diagnosis, assessment and management of ocd

8/17/2019 Diagnosis, Assessment and Management of OCD

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CHAIR-PERSON:

DR.MANJU

BHASKAR

Diagnosis, Assessment andManagement o OCD


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Int!od"#tionO$sessi%eom'"(si%e diso!de! )OCD* is an

int!ig"ing and oten de$i(itating s+nd!ome#a!a#te!ied $+ te '!esen#e o to

distin#t 'enomena: o$sessions and

#om'"(sions.O$sessions a!e int!"si%e, !e#"!!ent,

"nanted ideas, to"gts, images o!im'"(ses tat a!e di/#"(t to dismiss des'ite

tei! dist"!$ing nat"!e.

0e int!"si%e and ina''!o'!iate 1"a(it+ &

ego-d+stoni#.


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Com'"(sions a!e !e'etiti%e $ea%io!s,eite! o$se!%a$(e o! menta(, tat a!eintended to !ed"#e te an2iet+engende!ed $+ o$sessions.

O$sessions o! #om'"(sions tat #(ea!(+inte!e!e it "n#tioning and3o! #a"se

signi4#ant dist!ess a!e te a((ma!5 oOCD.


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0+'es6. Contamination7.Need o! s+mmet!+

8.Somati# O$sessions

9.Se2"a( and Agg!essi%e O$sessions.Pato(ogi#a( Do"$t


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m


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In a !e#ent meta-ana(+sis ,B(o# et a( )7


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E'idemio(og+Comm"nit+ st"dies: (ietime '!e%a(en#e-7-

? and 6+!- , in #i(d!en $o+s gi!(s.

Indian st"d+- (ie time '!e%a(en#e o


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Co"!seAge o onset: ado(es#en#e o! ea!(+

#i(dood.

Moda( age: ma(es:-6+!s ema(es:7


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)7* te to"gts, im'"(ses, o! images a!enot sim'(+ e2#essi%e o!!ies a$o"t !ea(-(ie'!o$(ems.

)8* te 'e!son attem'ts to igno!e o!s"''!ess s"# to"gts, im'"(ses, o!images, o! to ne"t!a(ie tem it someote! to"gt o! a#tion.

)9* te 'e!son !e#ognies tat teo$sessiona( to"gts, im'"(ses, o! images

a!e a '!od"#t o is o! e! on mind)not


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Com'"(sions as de4ned $+ )6* and )7*:

!e'etiti%e $ea%io!s )e.g., and asing, o!de!ing,#e#5ing* o! menta( a#ts )e.g., '!a+ing, #o"nting,!e'eating o!ds si(ent(+* tat te 'e!son ee(s d!i%en to

'e!o!m in !es'onse to an o$session, o! a##o!ding to!"(es tat m"st $e a''(ied !igid(+.

te $ea%io!s o! menta( a#ts a!e aimed at '!e%enting o!!ed"#ing dist!ess o! '!e%enting some d!eaded e%ent o!

sit"ation oe%e!, tese $ea%io!s o! menta( a#ts eite!a!e not #onne#ted in a !ea(isti# a+ it at te+ a!edesigned to ne"t!a(ie o! '!e%ent o! a!e #(ea!(+ e2#essi%e.


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B. At some 'oint d"!ing te #o"!se o te diso!de!,te 'e!son as !e#ognied tat te o$sessions o!#om'"(sions a!e e2#essi%e o! "n!easona$(e.

Note: 0is does not a''(+ to #i(d!en.

C. 0e o$sessions o! #om'"(sions #a"se ma!5eddist!ess, a!e time #ons"ming )ta5e mo!e tan 6o"! a da+*, o! signi4#ant(+ inte!e!e it te'e!sons no!ma( !o"tine, o##"'ationa( )o!a#ademi#* "n#tioning, o! "s"a( so#ia( a#ti%ities o!!e(ationsi's.


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D. I anote! A2is I diso!de! is '!esent, te #ontento te o$sessions o! #om'"(sions is not !est!i#tedto it )e.g.,'!eo##"'ation it ood in te '!esen#e

o an Eating Diso!de! ai! '"((ing in te '!esen#eo 0!i#oti((omania #on#e!n it a''ea!an#e in te'!esen#e o Bod+ D+smo!'i# Diso!de!'!eo##"'ation it d!"gs in te '!esen#e o aS"$stan#e Use Diso!de! '!eo##"'ation ita%ing a se!io"s i((ness in te '!esen#e o

H+'o#ond!iasis '!eo##"'ation it se2"a( "!geso! antasies in te '!esen#e o a Pa!a'i(ia o!g"i(t+ !"minations in te '!esen#e o MaGo!De'!essi%e Diso!de!*.


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E. 0e dist"!$an#e is not d"e to te di!e#t'+sio(ogi#a( ee#ts o a s"$stan#e )e.g., ad!"g o a$"se, a medi#ation* o! a gene!a(medi#a( #ondition.

S'e#i+ i: it Poo! Insigt.


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Inern!ion!l Cl!ssi"#!ion o$ Disorders-%0di!&nosi# #rieri! $or ') Obsessive-Compulsive Disorder

A.Eite! o$sessions o! #om'"(sions )o! $ot*, '!esenton most da+s o! a 'e!iod o at (east to ee5s.

B. O$sessions )to"gts, ideas o! images* and#om'"(sions )a#ts* sa!e te o((oing eat"!es, a(( oi# m"st $e '!esent:

)6* 0e+ a!e a#5no(edged as o!iginating in te mindo te 'atient, and a!e not im'osed $+ o"tside 'e!sonso! in"en#es.


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)7* 0e+ a!e !e'etiti%e and "n'(easant, and at (east oneo$session o! #om'"(sion m"st $e '!esent tat isa#5no(edged as e2#essi%e o! "n!easona$(e

)8* 0e s"$Ge#t t!ies to !esist tem )$"t i %e!+ (ong-

standing, !esistan#e to some o$sessions o! #om'"(sionsma+ $e minima(*. At (east one o$session o! #om'"(sionm"st $e '!esent i# is "ns"##ess"((+ !esisted.

)9*Ca!!+ing o"t te o$sessi%e to"gt o! #om'"(si%e a#tis not in itse( '(eas"!a$(e.)0is so"(d $edisting"ised !om te tem'o!a!+ !e(ie o tension o!an2iet+*.


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C. 0e o$sessions o! #om'"(sions #a"se dist!ess o!inte!e!e it te s"$Ge#tLs so#ia( o! indi%id"a("n#tioning, "s"a((+ $+ asting time.

D. Most #ommon(+ "sed e2#("sion #!ite!ia: not d"e toote! menta( diso!de!s, s"# as s#io'!enia and!e(ated diso!de!s )>7*, o! mood ae#ti%e diso!de!s)>8*.

In#("des: anan5asti# ne"!osis, o$sessi%e-#om'"(si%e

ne"!osisE2#("des: o$sessi%e-#om'"(si%e 'e!sona(it+ diso!de!.


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0e diagnosis ma+ $e s'e#i4ed $+ teo((oing o"! #a!a#te! #odes:

>97.< P!edominant(+ o$sessiona( to"gtsand !"minations

>97.6 P!edominant(+ #om'"(si%e a#ts

>97.7 Mi2ed o$sessiona( to"gts and a#ts

>97.= Ote! o$sessi%e-#om'"(si%e

diso!de!s>97.F O$sessi%e-#om'"(si%e diso!de!,

"ns'e#i4ed

'*AT+R*S DSM IV ICD %0


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'*AT+R*S DSM-IV ICD-%0

D"!ation Not mentioned 7ee5s

0ime #ons"m'tion 6o"! Not mentioned

Patient !ea(ies te+ a!ee2#essi%e and"n!easona$(e

es, it e2#("sion in#i(d!en

es, no e2#("sion #!ite!iao! #i(d!en

N"m$e! o o$sessions Not mentioned At(east oneo$session3#om'"(sionm"st $e '!esent tat is#onside!ed e2#essi%eand "n!easona$(e.

I ote! A2is I diso!de! is'!esent,o$sessiona( o!#om'"(si%e #on tent not

!est!i#ted to it

es Mentions #o-mo!$idit+ ode'!ession.

E2#("sion o MC Qs"$stan#e

es No

Mention a$o"t insigt es No


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IM,ROVING DIAGNOSIS ANDDISS*MINATION

0e diagnosti# #!ite!ia o! OCD a%e!emained !e(ati%e(+ "n#anged sin#e te'"$(i#ation o DSM-II.

DSM-I 4e(d t!ia(s e2amined t!ee iss"es:

6.0e !e1"i!ement tat s+m'toms $e%ieed as e2#essi%e o! "n!easona$(e.

7.0e '!esen#e o menta( #om'"(sions.

8.0e ICD s"$#atego!ies)e.g.,'!edominant(+ o$sessi%e %e!s"s'!edominant(+ #om'"(si%e*.


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0e!e !emains se%e!a( #on#e!ns a$o"t DSM-I de4nitions o O$sessions and Com'"(sions.

6.0e te!m im'"(se in te #!ite!ia is 'ossi$(+#on"sing.

7. A(to"g it is im'o!tant to die!entiateOCD o$sessions !om o!!ies a$o"t !ea(-(ie'!o$(ems, tis #om'onent o te de4nition is#on"sing.

8. 0e de4nition o #om'"(sion, "n(i5eo$session, doesnot !ee! to o! s'e#i+die!ent o!ms o a%oidan#e.


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9. ete! to de(ete te #!ite!ion tat'e!tains to te 'e!sons !e#ognition tatte o$sessions and #om'"(sions a!ee2#essi%e and "n!easona$(e.

.0e #!ite!ia on time d"!ation o one o"!o! mo!e a da+- 1"estion o de$ate.

. 0o do#"ment te '!esen#e o '!ominents+m'tom dimensions t!o"g te "se os'e#i4e!s.

.0e 1"estion o in#("ding oa!ding as as'e#i4e! o! a se'a!ate #atego!+ is !aised.


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P!o'osed #!ite!ia o O$sessi%e &Com'"(si%eDiso!de! in DSM-

A.Eite! o$sessions o! #om'"(sions:

O$sessions as de4ned $+ )6* and )7*:

6. Re#"!!ent and 'e!sistent to"gts,"!ges, o! images tat a!e e2'e!ien#ed, atsome time d"!ing te dist"!$an#e, as

int!"si%e and "nanted and tat in mostindi%id"a(s #a"se ma!5ed an2iet+ o!dist!ess.


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7. 0e 'e!son attem'ts to igno!e o!s"''!ess s"# to"gts, "!ges, o! images,o! to ne"t!a(ie tem it some ote!to"gt o! a#tion )i.e., $+ 'e!o!ming a

#om'"(sion*Com'"(sions as de4ned $+ )6* and )7*:

6. Re'etiti%e $ea%io!s )e.g., andasing, o!de!ing, #e#5ing* o! menta( a#ts)e.g., '!a+ing, #o"nting, !e'eating o!dssi(ent(+* tat te 'e!son ee(s d!i%en to'e!o!m in !es'onse to an o$session, o!a##o!ding to !"(es tat m"st $e a''(ied!igid(+.


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7. 0e $ea%io!s o! menta( a#ts a!e aimedat '!e%enting o! !ed"#ing an2iet+ o!dist!ess, o! '!e%enting some d!eaded e%ento! sit"ation oe%e!, tese $ea%io!s o!

menta( a#ts eite! a!e not #onne#ted in a!ea(isti# a+ it at te+ a!e designedto ne"t!a(ie o! '!e%ent, o! a!e #(ea!(+e2#essi%e

B. 0e o$sessions o! #om'"(sions a!e time#ons"ming )o! e2am'(e, ta5e mo!e tan 6o"! a da+*, o! #a"se #(ini#a((+ signi4#antdist!ess o! im'ai!ment in so#ia(,

o##"'ationa(, o! ote! im'o!tant a!eas o


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C. )o!me!(+ C!ite!ion E.*. 0e o$sessi%e-#om'"(si%e s+m'toms a!e not d"e to tedi!e#t '+sio(ogi#a( ee#ts o a s"$stan#e)e.g., a d!"g o a$"se, a medi#ation* o! a

gene!a( medi#a( #ondition.


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D. 0e #ontent o te o$sessions o!#om'"(sions is not !est!i#ted to tes+m'toms o anote! menta( diso!de! )e.g.,e2#essi%e o!!ies a$o"t !ea( (ie '!o$(ems

in ene!a(ied An2iet+ Diso!de!'!eo##"'ation it ood o! !it"a(ied eating$ea%io! in an Eating Diso!de! ai! '"((ingin Hai! P"((ing Diso!de!)0!i#oti((omania*

ste!eot+'ies in Ste!eot+'i# Mo%ementDiso!de!

CON0D.


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'!eo##"'ation it a''ea!an#e in Bod+D+smo!'i# Diso!de! '!eo##"'ation itd!"gs in a S"$stan#e Use Diso!de!'!eo##"'ation it a%ing a se!io"s i((ness

in H+'o#ond!iasis '!eo##"'ation itse2"a( "!ges o! antasies in a Pa!a'i(iao! H+'e!se2"a( Diso!de! '!eo##"'ationit gam$(ing o! ote! $ea%io!s in

$ea%io!a( addi#tions o! im'"(se #ont!o(diso!de!s g"i(t+ !"minations in MaGo!De'!essi%e Diso!de! 'a!anoia o! to"gtinse!tion in a Ps+#oti# Diso!de! o!

!e'etiti%e 'atte!ns o $ea%io! in A"tism


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Specify whether OCD beliefs are currentlycharacterized by:

Good or fair insight

Poor insight :

Absent insight

Specify if:

Ticrelated OCD: 0e indi%id"a( as a(ietime isto!+ o a #!oni# ti# diso!de!.


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7.O0HER ANTIE0 DISORDERS

Die!entiating eat"!es $eteen OCD Q ote!an2iet+ diso!de!s:

0e age o onset o! OCD is +o"ng #om'a!ed ittat o! 'atients it 'ani# diso!de!.In OCD, te!e is an e1"a( dist!i$"tion o men and

omen.

Patients it OCD do not de%e(o' in#!easeds+m'toms ate! administ!ation o an2iogeni##om'o"nds s"# as (a#tate, +oim$ine, and #aeine. 0e+ a!e !e!a#to!+ to an2io(+ti# medi#ations Qt!i#+#(i# antide'!essants .

Ma5ing a diagnosis o OCD #an e(' #(ini#ians a%oidte "se o nonse!otone!gi# medi#ations tat i(((i5e(+ $e inee#ti%e


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ene!a(ied an2iet+ diso!de!:

0e 'e!son e2'e!ien#es tem as e2#essi%e

#on#e!ns a$o"t !ea(-(ie #i!#"mstan#esMo!e ego-s+ntoni#.

So#ia( 'o$ia and s'e#i4# 'o$ia:>ea!s a!e #i!#"ms#!i$ed and !e(ated to

s'e#i4# t!igge!s )in s'e#i4# 'o$ia* o!so#ia( sit"ations )in so#ia( 'o$ia*.

Pani# diso!de!:

Pani# atta#5s o##"! s'ontaneo"s(+.


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8.De'!essionMood #ong!"ent $!ooding.

Not ego-d+stoni#

en $ot o tem #o-o##"!: In an a#"te e'isode o diso!de!:

P!e#eden#e

P!edominan#e In #!oni# diso!de!s: Pe!sisten#e


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9.Ps+#oti# Diso!de!Not #a!a#te!ied $+ '!ominent !it"a(isti#

$ea%io!s.

S#io'!enia ma+ $e #a!a#te!ied $+ o$sessiona(

tin5ing, Q ote! #a!a#te!isti# eat"!es o tediso!de!, s"# as '!ominent a(("#inations o!to"gt diso!de!, a!e a(so '!esent.

0e !"minati%e de("siona( to"gts and $ia!!este!eot+'ed $ea%io!s tat o##"! in s#io'!enia

a!e not ego-d+stoni# and a!e not s"$Ge#ti%e to!ea(it+ testing.


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it !ega!d to de("siona( diso!de!, 'a!anoidand g!andiose #on#e!ns a!e gene!a((+ not#onside!ed to a(( "nde! te OCD !"$!i#.

Hoe%e!, some ote! t+'es o de("siona(

diso!de!s, s"# as te somati# and Gea(o"st+'es, seem to $ea! a #(ose !esem$(an#e toOCD and a!e not a(a+s easi(+disting"ised !om it.


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.0o"!ettes Diso!de!:No menta( "!ge, on(+ '+si#a( "!ge

J"st !igt 'enomenon

.Ste!eot+'i# mo%ement diso!de!

.Bod+ d+smo!'i# diso!de!

=.H+'o#ond!iasis

F.Im'"(se #ont!o( diso!de!s.

6


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68.SUPERS0I0IONS AND REPE0I0IECHECKIN BEHAIOUR

69.ANTIE0 DISORDERS DUE 0O ENERA@MEDICA@ CONDI0ION3SUBS0ANCE

0is diagnosis is made en teo$sessions and #om'"(sions a!e G"dged to$e te di!e#t '+sio(ogi#a( #onse1"en#e oa s'e#i4# MC $ased on isto!+, '+si#a(e2amination and (a$o!ato!+ 4ndings.


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Assessment

%.Assess /e p!iens #urrens1mpoms !nd severi1

A. Diagnosti# Inte!%ies

i*St!"#t"!ed C(ini#a( Inte!%ie o! DSM-I,A2is I )SCID-I*

ii*MINI '("s

iii*An2iet+ Diso!de!s Inte!%ie S#ed"(e .


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B.O$se!%e! &Rated S#a(esO$Ge#ti%e assessment is needed:

0o assess $ase(ine se%e!it+

0o do#"ment #anges 0o assess t!eatment !es'onse


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i*a(e &B!on O$sessi%e Com'"(si%e S#a(e)BOCS*

De%ised $+ oodman et a()6F=F*.It is a semi-st!"#t"!ed inte!%ie

Assesses OCD s+m'tom se%e!it+inde'endent o te n"m$e! and t+'e o

o$sessions and #om'"(sions '!esent.It #om'!ises t!ee se#tions.

Se#tion 6: Contains de4nitions ande2am'(es o o$sessions and #om'"(sions.

Se#tion 7: #onsists o 9-item ta!gets+m'tom (ist.

Se#tion 8: Consists o 6< #o!e items and 66in%estigationa( items


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0e 6< #o!e items a!e "sed to !ate te#(ients '!ominent o$sessions and#om'"(sions on te o((oing 'a!amete!s:

Amo"nt o time s'ent3!e1"en#+

S"$Ge#ti%e dist!ess

Inte!e!en#e in so#ia( and o##"'ationa(

"n#tioningDeg!ee o Resistan#e

Pe!#ei%ed Cont!o( o%e! s+m'toms


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Ea# item is !ated on a 4%e-'oint )


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ii* Nationa( Instit"te o Menta( Hea(t (o$a(O$sessi%e- Com'"(si%e S#a(e)NIMH-OCS*

It is a sing(e-item,#(ini#ian-administe!edmeas"!e o g(o$a( se%e!it+ o OCD

s+m'toms.S#o!e !ange !om 6)minima( s+m'toms* to

6)%e!+ se%e!e o$sessi%e #om'"(si%e$ea%io"!*.

S#o!es a(( itin #("ste!s o se%e!it+) i.e6-8,9-, -F,6


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iii*Com'"(si%e A#ti%it+ Ce#5(istIt is a 7-item ,#(ini#ian administe!ed

inte!%ie, de%e(o'ed to assess te e2tentto i# o$sessi%e-#om'"(si%e s+m'toms

inte!e!e it da+ to da+ a#ti%ities.Ea# item (ists an a#ti%it+ and te a$i(it+ to

'e!o!m tat $ea%io! is !ated on a o"!'oint)!e1"en#+, d"!ation, a%oidan#eand oddit+ o $ea%io!.

i%* OCD s"$s#a(e o CPRS


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#. Se( !e'o!ted S#a(es

i*Ma"ds(e+ O$sessi%e-Com'"(si%e In%ento!+o 8


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iii*Pad"a In%ento!+

It as 9 s"$s#a(es: #ontamination,#e#5ing, im'ai!ed #ont!o( o menta(a#ti%ities,"!ges Q o!!ies o%e! (osing#ont!o( o%e! moto! $ea%io"!s.

Ea# item is s#o!ed on a 4%e 'oint )


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%*@i5e!t s#a(es%i*O$sessi%e- Com'"(si%e In%ento!+

It is 97-item se(-!e'o!t meas"!e.

It #om'!ises s"$s#a(es : asing ,#e#5ing, do"$ting, o!de!ing, o$sessing,oa!ding and menta( ne"t!a(iing.

Ea# item is !ated on a 4%e &'oint )


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D.Bea%io"!a( A%oidan#e 0ests 0e+ a!e designed to assess in %i%o ea!

and a%oidan#e $ea%io!.

Se%e!a( t+'es o BA0 as $een de%e(o'edo! "se in OCD.

0e sing(e-tas5 BA0 in%o(%es te 'atienta''!oa#ing as nea! as 'ossi$(e to a ea!edstim"("s and !e'o!ting is o! e! s"$Ge#ti%e"inits o dist!ess)SUDs*.

0e SUDs !ating is an inde2 o ea! anddist!ess meas"!ed on a


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In%estigations

6.B(ood #emist!+ Q "!ine ana(+sis.7.! 00

8.Se!"m B67 and B.

9.Ne"!oimaging Q EE

.Bio(ogi#a( #a((enges

.Bio(ogi#a( ma!5e!s

.Imm"no(ogi#a( 4ndings


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). *v!lu!e /e e2e#s o$ s1mpoms onell-bein&4 $un#ionin&4 !nd 5u!li1 o$ li$e

3.*v!lu!e /e s!$e1 o$ /e p!ien !ndo/ers

Assessing te !is5 o! s"i#ide and se(-inG"!io"s$ea%io!, as e(( as te !is5 o! a!m to ote!s,

is #!"#ia(. 0e 's+#iat!ist so"(d a(so e%a("ate te

'atients 'otentia( o! a!ming ote!s.

.Assessmen o$ ps1#/i!ri# #o-morbidi1Pa!ti#"(a! attention so"(d $e gi%en to mood

diso!de!s and Ote! an2iet+ diso!de!s.


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6.Assessmen o$ p!s /isor1S'e#i4# attention as to $e gi%en to te

i*Co"!se o s+m'toms

ii*0!eatment isto!+, in#("dingos'ita(iations and t!ia(s o medi#ationsand 's+#ote!a'ies, it detai(s ot!eatment ade1"a#+, d"!ation, !es'onse,and side ee#ts

iii*Past isto!ies o #o-o##"!!ing diso!de!stat ma+ in"en#e t!eatment )e.g., moodo! s"$stan#e "se diso!de!s 'ani# atta#5s.


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7. Assessmen o$ Gener!l Medi#!l Condiions 0e gene!a( medi#a( isto!+ so"(d do#"ment an+

#"!!ent gene!a( medi#a( #onditions, !e#ent o!!e(e%ant os'ita(iations, and an+ isto!+ o eadt!a"ma, (oss o #ons#io"sness, o! sei"!es.

Histo!+ o !e#"!!ent $eta emo(+ti# st!e'to#o##a(ine#tions and an+ t!eatment !e#ei%ed o! tesame.

C"!!ent medi#ations and doses so"(d $e !e%ieed

to dete!mine 'otentia( 'a!ma#o5ineti# and'a!ma#od+nami# inte!a#tions it 's+#ot!o'i#d!"gs.


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He!$a( o! nat"!a(V !emedies m"st a(so $e in1"i!eda$o"t, a(ong it o!mona( te!a'ies, %itamins,ote! o%e!-te-#o"nte! medi#ations, and ote!a(te!nati%e o! #om'(ementa!+ t!eatments.

A((e!gies and sensiti%ities to medi#ations, in#("dingte nat"!e o te 'atients !ea#tion, so"(d $e!e#o!ded.

In 'e!o!ming te !e%ie o s+stems, te

's+#iat!ist so"(d !e#o!d te '!esen#e and se%e!it+o somati# o! 's+#o(ogi#a( s+m'toms tat #o"(d $e#on"sed it medi#ation side ee#ts.


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8. D*V*O,M*NTA4,S9C:OSOCIA ANDSOCIO-C+T+RA :ISTOR9

i*De%e(o'menta( t!ansitions in #i(doodand ad"(tood

ii*0e 'atients #a'a#it+ to a#ie%e sta$(eand g!ati+ing ami(ia( and so#ia(

!e(ationsi's.iii*Se2"a( Histo!+

i%*Ed"#ationa( Q O##"'ationa( Histo!+

%*P!ima!+ and so#io-#"(t"!a( s"''o!t g!o"'%i*Assessment o 's+#oso#ia( st!esso!s


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;.Assessmen o$ '!mil1 :isor1A ami(+ isto!+ o ote! 's+#iat!i#

diso!de!s es'e#ia((+ Ca!e"( e2'(o!ation o!$i'o(a! diso!de! in %ie o te !is5 o

'!e#i'itating +'omania o! mania it anti-OCD medi#ations

>ami(+ isto!+ o ti#s o! 0o"!ette diso!de!.


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Management

Ps+#iat!i# management #onsists o ana!!a+ o te!a'e"ti# a#tions tat ma+ $eoe!ed to a(( 'atients it OCD d"!ing te#o"!se o tei! i((ness at an intensit+

#onsistent it te indi%id"a( 'atientsneeds and #a'a#ities .

% *STA>IS:M*NT O' T:*RA,*+TIC AIANC*


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%.*STA>IS:M*NT O' T:*RA,*+TIC AIANC*

0e te!a'e"ti# a((ian#e a((os te 's+#iat!ist to

o$tain te ino!mation needed to '(an ee#ti%e

t!eatment. 0e e2#essi%e do"$ting tat is #a!a#te!isti# o OCD

ma+ !e1"i!e s'e#ia( a''!oa#es to $"i(ding tea((ian#e.

In#!eased attention to e2#essi%e o!!+ a$o"t

medi#ation side ee#ts, 'e!e#tionism, o! #e#5ing$ea%io!s ma+ $e needed.

0!eatment o 'atients it OCD as a

'otentia( o! t!anse!en#e and3o!

#o"nte!t!anse!en#e iss"es tat ma+ dis!"'t ade!en#e and te te!a'e"ti#

a((ian#e.

) *STA>IS:ING GOAS O' TR*ATM*NT


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). *STA>IS:ING GOAS O' TR*ATM*NT

oa(s o t!eatment in#("de:

i*de#!easing s+m'tom !e1"en#+ and se%e!it+,

ii* im'!o%ing te 'atients "n#tioning,iii*e('ing te 'atient to im'!o%e is o! e!

1"a(it+ o (ie.

i%* Enan#ing te 'atients a$i(it+ to #oo'e!ate

it #a!e des'ite te !igtening #ognitions tata!e t+'i#a( o OCD.

%* He('ing te 'atient de%e(o' #o'ing st!ategies.

%i*Minimiing an+ ad%e!se ee#ts o t!eatment

and%ii*Ed"#ating te 'atient and ami(+ !ega!ding

te diso!de! and its t!eatment.


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Reasona$(e t!eatment o"t#ome ta!getsin#("de:

@ess tan 6 o"! 'e! da+ s'ent o$sessingand 'e!o!ming #om'"(si%e $ea%io!s

No mo!e tan mi(d OCD-!e(ated an2iet+An a$i(it+ to (i%e it "n#e!taint+

@itt(e o! no inte!e!en#e o OCD it te

tas5s o o!dina!+ (i%ing.


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3.*STA>IS:ING A,,RO,RIAT* S*TTING'OR TR*ATM*NT

In gene!a(, 'atients so"(d $e #a!ed o! in te

(east !est!i#ti%e setting tat is (i5e(+ to $e sae

and to a((o o! ee#ti%e t!eatment.Conse1"ent(+, te a''!o'!iate t!eatment

setting i(( de'end on a n"m$e! o a#to!s:

a.Hos'ita( t!eatment: ma+ $e indi#ated $+:

i*s"i#ide !is5,ii*an ina$i(it+ to '!o%ide ade1"ate se(-#a!e,

dange! to ote!s


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iii* need o! #onstant s"'e!%ision o!s"''o!t,

i%* An ina$i(it+ to to(e!ate o"t'atientmedi#ation t!ia(s $e#a"se o side ee#ts,

%*need o! intensi%e CB0,%i*te '!esen#e o medi#a( #onditions tat

ne#essitate os'ita( o$se!%ation i(emedi#ations a!e initiated, o! $+ #o-o##"!!ing #onditions tat temse(%es!e1"i!e os'ita( t!eatment, s"# as se%e!eo! s"i#ida( de'!ession, s#io'!enia, o!mania.


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$.Residentia( t!eatment :ma+ $e indi#ated ini*indi%id"a(s it se%e!e t!eatment-

!esistant OCD,

ii*o !e1"i!e m"(tidis#i'(ina!+ t!eatment .

#.Pa!tia( os'ita(iation ma+ $e indi#ated $+:

i*a need o! dai(+ CB0 and monito!ing o

$ea%io! o! medi#ations o! a s"''o!ti%emi(ie" it ote! adG"n#ti%e 's+#oso#ia(inte!%entions, o!

ii* to sta$i(ie and in#!ease te gains made

d"!ing a 'e!iod o "(( os'ita(iation.


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d.Home-$ased t!eatment ma+ $e ne#essa!+ o!:i*'atients it oa!ding o!, initia((+, o! tose

it #ontamination ea!s o! ote! s+m'toms soim'ai!ing tat te+ #annot #ome to te o/#e o!#(ini#.

ii*indi%id"a(s o e2'e!ien#e s+m'toms'!ima!i(+ o! e2#("si%e(+ at ome.

e. O"t'atient t!eatment is "s"a((+ s"/#ient o! tet!eatment o OCD, $"t te intensit+ ma+ %a!+!om dai(+ 's+#ote!a'+, s"# as intensi%eCB0, to t!eatment (ess tan on#e a ee5.


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.*N:ANC*M*NT O' TR*ATM*NTAD:*R*NC*

0o enan#e t!eatment ade!en#e, te's+#iat!ist so"(d #onside! a#to!s !e(ated

to te i((ness, te 'atient, te '+si#ian,te 'atient-'+si#ian !e(ationsi', tet!eatment, and te so#ia( o! en%i!onmenta(mi(ie".

0e 'atients $e(ies a$o"t te nat"!e ote i((ness and its t!eatments i(( in"en#eade!en#e, '!o%iding 'atient and ami(+ed"#ation ma+ enan#e ade!en#e.


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. *D+CATING T:* ,ATI*NT AND 'AMI9 Patients oten a%e (itt(e 5no(edge o te nat"!e,

$io(og+, #o"!se, and t!eatment o tei! diso!de!s.

0ose it #i(dood onset o OCD ma+ #on"ses+m'toms it as'e#ts o tei! innate se(%es.

A(( 'atients it OCD so"(d $e '!o%ided it ino!mationand a##ess to ed"#ationa( mate!ia(s e2'(aining te nat"!eo te diso!de! and te !ange o a%ai(a$(e t!eatments.

Ed"#ation i(( e(' destigmatie te i((ness and a((o te'atient to ma5e mo!e "((+ ino!med de#isions a$o"t

t!eatments. Ed"#ation ma+ a(so in#!ease te 'atients moti%ation

and a$i(it+ to #oo'e!ate in #a!e.

7.MANAG*M*NT O'


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7.MANAG*M*NT O'AC+T* ,:AS*

A. Coosing an Initia( 0!eatment Moda(it+CB0 and SRIs a!e !e#ommended on te

$asis o #(ini#a( t!ia( !es"(ts as sae andee#ti%e

4!st-(ine t!eatments o! OCD. SRIs in#("de #(omi'!amine

and a(( o te SSRIs.


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ete! to !e#ommend a o!m o CB0, anSRI, o! #om$ined t!eatment i(( de'end ona n"m$e! o a#to!s. 0ese in#("de:

0e nat"!e and se%e!it+ o te 'atients

s+m'toms, 0e nat"!e o an+ #o-o##"!!ing 's+#iat!i#

and medi#a( #onditions and tei!t!eatments,

0e a%ai(a$i(it+ o CB0, and

0e 'atients 'ast t!eatment isto!+,#"!!ent medi#ations, and '!ee!en#es.


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0e e%iden#e $ase o! te o!m o CB0 tat!e(ies '!ima!i(+ on $ea%io!a( te#ni1"es,s"# as ERP , is te st!ongest.

CB0 a(one, #onsisting o ERP, is

!e#ommended as initia( t!eatment o! aPatient o is not too de'!essed, an2io"s,

o! se%e!e(+ i(( to #oo'e!ate it tist!eatment moda(it+, o! o '!ee!s not to

ta5e medi#ations. 0e 'atient m"st $e i((ing to do te o!5

tat CB0 !e1"i!es )e.g., !eg"(a! $ea%io!a(omeo!5*.


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Com$ined t!eatment so"(d $e #onside!edo! 'atients it:

An "nsatisa#to!+ !es'onse tomonote!a'+,

0ose it #o-o##"!!ing 's+#iat!i##onditions o! i# SRIs a!e ee#ti%e,

0ose o is to (imit te d"!ation ot!eatment it medi#ation.

Patients it se%e!e OCD, sin#e temedi#ation ma+ diminis s+m'tom se%e!it+s"/#ient(+ to a((o te 'atient to engagein CB0.


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B. Coosing a S'e#i4# Pa!ma#o(ogi#a( 0!eatment

C(omi'!amine, "o2etine, "%o2amine,'a!o2etine, and se!t!a(ine, i# a!e

a''!o%ed $+ te >DA o! t!eatment o OCD,a!e !e#ommended 'a!ma#o(ogi#a( agents.

A(to"g meta-ana(+ses o '(a#e$o-#ont!o((ed t!ia(s s"ggest g!eate! e/#a#+ o!

#(omi'!amine tan o! "o2etine,"%o2amine, and se!t!a(ine, te !es"(ts oead to- ead t!ia(s #om'a!ing#(omi'!amine and SSRIs di!e#t(+ do not

s"''o!t tis im'!ession.


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SSRIs a%e a (ess t!o"$(esome side-ee#t'!o4(e tan #(omi'!amine , an SSRI is '!ee!!edo! a 4!st medi#ation t!ia(.

In #oosing among te SSRIs, te 's+#iat!istso"(d #onside!:

i.0e saet+ and a##e'ta$i(it+ o 'a!ti#"(a! sideee#ts o! te 'atient, in#("ding an+ a''(i#a$(e

>DA a!nings,ii.Potentia( d!"g inte!a#tions and te deg!ee to

i# te+ a(te! meta$o(ism t!o"g tee'ati# #+to#!ome P9< en+me s+stem o!

"!idine W-di'os'ate g("#"!onos+(t!anse!ases)U0s*, a#t at te P-g(+#o'!otein t!ans'o!te!, o!dis'(a#e d!"gs tigt(+ $o"nd to '(asma '!oteins.


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iii.Past t!eatment !es'onse, andi%.0e '!esen#e o #o-o##"!!ing gene!a(

medi#a( #onditions.

a IMP@EMEN0IN PHARMACO0HERAP


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a.IMP@EMEN0IN PHARMACO0HERAP

SRI(m&?d@ STARTING +S+ATARG*T

+S+AMAIMA

OCCASIONA9,R*SCRI>*DMAM

C@OMIPRAMINE

7 6


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Sta!t it a( te dose:'atients o a!e o!!ied a$o"t side ee#ts

'atients it #o-o##"!!ing an2iet+diso!de!s.

E(de!(+

Most 'atients i(( not e2'e!ien#es"$stantia( im'!o%ement "nti( 9& ee5sate! sta!ting medi#ation.

Some 'atients, s"# as tose o a%e ad(itt(e !es'onse to '!e%io"s t!eatments anda!e to(e!ating te medi#ation e((, ma+

$ene4t !om e%en ige! doses


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C@OMIPRAMINEC(omi'!amine ,te 8-#(o!o ana(og"e o te

t!i#+#(i# imi'!amine, is "ni1"e among tet!i#+#(i#s in its ma!5ed 'oten#+ o! $(o#5ing

se!otonin !e"'ta5e.C(omi'!amine as te 4!st >DA a''!o%ed

d!"g o! OCD)6F=F*.

Desmet+(#(omi'!amine, a maGo!

meta$o(ite o #(omi'!amine, 'otent(+$(o#5s !e"'ta5e o $ot -H0 andno!e'ine'!ine.


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Se%e!a( st"dies o I #(omi'!amine e!e'!omising as te+ demonst!ated 1"i#5e!onset o a#tion and ee! side ee#ts tan

te o!a( o!m and ma+$e e%en ee#ti%e in'atients o donot !es'ond to o!a(#(omi'!amine.


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>@UOTE0INEInitia((+, on te $asis o "o2etines

se(e#ti%it+ o! se!otonin !e#e'to!s,!esea!#e!s e!e o'e"( tat tis

medi#ation o"(d $e mo!e e/#a#io"s tan#(omi'!amine, i# as a/nit+ o!#o(ine!gi#, ad!ene!gi#, and istamini#!e#e'to!s in addition to se!otone!gi# ones.

A''!o%ed $+ >DA in 6FF9.>("o2etines (ong a(-(ie, i# is "ni1"e

among te SRIs, is 7&9 da+s o! te 'a!ent#om'o"nd and 9&6 da+s o! its a#ti%e

meta$o(ite.


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0is (ong a(-(ie #an $e $ene4#ia( o! 'atients odo not #om'(+ it t!eatment, $e#a"se !e(ati%e(+ igstead+-state (e%e(s a!e maintained e%en en se%e!a(doses a!e missed.

Hoe%e!, te (ong a( (ie #an '!esent '!o$(emsen sit#ing o! dis#ontin"ing "o2etine, $e#a"se ee5s o! mo!e ma+ $e !e1"i!ed o! te medi#ation to

$e #om'(ete(+ #(ea!ed !om te $od+.

Hen#e te added de(a+, ee5s !ate! tan 7 ee5so! te ote! SRIs, is !e1"i!ed en sit#ing !om"o2etine to an MAOI.


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>@UOTAMINEIt is a "ni#+#(i# agent tat die!s !om te

ote! SSRIs in tat it does not a%e ana#ti%e meta$o(ite.

A''!o%ed $+ >DA in 6FF9.

SER0RA@INE

Se!t!a(ine is a na'ta(enamine de!i%ati%eit an a#ti%e meta$o(ite, n &desmet+(se!t!a(ine.

A''!o%ed $+ >DA in 6FF.


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In te 42ed-dose st"d+, te!e as a t!endtoa!d 7


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CI0A@OPRAM3ESCI0A@OPRAMCita(o'!am is a #+#(i# 'ta(in de!i%ati%e

it S )a#ti%e*and R )ina#ti%e* enantiome!s

it is "ni1"e in its se(e#ti%it+ o! se!otonin

!e"'ta5e #om'a!ed to te ote! SRIs.It as e signi4#ant se#onda!+ $inding

'!o'e!ties, and its minima( ee#t one'ati# meta$o(ism '!o$a$(+ ma5es it sae!

to #om$ine it ote! medi#ations.

$.MANAIN SIDE E>>EC0S


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$.MANAIN SIDE E>>EC0S

C(omi'!amine is mo!e (i5e(+ to ind"#e:Anti#o(ine!gi# ee#ts s"# as ta#+#a!dia, d!+

mo"t, #onsti'ation, and $("!!ed %ision, ind"#ede(a+ed "!ination o!, "n#ommon(+, "!ina!+!etention, a(to"g tese t+'i#a((+ diminis o%e!time.

Histamini# $(o#5ade is asso#iated it eigtgain and sedation.

Ad!ene!gi# $(o#5ade ma+ (ead to o!tostati#

+'otension and 'ost"!a( diiness.Sodi"m #anne( $(o#5ade #an ind"#e #a!dia#

a!!+tmias o! sei"!es


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0e most #ommon side ee#ts o te SSRIsin#("de gast!ointestina( dist!ess )es'e#ia((+in te 4!st ee5s o t!eatment*, agitation,insomnia o! somno(en#e, in#!eased

tenden#+ to seat, and se2"a( side ee#ts,in#("ding diminised (i$ido and di/#"(t+it e!e#tion and o!gasm.

A 4!st ste' in managing an+ side ee#t is

to #onside! ete! (oe!ing te d!"g dosema+ a((e%iate te side ee#t ito"t (oss ote!a'e"ti# ee#t.


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Data in #i(d!en and ado(es#ents- 'otentia(o! in#!eases in se(-a!ming o! s"i#ida($ea%io!s in indi%id"a(s t!eated itantide'!essant medi#ations, in#("ding SRIs.

SSRIs ma+ $e asso#iated it in#!easedint!a-o'e!ati%e $(ood (oss in 'atients a(sota5ing nonste!oida( anti-inammato!+d!"gs and, a(ong it #(omi'!amine, ma+

inte!a#t it anesteti#s and o'iate 'ain!e(ie%e!s.


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A d!"g dis#ontin"ation s+nd!ome #onsistingmost oten o diiness, na"sea3%omiting,eada#e, and (eta!g+, $"t a(so in#("dingagitation, insomnia, m+o#(oni# Ge!5s, and

'a!estesias, ma+ o##"! i medi#ation iss"dden(+ sto''ed.


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C. Coosing a S'e#i4# >o!m o Ps+#ote!a'+

CB0 is te on(+ o!m o 's+#ote!a'+ o!OCD ose ee#ti%eness is s"''o!ted $+#ont!o((ed t!ia(s.

Ps+#od+nami# 's+#ote!a'+ ma+ sti(( $e

"se"( in e('ing 'atients o%e!#ome tei!!esistan#e to a##e'ting a !e#ommendedt!eatment.

It ma+ a(so $e "se"( in add!essing te

inte!'e!sona( #onse1"en#es o te OCDs+m'toms .

Moti%ationa( inte!%ieing ma+ a(so e('o%e!#ome !esistan#e to t!eatment.

D.Im'(ementing Cogniti%e Bea%io"!a(


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St!ategies

0e int!od"#tion o te $ea%io!a(te#ni1"es o e2'os"!e and !es'onse'!e%ention, a %a!iation o CB0, as a 5e+ad%an#e in te t!eatment o OCD.

ERP in%o(%es s+stemati#a((+ e2'osing a'atient to te to"gts, images, sit"ationso! stim"(i tat e(i#it o$sessi%eea!)e2'os"!e*, i(e sim"(taneo"s(+

e('ing te 'atient to !e!ain !omengaging in #om'"(si%e !it"a(s.

0e#ni1"e


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1

a.Bea%io"!a( Assessment 0e te!a'ist e('s te 'atient to identi+

s'e#i4# t!igge!s o! o$sessions,#om'"(sions, !it"a(s, and dis#omo!t.

0!igge!s a!e a!!anged in ie!a!#ies !om(east to te most dist!essing, i# g"ides'atient and te #(ini#ian in se(e#tinga''!o'!iate ta!gets o t!eatment.

0e "se o BOCS-s+m'tom #e#5(ist, otene('s 'atients to des#!i$e tei! diso!de!mo!e #om'(ete(+.


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Identi+ing a(( te sit"ations o! 'eo'(ea%oided is a 5e+ to designing ee#ti%e$ea%io! te!a'+ '!og!ams.

Ino!mation a$o"t te in%o(%ement o

ami(+, !iends and #o-o!5e!s in te'atients !it"a(s so"(d a(so $e e(i#ited.

0e+ #an $e "sed as #o-te!a'ists.


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$.Ed"#ationPatients need an "nde!standing o OCD , an

e2'(anation o! o e2'os"!e in %i%o and !it"a('!e%ention #an (ead to a$it"ation, and an o"t(ine ote gene!a( t!eatment '(an.

C(ini#ians need to (ea!n a$o"t te 'atientse2'e!ien#es and nat"!a(isti# e2'os"!e and !it"a('!e%ention, '!ee!en#es !ega!ding s'eed o t!eatment,

time a%ai(a$(e o! t!eatment, ee#ts o an2iet+ andote! dis#omo!t, and te a%ai(a$i(it+ o #o-te!a'ists

and ote! s"''o!te!s i(e te B0 is '!o#eeding.Ra''o!t !es"(ts !om m"t"a( "nde!standings and

ag!eements.


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#.Intensit+ and @engt o e2'os"!e Setting s'e#i4# goa(s o! e2'os"!e and

!it"a( '!e%ention is a Goint tas5.

Ate! ie!a!#ies a%e $een '!e'a!ed ,

ag!eement is !ea#ed on te 4!st t!igge! to$e t!eated.

A s#a(e o dis#omo!t so"(d $e de%e(o'edto aid $ot 'atient and #(ini#ian in de#iding

i# t!igge! to ta#5(e, o m"# dist!esste e2'os"!e and !it"a( '!e%ention sessions'!od"#e, and o (ong it ta5es o!a$it"ation to o##"!.


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0e (engt o te session de'ends on'atients !ate o a$it"ation.

In gene!a(,sessions (asts ti(( te 'atientsdis#omo!t as diminised signi4#ant(+. It

ma+ %a!+ !om 6mins to at(east an o"!.


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d.P!og!ess t!o"g a Hie!a!#+Ate! te 'atient as (a!ge(+ maste!ed

is3e! 4!st ta!get o t!eatment, tee2'e!ien#e gained #an $e "sed to

o%e!#ome te ne2t t!igge!s and !it"a(s inte ie!a!#+.

Ate! a 'atient as !ed"#ed te ma2im"m

dist!ess !ating to a (e%e( $eteen < and 7o! t!ee o! mo!e da+s, it is a''!o'!iate toadd goa(s to dea( it ote! t!igge!s odis#omo!t, o$sessions and !it"a(s.


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e. Managing An2iet+ d"!ing sessions

Rit"a(s e%o(%e to #ont!o( te dis#omo!t ate!

e2'os"!e to t!igge!s.

At te $eginning o te!a'+, te!eo!e, so!t &te!mt!ansient in#!eases in o$sessions and dis#omo!tma+ o##"! as !it"a(s a!e '!e%ented.

Co'ing ta#ti#s #an $e '(anned to ena$(e 'atients to#ontin"e e2'os"!e "nti( a$it"ation o##"!s ito"t!esto!ing to !it"a(isti# $ea%io!s.


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Cogniti%e te!a'+

indi%id"a(s it OCD ide tei! !it"a(s $e#a"se te+5no tat ote!s o"(d 4nd tem "n"s"a( o! $ia!!e

te+ te(( temse(%es !e'eated(+ tat tei! #ognitionsa!e in#o!!e#t, $"t #annot t"!n tei! attention !omtem

#ogniti%e te!a'ies aimed at #anging a"(t+#ognitions a$o"t !is5s Q !es'onsi$i(it+ seem (ogi#a(,$"t most st"dies a%e not o"nd tem ee#ti%e.


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A##e'tan#e and Commitment 0e!a'+)AC0*, a %a!iation o CB0, !e#ent(+ as $eena''(ied to OCD.

It aims to e(' 'atients (ea!n to distan#e

temse(%es !om tei! to"gts and not tot!eat tem as (ite!a(, i(e de#!easinge2'e!ientia( a%oidan#e.


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O/er 1pes o$ ,s1#/o/er!p1 0e "se o 's+#ote!a'e"ti# te#ni1"es o

eite! a 's+#oana(+ti# o! a s"''o!ti%enat"!e as not $een '!o%ed s"##ess"( in

t!eating te s'e#i4# o$sessions and#om'"(sions tat a!e a a((ma!5 o OCD.

0e deense me#anisms o !ea#tiono!mation, iso(ation, and "ndoing, as e((

as a 'e!%asi%e sense o do"$t and need to$e in #ont!o(, a!e a((ma!5s o teo$sessi%eom'"(si%e #a!a#te!.

E.Monito!ing te 'atients 's+#iat!i#


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stat"s

0e !e1"en#+ o o((o-"' %isits ate! ane 'a!ma#ote!a'+ is initiated ma+ %a!+!om a e da+s to 7 ee5s.

0e indi#ated !e1"en#+ o %isits i((

de'end on te:Se%e!it+ o te 'atients s+m'toms,

0e #om'(e2ities int!od"#ed $+ #o-o##"!!ing #onditions,

ete! s"i#ida( ideation is '!esent, and

0e (i5e(iood o t!o"$(ing side ee#ts.

i


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P!ognosti# a#to!s

Good ,ro&nosis ,oor ,ro&nosisP!e#i'itating e%entE'isodi# nat"!e os+m'toms

ood '!emo!$idadG"stment

Ci(dood onset ie(ding to #om'"(sionsBia!!e #om'"(sions

O%e!%a("ed ideasCoe2isting maGo! de'!essionPe!sona(it+ diso!de!sPoo! #om'(ian#ePoo! insigt

O$sessi%e s(onessCogniti%e im'ai!ment Need o! IP t!eatment

>.Dete!mining en and ete! to #ange


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t!eatment

D*'INITION CRIT*RIA

S0AE 6 RECOER3NO0 A0A@@ I@@

BOCSY=

S0AE II REMISSION BOCSY6

S0AE III >U@@ RESPONSE 8? o! g!eate! !ed"#tion on BOCS Q #gi 6 o! 7

S0AE I PAR0IA@ RESPONSE 7? $"t Y8? !ed"#tion in BOCS

S0AE NONRESPONSE Y 7? !ed"#tion in BOCS andCI 9

S0AE I RE@APSE S+m'toms !et"!n ate! 8Zmonts i.e 7? in#!ease in BOCS !om !emission s#o!e o!CI

S0AE II RE>RAC0OR No #ange o! o!sening ita%ai(a$(e te!a'ies.


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0e 's+#iat!ist m"st de#ide it te 'atient en,ete!, and o to a(te! te t!eatment a''!oa#.

In te o'inion o CB0 e2'e!ts, 68&7< sessions oee5(+ o"t'atient CB0 it dai(+ omeo!5 o!ee5da+ dai(+ CB0 o! 8 ee5s )a$o"t < o"!s,

a( te!a'ist g"ided, a( omeo!5* is anade1"ate dose ate! i# ne2t ste's #an $e#onside!ed.

it !ega!d to SRIs, e2'e!t o'inion s"''o!ts#anging medi#ation st!ateg+ )sit#ing o!a"gmenting* ate! a t!ia( o =&67 ee5s it at (east9& ee5s at te igest #omo!ta$(+ to(e!ateddose .


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en te o"t#ome o initia( t!eatment as$een "nsatisa#to!+,te 's+#iat!ist so"(d4!st #onside! te 'ossi$(e #ont!i$"tion ose%e!a( a#to!s:

P!o$(ems in te te!a'e"ti# a((ian#e Inte!e!en#e $+ #o-o##"!!ing #onditions

s"# as 'ani# diso!de!, maGo! de'!ession,a(#oo( o! s"$stan#e "se diso!de!s, ti#

diso!de! o! se%e!e 'e!sona(it+)s#iot+'a(*diso!de!.

Inade1"ate 'atient ade!en#e to t!eatment'atients it OCD a!e gene!a((+ #om'(iant


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'atients it OCD a!e gene!a((+ #om'(iante2#e't en OC s+m'toms inte!e!e.

0e ade1"a#+ o te a#"te d!"g t!ia( andd"!ation o t!ia( as ade1"ate[

0e '!esen#e o 's+#oso#ia( st!esso!s

Patients it a #(ini#a( s"$t+'e o

OCD-P!ima!+ O$sessiona( S(onessV. 0e (e%e( o ami(+ mem$e!s a##ommodation

to te o$sessi%e-#om'"(si%e s+m'toms and

An ina$i(it+ to to(e!ate an ade1"ate t!ia( o

's+#ote!a'+ o! te ma2im"m!e#ommended d!"g doses.

P"!s"ing Se1"entia( 0!eatment 0!ia(s


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. P"!s"ing Se1"entia( 0!eatment 0!ia(s

en te 'atient as an inade1"ate!es'onse to te initia( t!eatment and nointe!e!ing a#to! #an $e identi4ed, te's+#iat!ist and 'atient m"st de#ide on

ne2t t!eatment ste's.A"gmentation st!ategies:

6.C(onae'am

7.B"s'i!one

8.@iti"m

9.At+'i#a( anti's+#oti#s

.0+'i#a( anti's+#oti#s


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.>en"!amine.@-0!+'to'an

=.0!aodone

F.Pindo(o(

Com$ination te!a'+:

6.C(omi'!amine it SSRIs

7.C(omi'!amine it MAOI.


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Sit#ing antide'!essants:SNRI- %en(aa2ine

MAOI-B

Neaodone

No%e( st!ategies:

6.Int!a%eno"s #(omi'!amine.

7.MAOIs

8.C(onidine9.>("tamide


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.Inosito(.D-#+#(ose!ine

.Non-'a!ma#o(ogi#a( Bio(ogi#a(A''!oa#es: In#("des: E(e#t!o-Con%"(si%e

0e!a'+, Ne"!os"!ge!+, S(ee' de'!i%ation,Potote!a'+ and Re'etiti%e 0!ans#!ania(Magneti# Stim"(ation.

Ste!eota#ti# s"!gi#a( '!o#ed"!es "sed in

OCD a!e !ese!%ed o! 'atients it mo!ese%e!e OCD.

C.DISCONTIN+ATION O' ACTIV*TR*ATM*NT


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TR*ATM*NT

S"##ess"( medi#ation t!eatment so"(d $e#ontin"ed o! 6&7 +ea!s $eo!e #onside!inga g!ad"a( ta'e! $+ de#!ements o 6


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An o'en dis#ontin"ation st"d+)Ra%ia et a(6FF* a(so !e'o!ted signi4#ant(+ ige! -mont, 6-+ea!, and 7-+ea! !e(a'se !ates o!te 'atients ose SRI t!eatment as

dis#ontin"ed 0"s, !ates o !e(a'se a''ea! to $e

in#!eased ate! dis#ontin"ation o SRIt!eatment $"t #annot $e '!e#ise(+

s'e#i4ed.


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A !e%ie o CB0 st"dies)>oa et a( 6FF*#onsisting o ERP #on#("ded tat a$o"tt!ee-1"a!te!s o 'atients !e#ei%ing ERP)it and ito"t #on#omitant medi#ation*

e!e doing e(( at a mean o((o-"' o a(itt(e mo!e tan 7 +ea!s ate! te inde2t!eatment #o"!se.

S,*CI'IC CINICA '*AT+R*S


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IN'+*NCING T:* TR*ATM*NT ,AN

A.PSCHIA0RIC >EA0URES

6. C!oni# Moto! 0i#s

7.0o"!ettes s+nd!ome

8.MaGo! De'!ession

9.Bi'o(a! diso!de!

.Pani# diso!de!

.So#ia( Po$ia


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.S#io'!enia=.S"$stan#e "se diso!de!s

F.A"tism Q As'e!ge!s diso!de!.

6


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Demog!a'i# and Ps+#oso#ia( >a#to!s6.ende!

7.Etni#it+

8.P!egnan#+ and B!east eeding.

9.Ci(d!en and ado(es#ents

.E(de!(+

.Medi#a( #onditions

Con#("sion


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Con#("sion

>o! man+ 'atients it OCD te i((ness is(ie(ong, sta!ting in ea!(+ #i(dood ande2tending into ad"(tood.

It is oten ami(ia( and a##om'anied $+

#omo!$id #onditions in#("ding,de'!ession,ote! an2iet+ diso!de!s, 0o"!ettess+nd!ome and e%en 's+#osis.

Hoe%e!, it a #om$ination o

'a!ma#o(ogi# and $ea%io!a( t!eatment,at ade1"ate dose and d"!ation, 'atients#an oten a%e signi4 #ant im'!o%ement in

diagnosis, assessment and management of ocd

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