Obsessive Compulsive Disorder  (OCD) is an anxiety disorder. Individuals with OCD suffer with recurrent thoughts (or images) that can be violent or disturbing and cause significant anxiety and distress. Most of these thoughts or images are intrusive. Doubt is a central theme. In an attempt to reduce distress and anxiety, individuals with OCD may perform compulsive rituals such as counting, checking, or repeating words in a very specific way. These behaviors are both time consuming and unproductive. This is in contrast to individuals with Obsessive Compulsive Personality, who are organized perfectionists who are not distressed by their thoughts and behaviors because they align with their values and beliefs (ego syntonic). One of the most debilitating aspects of OCD is the insatiable nature of the compulsive behavior that never quite reaches an acceptable level of reassurance. This leads to tortuous repetition of the compulsive acts that the individual recognizes as being irrational (ego dystonic). 

 

A persistent need for reassurance, significant doubt, and catastrophic thinking are often prominent. Individuals with OCD may exhibit irrational thinking, called “magical thinking,” whereby things need to be performed or thought about in a specific way for fear that something unrelated and bad will happen. Example: “If I step on the crack, something bad will happen to my dog.” All of the Obsessive Compulsive and related disorders likely involve similar neurological substrates supported by overlap in symptoms and behavior patterns, neuroimaging studies and the high comorbidity in individuals with OCD.

 

Below is additional information about OCD and related disorders.

 

What is an obsession?

  • A recurrent and intrusive thought, feeling, idea, or sensation
  • An obsession is a mental event

 

What is a compulsion?

  • A compulsion is a conscious, standardized, recurrent behavior, such as counting, checking, or avoiding
  • A compulsion is a behavior
  • Compulsive acts are carried out in an attempt to relieve the anxiety associated with the obsession
  • Sometimes it works, sometimes it doesn’t work
  • Resisting a compulsive act increases anxiety

 

NOTE: In OCD, obsessions and compulsions are ego-dystonic (i.e., patient is disturbed by them)

 

EPIDEMIOLOGY

  • 2-3% lifetime prevalence in general population
  • 4th most common outpatient psychiatric diagnosis
  • 10% of outpatients in psychiatric clinics
  • Epidemiological studies in Europe, Asia, and Africa have confirmed these rates across cultural boundaries
  • Estimated that 40% of patients do not achieve a clinical response from SSRIs1
  • Females slightly more than males in adulthood
  • Boys 2-3 times more affected than girls in childhood
  • Mean onset 19.5 years old, rarely onset after 35
  • Males earlier age of onset than females
  • Mean age of onset: 20 years
  • Boys: 19 years (mean)
  • Girls: 22 years (mean)
  • ~60% have onset of symptoms before 25yo
  • <15% have onset of symptoms after 35yo
  • Single persons > Married persons

 

POSSIBLE RISK FACTORS

  • Genetic factors (monozygotic concordance rate of 0.57)
  • Environmental factors (trauma, abuse, perinatal, infectious)
  • Psychosocial and developmental factors
  • Controversy and debate continues about childhood streptococcal infections increasing the risk of OCD (PANDAS, see below) 

 

ASSOCIATED | COMORBID CONDITIONS

90% of patients with OCD have psychiatric comorbidities

  • 76% Anxiety disorders
  • 63% Mood disorders
  • 56% Impulse control disorders
  • 39% Substance use disorders
  • 30% of patients with OCD have accompanying tic disorder

Comorbidities reported in up to 50% pediatric patients

  • ADHD
  • Separation anxiety disorder
  • Specific phobias
  • Anxiety disorders
  • Tourette disorder

COMMON SYMPTOM PATTERNS IN OCD:

 

NEUROBIOLOGY

  • Neurotransmitters implicated in OCD pathophysiology include:
    • Serotonin 
    • Glutamate
    • Dopamine
  • Cortico-striato-thalamo-cortical circuit (CSTC) is involved
    • Hyperactivity in orbitofrontal cortex (OFC), anterior cingulate cortex (ACC), and caudate nucleus
    • Glutamate is the primary excitatory neurotransmitter in CSTC
    • Increased Glutamate levels in CSF, caudate, and OFC in OCD patients

 

PATHOPHYSIOLOGY 

  • Remains unclear
  • Most likely heterogeneous
    1. Biological Factors
      • Genetic polymorphisms
      • Autoimmune processes
      • Infection
      • Inflammatory and oxidative stress
      • Abnormalities of neurotransmission
    2. Behavioral Factors
    3. Psychosocial Factors

 

TREATMENT OF OBSESSIVE COMPULSIVE DISORDER (OCD)

 

Pharmacotherapy + Cognitive Behavioral Therapy

  • Pharmacotherapy
    • Selective Serotonin Reuptake Inhibitors (SSRIs)
      • Fluoxetine
      • Fluvoxamine
      • Paroxetine
      • Sertraline
      • Citalopram
      • Individuals with OCD typically require higher doses of SSRIs compared to individuals with depression
    • Clomipramine
      • TCA most selective for serotonin reuptake
  • Other therapies
      • ECT
      • Surgery (Psychosurgery)
      • Deep Brain Stimulation
      • Glutamatergic agents
  • Psychotherapy
    • Cognitive Behavioral Therapy (Exposure-Response Prevention)

 

Problems with current treatment

  • Only 20-30% of patients have significant improvement
  • 40-50% of patients have moderate improvement
  • 20-40% of patients do not respond or get worse!
  • Higher doses of SSRIs required to alleviate symptoms in OCD
    • Associated adverse effects lead to patient non-compliance
 
 

American Psychiatric Association (APA) Treatment Algorithm for OCD:

Body Dysmorphic Disorder

  • Preoccupation with an imagined defect in appearance that causes clinically significant distress
  • If a slight physical anomaly is actually present, the person’s concern with the anomaly is excessive and bothersome
  • Often accompanied by compulsions:
    • Mirror checking
    • Excessive grooming
    • Comparing appearance to others
    • Men: preoccupation with muscle mass and “bulking up”
  • Women more commonly affected than men
  • Age of onset is typically between 15 years old and 30 years old
  • High comorbidity with Depression, Anxiety, Psychosis
  • Patients with Body dysmorphic Disorder are more commonly seen in
    • Plastic Surgery Clinics
    • Dermatology Clinics
    • Internist/Primary Care Clinics

TREATMENT OPTIONS

    • Fluoxetine
    • Clomipramine
    • TCAs
    • MAOIs
    • Psychotherapy 
    • Surgical/procedural interventions rarely benefit these patients

Hoarding Disorder 

  • Acquiring and not discarding unimportant possessions of little or no value
    • Obsessive fear of losing important items that may be needed in the future
    • Distorted beliefs about the importance of possessions
    • Excessive emotional attachment to possessions
  • The hoarding behavior leads to
    • Cluttering
    • Unsanitary living conditions
    • Health risks (falls, animal born diseases)
    • Fire risks
  • Commonly seen in single persons with social anxiety or dependent personality traits
  • Seen in dementia, Cerebrovascular disease, and schizophrenia
  • Begins in early adolescence, often persists over lifetime
  • Most lack insight into their illness (ego-syntonic)

 

Treatment

  • Medications aren’t effective
  • Cognitive behavioral interventions are most effective

Hair-Pulling Disorder (Trichotillomania)

  • Trichotillomania was coined by a French dermatologist Francois Hallopeau in 1889
  • Chronic disorder characterized by repetitive hair pulling
  • Results in hair loss
  • Increased tension prior to hair pulling and relief of tension or gratification after the hair pulling
  • 0.6-3.4% lifetime prevalence
  • Women:Men = 10:1
  • 35%-40% chew or swallow the hair
    • Bezoars – hairballs in the GI tract which can cause obstruction

 

Pharmacological Treatments

  • SSRIs
  • SNRIs
  • Lithium
  • Pimozide
  • Naltrexone
  • Buspirone
  • Clonazepam
  • Trazodone

 

Behavioral Treatments

  • Biofeedback
  • Insight-oriented psychotherapy
  • Hypnotherapy

Excoriation (Skin-Picking) Disorder

  • Compulsive and repetitive picking of the skin
  • 1-5% lifetime prevalence
  • Women are affected more than Men
  • Rule out stimulant induced excoriation
  • Face (most common)
    • Also: Legs, Arms, Torso, Hands, Cuticles, Fingers, Scalp
  • Embarrassment leads to avoidance and social withdrawal
  • 12% of skin-picking patients have attempted suicide

Pharmacological Treatments

  • Fluoxetine
  • Naltrexone
  • Lamotrigine

 

Behavioral Treatments

  • Cognitive Behavioral Therapy
  • Habit Reversal

Olfactory Reference Syndrome

  • A false belief by the patient that he or she has a foul body odor
  • The odor is not perceived by others
  • Leads to excessive showering, changing clothes
  • May rise to level of somatic delusion
    • (Delusional Disorder)
  • Rule out “organic” illnesses
    • Temporal lobe epilepsy
    • Pituitary tumors
    • Sinusitis

 

Treatment

  • Little evidence 

Common Medications/Drugs that may cause OCD-like Symptoms:

 

 

  1. Psychostimulants 
    • Amphetamines
    • Methylphenidate (rare)
    • Methamphetamine
    • Cocaine
    • Nicotine
  2. MDMA (Ecstasy)
  3. PCP
  4. Synthetic Cathinones (“Bath Salts”)
  5. Dopamine agonists
    • L-dopa
    • Ropinirole
    • Pramipaxole
    • Aripiprazole (Abilify)
    • Bromocriptine
    • Amantadine 
  6. Bupropion

MEDICAL/NEUROLOGICAL CONDITIONS WITH OCD SYMPTOMS:

  1. Huntington’s Disease
  2. Wilson’s Disease
  3. Seizures
  4. Surgery-Related
  5. Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) (See Below)

References

  1. Afshar, Hamid et al. “N-Acetylcysteine Add-On Treatment in Refractory Obsessive-Compulsive Disorder.” Journal of Clinical Psychopharmacology (2012): 797-803. Print.
  2. Pauls, David L., Amitai Abramovitch, Scott L. Rauch, and Daniel A. Geller. “Obsessive–compulsive Disorder: An Integrative Genetic and Neurobiological Perspective.” Nature Reviews Neuroscience Nat Rev Neurosci (2014): 410-24. Print.
  3. Oliver, Georgina, Olivia Dean, David Camfield, Scott Blair-West, Chee Ng, Michael Berk, and Jerome Sarris. “N-Acetyl Cysteine in the Treatment of Obsessive Compulsive and Related Disorders: A Systematic Review.” Clin Psychopharmacol Neurosci Clinical Psychopharmacology and Neuroscience (2015): 12-24. Print.
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  9. Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
  10. Mendez, M. F., Clark, D. L., Boutros, N. N. (2018). The Brain and Behavior: An Introduction to Behavioral Neuroanatomy. United States: Cambridge University Press.
  11. Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
  12. Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  13. Sixth Edition. Edited by Dale Purves, George J. Augustine, David Fitzpatrick, William C. Hall, Anthony-Samuel LaMantia, Richard D. Mooney, Michael L. Platt, and Leonard E. White.
  14. Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
  15. Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 6th Ed.

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