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Key Features

  • The irrational idea or the impulse persistently intrudes into awareness

  • Obsessions (recurring anxiety-provoking thoughts such as fears of exposure to germs) and compulsions (repetitive actions such as washing the hands many times)

    • Are recognized by the individual as absurd and are resisted

    • However, anxiety is alleviated only by ritualistic performance of the action or by deliberate contemplation of the intruding idea or emotion

  • There is a high comorbidity with major depression

  • The prevalence in the general population is 2–3%

  • Male to female ratios are similar, with the highest rates occurring in the young, divorced, separated, and unemployed

Clinical Findings

  • Chronic disorder with a waxing and waning course

  • Many patients do not volunteer the symptoms and must be asked about them

  • There is an overlapping of OCD with other behaviors ("OCD spectrum"), including

    • Tics

    • Trichotillomania (hair pulling)

    • Excoriation (skin picking) disorder

    • Hoarding

    • Body dysmorphic disorder

  • Neurologic abnormalities of fine motor coordination and involuntary movements are common

  • Under extreme stress, these patients sometimes exhibit paranoid and delusional behaviors, often associated with depression, and can mimic schizophrenia


  • Clinical


  • Selective serotonin reuptake inhibitors (SSRIs) and clomipramine (Table 25–7)

    • Fluoxetine (up to 60–80 mg orally daily)

    • Sertraline, paroxetine, and fluvoxamine are used with comparable efficacy, each with its own side-effect profile

  • Low-dose clomipramine

    • May be an effective adjunct to an SSRI

    • Caution should be used when prescribing multiple serotonergic agents given the risk of serotonin syndrome

    • Plasma levels of clomipramine and its metabolite should be

      • Checked 2–3 weeks after a dose of 50 mg/day has been reached

      • Kept under 500 ng/mL to avoid toxicity

  • Antipsychotics and topiramate may be helpful as adjuncts to the SSRIs in treatment-resistant cases

  • Ketamine and esketamine

    • Small randomized trials have suggested up to 50% of OCD patients get some relief of their OCD symptoms with 1 week of a ketamine infusion

    • However, the effects of ketamine are short-lived

    • Further studies are required to confirm efficacy and optimal dosing

  • Psychosurgery (eg, cingulotomy) has a limited place in selected cases of severe unremitting OCD

  • Deep brain stimulation is FDA approved on a humanitarian device exemption basis for patients with refractory OCD

  • Behavioral

    • Systematic desensitization involves gradually exposing the OCD spectrum patient to situations that the patient fears

    • Thought stopping is a technique used to help quell obsessive thoughts

  • Patients may respond to cognitive-behavioral therapy in which the patient learns to identify maladaptive cognitions associated with obsessive thoughts and to challenge them

  • Transcranial magnetic stimulation is FDA-approved for OCD

Table 25–7.Commonly used antidepressant medications (listed in alphabetical order within classes).

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