1. Obsessive-Compulsive Disorder (OCD) A Patient-Centered, Evidence-Based Diagnostic and Treatment Process A Presentation for the Students of Ohio University College of Osteopathic Medicine Kendall L. Stewart, MD, MBA, DFAPA November 29, 2011

2. Why is this important? This potentially disabling disorder is the fourth most common mental disorder in the general population. The lifetime prevalence is 2 to 3- percent. These folk make up about 10-percent of presenting psychiatric patients. Men and women are equally affected, but boys are more commonly affected than girls. People with OCD commonly suffer with comorbid mental disorders. 1OCD Thought for many years to be untreatable, several medications and behavioral strategies can provide significant benefit.medications These people are often hesitant to talk about their symptoms. 2 You must ask. After mastering the information in this presentation, you will be able to –Describe how patients with OCD often present, –Detail the diagnostic criteria, –Describe some of the associated features, –List some differential diagnoses, –Write a preliminary treatment plan, and –Identify some of the frequent treatment challenges. 1 The lifetime prevalence of depression in patients with OCD is 67-percent. (Sadock and Sadock, 2003) 2 These people feel and appear strange. You will do better as a physician if you don’t see yourself as all that different. That principle was powerfully reinforced the first day I took over as a “real” doctor.

3. How might a patient with obsessive- compulsive disorder present? This is a 30-year-old male ED physician. “About seven years ago, I began to worry that I would become contaminated with germs from my work.” “I began to wash my hands every few minutes.” “This has worsened to the point that I’m the slowest doctor in our group.” “I worry that I’ve punctured my gloves and I can’t relax until I’ve changed them.” “My Medical Director says I’ve got to deal with this problem.” “These irrational fears now bother me even at home.” “I avoid touching door knobs and such with my bare hands.” “I wash hands to the point that they crack and bleed.” “I’ve been to a counselor who has told me to make myself wait when I feel the urge to wash my hands, but I can’t stand it.” “I understand that one of the SSRIs might help, but I don’t want to take loony pills.” 1 You can listen to one of these patients here.here 1 It’s important not to take non-compliance personally. When you become emotionally aroused, view that as a significant warning sign. I once evaluated an angry, anxious woman who would do nothing I suggested.

4. What are the diagnostic criteria for obsessive-compulsive disorder? Either obsessions or compulsions Except for children, the sufferer has recognized that the obsessions or compulsions are excessive or unreasonable. The obsessions or compulsions cause marked distress or interfere with the person’s normal functioning. interfere If the person has another Axis I disorder, 1 the content of the obsessions or compulsions is not restricted to it. The disorder is not due to a substance or general medical condition. 1 A complete psychiatric diagnosis includes five axes. Axis I includes the Clinical Disorders. Axis II includes Personality Disorders and Mental Retardation. Axis III includes General Medical Conditions. Axis IV includes Psychosocial Stressors. Axis V includes the Global Assessment of Functioning. (DSM-IV-TR, 2000)

5. What are the criteria for obsessions? Obsessions are recurrent and persistent thoughts, impulses or images that are experienced as intrusive or inappropriate and that cause marked anxiety and distress. 1Obsessions The thoughts, impulses or images are not simply excessive worries about real-life problems. The person attempts to ignore or suppress these obsessions or to neutralize them with some other thought or action. The person recognizes that these obsessions are the product of his or her own mind (not imposed from without—as in thought insertion). 1 Certain obsessions can even spook treating physicians. Obsessions of suicide or child abuse usually make referring physicians very uncomfortable.

6. What are the most common obsessions? 1,2 1 Minor compulsions are very common. I picked up a physician and started to the airport when I noticed his extreme distress over his uncertainly about whether he had locked his car. 2 I ask patients whether these things significantly interfere with their lives.

7. What are the criteria for compulsions? Compulsions are repetitive behaviors (hand washing, arranging, checking) or mental acts (praying, counting, repeating silently) that the persons feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. 1Compulsions These compulsions are intended to reduce distress, or to prevent some dreaded event or situation. Compulsions are either not connected in a realistic way with the what they are intended to neutralize or prevent or they are clearly excessive. 1 I watched one of my patients try to put on his socks while I was speaking on the phone with this wife.

8. What are the most common compulsions? 1 1 Many of these people describe their suffering in YouTube™.

9. What associated features might you see? These people try to avoid situations and environments that make them uncomfortable such as public restrooms or shaking hands. Hypochondriacal concerns and repeated doctor visits are common. Unreasonable guilt, 1 a pathological sense of responsibility and sleep disturbances are often present. Substance abuse is common. A dramatically constricted lifestyle may limit the patient’s ability to improve. Other mental disorders frequently complicate the picture. Obsessions and compulsions often complicate the treatment of Tourette’s Disorder. Tourette’s Disorder Dermatologic problems caused by washing are common. About 75-percent of these patients have both obsessions and compulsions. 1 Helping your patients see the difference between “reasonable” and “unreasonable” guilt is a very helpful clinical tool.

10. What other diagnoses might you include in the differential diagnosis? Normal anxiety –Checking the locks after a robbery is normal. Other anxiety disorders –Other comorbid anxiety disorders are common and are much more likely to included in the initial complaints. Anxiety secondary to a general medical conditiongeneral medical condition –Fear and dread are common, but overt obsessions and compulsions are unusual. Substance-induced anxiety –Skin picking is seen with some drugs of abuse, but overt obsessions or compulsions are unusual Anxiety secondary to other psychiatric disorders –Delusions and hallucinations are common in the psychotic disorders.

11. What might a typical treatment plan look like? Obsessions and Compulsions –Provide reassurance. –Consider paroxetine 10 mg/day and increase to maximum dose of 60 mg/day.paroxetine –If no response or inadequate response, consider clomipramine 25 mg/day and increase slowly to 300 mg/day.clomipramine –Consider augmentation with atypical antipsychotics for non-responders. 1atypical antipsychotics –Recommend “response-prevention” behavioral therapy. –Consider neurosurgery in life- threatening cases. Generalized anxiety –Consider buspirone 15 mg twice per day.buspirone –Consider clonazepam 0.5 mg twice per day for the short-term treatment of intense anxiety.clonazepam Other comorbid disorders –Diagnose and treat these conditions vigorously. Maladaptive attitudes and behaviors –Consider cognitive behavioral psychotherapy (CBT)cognitive behavioral psychotherapy (CBT) Education and self help –Provide educational resources. –Recommend a daily exercise regimen. –Recommend a healthy diet. –Suggest healthy distractions. –Recommend meditation.meditation –Recommend online resources with caution. –Recommend self help groups with caution. –You can follow your patient’s progress with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS).Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

12. What are some of the treatment challenges you can expect? This disorder tends to be chronic with ups and downs throughout the patient’s life.chronic Non-compliance with the physician’s recommendations is a considerable challenge. Families’ accommodation and seething frustration are therapeutic issues. Response to medication is usually partial at best. Lack of motivation to follow the simplest behavioral instructions can be maddening. The family’s unrealistic expectations of the physician can be difficult.

13. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,”

14. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.here Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. www.KendallLStewartMD.com Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.www.SOMC.org Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.here

15. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

16.  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? Terry Johnson, DO OUCOM 1991 Adenike Moore, DO OUCOM 2002