What is Obsessive Compulsive Disorder (OCD)?

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 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). 

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.

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 will happen.

Example: “If I don’t pet my dog three times every morning, something bad will happen.” 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.

Obsessive Compulsive and Related Disorders

Obsessive-Compulsive Disorder

What is an obsession?

An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. Obsessions are mental events. This can include worries about contamination (germs), health problems (e.g., worrying about having cancer or some other devastating disease without any clinical evidence that it exists), sexual thoughts (e.g., worrying about being a pedophile, sex offender, or fear of molesting others when there is no evidence or history to support it), perfectionism or “just right” obsessions, moral OCD (e.g., worrying about being an immoral or horrible person), among others. 

What is a compulsion?

A compulsion is a conscious, standardized, recurrent behavior, such as counting, checking, or avoiding. Compulsions are mental and/or behavioral events. 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. Compulsions include checking to make sure the door is locked numerous times despite knowing it is locked, counting, banging or hitting yourself, skin picking, tongue biting, repeating a sentence, saying something out loud, constantly seeking reassurance (e.g., asking friends, visiting numerous doctors), among others. 

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

A Disorder of Pathological Doubt

OCD can be thought of as a disorder of doubt. There are numerous symptom “clusters” that can occur. 

Epidemiology

  • OCD is the 4th most common outpatient psychiatric diagnosis with approximately 10% of patients having the diagnosis in psychiatric clinics
  • Epidemiological studies in Europe, Asia, and Africa have confirmed these rates across cultural boundaries
  • Females are slightly more affected than males in adulthood
  • Boys are 2-3 times more affected than girls in childhood
  • Mean age of onset is approximately 19.5 years old (Boys, 19yo; Girls 22yo)
  • OCD rarely presents after age 35
  • Males typically have an earlier age of onset than females

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 Conditions

90% of patients with OCD suffer from other disorders:

Anxiety disorders

Mood disorders

Impulse control disorders

Substance use disorders

Tic disorder

Associated disorders reported in up to 50% of children with OCD:

ADHD
Separation anxiety disorder
Specific phobias
Anxiety disorders
Tourette disorder
Common Symptom Patterns in OCD

Neurobiology of OCD

Treatment of OCD

Current evidence suggests the combination of medication and therapy (Cognitive Behavioral Therapy) is the most effective approach to treating OCD

Medications

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Tricyclic Antidepressants

Antipsychotics

Buprenorphine (experimental)

Naltrexone (experimental)

Ketamine (experimental)

Supplements (N-Acetylcysteine)

Therapy

Cognitive Behavioral Therapy

Exposure Response Prevention Therapy

Acceptance Commitment Therapy

Mindfulness Based Stress Reduction Therapy

Other Options 

Transcranial Magnetic Stimulation (TMS)

Electroconvulsive Therapy (ECT)

Deep Brain Stimulation (DBS)

Problems with current treatment

  • 20-30% of patients have significant improvement in symptoms with medication alone (this is increased when combined with therapy)
  • 40-50% of patients have moderate improvement
  • Higher doses of SSRIs may be required to alleviate symptoms in OCD

American Psychiatric Association (APA) Treatment Algorithm for OCD:

Body Dysmorphic Disorder (BDD)

Body Dysmorphic Disorder is a type of OCD-related disorder whereby individuals are preoccupied with an imagined defect in appearance which causes clinically significant distress. If a slight physical anomaly is actually present, the individual’s concern with the anomaly is excessive and bothersome. BDD is often accompanied by compulsions such as Mirror checking, Excessive grooming, and Comparing appearance to others. Women are more commonly affected than men and the age of onset is typically between 15 years old and 30 years old. Individuals with BDD often suffer with mood disorders, anxiety disorders, and psychotic disorders. Individuals with BDD are more commonly seen in Plastic Surgery Clinics, Dermatology Clinics, and/or Primary Care Clinics.

Treatment Options for BDD

Medications

  • Fluoxetine
  • Clomipramine
  • TCAs
  • MAOIs

Psychotherapy 

Surgical/procedural interventions rarely benefit these patients

Hoarding Disorder 

Hoarding Disorder is another type of OCD-related disorder whereby individuals acquire and “hoard” unimportant possessions with little or no value due to an obsessive fear that may be needed in the future. This is a disorder of distorted beliefs about the importance of possessions. There is often excessive emotional attachment to possessions. The hoarding behavior leads to Cluttering, Unsanitary living conditions, Health risks (falls, animal born diseases), and Fire risks. Hoarding Disorder is commonly diagnosed in single persons with social anxiety or dependent personality traits. However, Hoarding Disorder can occur as a manifestation of other disorders/diseases such as dementia, Cerebrovascular disease, and schizophrenia. Unfortunately, most individuals with Hoarding Disorder not present to mental health clinics because most lack insight into their illness (ego-syntonic).

Treatment Options

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 and is a chronic disorder characterized by repetitive hair pulling which results in hair loss. There is increased tension prior to hair pulling and relief of tension or gratification after the hair pulling. Women are affected more than men (10:1). Roughly 35%-40%  of individuals with Trichotillomania chew or swallow their hair. Swallowing hair increases the risk of Bezoars (hairballs in the GI tract) which can cause obstruction.

Treatment Options

Medication Options

SSRIs
SNRIs
Lithium
Pimozide
Naltrexone
Buspirone
Clonazepam
Trazodone

Therapy Options

Exposure Response Prevention

Cognitive Behavioral Therapy

Insight-oriented psychotherapy

Hypnotherapy

Biofeedback

 

Excoriation (Skin-Picking) Disorder

Compulsive and repetitive picking of the skin. 1-5% lifetime prevalence. Women are affected more than Men. It is important to rule out stimulant-induced excoriation. Skin picking is most often seen on the Face but also Legs, Arms, Torso, Hands, Cuticles, Fingers, Scalp. Embarrassment leads to avoidance and social withdrawal. 12% of skin-picking patients have attempted suicide

Treatment Options

Medications

Fluoxetine
Naltrexone
Lamotrigine

Therapy Options

Exposure Response Prevention

Cognitive Behavioral Therapy

Insight-oriented psychotherapy

Hypnotherapy

Biofeedback

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). It is important to rule out “organic” illnesses such as Temporal lobe epilepsy, Pituitary tumors, and Sinusitis. Currently there is little evidence for treatment. 

Medication or Drug-Induced OCD-like Disorder

The following medications/drugs have been associated with worsening or causing obsessive compulsive symptoms:

Psychostimulants
Amphetamines
Methylphenidate (rare)
Methamphetamine
Cocaine
Nicotine
MDMA (Ecstasy)
PCP
Synthetic Cathinones (“Bath Salts”)
Dopamine agonists
L-dopa
Ropinirole
Pramipaxole
Aripiprazole (Abilify)
Bromocriptine
Amantadine 
Bupropion

Medical Problems that often present with OCD-like Symptoms

Huntington’s Disease
Wilson’s Disease
Seizures
Surgery-Related
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS)

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS)

Introduction to OCD (Video)

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.
  4. “Obsessive Compulsive Disorder.” Dynamed.
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  7. Stahl’s Essential Psychopharmacology, 4th Edition. Cambridge University Press. 2013
  8. Iversen, L. L., Iversen, S. D., Bloom, F. E., & Roth, R. H. (2009). Introduction to neuropsychopharmacology. Oxford: Oxford University Press.
  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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