I. OCD DIAGNOSIS

Provide definition (DSM IV). Screen all clients with sx of anxiety &/or depression for OCD. 30% also depressed / dysthymic at intake. 67-75% MD & 25% social phobia lifetime prevalence. 75% with coexisting PD (avoidant, dependent, histrionic, schizotypal). Distinguish between OCD & OCPD (25%). Waxing / waning Sx. "OCD Spectrum Disorders" debate. Use the Yale-Brown OC Scale to dx and set up tx.

II. BASE RATE

2-3% lifetime prevalence, 10% in outpatient clinics. 4^th most common Dx. OCD afflicts as many as 5 million Americans, or 1 in 50. Epidemiological studies in Europe, Asia, Africa confirms rates across cultural boundaries. Usually begins in adolescence and early adulthood (x age 20), 2/3’s by age 25. Some cases occur in childhood, ration is 75% male. For adults, affects males and females equally. More prevalent than schizophrenia, panic disorder.

Neurotransmitter / Brain Imaging Studies: OCD caused by abnormal metabolism in specific areas of the brain, specifically a dysregulation of the neurotransmitter serotonin. See Brain Lock chapter 2 for explanation of biology of OCD.

1. ORBITAL GYRI (Frontal Lobe) — Involved in social consciousness regarding proper behavior. Underactivity leads to coarsening of social consciousness and behavior such as hypersexuality, overeating to the point of obesity, and personality changes, such as inappropriate use of profanity and crude jokes. Overactivity leads to excessive concern with meticulousness fastidiousness and "nit picking." Believed to be underlying the symptoms of OCD.

2. CAUDATE NUCLEI — Filter info coming from the frontal lobe. Some believe that if too many messages regarding worries about how things should be done reach the caudate nuclei, they are not filtered properly and spill over and can flood consciousness.

Genetics: Inherited. Family studies of OCD patients show that 35% of their first degree relatives also have OCD. 32 (63%) of 51 monozygotic twins concordant for OCD.

Trauma / Head Injury / Infections: Termed "secondary OCD." Children (1%) strep infection can trigger an autoimmune response leading to OCD (rare, but 75% of children w/ Sydenham’s chorea have OCD). Adults: childbirth may trigger OCD in women.

1. Behavioral Factors:

Obsession is created by a neutral stimulus that becomes associated with fear through conditioning. Compulsion created because the person discovers a certain action reduces the anxiety attached to the obsessional thought. Avoidance strategies become fixed as learned patterns of compulsive behavior. Develops frequently (50-70%) after a stressful event, e.g. pregnancy, sexual problem, death of a relative.

2. Psychodynamic Issues:

IV. TREATMENT:

28% of people with OCD do not seek Tx. 50% who do seek Tx do not seek help from a mental health professional. Mean time between onset and seeking Tx is 7.6 years. 70-90% of people who begin combination of behavior and drug therapy significantly decrease symptoms 60% average improvement rate. Improvement in 3 months to 6 years. Outpatient Tx. Number who decline to start Tx or drop out: 10-25% (both beh and meds). Combination of pharmacotherapy and behavior therapy recommended.

1. Pharmacotherapy:
The following psychotropic medications are typically prescribed for OCD. The patient must be evaluated, however, by a psychiatrist with expertise in OCD.

1. Serotonin-Specific Reuptake Inhibitors: (transient side effects of sleep disturbance, sexual difficulties, nausea, headache, anxiety, restlessness)

1. Augmenting Agents: (used only if no improvement on second anti-obsessional drug, helps with comorbid sx)

1. Behavior Therapy: (Pioneered by Victor Meyer in 1966)

1. Psychoeducation — Treatment is an active partnership involving development of self-management skills. Disconfirm erroneous beliefs.
2. Self Monitoring — forms, diaries. Provides baseline, info.
3. Hierarchy Construction - (SUDS) Separate hierarchies of 10-15 situations for each obsessional theme.
4. Exposure Therapy and Ritual Prevention —

V. RECOMMENDED SELF HELP BOOKS