> Table of Contents > Obsessive-Compulsive Disorder (OCD)
Obsessive-Compulsive Disorder (OCD)
Amar Kapur, DO, CPT, MC, USA
image BASICS
DESCRIPTION
  • A psychiatric condition classified as an anxiety disorder characterized by pathologic obsessions (recurrent intrusive thoughts, ideas, or images) and compulsions (repetitive, ritualistic behaviors or mental acts) causing significant patient distress
  • Not to be confused with obsessive-compulsive personality disorder
EPIDEMIOLOGY
Incidence
  • Predominant age: mean age of onset 22 to 36 years
    • Male = female (males present at younger age)
    • Child/adolescent onset in 33% of cases
    • 1/3 of cases present by age 15 years
    • 85% of cases present at <35 years of age
    • Diagnosis rarely made at >50 years of age
  • Predominant gender: female > males but males more commonly affected in childhood
Pediatric Considerations
Insidious onset; consider brain insult in acute presentation of childhood obsessive-compulsive disorder (OCD).
Geriatric Considerations
Consider neurologic disorders in new-onset OCD in the elderly.
Prevalence
  • 2.3% lifetime in adults
  • 1-2.3% prevalence in children/adolescents
ETIOLOGY AND PATHOPHYSIOLOGY
  • Exact pathophysiology is unknown.
  • Dysregulation of serotonergic pathways
  • Dysregulation of corticostriatal-thalamic-cortico (CSTC) pathway
  • Exact etiology unknown
  • Genetic and environmental factors
  • Pediatric autoimmune disorder associated with streptococcal infections
Genetics
  • Greater concordance in monozygotic twins
  • Positive family history: prevalence rates of 7-15% in first-degree relatives of children/adolescents with OCD
RISK FACTORS
  • Exact cause of OCD is not fully elucidated.
  • Combination of biologic and environmental factors likely involved the following:
    • Link between low serotonin levels and development of OCD
    • Link between brain insult and development of OCD (i.e., encephalitis, pediatric streptococcal infection, or head injury)
GENERAL PREVENTION
  • OCD cannot be prevented.
  • Early diagnosis and treatment can decrease patient's distress and impairment.
COMMONLY ASSOCIATED CONDITIONS
  • Major depressive disorder
  • Panic disorder
  • Phobia/social phobia
  • Tourette syndrome/tic syndromes and other movement disorders
  • Substance abuse
  • Eating disorder/body dysmorphic disorder
image DIAGNOSIS
PHYSICAL EXAM
  • Dermatologic problems caused by excessive hand washing may be observed.
  • Hair loss caused by compulsive pulling/twisting of the hair (trichotillomania) may be observed.
DIFFERENTIAL DIAGNOSIS
  • Obsessive-compulsive personality disorder
    • In personality disorder, traits are ego-syntonic and include perfectionism and preoccupation with detail, trivia, or procedure and regulation. Patients tend to be rigid, moralistic, and stingy. These traits are often rewarded in the patient's job as desirable.
  • Impulse-control disorders: compulsive gambling, sex, or substance abuse: The compulsive behavior is not in response to obsessive thoughts, and the patient derives pleasure from the activity.
  • Major depressive disorder
  • Eating disorder
  • Tics (in tic disorder) and stereotyped movements
  • Schizophrenia: Patient perceives thought to be true and coming from an external source.
  • Generalized anxiety disorder, phobic disorders, separation anxiety: similar response on heightened anxiety, but presence of obsessions and rituals signifies OCD diagnosis
  • Anxiety disorder due to a general medical condition: Obsessions/compulsions are assessed to be a direct physiologic consequence of a general medical condition.
DIAGNOSTIC TESTS & INTERPRETATION
According to DSM-5, diagnostic criteria for OCD are (1)[C]:
  • Presence of obsessions, compulsions, or both
  • Obsessions are defined by:
    • Recurrent or 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 actions (i.e., by performing compulsion).
  • Compulsions are defined by the following:
    • Repetitive behavior (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
    • The behavior or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation. However, these behavior or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
  • The obsessions or compulsions are time-consuming (e.g., take >1 hr/day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The obsessive-compulsive symptoms are not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication, or other medical condition).
  • The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder, preoccupation with appearance, as in body dysmorphic disorder or skin picking etc.).
  • Specify if:
    • With good or fair insight: The individual recognizes the OCD beliefs are definitely or probably not true or that they may or may not be true.
    • With poor insight: The individual thinks that OCD beliefs are probably true.
    • With absent insight/delusional beliefs: The individual is completely convinced that OCD beliefs are true.
  • Specify if:
    • Tic related: The individual has a current or past history of tic disorder.
Diagnostic Procedures/Other
  • Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) or CY-BOCS for children (2)[C]
  • Maudsley Obsessive-Compulsive Inventory (MOCI) (3)[C]
Test Interpretation
  • Compulsions are designed to relieve the anxiety of obsessions; they are not inherently enjoyable (egodynastic) and do not result in completion of a task.
  • Common obsessive themes
    • Harm (i.e., being responsible for an accident)
    • Doubt (i.e., whether doors/windows are locked or the iron is turned off)
    • Blasphemous thoughts (i.e., in a devoutly religious person)
    • Contamination, dirt, or disease
    • Symmetry/orderliness
  • Common rituals or compulsions
    • Hand washing, cleaning
    • Checking
    • Counting
    • Hoarding
    • Ordering, arranging
    • Repeating
  • Neither obsessions nor compulsions are related to another mental disorder (i.e., thoughts of food and presence of eating disorder).
  • 80-90% of patients with OCD have obsessions and compulsions.
  • 10-19% of patients with OCD are pure obsessional.
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image TREATMENT
GENERAL MEASURES
  • Combined medications and cognitive-behavioral therapy (CBT) is most effective (1,2)[A].
  • Family psychoeducation
  • Parent behavior management training if patient is a child/adolescent
  • Brain modulation available for severe OCD includes electroconvulsive therapy and transcranial magnetic stimulation in small groups of patients.
MEDICATION
First Line
  • Adequate trial at least 10 to 12 weeks
  • Doses may exceed typical doses for depression.
  • Optimal duration for pediatrics unknown but recommended minimum of maintenance treatment: 6 months
  • SSRIs recommended first-line agents (4,5)[A]
    • Fluoxetine (Prozac)
      • Adults: 20 mg/day; increase by 10 to 20 mg every 4 to 6 weeks until response; range: 20 to 80 mg/day
      • Children (7 to 17 years of age): 10 mg/day; increase 4 to 6 weeks until response; range: 20 to 60 mg/day
  • Sertraline (Zoloft)
    • Adults: 50 mg/day; increase by 50 mg every 4 to 7 days until response; range: 50 to 200 mg/day; may divide if above 100 mg/day
    • Children (6 to 17 years of age): 25 mg/day; increase by 25 mg every 7 days until response; range: 50 to 200 mg/day
  • Paroxetine (Paxil)
    • Adults: 20 mg/day; increase by 10 mg every 4 to 7 days until response; range: 40 to 60 mg/day
    • Children: Safety and effectiveness in patients <18 years have not been established.
  • Fluvoxamine (Luvox)
    • Adult: 100 mg/day; increase by 50 mg every 4 to 7 days until response; range: 200 to 300 mg/day
    • Children (8 to 17 years of age): 25 mg/day; increase by 25 mg every 4 to 7 days until response; range: 50 to 200 mg/day
  • Absolute SSRI contraindications
    • Hypersensitivity to SSRIs
    • Concomitant use within 14 days of monoamine oxidase inhibitor (MAOI)
  • Relative SSRI contraindications
    • Severe liver impairment
    • Seizure disorders (lower seizure threshold)
  • Precautions
    • Watch for suicidal behavior/worsening depression during first few months of therapy/after dosage changes with antidepressants, particularly in children, adolescents, and young adults.
    • Long half-life of fluoxetine (>7 days) may be troublesome if patient has an adverse reaction.
    • May cause drowsiness and dizziness when therapy was initiated; warn patients about driving and heavy equipment hazards.
Pregnancy Considerations
All SSRIs are pregnancy Category C, except paroxetine, which is Category D.
Second Line
  • Try switching to another SSRI.
  • 40-60% of patients will remain refractory to SSRI
  • Tricyclic acid (TCA), clomipramine (Anafranil)
    • Adults: 25 mg/day; increase gradually over 2 weeks to 100 mg/day, then to 250 mg/day (max dose) over next several weeks, as tolerated.
    • Children (10 to 17 years of age): 25 mg/day; titrate as needed and tolerated up to 3 mg/kg/day or 200 mg/day (whichever is less).
    • Absolute clomipramine contraindications
      • Within 6 months of a myocardial infarction (MI)
      • Hypersensitivity to clomipramine or other TCA
      • Concomitant use within 14 days of an MAOI
      • 3rd-degree atrioventricular (AV) block
    • Relative clomipramine contraindications
      • Narrow-angle glaucoma (increased intraocular pressure)
      • Prostatic hypertrophy (urinary retention)
      • 1st- or 2nd-degree AV block, bundlebranch block, and congestive heart failure (proarrhythmic effect)
      • Pregnancy Category C
    • Precautions
      • Dangerous in overdose
      • Pretreatment ECG for patients >40 years of age
      • Watch for suicidal behavior/worsening depression during first few months of therapy or after dosage changes with antidepressants, particularly in children, adolescents, and young adults.
      • May cause drowsiness and dizziness when therapy is initiated; warn patients about driving and heavy equipment hazards.
ISSUES FOR REFERRAL
  • Psychiatric referral for CBT (in vivo exposure and prevention of compulsions)
  • Psychiatric evaluation if obsessions and compulsions significantly interfere with patient's functioning in social, occupational, or educational situations
ADDITIONAL THERAPIES
Dopamine receptor antagonists (antipsychotic agents) alone are not effective in treatment of OCD. They can be used as augmentation to SSRI therapy for treatment-resistant OCD; they also can worsen OCD symptoms (4)[C]. Some evidence show that addition of quetiapine or risperidone to antidepressants will increase efficacy; data with olanzapine are too limited to draw conclusions (4)[A].
  • Risperidone (Risperdal): initial dose: 0.5 mg/day; target dose: 0.5 to 2 mg/day
  • Quetiapine (Seroquel): initial dose: 25 mg/day; target dose: 600 mg/day
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Y-BCOS or MOCI surveys to track progress
Patient Monitoring
Monitor for decrease in obsessions and time spent performing compulsions.
DIET
No dietary modifications/restrictions recommended
PATIENT EDUCATION
  • Importance of medication adherence
  • Importance of psychotherapy (CBT)
  • International OCD Foundation, Boston, MA 617-973-5801: https://iocdf.org/
  • Obsessive Compulsive Anonymous, New Hyde Park, NY: http://obsessivecompulsiveanonymous.org
PROGNOSIS
  • Chronic waxing and waning course in most patients:
    • 24-33% fluctuating course
    • 11-14% phasic periods of remission
    • 54-61% chronic progressive course
  • Early onset a poor predictor
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association.
2. Sánchez-Meca J, Lopez-Pina JA, Lopez-Lopez JA, et al. The Maudsley Obsessive-Compulsive Inventory. Int J Clin Health Psychol. 2011;11(3):473-493.
3. Gava I, Barbui C, Aguglia E, et al. Psychological treatments versus treatment as usual for obsessive compulsive disorder (OCD). Cochrane Database Sys Rev. 2007;(2):CD005333.
4. Stein DJ, Denys D, Gloster AT, et al. Obsessivecompulsive disorder: diagnostic and treatment issues. Psychiatr Clin North Am. 2009;32(3):665-685.
5. Kakhi S, Soomro GM. Obsessive compulsive disorder in children and adolescents: duration of maintenance drug treatment [published ahead of print June 3, 2015]. BMJ Clin Evid.
6. Komossa K, Depping AM, Meyer M, et al. Second-generation antipsychotics for obsessive compulsive disorder. Cochrane Database Sys Rev. 2010;(12):CD008141.
Additional Reading
&NA;
Ruscio AM, Stein DJ, Chiu WT, et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010;15(1):53-63.
Codes
&NA;
ICD10
  • F42 Obsessive-compulsive disorder
  • F63.9 Impulse disorder, unspecified
  • F63.3 Trichotillomania
Clinical Pearls
&NA;
  • CBT is the initial treatment of choice for mild OCD.
  • CBT plus an SSRI or an SSRI alone is the treatment choice for more severe OCD.
  • The majority of patients with OCD respond to first SSRI treatment.
  • Improvement in symptoms however, is often incomplete, ranging from 25% to 60%.