Obsessive Compulsive Disorder, Trichotillomania, Hoarding D - PowerPoint Presentation

Slide1

Obsessive Compulsive Disorder, Trichotillomania, Hoarding Disorder and Excoriation Disorder

Allison E. Cowan MD

Julie P. Gentile MD

Ohio’s Coordinating Center of Excellence in MIDD

And

Ohio’s Telepsychiatry Project in IDSlide2

Diagnostic Manual-Intellectual Disability

DSM-V criteria adapted to better fit ID patient population

DM-ID published by The National Association for the Dually Diagnosed (NADD), in association with The American Psychiatric Association

Chapter: Obsessive Compulsive and Related Disorders (Drs. Benson,

Gillig

and Fleischer)Slide3

DSM-V

The DSM-

V

includes

a new chapter on Obsessive Compulsive and Related Disorders

New disorders also have been identified: Hoarding Disorder and Excoriation (skin-picking) Disorder

Similarity

among the set of disorders across symptoms, neurobiological networks, genetics, course of illness and treatment

responseSlide4

OCD CycleSlide5

OCD – Prevalence ~2.5%

R

ecurrent

obsessions and compulsions that are time-consuming (specifically more than one hour daily) or causing clinically significant

distress/impairment;

M

ust

experience obsessions

as

intrusive and

unwanted;

A

ttempts

to

ignore/suppress

the obsessions to neutralize them with some other thought or

action;

Anxiety

or distress occurs in most individuals but is not required to make the diagnosis.Slide6

Making the Diagnosis

Obsessive thoughts/compulsive

behavior: most

individuals with ID have an element of

OCD

Questions

:

Is it disruptive?

Causing

individual to be late?

Interfering in relationships and/or schedules?

Lasting

more than an hour daily?

Causing mental health symptoms?

Is the individual struggling?Slide7

Specific Issues Related to ID

Document observable/behavioral compulsions

D

ecrease

in self-report of internal

conflict/anxiety

M

ay

be unaware of societal disapproval and therefore this knowledge may not serve to reduce the behaviors

C

omplicated by

co-occurring stereotypies, tics,

dyskinesias

,

dystonias

,

akathisia

, self-injury, self-stimulatory

behavior

Most common compulsive behaviors - acts of cleanliness (Complicated in ID?)Slide8

Specific Issues Related to ID

More likely to demonstrate anxiety as opposed to reporting it

Compulsions that require abstract thought may not be possible (i.e. contamination or safety issues) and counting

skills are variable.

Children and Adolescents: usu. ordering, checking and cleaning rituals; usu. at home; use caution depending on developmental stage (toddlers and preschool: may have rituals; school age: may use strict rules w games/activities)Slide9

Autism vs. OCD

Repetitive and stereotyped behavior patterns in ASD can be similar to compulsive symptoms

More typical of ASD: Regression, religious, contamination, symmetry, somatic content

More typical of OCD: Ordering, tapping, rubbing

May co-occur Slide10

BioPsychoSocial Factors

Neurotransmitters: serotonin

and dopamine.

Syndromes:

Prader

Willi

syndrome (PWS), Down syndrome, Fragile X syndrome (FXS), Cornelia de Lange and Williams syndrome

Adaptive

functioning limitations with independence issues increase

prevalence of all anxiety disorders

Psychosocial factors: low self-esteem, fear of failure, deficits in problem solving, dependency needs, social stigma,

trauma

history… Slide11

ACES Research

The Adverse Childhood Experiences (ACE) Study is one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being. The study is a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente's Health Appraisal Clinic in San Diego. (1995-1997)Slide12

ACES Research

Surveys on

childhood maltreatment, household dysfunction, and other socio-behavioral factors examined in the ACE Study.

CEQ

designed by our group to reduce risk of re-

traumatization

IDD

are more likely to

experience trauma and

increase in medical and neurologic conditions; this study will add to the prevalence data

to establish

best practices

and

increased prevention Slide13

ACES Pyramid Slide14

How IDD “Readjusts” the ACE Pyramid Risk

ACE Pyramid (1998)

IDD Impact

Layer 2

: Social, Emotional & Cognitive Impairment

Present by definition

with IDD in absence of trauma

Layer 3

: Adoption of Health Risk Behaviors

Challenges in “

adherence

” and necessary skills/ understanding as well as

lower standard of care

Layer 4:

Disease, Disability, and Social Problems

Prevalence

of Medical & Mental Health Conditions in absence of traumaSlide15

Ohio’s Telepsychiatry

Project

for Intellectual Disability

Funders: DODD, ODMHAS, ODDC

Telepsychiatry

services initiated in 2012

Virtual software which abides by patient privacy guidelines (HIPAA Compliant)

Prioritize individuals from Developmental Centers and State Psychiatric

HospitalsSlide16

Ohio’s Telepsychiatry Project for ID

More

than 90

engaged

were discharged from state operated institutions and others were in danger of short-term

admission.

This saves the state approximately $80,000/person/year in support costs.

The

patients treated have experienced a decrease of

90%

in emergency department visits and 87% in hospitalizations.

775

patients/58 counties

Currently accepting referralsSlide17
Slide18

Adaptation of Diagnostic Criteria--OCD

Obsessions

Mild/Moderate

Severe/Profound

Recurrent

and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

The

individual

attempts to ignore or suppress

such

thoughts

, urges, or images, or to neutralize them with some other thought or action (i.e. by performing a compulsion).

Recurrent

and persistent thoughts, urges, or images may not be experienced as intrusive and

unwanted

May

or may

not

attempt to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action

SAME

SAME

May

be unable to report wanting to ignore, suppress or neutralize the obsessions.Slide19

Adaptation

Compulsions

Repetitive

behaviors

or

mental acts

that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

The

behaviors

are

aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or

situation

Mild/Moderate

May

be difficult to elicit due to cognitive deficits and limited expressive language skills. Consider ordering, telling, asking or repetitive physical acts (e.g. rubbing) as compulsions.

The

function of the compulsive behavior may not be

ascertainable;

recognition of excessiveness or intent of the behaviors may not be present.

Severe/Profound

Absence

of compulsions that require abstract

thinking

less likely;

observe

individuals for compulsions

requiring simple thinking, such as

excessive

ordering

and filling/emptying

.

The

criteria regarding intent of the behavior does not apply to children, and does not apply to individuals with severe/profound intellectual disability.

 Slide20

Adaptation

The

obsessions or compulsions are

time-consuming

(e.g. take more than 1 hour per day) or cause clinically

significant distress

or impairment in social, occupational, or other important areas of functioning.

Mild/Moderate

Severe/Profound

Distress

may not occur and/or may not be ascertainable. Intense preoccupation may be observed or drive to perform the compulsion may be observed. Challenging behavior, especially aggression, and self-injurious behavior, may occur if the individual is prevented from completing the compulsion.

Specify

if:

Good Insight, Fair Insight, Poor Insight or Absent/Delusional Beliefs

Specifiers

should

be applied in the context of the cognitive and developmental functioning of the individual. Slide21

Medications

Serotonin (SSRI, SNRI, TCA,

Buspirone

,

Remeron

,

etc

)

Dopamine (antipsychotic medications)

Benzodiazepines:

More sensitive to cognitive side

effects; hyperactivity;

disinhibition

;

affects seizure threshold; paradoxical reactions

Adjunct agents: mood stabilizers, clonidine, naltrexone, beta blockers,

etc

)Slide22

Cory

48 year old female with Moderate ID, Schizophrenia, OCD, Trauma history, Post-

inst

Food, crafts, drinking water, changing outfits, retracing steps, light switch, boyfriends, etc.

Triggers:

staff turnover

, UTIs,

change in rules

Interventions: Clozapine; SSRI

TIC; therapy; BSS; provider agency, SSASlide23

Treatment

Provide guidelines/boundaries for the

individual; Stick

to

them as a team

Reward

/acknowledge when individual follows

guidelines

Psychotherapy

(supportive

, cognitive, or

behavioral)

Positive Behavioral Support

Trauma Informed Approaches

Be consistent

(instills sense of safety)