Age of onset is usually approximately 20 years; however, in one third of the patients OCD first appears in adolescence. The condition is usually chronic.
Ask about compulsive behaviour and obsessive thoughts particularly if the patient has depression or anxiety.
Effective treatment forms include cognitive behaviour therapy as well as selective serotonin reuptake inhibitors (SSRIs) and clomipramine in fairly high doses and with a sufficiently long follow-up of response.
Epidemiology
According to cross-sectional studies, the prevalence of OCD in the general population is 1.6%. The lifetime prevalence rate for OCD is approximately 2.5%.
The prevalence of OCD shows no gender variation.
Aetiology
Genetic studies, the latest imaging techniques as well as the results achieved with psychosurgery suggest that OCD has a biological origin.
The serotonergic system has become the focus of the studies, because good treatment responses have been achieved in OCD with serotonin-selective drugs.
No specific OCD genes have yet been identified but some studies suggest that genetic predisposition may sometimes be associated with the disorder. Childhood onset OCD appears to be inherited (sometimes in association with tic disorders).
Clinical picture
OCD is in the current ICD-10 classified within anxiety disorders. In DSM-5 it forms, together with obsessive-compulsive spectrum disorders, its own entity.
The patient has either obsessive thoughts (obsessions) or compulsive behaviour (compulsions), or both. Obsessions and compulsions are repetitive, and the patient finds them disturbing.
Patients with OCD recognize that their obsessions are a creation from within their own minds.
Common obsessions include:
fear of contamination, avoidance of dirt, fear of germs
imagining having harmed oneself or others
fear of losing control
intrusive sexual thoughts
excessive religious or moral doubt
forbidden thoughts
a need to keep things a certain way
a compulsive need to talk, ask questions or confess.
Common compulsions include:
washing, repeating things, checking, counting
organising possessions, hoarding or keeping things.
Compulsions are often performed and repeated according to strict rituals. The aim is to obtain relief from something that is perceived to be unpleasant. Patients usually recognize that their behaviour is unreasonable.
OCD symptoms cause distress, take time (more than an hour a day) or significantly interfere with the person's everyday life.
OCD is usually a long-term condition, even lifelong. The symptoms often improve over time, but may also progressively worsen in some patients. The symptoms vary from being almost insignificant to symptoms causing severe distress.
OCD is an underdiagnosed and undertreated disorder, because patients either hide their symptoms or do not perceive them as a sign of an illness.
Differential diagnosis
Obsessive thoughts occur in many psychiatric illnesses, but not usually compulsive behaviour. The existence of compulsive behaviour therefore supports the diagnosis of OCD.
Tic disorders (Tourette's syndrome and other tic disorders; see Tic Disorders in Childhood) may resemble OCD. Tics and OCD often occur together, particularly in childhood onset disorders.
In the generalized anxiety disorder the patient sees the reason for his/her anxiety as realistic, whereas there is no realistic reasoning behind the OCD symptoms.
OCD patients may sometimes have panic attacks but they are secondary to obsessive fears.
OCD and depression often occur together in adults, but less commonly in children and adolescents.
Eating disorders and schizophrenia occur with OCD more commonly than usual. Unlike psychotic individuals, people with OCD have a clear idea of what is real and what is not.
In children and adolescents, OCD may worsen or cause disruptive behaviour as well as cause problems with attention and concentration.
Although stress can exacerbate OCD, symptoms do occur regardless of stress.
OCD patients usually seek treatment because of depression or anxiety, and not obsessions or compulsions per se. Short questions relating to repetitive hand washing, the need to check things or obsessive thoughts lead to the recognition of OCD in 80% of cases.
Only a small number of people with OCD suffer from obsessive compulsive personality disorder (OCPD). This refers to a personality pattern that involves a preoccupation with rules, time tables, perfectionism, rigidity and inflexibility.
Comorbidity
Psychiatric conditions that may co-exist with OCD include:
Anxiety disorders (such as panic disorder or social anxiety disorder, also known as social phobia, or other specific phobias)
Depression/dysthymia
Behaviour and attention disorders (e.g. attention-deficit hyperactivity disorder, ADHD)
Learning disorders
Tic disorders
Trichotillomania (hair pulling)
Body dysmorphic disorder.
Treatment
Education is crucial in helping patients and families learn how best to manage OCD and prevent its complications.
Clomipraminehttp://www.dynamed.com/condition/obsessive-compulsive-disorder-ocd#ANTIDEPRESSANTS is effective in 50-85% of patients in controlled studies. The starting dose is 25 mg. The dose may be increased up to 150-200 mg/day, which is a higher dose than used in depression. Clomipramine at a dose of 25-75 mg/day may also be a useful additional drug to be combined with an SSRI in order to increase the response to drug therapy.
An effect may appear slowly (within 2-3 months) and the efficacy may continue to increase for up to 1 year. Good treatment effect includes the decrease of the severity and/or duration of symptoms by 30-50%.
Drug treatment should be continued for at least 1.5 years, sometimes lifelong.
Relapse is very common when medication is withdrawn, particularly if the person has not had the benefit of cognitive behaviour therapy (CBT). It is recommended that patients continue medication, particularly if provision of CBT is not possible.
Other tricyclic antidepressants are not effective. Antipsychotics can be used as adjunctive therapy with SSRIs, and they can be used to alleviate tic symptoms.
A combination of drug treatment and cognitive behaviour therapy is often beneficial. Transcranial magnetic stimulation combined with other treatment may improve the response.
References
Pallanti S, Marras A, Salerno L et al. Better than treated as usual: Transcranial magnetic stimulation augmentation in selective serotonin reuptake inhibitor-refractory obsessive-compulsive disorder, mini-review and pilot open-label trial. J Psychopharmacol 2016;30(6):568-78. [PubMed]
Atli A, Boysan M, Çetinkaya N et al. Latent class analysis of obsessive-compulsive symptoms in a clinical sample. Compr Psychiatry 2014;55(3):604-12. [PubMed]