOURETTES SYNDROME
neurological

condition characterized by
motor and vocal tics
Repetitive movements or utterances
Bodily sensation, mental urges and
tension
Tics are believed to result from
dysfunction in cortical and subcortical
regions, thethalamus , basal ganglia
andfrontal cortex

Neuroanatomic

models- failures in
circuits connecting the brain's cortex and
subcortex,andimaging
techniquesimplicate the basal ganglia
and frontal cortex
Some

forms of OCD may be genetically

linked to Tourette's
A

subset of OCD is thought to

beetiologicallyrelated to Tourette's and
may be a different expression of the same
factors that are important for the
expression of tics

SYDENHAMS CHOREA:
neurological

disorder of childhood resulting

from infection via Group A beta-hemolytic
streptococcus
rapid, irregular, and aimless involuntary
movements of the arms and legs, trunk, and
facial muscles
girls more often than boys (5 and 15 years )
uncoordinated movements, muscular
weakness, stumbling and falling, slurred
speech, difficulty concentrating and writing,
and emotional instability
75% have aggressive, contamination
obsessions

PANDAS : Paediatric Autoimmune

Neuropsychiatric Disorders Associated
with Streptococcus

Presence of OCD/tic disorder

Pediatric onset
Acute onset and dramatic symptom
exacerbation
Choreiform movements or motor
hyperactivity
Temporal association with Beta
hemolytic streptococci

CRITICISMS
Repetitiveness

is not the sole criteria for

obsession and compulsions
Cognitive mediation is different across
the disorders
Treatment response is not the criteria
ex: aspirin is useful in IHD, arthritis and
fever. Differences in psychotherapeutic
principles
High degree of comorbidity with
affective disorders

DSM V
five

dimensions of OCD symptoms

(Symmetry, Hoarding,
Washing/contamination, Worries about
Harm/Checking/Doubt, Taboo thoughts (Sex
and violence)
strong evidence from at least three out of
the five domains (i.e., phenomenology,
comorbidity, family history, fronto-striatal
brain circuitry [e.g., caudate hyperactivity],
or treatment response), with either family
history or fronto-striatal brain circuitry
required

DSM V
Based

on this criterion, strongest

evidence for a relationship with OCD was
for Tourette's, body dysmorphic disorder,
and hypochondriasis . also support for
OCPD, hoarding, Sydenham's/PANDAS,
trichotillomania, and eating disorders,
and the least support for skin-picking
and nail-biting

DSM V

DSM-IVimpulse control disorders and the

ICD's-NOS (including impulsive-compulsive
buying, sex, and internet use) be grouped
together into a new category called
"Behavioral and Substance Addictions", or
alternatively "Impulsive-Compulsive
Disorders
Possible subtypes of OCD to be considered
include: "tic-related," "childhood-onset,"
"symmetry type," "hoarding type," "postpartum," "poor insight," "impulsive type,"
"inattentive type" and PANDAS

DSM V
Regarding

subtypes for OCD, strongest

evidence was for an early-onset type, for
which PANDAS could be listed as a specifier
(since all PANDAS cases are early-onset but
not all early-onset cases are PANDAS)
BDD, hypochondriasis, and tic disorders-inclusion into an OC spectrum grouping
also proposed that the reward/impulse
control related disorders (e.g., pathological
gambling, trichotillomania) not be included
in the OCD spectrum

DSM V
definition

of obsession be revisited
since not everyone with OCD
experiences them as "intrusive" as is
now required in DSM-IV
agreeing on the importance of
increasing awareness of the comorbidity
between schizophrenia and obsessive
compulsive disorder, the group was
divided on whether a specifier for schizoobsessive type should be added to
schizophrenia

SUMMARY
OCD and OCSD
Similarities in phenomenology
Family members of OCD have higher rate of
OCSD and vise versa
Significant comorbidity between the
disorders
Similar treatment response
Similarities in neurobiology

THANK YOU