Obsessive Compulsive Disorder

See Also

Epidemiology

Lifetime Prevalence: 1.6 to 2.5% (chronic in 60-70% of cases)
Onset: late adolescent or early adulthood (mean age 19.5 years)
Fourth most common psychiatric diagnosis in U.S.
Females have an increased lifetime risk of OCD (typically as teens)
1. Higher risk during pregnancy and postpartum (up to a 2 fold increased risk)

Risk factors
Childhood findings suggestive of OCD Development

Separation Anxiety
Resistance to change or novelty
Risk aversion
Submissiveness
Sensitivity
Perfectionism
Hyper-morality
Ambivalence
Excessive devotion to work

Pathophysiology

Involvement of dorsolateral prefrontal cortex, Basal Ganglia, and Thalamus
Serotonin mediated, as well as Glutamate and Dopamine
Possible association with PANDA Syndromes (e.g. Abrupt OCD onset in children with Strep Pharyngitis)

Symptoms
Obsessions

Intrusive, distressing thoughts, impulses, urges or images that are recurrent and persistent
Obsessions are not related to real-life problems
Attempts to ignore, suppress or neutralize Obsessions (often with compulsions)
Recognition that Obsessions are product of one's own mind
Examples
1. Contamination (50%)
  1. Worry about infection from others (e.g. shaking hands)
  2. Associated compulsions: Hand Washing, cleaning
2. Pathologic doubt (42%)
  1. Persistent worrying about doing things incorrectly and negatively impacting others
  2. Examples: An unlocked door, or oven left on
  3. Associated compulsions: Excessive checking, Performing tasks in a strict order
3. Somatic (33%)
4. Need for symmetry or Order (32%)
  1. Needs to perform tasks in a balanced, exact manner
  2. Associated compulsions: ordering, arranging
5. Aggressive (31%)
  1. Intrusive images of hurting another person
  2. Experiences recurrent violent images
  3. Associated compulsions: Needs reassurance of being a good person
6. Sexual (24%)
  1. Intrusive pornographic images (sexually deviant, pedophilia)
  2. Acting in a sexually inappropriate way toward others
  3. Associated compulsions: Follow mental rituals to counter intrusive thoughts
7. Religious
  1. Worry about unknowingly commiting a sin (immoral, eternal damnation)
  2. Associated compulsions: Asking for forgiveness, praying
8. Superstition
  1. Afraid of bad numbers or colors
  2. Associated compulsions: Counting

Symptoms
Compulsions

Repetitive behaviors or mental acts as a response to Obsessions
1. Checking (61%)
2. Washing (50%)
3. Counting (36%)
4. Need to ask or confess (34%)
5. Symmetry and precision (28%)
6. Hoarding trash or other items (18%)
7. Praying
8. Repeating words silently
Compulsions are intended to reduce distress
1. Patient feels compelled to respond to an Obsession
2. Patient may have a set of rigidly applied rules
3. Not connected realistically to preventing Obsession
4. Excessive measures
5. Mental rituals may be present without observable compulsive behaviors

History
Sample Questions

Do certain thoughts keep coming into your head?
1. Is this despite your trying to keep the thoughts out?
2. Do the thoughts make sense or do they seem absurd?
3. What do you do to try to counteract these thoughts?
4. Do you feel a need to put items in a certain order?
5. Are you very upset by mess?
Do you feel a need to do something over and over again (e.g. washing, cleaning, checking)?
1. Is this despite your not wanting to do these things?
2. Do these actions seem reasonable or excessive?

Signs

Raw chapped hands (constant Hand Washing)
Unproductive hours spent on homework
Erasure holes in test papers and school work
Repeatedly asking the same question
Persistent fear of illness
Persistent fear that someone else will experience harm
Difficulty leaving the house
Recurrent tardiness
Significant increase in laundry
Unusually long time to get ready for bed or dressing
Hoarding useless objects
Peculiar patterns of walking or sitting

Diagnosis
DSM-5

Obsessions or Compulsions as described above
Insight that Obsessions or compulsions are excessive
Impaired function
1. Marked distress
2. Time consuming (more than 1 hour per day)
3. Interfere with patient's normal routine
4. Interfere with occupation, education, relationships
Not limited to an Axis I Diagnosis (examples follow)
1. Not better explained by Generalized Anxiety Disorder with Excessive Worry
2. Not due to Eating Disorder and its related preoccupation with food
3. Not due to Body Dysmorphic Disorder and its preoccupation with appearance
4. Not due to specific compulsion disorders (hoarding disorder, Trichotillomania)
Obsessions or Compulsions not due to secondary cause
1. Not due to Substance Abuse (or to its related preoccupation with illicit substances)
2. Not due to underlying medical condition
3. Not due to a medication
Additional specifications
1. Tic-related
  1. Past or current Tic Disorder
2. Insight
  1. Good or fair insight
    1. Patient recognizes their OCD beliefs are unlikely to be true
  2. Poor insight
    1. Patient thinks their OCD beliefs are probably true
  3. Absent insight with Delusions
    1. Patient is convinced their OCD beliefs are true
References
1. (2022) DSM 5 revised, APA

Tools
Self-Assessment

Diagnosis
1. Obsessive-Compulsive Inventory-Revised
  1. https://psychology-tools.com/test/obsessive-compulsive-inventory-revised
2. Florida Obsessive-Compulsive Inventory
  1. https://projectteachny.org/app/uploads/2024/07/florida-oci-self.pdf
Monitoring for severity
1. Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
  1. https://pcl.psychiatry.uw.edu/wp-content/uploads/2021/12/YBOCS.pdf

Differential Diagnosis

Consider PANDAS in children with abrupt onset of OCD symptoms
Major Depression
Generalized Anxiety Disorder
Panic Disorder
Hypochondriasis
Tourette's Syndrome
Schizophrenia
Autism Spectrum Disorders
Obsessive Compulsive Personality
1. Behaviors centered around organization, perfectionism and control
2. Completely separate diagnosis from OCD without intrusive thoughts or compulsive, repetitive behaviors

Associated Conditions

OCD Spectrum Disorders
1. Body Dysmorphic Disorder
2. Hypochondriasis
3. Eating Disorders
4. Trichotillomania
  1. Hair Loss from recurrently pulling out hairs
  2. Typical onset at Puberty and more common in females
5. Skin-picking disorder
  1. Recurrent skin picking with secondary open lesions
  2. Typical onset at Puberty and more common in females
Comorbid axis I disorders (common)
1. Major Depression (>66% lifetime comorbid Prevalence)
2. Suicidality (Suicidal Ideation >50%)
3. Panic Disorder
4. Social Phobia
5. Substance Abuse

Types
Subtypes of Obsessive Compulsive Disorder

Early-Onset
1. Onset before Puberty (typically <10 years old)
2. Severe, frequent compulsions
3. Often refractory to first-line treatments
4. Associated with Family History of early onset OCD
5. Predominately males
Hoarding
1. Difficulty parting or discarding possessions, accumulating items that overflow their space
2. Lower insight into own condition
3. Symptoms are severe and often refractory to treatment, and increase in severity over time
4. Comorbid Anxiety Disorder and Major Depression
5. Onset age 11-15 years old
Just-Right
1. Perfectionists need to repeat actions until feels right
Primary Obsessional (25%)
1. Often obsess about sex, Violence and Religion without compulsions
Scrupulosity
1. Religious or moral Obsessions and compulsions focused around whether they have committed sin
Tic-Related
1. Associated with early onset OCD, OCD-Spectrum Disorders and Tourette Syndrome
2. May require combination therapy with SSRI and Atypical Antipsychotics
References
1. Fenske (2009) Am Fam Physician 80(3): 239-45 [PubMed]
2. McKay (2004) Clin Psychol Rev 24(3): 283-313 [PubMed]

Management
General

Evaluate for Suicide Risk at each visit
Overall goal of treatment
1. Spending <1 hour daily on obsessive-compulsive behaviors
2. Striving for minimal interference with daily tasks
Management: Non-pregnant adults
1. Cognitive Behavioral Therapy (esp. ERP, see below)
2. Medication management (see below)
Management: Children
1. ERP for at least 12 weeks adapted for age/development (preferred)
2. SSRI (Fluvoxamine, Fluoxetine, Sertraline) may be considered at age >= 8 years (monitor Suicidality)
3. Consider PANDAS in abrupt onset of pediatric OCD
Management: pregnancy
1. Antepartum: Intrusive thoughts related to fetal well-being
2. Postpartum: Intrusive thoughts related to worry about harming infant
3. Cognitive Behavioral Therapy (CBT) is preferred
4. Sertraline may be considered if CBT alone is ineffective

Management
Cognitive Behavioral Therapy

General
1. Cognitive Behavioral Therapy (CBT) in general is the mainstay of OCD treatment
2. Timing
  1. Initial therapy delivered 1-2 times weekly for at least 12 weeks
  2. Maintenance therapy delivered monthly for 3 to 6 months
3. Efficacy: 80-90% effective
  1. Clinically meaningful response in 68%
  2. Remission in 57%
4. References
  1. McGuire (2015) Depress Anxiety 32(8):580-93 +PMID: 26130211 [PubMed]
Traditional Cognitive Behavioral Therapy (CBT)
1. Traditional CBT challenges unrealistic beliefs and cognitive distortions to reduce anxiety and compulsions
2. As an example, patient keeps a log of times when they performed a fearful action
  1. Also log how often that fearful action led to an adverse outcome
Exposure and Response Prevention (ERP) Therapy
1. Most effective form of OCD psychotherapy
2. Desensitization over 13-20 week period (1-2 hours per session)
3. Patients taught to confront fearful situations that lead to Obsessions, compulsions
  1. Examples: Touch objects in public bathroom
  2. Patient is to refrain from responding with compulsive behaviors
4. Increasingly expose patient to avoided stimulus
  1. Patient develops strategies to reduce anxiety when exposed to similar situations
Other measures
1. Mindfulness
2. Thought stopping
3. Response prevention
  1. Prevented from performing associated rituals

Management
Medications

General
1. Adjunctive to Cognitive Behavioral Therapy
  1. Moderate effect
  2. Clinically meaningful response in 50%
  3. Remission in 47%
2. Continue therapy if effective for at least 1 to 2 years (often longterm)
  1. Gradually taper medications over months if patient wishes to stop pharmacologic management
3. Higher doses are typically required for OCD
  1. Gradually increase doses over 4-6 weeks and continue for at least a total of 8-12 weeks
  2. Trial a medication at maximal dose for 4-6 weeks before determining a medication failure
  3. Monitor for Serotonin Syndrome and other adverse effects
First-Line: Selective Serotonin Reuptake Inhibitors (SSRI)
1. Agents FDA approved for OCD
  1. Fluoxetine (Prozac) 40 to 60 mg (start: 20 mg, max: 80 mg) per day
  2. Fluvoxamine (Luvox) 200 mg (start: 50 mg, max: 300 mg) per day
  3. Paroxetine (Paxil) 40 to 60 mg (start: 20 mg, max: 60 mg) per day
  4. Sertraline (Zoloft) 150 to 200 mg (start: 50 mg, max: 200 mg) per day
2. Other agents found to be effective for OCD
  1. Citalopram (Celexa) 20 mg (max: 40 mg, risk of QT Prolongation) orally daily
  2. Escitalopram (Lexapro) 20 mg (start: 10 mg, max: 40 mg) orally daily
Second-Line Agents
1. Venlafaxine (Effexor) 75 to 225 mg orally daily
2. Tricyclic Antidepressants
  1. Most effective agents
  2. Limited to refractory cases (alone or in combination with SSRI)
    1. Risk of intentional Overdose
    2. Risk of Anticholinergic adverse effects
  3. Clomipramine (Anafranil) 150 to 250 mg/day
    1. Start at 25 mg orally daily and gradually titrate the dose
3. Othre agents with limited evidence
  1. Antiepileptics (e.g. Gabapentin, Topiramate, Lamotrigine)
  2. Mirtazapine
Third-Line Agents: Atypical Antipsychotics (typically in combination with a SSRI or SNRI)
1. Risperidone (Risperdal)
2. Quetiapine (Seroquel)
3. Olanzapine (Zyprexa)

Precautions

Obsessive Compulsive Disorder is at higher risk for Suicidality (yet patients under-report Suicidality)
1. Risk increases with comorbid Major Depression and Substance Use Disorder
Diagnostic delay is common, averaging 11 years between onset and formal diagnosis
1. Pinto (2006) J Clin Psychiatry 67(5): 703-11 [PubMed]

Prognosis
Predictors of Remission

Later age of onset
Symptoms of shorter duration
Good insight
Response to treatment
Early and aggressive treatment

Resources

International Obsessive-Compulsive Foundation
1. https://iocdf.org/
Mayo Clinic Anxiety Coach
1. https://anxietycoach.mayoclinic.org/

References

(2022) DSM 5 revised, APA
Biggs (2024) Mayo Clinic Pediatric Days, attended lecture 1/14/2024
Black (1997) Resident Staff Physician 43(3):64-76
Bagheri (1999) Am Fam Physician 59(8):2263-72 [PubMed]
Eddy (1998) Am Fam Physician 57(7):1623-8 [PubMed]
Rasmussen (1992) Psychiatr Clin North Am 15:743-58 [PubMed]
Fenske (2015) Am Fam Physician 92(10): 896-903 [PubMed]
Fenske (2009) Am Fam Physician 80(3): 239-45 [PubMed]
Semenya (2024) Am Fam Physician 110(4): 385-92 [PubMed]