Obsessive Compulsive Disorder

1. See Also
   1. Anxiety Disorder
   2. Anxiety Secondary Cause
   3. Anxiety Symptoms
   4. Generalized Anxiety Disorder
   5. Body Dysmorphic Disorder
   6. Panic Disorder
   7. Social Anxiety Disorder (Social Phobia)
   8. Acute Stress Disorder
   9. Post-Traumatic Stress Disorder
   10. Excessive Worry
   11. Anxiety Non-pharmacologic Management
   12. Anxiety Pharmacologic Management
2. 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)
3. 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
4. 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)
5. 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
6. 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
7. 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?
8. 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
9. 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
10. 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
11. 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
12. 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
13. 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]
14. 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
15. 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
16. 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)
17. 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]
18. 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
19. Resources
    1. Obsessive-Compulsive Foundation, Inc
       1. Address: 90 Depot St. PO Box 70, Milford, CT 06460
       2. Phone: (203) 878-5669
20. References
    1. APA (1994) DSM IV, APA, p. 417-23
    2. Black (1997) Resident Staff Physician 43(3):64-76
    3. Bagheri (1999) Am Fam Physician 59(8):2263-72 [PubMed]
    4. Eddy (1998) Am Fam Physician 57(7):1623-8 [PubMed]
    5. Rasmussen (1992) Psychiatr Clin North Am 15:743-58 [PubMed]
    6. Fenske (2015) Am Fam Physician 92(10): 896-903 [PubMed]
    7. Fenske (2009) Am Fam Physician 80(3): 239-45 [PubMed]