Practice Essentials
Obsessive-compulsive disorder (OCD) is characterized by distressing, intrusive obsessive thoughts and/or repetitive compulsive physical or mental acts. Once believed to be rare, OCD was found to have a lifetime prevalence of 2.5% in the Epidemiological Catchment Area study.
Signs and symptoms
Common obsessions include the following:
Contamination
Safety
Doubting one’s memory or perception
Scrupulosity (need to do the right thing, fear of committing a transgression, often religious)
Need for order or symmetry
Unwanted, intrusive sexual/aggressive thoughts
Common compulsions include the following:
Cleaning/washing
Checking (eg, locks, stove, iron, safety of children)
Counting/repeating actions a certain number of times or until it “feels right”
Arranging objects
Touching/tapping objects
Hoarding
Confessing/seeking reassurance
List making
Many patients with OCD have other psychiatric comorbid disorders, and may exhibit any of the following:
Mood and anxiety disorders
Somatoform disorders, especially hypochondriasis and body dysmorphic disorder
Eating disorders
Impulse control disorders, especially kleptomania and trichotillomania
Attention deficit–hyperactivity disorder (ADHD)
Obsessive-compulsive personality disorder
Tic disorder
Suicidal thoughts and behaviors
Skin findings in OCD patients may include the following:
Eczematous eruptions related to excessive washing
Hair loss related to trichotillomania or compulsive hair pulling
Excoriations related to neurodermatitis or compulsive skin picking
See Clinical Presentation for more detail.
Diagnosis
Once OCD is suspected, the following should be performed:
Define the range and severity of OCD symptoms; the Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
is a good tool for this purpose
Complete Mental Status Examination; look for comorbid symptoms and disorders
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
released in 2013, includes a new chapter for OCD and related disorders, including body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder. Previously, OCD was grouped together with anxiety disorders.
The American Psychiatric Association defines OCD as the presence of obsessions, compulsions, or both. Obsessions are defined by (1) and (2) as follows:
Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and cause marked anxiety and distress
The person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action
Compulsions are defined by (1) and (2) as follows:
Repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) in response to an obsession or according to rules that must be applied rigidly
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a way that could realistically neutralize or prevent whatever they are meant to address, or they are clearly excessive
See Workup for more detail.
Management
The mainstays of treatment of OCD are as follows:
Serotonergic antidepressant medications
Particular forms of behavior therapy (exposure and response prevention and some forms of cognitive-behavioral therapy [CBT])
Education and family interventions
Neurosurgery (anterior capsulotomy, or deep brain stimulation)
, in extremely refractory cases
First-line serotonergic antidepressants for OCD are selective serotonin reuptake inhibitors (SSRIs; (fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, escitalopram) and clomipramine (Anafranil), a tricyclic antidepressant. SSRIs are generally preferred over clomipramine, as their adverse effect profiles are less prominent. Results of serotonergic antidepressant treatment are as follows:
Complete or near-complete remission of OCD symptoms is rare with monotherapy
Perhaps half of patients may experience symptom reductions of 30-50%
Many other patients fail to achieve even this degree of relief
Interventions for patients with treatment resistance include the following:
Change or increase in medication (eg, increase dose or prescribe a different SSRI or clomipramine)
More intensive CBT
Other interventions, which have not received US Food and Drug Administration (FDA) approval for use in OCD, include the following:
Addition of a norepinephrine reuptake inhibitor (eg, desipramine) to an SSRI or a trial of venlafaxine
Addition of a typical or atypical antipsychotic (eg, haloperidol, olanzapine, risperidone), especially in patients with a history of tics
Augmentation with buspirone
Augmentation with ondansetron
Addition of inositol
Sole or augmented use of selected glutamatergic agents (eg, riluzole, glycine, memantine, ketamine)
Deep brain stimulation
or cingulotomy neurosurgery
for severe and intractable casesb
See Treatment and Medication for more detail.