//fpnotebook.com/
Obsessive Compulsive Disorder
Aka: Obsessive Compulsive Disorder, Obsessive-Compulsive Disorder, OCD
- See Also
- Anxiety Disorder
- Anxiety Secondary Cause
- Anxiety Symptoms
- Generalized Anxiety Disorder
- Body Dysmorphic Disorder
- Panic Disorder
- Social Anxiety Disorder (Social Phobia)
- Acute Stress Disorder
- Post-Traumatic Stress Disorder
- Excessive Worry
- Anxiety Non-pharmacologic Management
- Anxiety Pharmacologic Management
- 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)
- Females have an increased lifetime risk of OCD (typically as teens)
- 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, 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
- Contamination (50%)
- Worry about infection from others (e.g. shaking hands)
- Associated compulsions: Hand Washing, cleaning
- Pathologic doubt (42%)
- Persistent worrying about doing things incorrectly and negatively impacting others
- Examples: An unlocked door, or oven left on
- Associated compulsions: Excessive checking, Performing tasks in a strict order
- Somatic (33%)
- Need for symmetry or Order (32%)
- Needs to perform tasks in a balanced, exact manner
- Associated compulsions: ordering, arranging
- Aggressive (31%)
- Intrusive images of hurting another person
- Experiences recurrent violent images
- Associated compulsions: Needs reassurance of being a good person
- Sexual (24%)
- Intrusive pornographic images (sexually deviant, pedophilia)
- Acting in a sexually inappropriate way toward others
- Associated compulsions: Follow mental rituals to counter intrusive thoughts
- Religious
- Worry about unknowingly commiting a sin (immoral, eternal damnation)
- Associated compulsions: Asking for forgiveness, praying
- Superstition
- Afraid of bad numbers or colors
- Associated compulsions: Counting
- Symptoms: Compulsions
- Repetitive behaviors or mental acts as a response to Obsessions
- Checking (61%)
- Washing (50%)
- Counting (36%)
- Need to ask or confess (34%)
- Symmetry and precision (28%)
- Hoarding trash or other items (18%)
- Praying
- Repeating words silently
- Compulsions are intended to reduce distress
- Patient feels compelled to respond to an Obsession
- Patient may have a set of rigidly applied rules
- Not connected realistically to preventing Obsession
- Excessive measures
- Mental rituals may be present without observable compulsive behaviors
- History: Sample Questions
- Do certain thoughts keep coming into your head?
- Is this despite your trying to keep the thoughts out?
- Do the thoughts make sense or do they seem absurd?
- What do you do to try to counteract these thoughts?
- Do you feel a need to put items in a certain order?
- Are you very upset by mess?
- Do you feel a need to do something over and over again (e.g. washing, cleaning, checking)?
- Is this despite your not wanting to do these things?
- 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
- Obsessions or Compulsions as described above
- Insight that Obsessions or compulsions are excessive
- Impaired function
- Marked distress
- Time consuming (more than an hour per day)
- Interfere with patient's normal routine
- Interfere with occupation, education, relationships
- Not limited to an Axis I Diagnosis (examples follow)
- Not better explained by Generalized Anxiety Disorder with Excessive Worry
- Not due to Eating Disorder and its related preoccupation with food
- Not due to Body Dysmorphic Disorder and its preoccupation with appearance
- Not due to specific compulsion disorders (hoarding disorder, Trichotillomania)
- Obsessions or Compulsions not due to secondary cause
- Not due to Substance Abuse (or to its related preoccupation with illicit substances)
- Not due to underlying medical condition
- Additional specifications
- Tic-related
- Past or current Tic Disorder
- Insight
- Good or fair insight
- Patient recognizes their OCD beliefs are unlikely to be true
- Poor insight
- Patient thinks their OCD beliefs are probably true
- Absent insight with Delusions
- Patient is convinced their OCD beliefs are true
- References
- (2013) DSM 5, APA
- http://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5
- Tools: Self-Assessment
- Diagnosis
- Obsessive-Compulsive Inventory-Revised
- http://www.caleblack.com/psy5960_files/OCI-R.pdf
- Florida Obsessive-Compulsive Inventory
- http://www.ocdscales.org/index.php?page=scales
- Monitoring for severity
- Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
- http://www.stlocd.org/handouts/YBOC-Symptom-Checklist.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
- Behaviors centered around organization, perfectionism and control
- Completely separate diagnosis from OCD without intrusive thoughts or compulsive, repetitive behaviors
- Associated Conditions
- OCD Spectrum Disorders
- Body Dysmorphic Disorder
- Hypochondriasis
- Eating Disorders
- Trichotillomania
- Hair Loss from recurrently pulling out hairs
- Typical onset at Puberty and more common in females
- Skin-picking disorder
- Recurrent skin picking with secondary open lesions
- Typical onset at Puberty and more common in females
- Comorbid axis I disorders (common)
- Major Depression (>66% lifetime comorbid Prevalence)
- Suicidality (Suicidal Ideation >50%)
- Panic Disorder
- Social Phobia
- Substance Abuse
- Types: Subtypes of Obsessive Compulsive Disorder
- Early-Onset
- Onset before Puberty (typically <10 years old)
- Severe, frequent compulsions
- Often refractory to first-line treatments
- Associated with Family History of early onset OCD
- Predominately males
- Hoarding
- Difficulty parting or discarding possessions, accumulating items that overflow their space
- Lower insight into own condition
- Symptoms are severe and often refractory to treatment, and increase in severity over time
- Comorbid Anxiety Disorder and Major Depression
- Onset age 11-15 years old
- Just-Right
- Perfectionists need to repeat actions until feels right
- Primary Obsessional (25%)
- Often obsess about sex, Violence and religion without compulsions
- Scrupulosity
- Religious or moral Obsessions and compulsions focused around whether they have committed sin
- Tic-Related
- Associated with early onset OCD, OCD-Spectrum Disorders and Tourette Syndrome
- May require combination therapy with SSRI and Atypical Antipsychotics
- References
- Fenske (2009) Am Fam Physician 80(3): 239-45 [PubMed]
- McKay (2004) Clin Psychol Rev 24(3): 283-313 [PubMed]
- Management: General
- Evaluate for Suicide Risk at each visit
- Overall goal of treatment
- Spending <1 hour daily on obsessive-compulsive behaviors
- Striving for minimal interference with daily tasks
- Management: Cognitive Behavioral Therapy
- General
- Efficacy: 80-90% effective
- Mainstay of OCD treatment
- Exposure and Desensitization over 13-20 week period (1-2 hours per session)
- Patients taught to confront fearful situations that lead to Obsessions, compulsions
- Examples: Touch objects in public bathroom
- Increasingly expose patient to avoided stimulus
- Response prevention
- Prevented from performing associated rituals
- Thought stopping
- Management: Medications
- General
- Continue therapy if effective for at least 1 to 2 years (often longterm)
- Gradually taper medications over months if patient wishes to stop pharmacologic management
- Higher doses are typically required for OCD
- Gradually increase doses over 4-6 weeks and continue for at least a total of 8-12 weeks
- Trial a medication at maximal dose for 4-6 weeks before determining a medication failure
- Monitor for Serotonin Syndrome and other adverse effects
- First-Line: Selective Serotonin Reuptake Inhibitors (SSRI)
- Agents FDA approved for OCD
- Fluoxetine (Prozac) 40 to 60 mg (start: 20 mg, max: 80 mg) per day
- Fluvoxamine (Luvox) 200 mg (start: 50 mg, max: 300 mg) per day
- Paroxetine (Paxil) 40 to 60 mg (start: 20 mg, max: 60 mg) per day
- Sertraline (Zoloft) 200 mg (start: 50 mg, max: 200 mg) per day
- Other agents found to be effective for OCD
- Citalopram (Celexa) 20 mg (max: 40 mg, risk of QT Prolongation) orally daily
- Escitalopram (Lexapro) 20 mg (start: 10 mg, max: 40 mg) orally daily
- Second-Line Agents
- Venlafaxine (Effexor) 75 to 225 mg orally daily
- Tricyclic Antidepressants
- Most effective agents
- Limited to refractory cases (alone or in combination with SSRI)
- Risk of intentional Overdose
- Risk of Anticholinergic adverse effects
- Clomipramine (Anafranil) 150 to 250 mg/day
- Start at 25 mg orally daily and gradually titrate the dose
- Third-Line Agents: Atypical Antipsychotics (typically in combination with a SSRI or SNRI)
- Risperidone (Risperdal)
- Quetiapine (Seroquel)
- Olanzapine (Zyprexa)
- Precautions
- Diagnostic delay is common, averaging 11 years between onset and formal diagnosis
- 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
- Obsessive-Compulsive Foundation, Inc
- Address: 90 Depot St. PO Box 70, Milford, CT 06460
- Phone: (203) 878-5669
- References
- APA (1994) DSM IV, APA, p. 417-23
- 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]