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Obsessive-Compulsive Disorder

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.

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