OBSESSIVE-COMPULSIVE DISORDER (OCD)
What is an obsession?
An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. Obsessions are mental events.
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
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
Approximately 40% of patients do not achieve a clinical response from SSRIs
Females are slightly more 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/Co-morbid Conditions
90% of patients with OCD have psychiatric comorbidities including
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 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
Medication Options
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline
- Citalopram
- Clomipramine TCA most selective for serotonin reuptake
- Glutamatergic Agents (Ketamine, NAC)
- Opioid Medications (Naltrexone, Buprenorphine)
Other Options
- ECT
- Surgery (Psychosurgery)
- Deep Brain Stimulation
Psychotherapy Options
- Cognitive Behavioral Therapy
- Exposure-Response Prevention Therapy (Type of CBT)
- Mindfulness-Based Therapies
Problems with current treatment
- Only 20-30% of patients have significant improvement in symptoms
- 40-50% of patients have moderate improvement
- 20-40% of patients do not respond or get worse!
- Higher doses of SSRIs may be required to alleviate symptoms in OCD (but side effects become problematic)
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
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)

References
- Afshar, Hamid et al. “N-Acetylcysteine Add-On Treatment in Refractory Obsessive-Compulsive Disorder.” Journal of Clinical Psychopharmacology (2012): 797-803. Print.
- 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.
- 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.
- “Obsessive Compulsive Disorder.” Dynamed.
- Sadock, Benjamin J., and Harold I. Kaplan. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/clinical Psychiatry. 10th ed. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print.
- Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association, 2013. Print.
- Stahl’s Essential Psychopharmacology, 4th Edition. Cambridge University Press. 2013