Obsessive-Compulsive Disorder (OCD) & Related Disorders

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

Diagnosis

• Clinical

Treatment

• 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