Chaining
(Applied Behaviour Analysis)
Obsessive Compulsive
Disorder (OCD)
Presenters:
Sana Saif Malik
&
Nasir Ali Kharal
Overview
Introduction
OCD Treatments
Medications for OCD
Mechanism of Action
Therapeutic Uses
Adverse Effects
Treatment Options
Treatment Refractory
Interactive Session
DIAGONOSTIC CRITERIA
Presence of Obsessions/Compulsions or both
o Obsessions are recurrent or persistent
thoughts, urges or images which cause
anxiety or distress
o Compulsions are repetitive behaviors eg
H/washing, ordering, checking, or mental acts
Obsessions/Compulsions are time consuming
(take more than 1 hrs per day) or cause
significant distress
OCD Treatment
First Line Treatment of OCD
o CBT
o Exposure & Response Prevention (ERP)
Second Line Treatment of OCD
o Medications (SSRIs)
Medications for OCD
Approved by (FDA)
o Sertraline
o Fluvoxamine
o Fluoxetine
o Paroxetine
o Citalopram
o Clomipramine (Tricyclic)
Choosing Medication
Following are important
o Delayed Onset of Action (4 weeks)
o Full Therapeutic Effect (8 - 12 weeks)
o Moving gradually low to high doses
o Effective doses for OCD is higher than
Depression
Mechanism of Action
Therapeutic Use of SSRIs
o Depression
o Obsessive Compulsive Disorder
o Panic Disorder
o Generalized Anxiety Disorder
o Posttraumatic Stress Disorders
o Social Anxiety Disorder
o Premenstrual Dysphoric Disorder
o Bulimia Nervosa (Fluoxetine)
o Enuresis (involuntary nightly urinating in sleep)
(Clomipramine)
o
Adverse Effects of SSRIs
o Headache
o Sweating
o Anxiety, Agitation
o Nausea, Vomiting Diarrhea (GI effects)
o Sexual Dysfunction
o Changes in weight
o Sleep Disturbances
o Premature Ejaculation
o Trichotillomania (Hair Pulling)
o Discontinuation Syndrome
SUICIDE RISKS
Suicidal thoughts in many about half
of individuals with OCD
Suicide attempts upto one quarter of
individuals with OCD
NICE Guidelines (2005)
Stepped Care Model
o Severity and Assessment of OCD
o Y – BOCS Questionnaire
o Helpful Monitoring Tool
Treatment Options For
Children and Young
CBT & Medication in
Childhood OCD
NICE Recommendation
o NICE recommendation that all young people
with OCD should be offered CBT
o Medications may be indicated when capacity
of individual is limited i.e learning disability
o Treatment of OCD should begin with CBT
alone or CBT plus an SSRI
Treatment Refractory
o Individual may fail to respond SSRI, CBT
and ERP for at least 12 weeks
o Reassessment, clarifying compliance and
ensuring co-morbidity not missed
o Additional trial of SSRI
o Clomipramine and augmentation of
Risperidone may be considered
Interactive Session
THANK
S
FOR
ADDITIONAL SLIDES
CONTAINING RELEVANT INFORMATION
MAY BE USED FOR QUESTIONS &
ANSWER SESSIONS IF NEEDED SO
CULTURE-RELATED
OCD occurs across the world
Substantial similarities across cultures
o Cleaning
o Symmetry
o Hoarding
o Taboo thoughts or fear of harm
GENDER-RELATED
Males have earlier age onset of OCD
than females & are likely to have Tic
disorder
DIFFERENTIAL
Anxiety Disorders
Major Depressive Disorders
Eating Disorders
Tic Disorders
Psychotic Disorders
Obsessive Compulsive Personality
Disorder
ASSOCIATED /
SUPPORTING FEATURES
Specific content of OCD varies in
individuals
Contamination, symmetry, ordering,
counting, aggressive, sexual are common
Individual with OCD avoid people, places
and things that trigger obsessions &
compulsion
PREVALENCE
12 month is USA is 1.2%
Internationally 1.1%-1.8%
Females are slightly higher rate than
males
Males are more affected in childhood
DEVELOPMENT AND
COURSE
In USA mean age of onset is 19.5 yrs
& 25% cases start at 14 yrs
Male have earlier onset than females
Onset symptoms are gradual
If OCD untreated, course is chronic
with waxing and waning symptoms
RISK AND PROGNOSTIC
FACTORS
Temperamental Higher negative emotionality
and behavioral inhibitions in childhood
Enviornmental Physical or sexual abuse in
childhood associated higher risk for developing
OCD. Some children may develop sudden onset
of OCD
Genetic & Physiological OCD rate among 1st
degree relatives is high. However, among 1 st
degree relatives of individual with onset of OCD
in C/hood or Adol, the rate is 10 folds increased
Y-BOCS
One of the most widely used instruments for
assessing OCD includes a symptom checklist that
includes about 75 examples of obsessions and
compulsions. This instrument, called the Yale-Brown
Obsessive Compulsive Scale (Y-BOCS), is ordinarily
used by trained professionals to evaluate OCD.
The scale—developed by Wayne Goodman, MD,
of the Icahn School of Medicine at Mount Sinai, and
Steven Rasmussen, MD, and Lawrence Price, MD of
Brown University
Y-BOCS
Scale contains two parts:
1. The Symptom Checklist and
2. The 10-item severity measure
The psychometric properties of the Y-BOCS
have been extensively studied (Goodman
et al 1989; Goodman et al 1989).
The National Institute for Health and Care
Excellence (NICE) is an executive non-departmental
public body of the Department of Health in the United
Kingdom. It was set up as the National Institute
for Clinical Excellence in 1999, and on 1 April 2005
joined with the Health Development Agency to
become the new National Institute for Health and
Clinical Excellence (still abbreviated as NICE).
Following the Health and Social Care Act 2012, NICE
was renamed the National Institute for Health
and Care Excellence on 1 April 2013 reflecting its
new responsibilities for social care, and changed from
a special health authority to an Executive Non-
Departmental Public Body (ENDPB).
NICE publishes guidelines in four areas:
1. The use of health technologies within the NHS
(such as the use of new and existing medicines,
treatments and procedures)
2. Clinical practice (guidance on the appropriate
treatment and care of people with specific diseases
and conditions)
3. Guidance for public sector workers on health
promotion and ill-health avoidance
4. Guidance for social care services and users.
These appraisals are based primarily on evaluations
of efficacy and cost–effectiveness in various
circumstances