Obsessive Compulsive Disorder

Basics

Description

  • A psychiatric condition classified as an anxiety disorder characterized by 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 22–36 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: Male > Female (3:1).

Pediatric Considerations

Insidious onset; consider brain insult in acute presentation of childhood obsessive-compulsive disorder (OCD).

    • Not to be confused with obsessive-compulsive personality disorder

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

Risk Factors

  • Exact cause of OCD is not fully elucidated.
  • Combination of biologic and environmental factors likely involved:
    • 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)

Genetics

  • Greater concordance in monozygotic twins
  • Positive family history: Prevalence rates of 7–15% in 1st-degree relatives of children/adolescents with OCD

General Prevention

  • OCD cannot be prevented.
  • Early diagnosis and treatment can decrease patient’s distress and impairment.

Pathophysiology

  • Exact pathophysiology unknown
  • Dysregulation of serotonergic pathways
  • Dysregulation of corticostriatal-thalamic-cortico (CSTC) pathways

Etiology

  • Exact etiology unknown
  • Genetic and environmental factors
  • Pediatric autoimmune disorder associated with streptococcal infections

Commonly Associated Conditions

  • Major depressive disorder
  • Panic disorder
  • Social phobia
  • Phobia
  • Tourette syndrome
  • Substance abuse
  • Eating disorder
  • Body dysmorphic disorder

Insidious onset; consider brain insult in acute presentation of childhood obsessive-compulsive disorder (OCD). Diagnosis

History

  • Patient presents with either obsessions or compulsions, which cause marked distress, are time-consuming (>1 h/d), and cause significant occupational/social impairment.
  • 4 criteria support diagnosis of obsessions:
    • Patients are aware that they are thinking the obsessive thoughts; thoughts are not imposed from outside (as in thought insertion).
    • Thoughts are not just excessive worrying about real-life problems.
    • Recurrent thoughts are persistent, intrusive, and inappropriate, causing significant anxiety and distress.
    • Attempts to suppress intrusive thoughts are made with some other thought or activity.
  • 2 criteria support a diagnosis of compulsions:
    • The response to an obsession is to rigidly perform repetitive behaviors (e.g., hand washing) or mental acts (e.g., counting silently).
    • Although done to reduce stress, the responses are either not realistically connected with the obsession or they are excessive.
    • In children, check for precedent streptococcal infection.

Physical Exam

  • Dermatologic problems caused by excessive hand-washing may be observed.
  • Hair loss caused by compulsive pulling or twisting of the hair (trichotillomania) may be observed.

Diagnostic Tests & Interpretation

Lab

No diagnostic laboratory findings identified

Imaging

None indicated; consider brain MRI to rule out neurologic disorder.

Diagnostic Procedures/Surgery

  • Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) or CY-BOCS for children
  • Maudsley Obsessive-Compulsive Inventory (MOCI)

Pathological Findings

    • Compulsions are designed to relieve the anxiety of obsessions; they are not inherently enjoyable (ego-dynastic) 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 or windows are locked or the iron is turned off)
      • Blasphemous thoughts (i.e., in a devoutly religious person)
      • Contamination, dirt, or disease
      • Symmetry or 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.Early diagnosis and treatment can decrease patient's distress and impairment.

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.
    • Depression
    • Brooding, but ideas not as senseless as in OCD
    • 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 owing to a general medical condition: Obsessions or compulsions are assessed to be a direct physiologic consequence of a general medical condition.

Treatment

Medication

First Line

  • Adequate trial at least 10–12 weeks
  • Optimal doses may exceed typical doses for depression.
  • Current evidence suggests selective serotonin reuptake inhibitors (SSRIs) as 1st-line agents (1,2)[A].
    • Fluoxetine (Prozac):
      • Adults: 20 mg/d; increase by 10–20 mg every 4–6 weeks until response; range: 20–80 mg/d.
      • Children (7–17 years of age): 10 mg/d; increase 4–6 weeks until response; range: 20–60 mg/d.
    • Sertraline (Zoloft):
      • Adults: 50 mg/d; increase by 50 mg every 4–7 days until response; range: 50–200 mg/d; may divide if above 100 mg/d.
      • Children (6–17 years of age): 25 mg/d; increase by 25 mg every 7 days until response; range: 50–200 mg/d.
    • Paroxetine (Paxil):
      • Adults: 20 mg/d; increase by 10 mg every 4–7 days until response; range: 40–60 mg/d.
      • Children: Safety and effectiveness in patients <18 years have not been established.
    • Fluvoxamine (Luvox):
      • Adult: 100 mg/d; increase by 50 mg every 4–7 days until response; range: 200–300 mg/d.
      • Children (8–17 years of age): 25 mg/d; increase by 25 mg every 4–7 days until response; range: 50–200 mg/d.
    • Absolute SSRI contraindications:
      • Hypersensitivity to SSRIs
      • Within 14 days of monoamine oxidase inhibitor (MAOI)
    • Relative SSRI contraindications:
      • Severe liver impairment
      • Seizure disorders (lower seizure threshold)
    • Precautions:
      • Watch for suicidal behavior or worsening depression during 1st few months of therapy or 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 initiated; warn patients about driving and heavy-equipment hazards.

Pregnancy Considerations

All SSRIs are pregnancy category C, except paroxetine, which is category D.

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Second Line

  • Try switching to another SSRI.
  • Tricyclic acid (TCA), clomipramine (Anafranil):
    • Adults: 25 mg/d; increase gradually over 2 weeks to 100 mg/d, then to 250 mg/d (maximum dose) over next several weeks, as tolerated.
    • Children (10–17 years of age): 25 mg/d; titrate as needed and tolerated up to 3 mg/kg or 200 mg/d (whichever is less).
    • Absolute clomipramine contraindications:
      • Within 6 months of an MI
      • Hypersensitivity to clomipramine or other TCA
      • 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, bundle-branch block, and congestive heart failure (proarrhythmic effect)
      • Pregnancy category C
    • Precautions:
      • Dangerous in overdose
      • Pretreatment electrocardiogram (ECG) for patients >40 years of age
      • Watch for suicidal behavior or worsening depression during 1st 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.

Additional 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 or adolescent

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 (2).

  • Pimozide (Orap): Initial dose: 0.5 mg/d; target dose: 1–6 mg/d
  • Haloperidol (Haldol): Initial dose: 0.5 mg/d; target dose: 0.5–6 mg/d
  • Risperidone (Risperdal): Initial dose: 0.5 mg/d; target dose: 0.5–2 mg/d
  • Olanzapine (Zyprexa): Initial dose: 1.25 mg/d; target dose: 1.25–30 mg/d

Positive family history: Prevalence rates of 7–15% in 1st-degree relatives of children/adolescents with OCD 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 or restrictions are recommended.

Patient Education

  • Importance of medication adherence
  • Importance of psychotherapy (CBT)
  • International OCD Foundation, PO Box 961029, Boston, MA 02196; 617-973-5801; www.ocfoundation.org
  • Obsessive Compulsive Anonymous, PO Box 215, New Hyde Park, NY 11040; 516-739-0662; http://obsessivecompulsiveanonymous.org

Prognosis

  • Chronic waxing and waning course in majority of patients
    • 24–33% fluctuating course
    • 11–14% phasic periods of remission
    • 54–61% chronic progressive course
  • Early onset a poor predictor

Complications

  • Depression in 1/3 of patients with OCD
  • Avoidant behavior (phobic avoidance)
    • Children may drop out of education.
    • Adults may become home-bound.
  • Anxiety and panic-like episodes associated with obsessions

References

1. Gava I, et al. Psychological treatments versus treatment as usual for obsessive compulsive diorder (OCD). Cochrane Database Sys Rev. 2007;2:CD005333.

2. Stein DJ, et al. Obsessive-compulsive disorder: diagnostic and treatment issues. Psychiatr Clin N Am. 2009;32:665–685.

Additional Reading

Diagnostic and Statistical Manual of Mental Disorders DSM-IV (Text Revision), 4th ed. Washington, DC: American Psychiatric Association, 2000.

Koran LM, et al. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. 2007;164:5–53.

Kurlan R, Kaplan EL et al. The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) etiology for tics and obsessive-compulsive symptoms: hypothesis or entity? Practical considerations for the clinician. Pediatrics. 2004;113:883–6.

Nestadt G, et al. Genetics of obsessive compulsive disorder. Psychiatr Clin N Am. 2010;33:141–158.

Codes

ICD9

300.3 Obsessive-compulsive disorders

Snomed

191736004 obsessive-compulsive disorder (disorder)

Clinical Pearls

  • CBT is initial treatment of choice for mild OCD.
  • CBT plus an SSRI or an SSRI alone is the treatment choice for more severe OCD.
  • >65–70% of patients with OCD respond to 1st SSRI treatment.
  • Improvement in symptoms is often incomplete and ranges from 25–60%.

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