Topic Editor: Grant E. Fraser, M.D., FRACGP, FACRRM, ASTEM

Review Date: 3/5/2013

Definition

Obsessive-compulsive disorder (OCD) is a psychiatric anxiety disorder, which can be debilitating. It is characterized by intrusive thoughts(obsessions) and/or repetitive behaviors (compulsions).

Description

• OCD symptomatically heterogeneous and is characterized by obsessional thoughts and compulsive actions
• Obsessional thoughts and behaviors involve
• Recurrent persistent feelings, impulses or images that trigger anxiety
• These thoughts are unrelated to realistic concerns
• Attempts to curb, ignore, or neutralize disturbing thoughts with other thoughts or actions
• Recognition that these thoughts are a product of their own mind and not externally imposed
• Distressing, stereotyped thoughts or images may involve injuring loved ones, repetitive checking whether the door has been locked or electrical appliances have been switched off, obsessive fear of contamination, and morally or sexually offensive thoughts
• Compulsions are usually present as
• Repetitive behaviors (or thoughts) which include hand washing, ordering things, reassuring oneself, or repetitive mental acts including praying, counting, or similarly time and effort consuming repetitive activities
• These behaviors or thoughts have the goal of decreasing distress or possibly preventing a dreaded event or situation. However, the rituals of these behaviors or thoughts are not logically expected to have such an impact
• Potential causes of OCD include neurobiological and metacognitive-behavioral factors
• Neurobiological causes may be hereditary
• Infectious causative agents such as ß-hemolytic streptococci felt to trigger a CNS autoimmune reaction
• Dysfunctional interpretative patterns may also be responsible
• Clinical presentation: Onset of OCD is gradual; regardless of treatment, it tends to be chronic, but degree of symptomatology can be impacted by therapy. Onset usually occurs during adolescence or early adulthood, with symptoms comparable in children and adults
• Pathophysiology: Hypotheses include serotonin neurotransmitter abnormalities and neuroanatomical theories
• Development of OCD has been linked with abnormalities in the brain's serotonin system, and hypersensitivity of the postsynaptic serotonin receptors
• Specific brain regions such as the frontal orbito-striatal area and the dorsolateral prefrontal cortex may be responsible for response inhibition and disorganization in planning and recalling prior actions
• Orbito-subcortical circuits in the brain are associated with direct and indirect pathways
• Direct pathways move from the cerebral cortex to the ventromedial caudate, to the internal segment of the globus pallidus and substantia nigra, and then to the thalamus and back to the cortex. Indirect pathways are the same; however, it starts from the ventromedial caudate through various structures in the basal ganglia prior reaching to direct pathway. OCD symptoms are known to be linked with overactivity of the direct pathways
• Basal ganglia inflammation due to streptococcal infection leading to a CNS autoimmune reaction may also be responsible for the development of OCD
• OCD is classified as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), and it is classified as a neurotic, stress-related and somatoform disorder in the International Classification of Diseases (ICD-10)

Epidemiology

Incidence/Prevalence

• The National Comorbidity Survey Replication (NCS-R) reported a lifetime prevalence of 2.3% and a 12-month prevalence of 1.2% in the US
• A UK epidemiological study reported the 1-month prevalence to be 1.1%
• In children and adolescents, prevalence rate of OCD ranges from 1% to 3%
• A Singapore population based survey in 2012 found a lifetime prevalence for OCD of 3.0%

Age

• The NCS-R reported the mean age for development of OCD to be 19.5 years
• The mean age of onset for OCD based on epidemiological studies is 22–35 years

Gender

• Early onset of OCD is more common in males than females
• Comparable prevalence has been observed between genders; a slight female predominance has been observed by age 18 years in adult samples

Race

• OCD is equally prevalent among all ethnic classes and races

Genetics

• OCD may be a familial disorder; the obsessive component may be more phenotype-specific than the compulsive component
• Certain behaviors, such as compulsive hoarding, have a strong familial association. A significant linkage between OCD and chromosome 14 has been observed in families with at least two hoarding relatives

Risk factors

• Being in late adolescent or early adult years
• Childhood conduct, internalization and temperament disturbances
• Drug or substance abuse
• Family members with OCD
• Mood and anxiety disorders
• Negative emotionality
• Perinatal insults
• Physical abuse
• Social isolation

Etiology

• Neurobiological processes, metacognitive behavioral patterns and infectious agents have been implicated in the development of OCD
• Neurobiological processes
• Compared to the general population, there is a 3–12 times higher risk of OCD if a first-degree relative also has OCD
• Association of heritability and development of early-onset OCD has been demonstrated in studies of twins
• It is felt that patients with late-onset OCD have an increased role of environment, trauma, and psychological factors
• Metacognitive behavioral patterns
• Dysfunctional interpretation of intrusive negative thoughts may be a causative factor for OCD
• In such cases, OCD patients usually attempt to avert or curb disturbing thoughts, thereby becoming engrossed in such thoughts. This creates a vicious circle of intrusive thoughts which engender compulsive behaviors
• Compulsive behaviors may also occur due to a parent's participation in the compulsive behavior of the child with an intention to avert aggressive consequences
• Role of infectious agents
• ß-hemolytic streptococcal infections may be a causative factor for OCD, primarily mediated through neurologic autoimmune effects. It felt that some cross-reaction of anti-streptococcal antibodies occurs with the basal ganglia resulting in neuropsychiatric disturbances
• Streptococcal infection when associate with neuropsychiatric disorders in children is termed Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS)

History

• Screening questions may include those, such as in the Zohar-Fineberg Obsessive-Compulsive Screen (Z-FOCS) questionnaire:
• Do you wash or clean repetitively?
• Do you recheck things very often?
• Are there any bothersome things that you want to get rid of, but are not able to get rid of it?
• Do your normal activities take a longer time to get completed?
• Are you concerned about orderliness or symmetry?
• Detailed history of behaviors associated with compulsions and obsessions must be obtained, detailed, and evaluated
• For obsessive behavior, clinicians must ask about:
• Aggressive or sexually intrusive thoughts
• Concerns about symmetry
• Hoarding
• Pathological doubt
• Religious scrupulosity
• Thoughts of contamination
• For compulsive behavior, clinicians must ask about:
• Conduct of mental rituals
• Hoarding
• Orderliness beyond normal range
• Reassurance seeking behavior
• Re-checking to a pathological degree
• Repetitive counting behavior
• Repetitive washing behavior

Physical findings on examination

There are no specific physical findings associated with OCD, however, certain findings may be indicative of ritualistic behaviors

• Scratch marks or scarring associated with compulsive skin picking
• Visible hair loss or bald patches associated with trichotillomania (compulsive hair pulling)
• Dermal injury associated with excessive hand washing

• Alcohol abuse
• Attention deficit hyperactivity disorder (ADHD)
• Autism
• Body dysmorphic disorder
• Eating disorders (anorexia and bulimia)
• Generalized anxiety disorder
• Hypochondriasis
• Major depressive disorder
• Neurodermatitis
• Obsessive compulsive personality disorder
• Panic disorder
• Paraphilia
• Pathological gambling
• Phobias
• Schizophrenia
• Stereotypic movement disorder
• Substance-induced anxiety disorder
• Tic disorder
• Tourette's syndrome
• Trichotillomania

General treatment items

• Treatment of OCD includes pharmacological, non-pharmacological treatment, and in some patients refractory to these treatments, neurosurgical intervention
• Along with specific treatment modalities, clinicians must also consider education and support for patients throughout the treatment phase
• Pharmacological interventions
• It is important to note that pharmacotherapy generally does not yield a full response; but instead a relative reduction in symptomatology
• Selective serotonin reuptake inhibitors (SSRIs)
• SSRIs are the first-line treatment for OCD. Numerous SSRIs including fluoxetine, fluvoxamine, paroxetine, and sertraline have been approved by U.S. Food and Drug Administration (FDA) based on their favorable tolerability profile. Citalopram and escitalopram are also effective options
• Symptomatic improvement of OCD has been observed in 60% to 70% of patients receiving SSRIs
• Long-term treatment with SSRIs may effectively prevent relapse of OCD
• Tricyclic antidepressants (TCAs)
• TCAs are a second-line treatment for patients not effectively responding to SSRIs, or for those who cannot tolerate them
• Clomipramine (FDA approved) is effective for OCD
• Serotonin norepinephrine reuptake inhibitors (SNRIs)
• SNRIs are not currently approved by FDA for the treatment of OCD; however, several preclinical and clinical studies have advocated its potential role in treating OCD
• Venlafaxine and duloxetine have been found to be effective for treating OCD
• Antipsychotics
• Augmentation therapy with atypical antipsychotics is considered in OCD patients receiving SSRI treatment and reporting partial response
• Risperidone, quetiapine, olanzapine, and haloperidol are the preferred antipsychotics for OCD and comorbid tic conditions
• Others
• Other drugs, which have been investigated for treatment of refractory OCD include pindolol, buspirone, dextroamphetamine, memantine, topiramate, gabapentin, and ondansetron
• Non-pharmacological interventions
• Psychotherapy
• The Exposure and Response Prevention (ERP) technique is a form of Cognitive Behavioral Therapy (CBT), which exposes patients to obsessional situations during which they are compelled to not act or respond. Such preventive techniques include systematic desensitization, paradoxical intention, and satiation/habituation techniques
• The American Psychiatry Association (APA) recommends ERP or other CBT as first-line treatment for the majority of OCD patients, as it has demonstrated effectiveness with both short- and long-term use
• Repetitive transcranial magnetic stimulation (RTMS)
• RTMS is a non-invasive technique which may be considered in cases of treatment-resistant OCD; however, studies supporting its effectiveness are preliminary and limited
• In late 2012, a randomized, double-blind trial with 3 month follow-up demonstrated a response rate of 41% with active versus 10% with sham treatment. At 14 weeks, the active group had a 35% reduction on Y-BOCS versus 6% reduction with sham treatment
• Deep brain stimulation (DBS)
• DBS is non-ablative surgical procedure in which electrodes are surgically implanted to stimulate the basal ganglia
• DBS has been known to significantly reduce Y-BOCS scores and improve overall functional scores for OCD
• Studies have demonstrated promising long-term results with DBS in patients with refractory OCD. 50% reduction in Y-BOCS has been reported
• Surgical interventions
• Ablative surgical treatment is considered for patients refractory to pharmacotherapy and psychotherapy
• Commonly indicated surgical procedures include anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy

Medications indicated with specific doses

Selective serotonin reuptake inhibitors

• Citalopram
• Adult dosing
• Escitalopram
• Adult Dosing
• Fluoxetine
• Adult Dosing
• Pediatric Dosing
• Fluvoxamine
• Adult Dosing
• Pediatric Dosing
• Paroxetine
• Adult Dosing
• Pediatric Dosing
• Sertraline
• Adult Dosing
• Pediatric Dosing

• Clomipramine
• Adult Dosing
• Pediatric Dosing

• Duloxetine
• Adult Dosing
• Venlafaxine
• Adult Dosing

• Haloperidol [Oral]
• Adult dosing
• Olanzapine [Oral]
• Adult Dosing
• Quetiapine
• Adult Dosing
• Risperidone [Oral]
• Adult Dosing

Diet/Activity restrictions

• No specific dietary/activity restriction is indicated for patients with OCD

Disposition

• Outpatient management is appropriate for most cases of mild-to-moderate OCD
• Rarely, hospitalization with intensive psychiatric therapy may be indicated
• In refractory cases where DBS or surgical intervention is pursued, hospitalization for the neurosurgical procedure is indicated

Monitoring

• Patients should be monitored for risk of suicidal ideation or thoughts during both the initial stages of diagnosis, initiation of pharmacotherapy, and ongoing treatment
• Additional psychiatric support should be offered to patients presenting with comorbid depression
• During any dose change in the treatment, clinicians must review any new symptoms or worsening
• OCD patients reporting symptom remission after treatment are typically advised to undergo regular follow-up for at least 12 months with a mental health professional

Assessment of therapy

• Pharmacotherapy should be carefully monitored for side effects (including side effects and suicidality)
• When possible, doses should be tapered to the minimum effective dose

Complications

• Long-term complications are associated with certain types of obsessive and compulsive rituals, eg, skin breakdown due to continuous hand washing
• Depression occurs in approximately one-third of OCD patients
• OCD patients may have an increased risk of suicidal behavior, especially those with concurrent depression
• Avoidant behavior is common in OCD patients
• Anxiety and panic disorders are often linked with obsessive rituals
• Behavioral tendencies to restrict fluid or neglect nutrition may increase the risk of systemic disorders such as renal impairment and hyperlipidemia
• Patients may have issue with employment or social relationships due to OCD

Prevention

• Onset of OCD cannot presently be prevented
• Prevention of response to the obsessions can effectively occur with Exposure and Response Prevention (ERP) which is a specific use of Cognitive Behavioral Therapy (CBT) used for treatment of OCD

Prognosis

• Despite appropriate treatment, OCD is a chronic illness characterized by a waxing and waning course
• The clinical course of OCD can be classified into 5 types
• Continuous and consistent
• Continuous with deterioration
• Continuous with amelioration
• Episodic with partial remission
• Episodic with complete remission
• The majority of OCD patients report mild-to-moderate improvement in symptoms of OCD over time
• Some cases of OCD respond well to pharmacotherapy and/or CBT. The response is typically partial rather than complete. In particularly refractory cases, neurosurgical therapies may be utilized to achieve a response
• Pediatric-onset OCD typically continues chronically throughout the patient's lifetime

Associated conditions

• Anxiety
• Attention-deficit/hyperactivity disorder (ADHD)
• Crohn's disease
• Depression
• Drug and alcohol abuse
• Eating disorders
• Major depressive disorder
• Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS)
• Schizotypal personality disorders
• Social phobia
• Systemic lupus erythematosus
• Temporal lobe epilepsy

Pregnancy/pediatric effects on condition

• Pregnancy and parturition have been linked with new onset of OCD or exacerbation of this condition in those already diagnosed
• Perinatal OCD may be characterized by obsessive-compulsive behavior linked to the well-being of the fetus or neonate. However, it is necessary to differentiate perinatal OCD from other conditions such as postpartum depression or psychosis
• The use of SSRIs is generally avoided during pregnancy

Abbreviations

• OCD

ICD-9-CM

• 300.3 Obsessive-compulsive disorders

ICD-10-CM

• F42 Obsessive-compulsive disorder

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