OCD occurs with about 2% prevalence in the general population. 30% of cases start in childhood or adolescence.
OCD is divided by symptoms types;
- Checking compulsions and recurrent reassurance seeking
- Ordering and Counting Rituals
- Contaminations Fears with washing and cleaning rituals
- Repugnant obsessions concerning sex, violence or religion
Heredity accounts for about 27-47% of the risk and environmental factors account for 53-75% of risk. Streptococcal infections can trigger an autoimmune attack on parts of the brain which lead to OCD symptoms. Having an Obsessive parent can contribute to risk.
Its common for OCD patients to have additional disorders notably depression and social anxiety disorder. A minority of patients with adolescent onset OCD later develop schizophrenia.
There are a number of closely related conditions to OCD:
- Tourette’s Syndrome – Usually starts in childhood and there are accompanying tics and vocal utterances or swear words.
- Trichotillomania – Compulsions are limited to pulling out hair from the head, armpits or eyebrows
- Body Dysmorphic Disorder– There is Obsessive rumination that a body part such as the nose is misshapen and is causing social and emotional hardship that can only be fixed by plastic surgery.
The problem in OCD is with the cortico-striato-thalamo-cortico circuit (CSTC) which comprises an excitatory direct pathway and an inhibitory indirect pathway. In OCD the direct pathway is overactive resulting in persistent concerns of threat.
- Strategies to lower overall arousal level eg: graded exercise, yoga.
- Inositol 800mg twice a day ( helpful for anxiety and obsessing)
- Behaviour Therapy
For Obsessions- Thinking about is not the same as Causing / Tolerating ambiguity can be fun.
For Compulsions- Response Prevention with graded exposure
For Hoarding- Training in Organising and Prioritising and Practice in Disposal.
4. Options; (a) SSRI antidepressant such as Fluvoxamine 300mg/d
(b)Tricyclic antidepressant Clomipramine 150-250mg/d
(c) Glutamate Modulating Agent Topiramate 100-300mg/d N-Acetyl Cysteine 1000mg twice daily
(d)Opioid Agonist Tramadol 50mg bd
(e) Antipsychotic agent – Aripiprazole 10mg at night usually added to the antidepressant to boost its effect.
( I haven’t included some options not presently available in Australia).