Obsessive-Compulsive Disorder

Stephanie C. Eken, MD, FAAP Regional Medical Director

Rogers Behavioral Health

October 2015

Obsessive-Compulsive Disorder

• Either obsessions and/or compulsions.

• Obsessions are:

– Recurrent and intrusive thoughts, images and impulses.

– They are NOT excessive worries about real life problems.

– Because obsessions are unwanted and distressing, people try to

resist them, get rid of them, or reduce their distress in some way:

• Avoidance of triggers.

• Distraction.

• Compulsive behaviors or thoughts.

• Contamination (1).

• Repeated doubt (2).

• Harming (3).

• Need for exactness or

symmetry.

• Need to tell, ask, or

confess.

• Sexual imagery.

• Religious.

• Fear of Loss.

• Need for Perfection.

Examples of Obsessions

OCD: What is a compulsion?

• A compulsion is a behavior or mental act that a

person feels driven to perform over and over again

– to prevent or reduce anxiety, discomfort or distress.

– to “prevent” something bad from happening.

• Often performed in response to an obsession

• Often performed according to rigid rules or until it

feels “just right.”

Examples of Compulsions

• Checking (1).

• Washing or cleaning (2).

• Counting (3).

• Ordering/Arranging.

• Repeating.

• Praying.

• Requesting reassurance.

Commonly Asked Questions

• How common is OCD?

– 2.5% of population life-time prevalence.

• 1 in 100 adults diagnosed with OCD

• 1 in 200 children diagnosed with OCD

– 4th most common psychiatric condition in U.S.

• Sex differences?

– No (males do seem to develop earlier, however).

Commonly Asked Questions

• Onset?

– Onset can be as young as age three although the

average age of first symptoms is closer to age ten.

– Generally two ages when OCD first appears

• Between 8 and 12 years

• Between late teen years and early adulthood

– Roughly half by 18 years of age.

– Rarely after 50 years of age.

Associated Features

• Secondary depressed mood (85%).

• Academic and occupational impairment.

• Low self-esteem.

• Social withdrawal.

• Family discord.

• Fear of embarrassment (hide symptoms).

• Avoidance.

What is not OCD?

• Pathological gambling, kleptomania, substance

abuse disorders, certain sexual behaviors.

– Thoughts are not unwanted and may derive pleasure

from “compulsive” act.

– Typically, only want to stop because of negative

consequences of acts.

• Just because you do something over and over

again does not mean you have OCD.

Assessment of OCD

Children’s Yale-Brown Obsessive-Compulsive Scale

(CY-BOCS)

• 60 symptom checklist (past and current).

– 10 item severity rating scale (0-4).

– 5 questions regarding obsessions.

– 5 questions regarding compulsions.

– Mean score for OCD = 24.

CY-BOCS Scores

0 - 7 = subclinical.

8 - 15 = mild.

16 - 23 = moderate.

24 - 31 = severe.

32 - 40 = extreme.

Etiology of OCD

• Uncertain.

• Most believe that biology plays a role.

– Genetics?

• 20% of first-degree relatives will have OCD.

• Additional 15% will have “subclinical” symptoms.

• Does not appear to be learned (phenotypes different).

– Serotonin – chemical messenger in the brain

• Medications that reduce OCD symptoms increase available

levels of serotonin.

PANDAS

• Pediatric Autoimmune Neuropsychiatric

Disorders Associated with Strep.

– Acute (very sudden) onset of OCD-like symptoms

occurring during illness.

– May respond to antibiotic medications and reduce

symptoms.

– Accounts for small percentage of cases.

PANDAS (continued)

• May also exhibit:

– Challenges with eating.

– Sensory issues.

– Handwriting deterioration.

– Urinary frequency or bedwetting

– Tics.

– Separation anxiety and other fears.

• Typically, needs “traditional” treatment as well.

First-line Treatments of OCD

• Exposure and Response Prevention (ERP).

• Medications.

• Combination of medications and ERP.

Exposure and Response Prevention (ERP)

• A specific behavior therapy technique.

• Victor Meyer published first study in 1966.

• Based on the principle of habituation.

– Habituation is the decrease in anxiety experienced

with the passage of time.

• Examples: Wool sweater, cold pool

Exposure

• Placing an individual in feared situations (targets

the obsessions).

– Needs to be prolonged enough to lead to habituation

during an exposure to the feared situation (at least 50%

reduction in anxiety).

• Door knob example

– Needs to be repetitive enough to lead to habituation in

between exposures (until causes minimal to no anxiety).

– Needs to be graduated (increases compliance).

Response Prevention

• Blocking the typical response (compulsion)

before, during, and after exposure so habituation

can take place (targets compulsions).

– Replace the response with habituation as way of

controlling anxiety.

– Example, hand washing after touch a public door

knob

Typical OCD Scenario

High

(Anxiety)

Low

(Time)

60 sec

Trigger

Typical OCD Scenario

High

(Anxiety)

Low

Response/Ritual/Compulsion

60 sec

(Time)

High

(Anxiety)

Low

Exposure

60 sec

(Time)

Exposure and Response Prevention (ERP)

High

(Anxiety)

Low

Exposure

Response Prevention

20 min

Habituation

60 sec

(Time)

Exposure and Response Prevention (ERP)

High

(Anxiety)

Low

Exposure

Response Prevention

20 min 60 sec

(Time)

Exposure and Response Prevention (ERP)

ERP Treatment Steps

• Initial Evaluation (1-2 hours).

– Confirm diagnosis of OCD.

– Identify major problem areas (e.g., contamination,

doubting).

– Assess for common co-occurring illnesses.

– Educate patient and family about OCD and treatment

options.

ERP Treatment Steps (continued)

• Detailed Assessment Phase.

– CY-BOCS checklist and severity rating scale.

– Generate specific exposure exercises.

– Patient rates each exercise on scale of perceived

difficulty (i.e, 1-10 rating scale).

– Create exposure hierarchy/fear ladder.

ERP Treatment Steps (continued)

• Treatment Phase (conducting the hierarchy).

– Mild to moderate cases.

• Most cases can be treated in weekly outpatient .

– Moderate to severe cases.

• Typically need more intensive treatment (need more therapist-

aided exposure).

• Multiple visits per week, multiple hours per visit, for a 4-8 week

period of time.

• Dosage effect between severity of OCD and how much ERP

someone needs.

Thinking Errors

• Also known as Cognitive Restructuring

• Used as an addition to ERP.

• Attempts to identify and correct “errors” in thinking.

– Probability Overestimation Errors (e.g., contracting AIDS

from not washing hands).

– Catastrophizing Errors (e.g., my mom is late to pick me

up so I worry she was in a car accident).

– Intolerance of Uncertainty (increasing rituals or

reassurance reduces this).

Effectiveness of ERP

• Produces roughly 60% symptom reduction.

• Produces on average an 11.8 point reduction in

YBOCS scores.

• Low relapse rates.

• Key to medication discontinuation.

When to Consider Medication

• Child unable to participate in therapy due to severity of symptoms or developmental delay

• Child has another mental health diagnosis

– May reduce their ability to participate in ERP

• Symptoms that do not respond to an adequate trial of ERP

• No access to CBT with ERP

• Functional impairment is moderate to severe

• Poor insight into irrational nature of OCD

SSRIs

• First-line medication for OCD

– Make serotonin more available in the brain

– Safer side effect profile

• Typically require higher doses as compared to patients with mood disorders or other anxiety disorders

• May take 8-12 weeks to determine if medication works

– SSRIs typically take 4-6 weeks to determine effectiveness in depression

• Monitor more closely for side effects due to higher doses

• No evidence that one SSRI is superior to another

– No comparative trials

FDA Approved SSRI’s for OCD

• FDA approved for adults with OCD:

– Fluoxetine, Fluvoxamine, Paroxetine, Sertraline

• FDA approved SSRIs for childhood OCD:

– Sertraline (Zoloft) – age 6 and over

– Fluoxetine (Prozac) – age 7 and over

– Fluvoxamine (Luvox) – age 8 and over

• Research has demonstrated effectiveness of SSRI’s vs.

placebo including sertraline, fluvoxamine, fluoxetine and

paroxetine in children and adolescents

Dosing Guidelines

Drug

Starting Dose (mg)

Pre-Adolescent

Starting Dose (mg)

Adolescent

Typical Dose Range

(mg)

Clomipramine 6.25-25 25 50-200

Fluoxetine 2.5-10 10-20 10-80

Sertraline 12.5-25 25-50 50-200

Fluvoxamine 12.5-25 25-50 50-300

Paroxetine 2.5-10 10 10-60

Citalopram 2.5-10 10-20 10-60

Escitalopram 5 10 10-40

American Academy of Child & Adolescent Psychiatry. Practice parameter for the assessment

and treatment of children and adolescents with obsessive-compulsive disorder. Journal of Am

Acad of Child & Adolescent Psychiatry; 51 (1): 107.

Clomipramine (Anafranil)

• Only FDA approved tricyclic antidepressant in pediatric

OCD (10 years and older)

• Can be used as single agent or additional medication with

SSRIs

• Typically used after at least two SSRI failures

• Requires physical exam and lab work prior to starting

– Typically get baseline pulse, blood pressure, and EKG

– Get family history of heart disease

Strategies for Treatment Resistant OCD

• May try a different medication that effects serotonin

– SSRIs – failing one SSRI does not predict failure for another

– Clomipramine (Anafranil)

– Antidepressants that affect multiple chemical messengers (neurotransmitters) including serotonin

• May use other medications to increase effectiveness of SSRI’s

– Atypical anti-psychotics

– Mood stabilizers

– Medications that affect glutamate

• Gabapentin

• Memantine

Discontinuing Medication

• Consider after patient has been optimally treated and

stable for 12-18 months

• Done gradually with 25% reduction in dose as initial step

– Re-evaluate after each step in discontinuation

• CBT/ERP should be part of treatment plan

Multi-Center Research (continued)

• Pediatric OCD Treatment Study (POTS)

– N=112 (children 7-17).

– Randomized, placebo controlled study.

• 12 weeks of ERP.

• Sertraline.

• 12 weeks of ERP + sertraline (combined).

• Placebo.

– Looked at Clinical Remission rates (CY-BOCS <10).

POTS Team (2004)

Combining Treatments

• CBT superior in multiple studies to medication in mild and moderate OCD

• Evidence demonstrates superiority of combined treatment in moderate to severe cases of OCD

• May be a “synergistic” effect

– Both interventions effect serotonin in the brain

Addressing Family Accommodation in

OCD

What is Family Accommodation?

Specific behaviors of family members to:

• Provide reassurance to the child

• Yield to the child’s demands

• Assist in rituals

• Assist with or complete tasks for the child

• Decrease the child’s responsibility because anxiety or OCD

symptoms interfere with daily life

Examples of Family Accommodation

• Providing reassurance

• Physically assisting the child to hand wash or complete shower rituals

• Opening doors or turning on light switches

• Not entering child’s room or touching child’s objects

• Participating in bedtime rituals, such as saying certain prayers

• Changing your routine to be available to answer your child’s calls or texts from school

You are in Good Company!

AT LEAST

90% of families accommodate!

Why some families accommodate:

• It’s easier in the beginning

• It seems helpful

• It worked with your other children

• It’s hard to tolerate your child’s anxiety/distress

• You feel guilty or “mean” if you don’t accommodate

• You fear your child will feel unloved if you do not

accommodate

• You are scared of your child’s behavioral response

What’s the problem with accommodating?

• Accommodation conflicts with goals of CBT

– Limits opportunities for child to learn that feared consequences

do not happen

– Reduces child’s motivation to change

– Prevents habituation

• Associated with poorer treatment outcomes in children

and adults with OCD

– Reduces effectiveness of CBT and long-term outcomes

Treatment Outcomes

• Family accommodation is a major predictor of treatment response and outcomes in children (Storch et al., 2008) and adults (Ferrao et al., 2006)

• Numerous studies have demonstrated smaller reductions in CY-BOCS scores and worse functioning for children when families accommodate

• Family conflict typically increases with accommodation which also worsens outcomes (Peris et al., 2008)

• Family accommodation contributes to OCD severity (Noppen and Steketee, 2009)

Tolerating Your Child’s Anxiety

• You can be empathetic without being accommodating

• Have age-appropriate expectations

• Be aware of your body language and tone of voice when

your child is anxious

• Thought challenge: Anxiety is NOT dangerous.

• This is harder when you struggle with anxiety

– Seek help if you feel the need to rescue your child every time

Reducing Accommodations

• Needs to be in conjunction with the treatment team and the CBT goals

– Important that your child knows parents and therapist are working together and are in agreement

• Typically, accommodation reduction occurs gradually

• You should prepare your child for accommodation reduction through good communication

– Discuss working as a team to fight anxiety and OCD

– Separate anxiety and OCD driven behaviors from child

– Accommodation is allowing anxiety/OCD monster to “win”

Reducing Accommodations

• Practice accommodation reduction in therapy sessions

• Ask your child to rate his/her anxiety

– If anxiety is elevated this is a cue that it may be difficult to communicate effectively

– Do NOT over talk when your child is going into meltdown mode

– Reduce avoidance by “shaping” desired behaviors

• Help track ban/stop behaviors (ritual prevention)

– Remind your child to record ban behaviors (in calm manner)

• Do NOT provide mixed messages

– For example, having them hand wash before meals if they have a handwashing protocol.

Summary

• OCD is a common, debilitating condition.

• Cause is unknown, however biology appears to

play a role.

• OCD is a treatable disorder to treat when treated

properly.

– Proper type.

– Proper dose.

About OCD Awareness Week

OCD Awareness Week is coordinated by the

International OCD Foundation as a vehicle for

support, advocacy and education to help end the

stigma surrounding OCD and to encourage

people who have OCD to find treatment.

OCD Awareness Week

October 7 – 11, 2015

Resources

International Obsessive Compulsive Disorder Foundation

OCFoundation.org

Anxiety and Depression Association of America

ADAA.org

Rogers Memorial Hospital

rogershospital.org

Thank you

Stephanie C. Eken, MD, FAAP

Regional Medical Director

Rogers Memorial Hospital is a national leader in the treatment of

OCD and other anxiety disorders in children, teens and adults.

800-767-4411 | rogershospital.org