Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Obsessive-compulsive disorder

Patient will present as → a 26-year-old PA student presents to the student health center with the complaint being unable to sleep. Although he is a very successful student, over the past few months he has become increasingly preoccupied with failing. The patient states that he wakes up 10-15 times per night to check his textbooks for factual recall. He has tried unsuccessfully to suppress these thoughts and actions, and he has become extremely anxious and sleep-deprived. He has no past medical history and family history is significant for a parent with Tourette's syndrome. He is started on a first-line medication for his disorder, but after eight weeks of use, it is still ineffective.

Key Points:

Two components

  • Obsessions: Recurring, intrusive thoughts that cause severe distress and impairment
  • Compulsions: Performance of repetitive actions (rituals) in an attempt to neutralize the obsessions
    • e.g., hand washing, checking - the primary goal is to not lose control
    • The disorder is ego-dystonic: behavior inconsistent with one's own beliefs and attitudes - separates OCD from obsessive compulsive personality disorder
  • Associated conditions - Tourette's disorder

DSM-5 Diagnostic Criteria

A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2):

  1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
  2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are 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 individual 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 anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hairpulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

First line: psychotherapy

  • cognitive behavioral therapy

Pharmacotherapy options

  • SSRIs: 12-16 week trials - higher doses compared to those used in depression
  • Clomipramine
  • Augmentation therapy with antipsychotics
Obsessive compulsive disorder (OCD) is characterized by repetitive obsessions or compulsions that often interfere with a patient’s daily functioning. Patients with OCD experience high levels of anxiety about not being in control or about losing control. Anxiety in these patients is manifested as an obsession, which can only be suppressed by actions called compulsions. Patients with OCD can spend upwards of one hour per day carrying out their compulsion(s), though they may or may not be aware that they are performing an action or activity repeatedly. Interventions used to treat or manage OCD include drug therapy with selective serotonin reuptake inhibitors or anti-anxiety medications, limiting the time that a patient is allowed to spend on their compulsion, systematic desensitization, and flooding.

Obsessive compulsive disorder (OCD) Picmonic

Congratulations - you have completed obsessive compulsive disorder. You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
A 17-year-old boy feels compelled to walk around the house 12 times before leaving "to keep his family safe." What other psychological phenomenon might be seen in this patient?
A
Auditory hallucinations
Hint:
Schizophrenia and its associated auditory hallucinations are not associated with OCD.
B
Visual hallucinations
Hint:
Schizophrenia and its associated auditory hallucinations are not associated with OCD.
C
Night terrors
Hint:
Schizophrenia and its associated auditory hallucinations are not associated with OCD.
D
Vocal tics
E
Cataplexy
Hint:
Schizophrenia and its associated auditory hallucinations are not associated with OCD.
Question 1 Explanation: 
The patient described in the vignette suffers from obsessive-compulsive disorder. Vocal tics are one feature of Tourette's disorder, which is associated with OCD.
Question 2
An 11-year-old girl is brought into the clinic by her parents, who are distraught over her behavior. They state that over the past several months she has started to act oddly, combing the hair of her toy dolls for hours without stopping and repetitively counting her steps in the house. She is often brought to tears when confronted about these behaviors. The patient has no past medical history. When questioned about family history, the mother states she has needed close medical follow-up in the past, but declines to elaborate. The patient's vital signs are all within normal limits. On physical exam, the patient is a well-nourished 11-year-old girl in no acute distress. She has occasional motor tics, but the remainder of the exam is benign. What is the diagnosis in this patient?
A
Autism spectrum disorder (ASD)
Hint:
ASD is characterized by restricted interests and behaviors that are stereotyped. Patients often have poor eye contact.
B
Generalized anxiety disorder (GAD)
Hint:
ASD is characterized by restricted interests and behaviors that are stereotyped. Patients often have poor eye contact.
C
Obsessive compulsive disorder (OCD)
D
Tourette's syndrome
Hint:
ASD is characterized by restricted interests and behaviors that are stereotyped. Patients often have poor eye contact.
E
Major depressive disorder (MDD)
Hint:
MDD must meet 5 out of 9 criteria in SIG E CAPS.
Question 2 Explanation: 
This 11-year-old presents with compulsions which cause her distress concerning for OCD of the early-onset subtype. OCD is generally treated with psychotherapy (such as cognitive behavioral therapy, CBT), selective serotonin reuptake inhibitors (SSRIs), or both.
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