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Manish
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ahead… Residents
Lot more to cover Depression
in coming days..
OCD
Stay tuned…!!!
Psychopathology
Schizophrenia
and
other Psychosis
Bipolar
With all Disorder
authentic
and proper
references
Obsessive Compulsive Disorder - Basics ©Manish Roshan-AIIMS New Delhi

Obsessive-compulsive neurosis: a condition characterized by psychic distress and social embarrassment because of
“obsessions” and “compulsions” not attributable to some other psychiatric disorder.

Obsession:

1. An obsession (also termed a rumination) is a thought that persists and dominates an individual’s thinking despite
the individual’s awareness that the thought is either entirely without purpose or else has persisted and
dominated their thinking beyond the point of relevance or usefulness (Fish Psychopathology, 4th edition)
2. An anxiety-provoking psychic phenomenon that recurs in spite of the patient's resisting it and regarding it as
alien to himself and, at times, clearly absurd.

Compulsion:

1. Compulsions are, in fact, merely obsessional motor acts. They may result from an obsessional impulse that leads
directly to the action, or they may be mediated by an obsessional mental image or thought. (Fish
Psychopathology, 4th edition)
2. A reluctantly performed voluntary act that temporarily reduces the anxiety aroused by an obsession

Akhtar S, Wig NN, Varma VK, Pershad D, Verma SK. A phenomenological

analysis of symptoms in obsessive-compulsive neurosis. Br J Psychiatry.
1975;127:342-348.
 Obsessive Compulsive Disorder - Obsessive Form & Content

Obsessive Form

Obsessive Obsessive Obsessive Obsessive Obsessive

Doubts Obsessive
Thinking Fears Images Impulses
Thinking A fear of losing
An inclination A seemingly The A powerful
not to believe endless self
persistence urge to
that a thought chain, control and
before carry out
completed task usually one thus
actions which
inadvertently the mind's eye
has been pertaining to may be trivial
accomplished
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futureDonecevents. committing of something
adipiscing. risus or socially
a socially seen, usually
satisfactorily. dolor, porta venenatis neque disruptive or
pharetra luctus felis vel embarrassing recently.
tellus nec felis. even
©Manish Roshan-AIIMS New Delhi act.
assaultive

Obsessive Contents: One Liners

1. Dirt and Contamination ● Total 6 Obsessive forms have been described: 6th one
2. Aggression being Miscellaneous
3. Inanimate-impersonal
4. Sex ● Most common form of obsession: Obsessive Doubts
5. Religion ● Most common content : Dirt and Contamination

Akhtar S, Wig NN, Varma VK, Pershad D, Verma SK. A phenomenological analysis of symptoms
in obsessive-compulsive neurosis. Br J Psychiatry. 1975;127:342-348.
 Avasthi A, Kumar D. Phenomenology of obsessive compulsive disorder.
Obsessive Compulsive Disorder - Basics JK Sci. 2004;6(1):9–14.

Jaspers in 1963 in his phenomenological analysis identified five essential characteristics of obsessional symptoms:

● A nonsensical, meaningless and absurd quality to the thoughts and actions of the obsessive that is recognized
by the obsessive himself.
● The thoughts and acts having a compelling force.
● A belief that thoughts and actions can influence events (magical thinking).
● Need for order.
● Unacceptable impulses. ©Manish Roshan-AIIMS New Delhi

Forms of compulsions:

- Yielding compulsion (60%): A compulsive act that gives

expression to the underlying obsessive urge or thought

- Controlling compulsion (<10%): A compulsive act that

tends to ward off and divert the underlying obsession
without giving expression to it

Compulsions without associated obsessions have been

termed as autonomous compulsion.
 Just Right Phenomenon - OCD ©Manish Roshan-AIIMS New Delhi

● Leckman and colleagues used the term "Just-Right”. “Just right” obsessions are thoughts and/or feelings that
something is not quite right or that something is incomplete.

● “Just right” OCD symptoms involve more of a sense of “incompleteness” rather than the need to “avoid
harm” seen in more typical OCD symptoms. “Just right” symptoms are more likely to be experienced as
discomfort or tension rather than anxiety.

● “Just Right” obsession would be a person feeling that their hands are not quite clean when washing them.
An example of a “Just Right” compulsion is a person washing their hands until the sense of “incompleteness”
goes away.
● Over 50% of those with OCD experience “just right” obsessions or compulsions.

● Those with “just right” OCD symptoms are likely to have:

- perfectionism (e.g., concern over mistakes)
- ‘obsessional slowness’ (i.e., loss of time due to obsessional ‘loops’)
- a need for control/predictability
- ordering/arranging/symmetry behaviors/evening-up

Moshinsky M. Just Right Phenomenon,. Nucl Phys. 1959;13(1):104–16.

Obsessive Slowness ©Manish Roshan-AIIMS New Delhi

- Rachman (1974) first described 10 cases of “primary obsessional slowness”

- The main feature described was a meticulous concern for orderliness in which a patient would take hours to carry
out daily tasks of self care such as washing, shaving, brushing his teeth or getting dressed
- Rachman (1974) acknowledged that obsessional slowness can be secondary to rituals, but wanted to draw
attention to a new syndrome. He proposed the term “primary obsessional slowness' because the activities
concerned were not rituals - there was no reduction in anxiety or dysphoria before or after the activity
- Components of obsessional slowness are usually multiple, excessive time spent completing an activity is not just
related to orderliness or meticulousness, but usually a wide range of strategies adopted by the patient. None of
the components of obsessional slowness are mutually exclusive; they may interact with one another in a complex
fashion.

The criteria for obsessive compulsive personality disorder in DSM-III Rare more restrictive but the components of
slowness may be associated with three out of the ten criteria:

1. perfectionism that interferes with task completion

2. preoccupation with details, rules, lists, order, organisation, or schedules to the extent that the major point of the
activity is lost
3. indecisiveness: decision making is either avoided, postponed or protracted, e.g. the person cannot get an
assignment done on time because of ruminating about priorities.

Veale D. Classification and treatment of obsessional slowness. Br J Psychiatry. 1993;162(FEB.):198–203.

Scales in OCD ©Manish Roshan-AIIMS New Delhi

Clinician-rated Self-report Impairment rating Family Insight rating

measures of OCD measures of OCD Scales accommodation scales
symptom severity symptom severity rating scales

Sheehan Disability Family Brown Assessment

Scale & Accommodation of Beliefs Scale
YBOCS YBOCS Self Report Child Sheehan Scale for Obsessive
Disability Scale Compulsive
Parent and Child Disorder
Report

Family
Obsessive Accommodation
Children’s YBOCS Compulsive Scale Patient
Inventory Version
Child Obsessive
Compulsive Impact
National Institute of Scale- Revised Family
Mental Health Florida Obsessive Accommodation
(NIMH) Compulsive Scale Self-Report
Global Obsessive Inventory
Compulsive Scale
 ● Meta-analyses of RCTs show that SSRIs are ©Manish Roshan-AIIMS New Delhi Treatment of OCD
significantly more effective than placebo in
the treatment of OCD and head-to-head Strategies for non-responders to SSRIs
comparisons have not shown superiority of —-----------------------------------------------------------
Given in sequence i.e. Steps 1 to 9
any one SSRI over the other
[next step to be taken in case of non-response to one]
—-------Predictors of response to SSRI—-------
1. Adequate trial of two SSRI
- Early age of onset, longer duration of illness 2. CBT or Clomipramine
and poor insight 3. Third SSRI
- Presence of hoarding, sexual/religious
4. Augment with Risperidone / Aripiprazole
obsessions, cleaning/washing,
5. Add on to SSRI [Memantine/ 5HT3
repeating/counting compulsions
antagonist/Lamotrigine]
- Comorbidities in the form of tics, depressive
6. Trial of untried SSRI or Venlafaxine
disorder, comorbid schizotypal, borderline
and anxious avoidant personality disorders 7. Inpatient treatment with intensive
- CYP2D6 polymorphisms associated with SSRI+CBT
SSRI response 8. Ultra-high dose SSRIs, addition of
- Reduction in thalamic volume and increase in clomipramine, rTMS, Mirtazapine,
OFC volume is associated with SSRI N-acetyl cysteine, Ketamine
response (structural MRI) 9. DBS or ablative surgery
 Treatment - OCD Strategies for non-responders to SSRIs ©Manish Roshan-AIIMS New Delhi

1 2

Ref: Janardhan Reddy, Y.C.; Sundar, A. Shyam; Narayanaswamy, Janardhanan C.; Math, Suresh Bada. Clinical practice
guidelines for Obsessive-Compulsive Disorder. Indian Journal of Psychiatry 59(Suppl 1):p S74-S90, January 2017.
Treatment Non- Response (Refractory) in OCD Pallanti S, Quercioli L. Treatment-refractory obsessive
compulsive disorder: methodological issues, operational
©Manish Roshan-AIIMS New Delhi definitions and therapeutic lines.
Prog Neuropsychopharmacol Biol Psychiatry. 2006; 30(3)
‘‘Levels of non-response’’ enables individual
clinicians to decide the ‘‘next step’’ approach

©Manish Roshan-AIIMS New Delhi

Pallanti S, Quercioli L. Treatment-refractory obsessive compulsive disorder: Treatment Resistant OCD
methodological issues, operational definitions and therapeutic lines.
Prog Neuropsychopharmacol Biol Psychiatry. 2006; 30(3)

No consensus definition of TR-OCD till date

Definition of TR-OCD: ©Manish Roshan-AIIMS New Delhi —---------------------------------------------------
—------------------------------------------------------------------------- Treatment Resistant- OCD
Even after using the first and second line treatment - Two SSRi + Clomipramine (CMN) +
—---------------------------------------------------------------- Adequate sessions of CBT (16-24
YBOCS Score: sessions)
- Improvement in YBOCS score <35% (Ackerman et al., (Feusner & Bystritsky,2005)
1994) —---------------------------------------------------
- Improvement in YBOCS score <25% (Goodman 1999) Treatment of TR-OCD:
- YBOCS >16 score (McDougle et al., 1994,2000)
CGI (Improvement) Combination therapy is considered with CMN
- Score of 3 or more is considered as non-response being the common drug
—-------------------------------------------------------------------------
Based upon number of SSRi tried - Combining SSRi with low dose CMN
- Failure of 2 SSRI (Shetti et al., 2005) - Combining CMN with low dose SSRI
—------------------------------------------------------------------------- - Combining CMN with
Refractory OCD: Venlafaxine/Mirtazapine
- Failure to respond to all available treatments —---------------------------------------------------
(Pallanti et al.,2002) Novel methods can be tried
- Failure to respond to two adequate trial of SRi - Psychosurgery
(Hollander et al.,2022) - DBS
Indication of Psychosurgery: Indication and targets of Psychosurgery in OCD
1. Severe (YBOCS >28) and chronic unremitting
OCD —-------------------------------------------------------------------------
2. Impairment in functioning (GAF ≤45) Targets for ablative surgery in OCD includes
3. The following treatment options tried 1. Anterior cingulate gyrus and the cingulum bundle
systematically without appreciable effect on the (Anterior cingulotomy) [most commonly used]
symptoms (Adequate trial) 2. Anterior limb of internal capsule (Anterior capsulotomy)
- 2 SSRI for at least 3 months each 3. Corticostriatal tracts ventral to the head of the caudate
- Clomipramine for at least 3 months nucleus (Subcaudate tractotomy).
- Augmentation with at least 2 agents one of them —-------------------------------------------------------------------------
being an atypical antipsychotic Anterior Cingulotomy (Balachander et al.,2019)
- At least one adequate trial of CBT (at least 20 The anterior cingulate cortex (Brodmann area 24 and 32) along
sessions of ERP) with the underlying white matter tract known as the cingulum
4. Previous treatment trials have not been bundle are targeted in this procedure
abandoned prematurely due to solely mild side
effects Relative contraindications: ©Manish Roshan-AIIMS New Delhi
©Manish Roshan-AIIMS New Delhi
5. Patient gives informed consent - Comorbid intellectual disability, psychosis, bipolar disorder
6. Willing to participate in the preoperative and severe personality disorders
evaluation and post‑operative periodic follow‑up - Clinically significant and unstable neurologic illnesses

Ref: Janardhan Reddy, Y.C.; Sundar, A. Shyam; Narayanaswamy, Janardhanan C.; Math, Suresh Bada. Clinical practice guidelines for Obsessive-Compulsive
Disorder. Indian Journal of Psychiatry 59(Suppl 1):p S74-S90, January 2017.
Balachander S, Arumugham SS, Srinivas D. Ablative neurosurgery and deep brain stimulation for obsessive‑compulsive disorder. Indian J Psychiatry
2019;61:S77-84.
 ©Manish Roshan-AIIMS New Delhi
Targets and Steps of DBS in OCD

Targets for DBS in OCD:

1. ALIC (Anterior limb of Internal Capsule), ventral capsule/ventral striatum (VC/VS), nucleus accumbens (NA), bed
nucleus of stria terminalis (BNST): [most common areas targeted in DBS for OCD]
The above targets are close to each other and they can be collectively called “Striatal DBS”
2. Subthalamic nucleus (STN): This is the most widely used site for DBS in idiopathic Parkinson’s disease; hence,
most neurosurgery centers have a greater degree of experience in electrode implantation at this site.
3. Others: inferior thalamic peduncle, medial dorsal nucleus of thalamus, and medial forebrain bundle.
—--------------------------------------------------------------------------------------------------------------------------------------------

DBS (3 steps):
1. Surgery for stereotactic image‑guided insertion of electrodes- bilateral burr holes, performed under local anesthesia
and mild sedation. [Intraoperative “macrostimulation” is done for monitoring adverse effects]
2. Subcutaneous implantation of the pulse generator, commonly in the infraclavicular space
3. Programming is generally done on an outpatient basis using a handheld programming device which communicates
wirelessly to the implanted pulse generator.

Ref:Balachander S, Arumugham SS, Srinivas D. Ablative neurosurgery and deep brain stimulation for obsessive‑compulsive disorder. Indian J
Psychiatry 2019;61:S77-84.
 Macerollo A, Martino D. Pediatric Autoimmune
PANDAS, PANS, CANS - The Evolving Concept [Operational Definitions] Neuropsychiatric Disorders Associated with
Streptococcal Infections (PANDAS): An Evolving
Concept. Tremor Other Hyperkinet Mov (N Y). 2013;
3:tre-03-167-4158-7.

● The PANDAS clinical course was

characterized by a
relapsing-remitting symptom
pattern with significant psychiatric
comorbidity accompanying the
exacerbations; emotional lability,
separation anxiety, nighttime fears
and bedtime rituals, cognitive
deficits, oppositional behaviors, and
motoric hyperactivity were
particularly common.

● Association between GABHS

group-A-beta-hemolytic
streptococcal infection and
neuropsychiatric symptoms should
be preferably observed on at least
two occasions (i.e.,two
exacerbations).

● The time lag between infection and

exacerbations may vary with in and
across individuals, often between
©Manish Roshan-AIIMS New Delhi several days and a few weeks.
PANDAS, PANS, CANS - Approach to the THREE Syndromes Diagnostic Approach to Pediatric Autoimmune Neuropsychiatric
Disorders Associated With Streptococcal Infections (PANDAS): A
Narrative Review of Literature Data - Scientific Figure on
ResearchGate.

● The basic differences are shown through the

highlighted points.

● The essential criteria is

- Age<18 years
- OCD diagnosis

—-------------Differentiating features—------------

- GABHS +/- (if positive PANDAS else PANS &

CANS)

- Psychosis present(CANS >> PANS and

PANDAS)

- Anorexia present (PANS>> CANS and

PANDAS)

©Manish Roshan-AIIMS New Delhi

Psych reads with Dr. Manish
Only page
exclusively
for
Miles to go Psychopharmacology Psychiatry
ahead… Residents
Lot more to cover Depression
in coming days..
OCD
Stay tuned…!!!
Psychopathology
Schizophrenia
and
other Psychosis
Bipolar
With all Disorder
authentic
and proper
references