Obsessive-Compulsive Disorder (OCD)

Obsessions are unwanted, intrusive thoughts, urges, or mental images, the presence of which usually causes marked distress or anxiety. The dominant themes of the obsessions include harm (eg, fears of harm to self or others), cleaning or contamination (eg, patients may obsess about becoming contaminated with dirt or germs), forbidden or taboo thoughts (eg, aggressive or sexual obsessions), and the need for symmetry, although other themes may occur as well. The obsessions are not pleasurable. Thus, patients usually try to ignore and/or suppress them, or they try to neutralize them by performing a compulsion.

Compulsions (often called rituals) are excessive, repetitive, purposeful behaviors that people feel they must do to prevent or reduce the anxiety caused by their obsessive thoughts or to neutralize their obsessions. Examples include:

• Washing (eg, handwashing, showering)

• Checking (eg, that the stove is turned off, that doors are locked)

• Counting (eg, repeating a behavior a certain number of times)

• Ordering (eg, arranging tableware or workspace items in a specific pattern)

Most rituals, such as handwashing or checking locks, are observable, but mental rituals, such as silent repetitive counting, are not. Typically, the compulsive rituals must be carried out in a precise way according to rigid rules. The rituals may or may not be connected realistically to the feared event. When connected realistically (eg, showering to avoid being dirty, checking the stove to prevent fire), the compulsions are clearly excessive—eg, showering for hours each day or always checking the stove 30 times before leaving the house. In all cases, for OCD to be diagnosed, the obsessions and/or compulsions must be time-consuming (ie, they take up an hour a day and often much more) or cause patients significant distress or significant impairment in functioning; at their extreme, obsessions and compulsions may be incapacitating.

The degree of insight individuals have about their obsessions or compulsions varies. Most people with obsessive-compulsive disorder (OCD) recognize to at least some degree that the beliefs underlying their obsessions are not realistic (eg, that they really will not get cancer if they touch an ashtray). However, occasionally, insight is completely lacking (ie, patients are convinced that the beliefs underlying their obsessions are true and that their compulsions are reasonable).

Because people with this disorder may fear embarrassment or stigmatization, they often conceal their obsessions and rituals. The time, distress, or poor functioning associated with the obsessions and compulsions may cause relationships to be disrupted and performance in school or at work to decline.

Many people with OCD have coexisting past or current psychiatric disorders, including

• Anxiety disorders (50 to 76%) (1, 2)

• Mood disorders (50 to 63%; the most common is major depressive disorder [41%]) (3)

• Obsessive-compulsive personality disorder (23 to 32%) (4)

Up to 50% of people with OCD have suicidal thoughts at some point, and approximately 15% attempt suicide (see Suicidal Behavior) (5, 6). Risk of an attempt is increased if people also have major depressive disorder.

• Psychiatric assessment

• General medical evaluation to exclude other conditions

Clinical criteria for diagnosis of OCD from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) is based on the presence of obsessions, compulsions, or both (1).

Obsessions are defined by both of the following:

• Recurrent and 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 action (ie, by performing a compulsion).

Compulsions are defined by both of the following:

• Repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, silently 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 behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

The obsessions or compulsions must be time-consuming (eg, > 1 hour a day in total) or cause clinically significant distress or clinically significant impairment of functioning. In addition, they must not be attributable to the physiologic effects of a substance (eg, medication, drug) or another medical condition (such as basal ganglia ischemic stroke). The diagnosis may also include a specifier of the patient's level of insight (good or fair, poor, or absent/delusional beliefs), or of a past or current tic disorder.

• Cognitive-behavioral therapy (CBT), including exposure and response (ritual) prevention

• Selective serotonin reuptake inhibitor (SSRI) or clomipramine, plus, if needed, an augmenting medicationSelective serotonin reuptake inhibitor (SSRI) or clomipramine, plus, if needed, an augmenting medication

Choice of initial therapy may be CBT or medication, with combination therapy used if preferred or if response to the initial type of therapy is inadequate (1). Many experts believe that combining exposure and ritual prevention with pharmacologic therapy is best, especially for severe cases (2).

Cognitive-behavioral therapy, which includes exposure and ritual prevention therapy, has been shown to be effective for patients with obsessive-compulsive disorder (3, 4). The essential element of exposure and ritual prevention therapy is gradually exposing patients to situations or people that trigger the anxiety-provoking obsessions and rituals while asking them not to perform their rituals. For example, a patient with contamination obsessions and washing compulsions may be asked to touch a toilet seat without washing her hands. This approach allows the anxiety triggered by exposure to diminish through habituation and learning. Improvement is often sustained for years, especially in patients who master the approach and use it after formal treatment has ended. However, some patients have incomplete responses (as some also do to medications).

Cognitive therapy techniques (eg, cognitive restructuring) may also be useful in targeting some symptoms of obsessive-compulsive disorder (5).

SSRIs and clomipramine (a tricyclic antidepressant with potent serotonergic effects) are often very effective (and clomipramine (a tricyclic antidepressant with potent serotonergic effects) are often very effective (6). An SSRI is usually preferred over clomipramine as initial pharmacologic therapy. Patients often require higher doses than are typically needed for depression and most anxiety disorders. ). An SSRI is usually preferred over clomipramine as initial pharmacologic therapy. Patients often require higher doses than are typically needed for depression and most anxiety disorders.

Some patients who do not substantially improve with adequate trials of these medications may benefit from augmentation with a medication such as an atypical neuroleptic (eg, aripiprazole, risperidone). Patients with current or past tic comorbidity may be more responsive to augmentation with a neuroleptic (Some patients who do not substantially improve with adequate trials of these medications may benefit from augmentation with a medication such as an atypical neuroleptic (eg, aripiprazole, risperidone). Patients with current or past tic comorbidity may be more responsive to augmentation with a neuroleptic (6). Augmentation with buspirone or with a glutamate modulator (eg, memantine, ). Augmentation with buspirone or with a glutamate modulator (eg, memantine,N-acetylcysteine) has also shown promise. However, there are more supporting data for atypical neuroleptics as SSRI-augmenting agents than for other medications. -acetylcysteine) has also shown promise. However, there are more supporting data for atypical neuroleptics as SSRI-augmenting agents than for other medications.