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Spectrum Disorders
Concept of spectrum
To
Concept of spectrum
Not
continuum
Manifestations vary widely in type and
severity
All kinds of combinations are possible
These combinations syndromes
OC spectrum disorders
model of medical classification where
various psychiatric, neurological and/or
medical conditions are described as existing
on a spectrum of conditions related to
obsessivecompulsive disorder (OCD)
The model suggests that many conditions
overlap with OCD in symptomatic profile,
demographics, family history, neurobiology,
comorbidity, clinical course and response to
various pharmacotherapies
Motor disorders
OCD
Impulse control
disorder
Trichotillomania
Pathological gambling
Compulsive sexual
disorder
Kleptomania
Tics
Tourettes disorder
Sydenhams chorea
PANDAS
OC spectrum disorders
MOTOR DISORDERS
Tourettes
disorder
Sydenhams chorea
Tics
PANDAS
OC spectrum disorders
IMPULSE CONTROL DISORDERS
Trichotillomania
Kleptomania
Pathological gambling
Pyromania
Intermittent explosive disorder
Compulsive sexual disorder
Compulsive buying
Skin picking (dermatillomania)
Nail biting (onychophagia)
OC spectrum disorders
PREOCCUPATION WITH BODY
Body dysmorphic disorder
Hypochondriasis
Anorexia nervosa
Bulimia nervosa
Controversial
Autism
Substance
use disorder
Self injurious behavior
Depersonalization
OCPD
COMORBIDITY
Patients
Family history
Among
Animal studies
Hoxb8
Excessive grooming
Excessive hair removal
Similar
to trichotillomania
If treated with SSRI there is no grooming
Animal studies
companion
stereotypies in locomotion
Cows and pigs - chewing stereotypies
Primates - grooming abnormalities
some
NEUROCIRCUITRY
DISRUPTION OF CONTROL MECHANISMS:
Cortico-striatal neurocircuitry : mediate
the control of procedural strategies
Dysfunction
neurologic
disorders characterized by
striatal lesions may be accompanied by
obsessive-compulsive symptoms
functional imaging studies demonstrate
that during implicit learning there is
striatal activation in healthy controls but
abnormal extra-striatal activity in OCD
successful treatment, whether using
medication, cognitive-behavioral
therapy, or neurosurgery, results in
decreased symptoms and altered activity
in cortico-striatal circuitry
NEUROCHEMISTRY
The Serotonin Hypothesis:
OCD
Higher levels of HIAA
Reduction in 5 HIAA after treatment with
clomipramine
Meta chloro phenyl piperazine (mCPP)
administation serotonin agonist
worsening of OCD
SSRI are effective in treatment
Autism :
decreased capacity to synthesize
serotonin during development
de
Functional
NEUROANATOMIC:
SYDENHAMS CHOREA
Alterations to basal ganglia
Signal hyper intensity in caudate nucleus
PANDAS
Enlarged basal ganglia
TOURETTE SYNDROME
Volume of caudate nucleus was decreased
AUTISM
Enlargement of caudate
BDD
Caudate nuclear asymmetry
Increased white matter volume
TRICHOTILLOMANIA
Decreased left putamen and lenticular
nucleus
IMMUNE MECHANISMS:
patients may develop OC symptoms in the
aftermath of streptococcal infection -antinuclear antibodies
Anti basal ganglia antibodies found in OCD
Antiputamen antibodies in anorexia
nervosa
D8/17 expression appears increased in
childhood-onset OCD and TD and in autism
CSF type 1 cytokines, consistent with a
cell-mediated immune process
preponderance in OCD
PSYCHODYNAMIC FACTORS:
Freud : obsessive-compulsive neurosis,
and obsessive-compulsive psychosis lay
on a spectrum and were all characterized
by specific unconscious mechanisms (eg,
heightened anal
drive)
If
COMPULSIVITY vs IMPULSIVITY
OCD
spectrum : dimension of
compulsivity and impulsivity
compulsivity may reflect harm avoidance,
whereas impulsivity reflects risk seeking
OCD falls on the compulsive end of an
OCD spectrum, whereas impulsive
disorders fall on the impulsive end
disorders such as TD, trichotillomania,
and obsessive compulsive personality
disorder demonstrate both compulsive
and impulsive characteristics
TRICHOTILLOMANIA
Epidemiology
Prevalence
0.6%
SexFemales> males
Age of onset- usually 18 years
TRICHOTILLOMANIA
Repetitive
hair loss
There is an increasing level of tension
immediately before hair pulling or during
attempts to avoid pulling
There is a sensation of relief, pleasure or
gratification during hair pulling
The pulling is not explained by general medical
condition/other mental disorder
Significant distress or impairment in
occupational, social or other areas of
functioning is experienced as a result of pulling
TRICHOTILLOMANIA
Environmental factors- acts as triggering
events
Physical features of haircolor/shape/texture
Negative cognition- about appearance,
fear of being negatively evaluated,
shame related cognitions
Negative affective states-anxiety,
frustration, loneliness, fatigue
Specific settings- studying, watching TV,
driving, talking over phone
TRICHOTILLOMANIA
Possible subtypes
Focused hair pulling
Non focused hair pulling
TRICHOTILLOMANIA
Treatment
There is neither a universal nor a
complete response to any treatments for
TTM
Monotherapy with CBT or
pharmacotherapy is likely to produce
only partial symptom reduction in the
long run
Might yield superior improvement when
combined- but no evidence support
TRICHOTILLOMANIA
Pharmacotherapy
SSRI
Clomipramine
Psychotherapy
CBT/BT- Habit reversal, awareness
training, stimulus control
PATHOLOGICAL GAMBLING
Public
health issue
1980:
More
PATHOLOGICAL GAMBLING
PATHOLOGICAL GAMBLING
Treament:
Psychotherapeutic approaches:
Psychoanalysis
CBT
Pharmacotherapy:
SSRIs
Mood Stabilizers: carbamazepine, lithium
Opioid antagonists- naltrexone
Gamblers anonymous
KLEPTOMANIA
Recurrent, impulsive pathological
stealing
Resistance to stealing is met with
anxiety and tension
COMPULSIVE BUYING
Uncontrollable buying which is markedly
distressing, time consuming and
resulting in socio occupational
dysfunction
HYPOCHONDRIASIS
Disorder
HYPOCHONDRIASIS
Phenomenology:
Rasmussen and Eisen: pts. With OCD who
have somatic or illness obsessions are
virtually indistinguishable from pts. With
hypochondriasis
Obsessions: intrusive, distressing and only
temporarily responsive to reassuarance
Compulsions: repetitive and performed to
reduce distress, manifesting primarily in
the form of checking ones body or checking
with others
HYPOCHONDRIASIS
Barsky
HYPOCHONDRIASIS
Course
Acute onset : good outcome
Improvement assc with shorter duration
of illness and less depression at baseline
HYPOCHONDRIASIS
Treatment:
Pharmacoterapy : SSRIs fluoxetine,
clomipramine, fluvoxamine
CBT
mirror checking
Less insight than OCD patients
Chronic course and similar age at onset
High co morbidity with social phobia,
depression and trichotillomania
Pts with BDD conceptualized as varying
between a continuum of insight or
uncertainty--- ? two variants of the same
disorder
ANOREXIA NERVOSA
Obsessive fears about being fat
Compulsive attempts to reduce weight
BULIMIA NERVOSA
Preoccupied with body image
Leads to compulsive vomiting and
impulsive laxative abuse
Binge eating
Compulsive eating without efforts to
decrease weight
TOURETTES SYNDROME
neurological
condition characterized by
motor and vocal tics
Repetitive movements or utterances
Bodily sensation, mental urges and
tension
Tics are believed to result from
dysfunction in cortical and subcortical
regions, thethalamus , basal ganglia
andfrontal cortex
Neuroanatomic
models- failures in
circuits connecting the brain's cortex and
subcortex,andimaging
techniquesimplicate the basal ganglia
and frontal cortex
Some
SYDENHAMS CHOREA:
neurological
CRITICISMS
Repetitiveness
DSM V
five
DSM V
Based
DSM V
DSM V
Regarding
DSM V
definition
of obsession be revisited
since not everyone with OCD
experiences them as "intrusive" as is
now required in DSM-IV
agreeing on the importance of
increasing awareness of the comorbidity
between schizophrenia and obsessive
compulsive disorder, the group was
divided on whether a specifier for schizoobsessive type should be added to
schizophrenia
SUMMARY
OCD and OCSD
Similarities in phenomenology
Family members of OCD have higher rate of
OCSD and vise versa
Significant comorbidity between the
disorders
Similar treatment response
Similarities in neurobiology
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