II. Epidemiology

  1. Lifetime Prevalence: 1.6 to 2.5% (chronic in 60-70% of cases)
  2. Onset: late adolescent or early adulthood (mean age 19.5 years)
  3. 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)

III. Risk factors: Childhood findings suggestive of OCD Development

  1. Separation anxiety
  2. Resistance to change or novelty
  3. Risk aversion
  4. Submissiveness
  5. Sensitivity
  6. Perfectionism
  7. Hyper-morality
  8. Ambivalence
  9. Excessive devotion to work

IV. Pathophysiology

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

V. Symptoms: Obsessions

  1. Intrusive, distressing thoughts, impulses, or images that are recurrent and persistent
  2. Obsessions are not related to real-life problems
  3. Attempts to ignore, suppress or neutralize Obsessions (often with compulsions)
  4. Recognition that Obsessions are product of one's own mind
  5. 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

VI. Symptoms: Compulsions

  1. 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
  2. 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

VII. History: Sample Questions

  1. 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?
  2. 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?

VIII. Signs

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

IX. Diagnosis

  1. Obsessions or Compulsions as described above
  2. Insight that Obsessions or compulsions are excessive
  3. Impaired function
    1. Marked distress
    2. Time consuming (more than an hour per day)
    3. Interfere with patient's normal routine
    4. Interfere with occupation, education, relationships
  4. 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)
  5. 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
  6. 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
  7. References
    1. (2013) DSM 5, APA
      1. http://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5

X. Tools: Self-Assessment

  1. Diagnosis
    1. Obsessive-Compulsive Inventory-Revised
      1. http://www.caleblack.com/psy5960_files/OCI-R.pdf
    2. Florida Obsessive-Compulsive Inventory
      1. http://www.ocdscales.org/index.php?page=scales
  2. Monitoring for severity
    1. Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
      1. http://www.stlocd.org/handouts/YBOC-Symptom-Checklist.pdf

XI. Differential Diagnosis

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

XII. Associated Conditions

  1. 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
  2. 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

XIII. Types: Subtypes of Obsessive Compulsive Disorder

  1. 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
  2. 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
  3. Just-Right
    1. Perfectionists need to repeat actions until feels right
  4. Primary Obsessional (25%)
    1. Often obsess about sex, Violence and Religion without compulsions
  5. Scrupulosity
    1. Religious or moral Obsessions and compulsions focused around whether they have committed sin
  6. Tic-Related
    1. Associated with early onset OCD, OCD-Spectrum Disorders and Tourette Syndrome
    2. May require combination therapy with SSRI and Atypical Antipsychotics
  7. References
    1. Fenske (2009) Am Fam Physician 80(3): 239-45 [PubMed]
    2. McKay (2004) Clin Psychol Rev 24(3): 283-313 [PubMed]

XIV. Management: General

  1. Evaluate for Suicide Risk at each visit
  2. Overall goal of treatment
    1. Spending <1 hour daily on obsessive-compulsive behaviors
    2. Striving for minimal interference with daily tasks

XV. Management: Cognitive Behavioral Therapy

  1. General
    1. Efficacy: 80-90% effective
    2. Mainstay of OCD treatment
  2. Exposure and Desensitization over 13-20 week period (1-2 hours per session)
    1. Patients taught to confront fearful situations that lead to Obsessions, compulsions
      1. Examples: Touch objects in public bathroom
    2. Increasingly expose patient to avoided stimulus
  3. Response prevention
    1. Prevented from performing associated rituals
  4. Thought stopping

XVI. Management: Medications

  1. General
    1. 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
    2. 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
  2. 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) 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
  3. 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
  4. Third-Line Agents: Atypical Antipsychotics (typically in combination with a SSRI or SNRI)
    1. Risperidone (Risperdal)
    2. Quetiapine (Seroquel)
    3. Olanzapine (Zyprexa)

XVII. Precautions

  1. Diagnostic delay is common, averaging 11 years between onset and formal diagnosis
    1. Pinto (2006) J Clin Psychiatry 67(5): 703-11 [PubMed]

XVIII. Prognosis: Predictors of Remission

  1. Later age of onset
  2. Symptoms of shorter duration
  3. Good insight
  4. Response to treatment
  5. Early and aggressive treatment

XIX. Resources

  1. Obsessive-Compulsive Foundation, Inc
    1. Address: 90 Depot St. PO Box 70, Milford, CT 06460
    2. Phone: (203) 878-5669

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Obsessive-Compulsive Disorder (C0028768)

Definition (MEDLINEPLUS)

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder. If you have OCD, you have frequent, upsetting thoughts called obsessions. To try to control the thoughts, you feel an overwhelming urge to repeat certain rituals or behaviors. These are called compulsions.

Examples of obsessions are a fear of germs or a fear of being hurt. Compulsions include washing your hands, counting, checking on things, or cleaning. With OCD, the thoughts and rituals cause distress and get in the way of your daily life.

Researchers think brain circuits may not work properly in people who have OCD. It tends to run in families. The symptoms often begin in children or teens. Treatments include therapy, medicines, or both. One type of therapy, cognitive behavioral therapy, is useful for treating OCD.

NIH: National Institute of Mental Health

Definition (NCI_NCI-GLOSS) An anxiety disorder in which a person has intrusive ideas, thoughts, or images that occur repeatedly, and in which he or she feels driven to perform certain behaviors over and over again. For example, a person may worry all the time about germs and so will wash his or her hands over and over again. Having an obsessive-compulsive disorder may cause a person to have trouble carrying out daily activities.
Definition (NCI) A disorder characterized by the presence of persistent and recurrent irrational thoughts (obsessions), resulting in marked anxiety and repetitive excessive behaviors (compulsions) as a way to try to decrease that anxiety.
Definition (MSH) An anxiety disorder characterized by recurrent, persistent obsessions or compulsions. Obsessions are the intrusive ideas, thoughts, or images that are experienced as senseless or repugnant. Compulsions are repetitive and seemingly purposeful behavior which the individual generally recognizes as senseless and from which the individual does not derive pleasure although it may provide a release from tension.
Definition (PSY) Disorder characterized by recurrent obsessions or compulsions that may interfere with the individual's daily functioning or serve as a source of distress.
Definition (CSP) anxiety disorder characterized by recurrent, persistent obsessions or compulsions: obsessions are the intrusive ideas, thoughts, or images that are experienced as senseless or repugnant; compulsions are repetitive and seemingly purposeful behavior which the individual generally recognizes as senseless and from which the individual does not derive pleasure although it may provide a release from tension.
Concepts Mental or Behavioral Dysfunction (T048)
MSH D009771
ICD9 300.3
ICD10 F42 , F42.9
SnomedCT 192406007, 71478004, 192411009, 191739006, 191736004
DSM4 300.3
LNC LA10581-9
English Disorders, Obsessive-Compulsive, Obsessive-Compulsive Disorder, Obsessive-compulsive neurosis, Disorder, Obsessive-Compulsive, OBSESSIVE-COMPULSIVE NEUROSIS, Obsessive-Compulsive Disorders, Obsessive-compulsive reaction, Obsessive-compulsive dis NOS, Obsessive-compulsive disorder NOS, Obsessive-compulsive disorder, unspecified, Obsessve-complsve dis unsp, [X]Obsessive-compulsive disorder, unspecified, [X]Obsessve-complsve dis unsp, OBSESSIVE COMPULSIVE DIS, obsessive compulsive disorder (diagnosis), obsessive compulsive disorder, anancastic neurosis, obsessive-compulsive psychoneurosis or reaction, OCD (obsessive compulsive disorder), OCD - Obsessive-compuls disord, Neuroses, Obsessive-Compulsive, Neurosis, Obsessive-Compulsive, Neurosis, Obsessive Compulsive, Obsessive-Compulsive Neurosis, Anankastic Personalities, Personalities, Anankastic, Personality, Anankastic, Anankastic Personality, Obsessive-Compulsive Neuroses, Reaction obsessive-compulsive, OBSESSIVE COMPULSIVE NEUROSIS, Obsessive-compulsive dis, OCD, OBSESSIVE-COMPULSIVE DISORDER, Obsessive-Compulsive Disorder [Disease/Finding], obsessive compulsive disorder (OCD), Disorder;obsessive-compulsive, obsessive-compulsive disorders, obsessive compulsive neurosis, Obsessive Compulsive Disorder, [X]Obsessive-compulsive disorder, unspecified (disorder), Obsessive compulsive disorder (disorder), Obsessive-compulsive disorder NOS (disorder), obsessive-compulsive disorder, -- Obsessive Compulsive Disorder, Obsessive compulsive disorder, Obsessive compulsive neurosis, Anankastic neurosis, Obsessive-compulsive disorder, Anancastic neurosis, OCD - Obsessive-compulsive disorder, Obsessive-compulsive disorder (disorder), disorder; obsessive-compulsive, neurosis; anankastic, neurosis; obsessive-compulsive, obsessive-compulsive neurosis or reaction, obsessive-compulsive neurosis, obsessive-compulsive; disorder, obsessive-compulsive; neurosis, obsessive-compulsive; reaction, reaction; obsessive-compulsive, anankastic; neurosis, Obsessive compulsive disorder, NOS, Obsessive Compulsive Neurosis, Obsessive-compulsive disorders
Dutch OCS, obsessieve-compulsieve neurose, reactie obsessief-compulsief, obsessieve-compulsieve stoornissen, obsessieve-compulsieve reactie, anankastisch; neurose, neurose; anankastisch, neurose; obsessief-compulsief, obsessief-compulsief; neurose, obsessief-compulsief; reactie, obsessief-compulsief; stoornis, reactie; obsessief-compulsief, stoornis; obsessief-compulsief, Obsessieve-compulsieve stoornis, niet gespecificeerd, obsessieve-compulsieve stoornis, Obsessieve-compulsieve stoornis [dwangstoornis], Dwangneurose, Obsessief-compulsieve stoornis, Obsessief-compulsieve stoornissen
French Psychonévrose obsessionnelle, Névrose obsessive-compulsive, Troubles obsessifs-compulsifs, Réaction obsessive-compulsive, TOC, Trouble obsessionnel compulsif, Trouble obsessionnel compulsif (TOC)
German Reaktion zwanghaft, Zwangsstoerungen, Zwangsreaktionen, OCD, Zwangsneurose, Zwangsstoerung, nicht naeher bezeichnet, Zwangsstoerung, Zwangsstörung
Italian Nevrosi ossessivo-compulsiva, Reazione ossessivo-compulsiva, Sindrome ossessivo-compulsiva, Disturbo ossessivo compulsivo, Disturbo ossessivo-compulsivo
Portuguese Neurose obsessivo-compulsiva, Perturbações obsessivo-compulsivas, Reacção obsessivo-compulsiva, Personalidade Anancástica, Neurose Obsessiva Compulsiva, Neurose Obsessivo-Compulsiva, Perturbação obsessivo-compulsiva, Transtorno Obsessivo-Compulsivo
Spanish Reacción obsesivocompulsiva, TOC, Trastornos obsesivocompulsivos, Neurosis obsesivocompulsiva, Neurosis Obsesiva Compulsiva, Personalidad Anancástica, trastorno obsesivo - compulsivo (trastorno), neurosis obsesiva - compulsiva, trastorno obsesivo - compulsivo, SAI (trastorno), [X]trastorno obsesivo - compulsivo, no especificado, trastorno obsesivo - compulsivo, SAI, trastorno obsesivo - compulsivo, [X]trastorno obsesivo - compulsivo, no especificado (trastorno), neurosis anancástica, trastorno obsesivo-compulsivo (trastorno), trastorno obsesivo-compulsivo, Trastorno obsesivo-compulsivo, Trastorno Obsesivo Compulsivo
Japanese 強迫性障害, 強迫性反応, キョウハクシンケイショウ, キョウハクセイハンノウ, キョウハクセイショウガイ, 強迫神経症, 神経症-強迫, 強迫ノイローゼ
Swedish Tvångssyndrom
Czech obsedantně kompulzivní porucha, Obsedantně-kompulzivní reakce, OCD, Obsedantně-kompulzivní poruchy, Obsedantně-kompulzivní porucha, Obsedantně-kompulzivní neuróza, Reakce obsedantně-kompulzivní, anankastická porucha osobnosti
Finnish Pakko-oireinen häiriö
Korean 강박 장애, 상세불명의 강박 장애
Polish Natręctwa, Osobowość anankastyczna, Zaburzenie obsesyjno-kompulsyjne, Nerwice natręctw, Osobowość obsesyjno-kompulsyjna, Zespół obsesyjno-kompulsyjny, Zespół natręctw
Hungarian Obsessiv-compulsiv neurosis, Obsessiv-compulsiv betegségek, Obsessiv-compulsiv reakció, OCD, Obsessiv-compulsiv zavar, Obszesszív-kompulzív válasz
Norwegian Tvangsnevrose, Obsessiv-kompulsiv forstyrrelse, Obsessiv-kompulsiv nevrose, Tvangsforstyrrelse, Anankastisk personlighet