Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 25-06: Obsessive-Compulsive Disorder & Related Disorders + Key Features Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ Clinical + Treatment Download Section PDF Listen +++ ++ 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 Graphic Jump LocationTable 25–7.Commonly used antidepressant medications (listed in alphabetical order within classes).View Table||Download (.pdf) Table 25–7. Commonly used antidepressant medications (listed in alphabetical order within classes). Medication Usual Daily Oral Dose (mg) Usual Daily Maximum Dose (mg) Sedative Effects1 Anticholinergic Effects1 Cost per Unit Cost for 30 Days of Treatment Based on Maximum Dosage2 SSRIs Citalopram (Celexa) 20 40 < 1 1 $0.14/40 mg $4.20 Escitalopram (Lexapro) 10 20 < 1 1 $0.13/20 mg $3.90 Fluoxetine (Prozac, Sarafem) 5–40 80 < 1 < 1 $4.20/20 mg $504.00 Fluvoxamine (Luvox) 100–300 300 1 < 1 $2.63/100 mg $236.70 Paroxetine (Paxil) 20–30 50 1 1 $2.64/20 mg $161.10 Sertraline (Zoloft) 50–150 200 < 1 < 1 $2.70/100 mg $162.00 SNRIs Desvenlafaxine (Pristiq) 50 100 1 < 1 $5.80/100 mg $179.00 Duloxetine (Cymbalta) 40 60 2 3 $1.92/60 mg $57.60 Levomilnacipran (Fetzima) 40 120 1 1 $16.50/80 mg $495.00 Milnacipran (Savella) 100 200 1 1 $8.02/100 mg $481.20 Venlafaxine XR (Effexor) 150–225 225 1 < 1 $0.63/75 mg $56.70 Tricyclic and Clinically Similar Compounds Amitriptyline (Elavil) 150–250 300 4 4 $2.14/150 mg $128.40 Amoxapine (Asendin) 150–200 400 2 2 $1.98/100 mg $237.60 Clomipramine (Anafranil) 100 250 3 3 $9.70/75 mg $1164.00 Desipramine (Norpramin) 100–250 300 1 1 $4.48/100 mg $403.20 Doxepin (Sinequan) 150–200 300 4 3 $1.97/100 mg $177.30 Imipramine (Tofranil) 150–200 300 3 3 $1.16/50 mg $219.60 Maprotiline (Ludiomil) 100–200 300 4 2 $2.34/75 mg $280.80 Nortriptyline (Aventyl, Pamelor) 100–150 150 2 2 $0.29/75 mg $17.40 Protriptyline (Vivactil) 15–40 60 1 3 $3.30/10 mg $594.00 Trimipramine (Surmontil) 75–200 200 4 4 $9.44/100 mg $566.40 Monoamine Oxidase Inhibitors Phenelzine (Nardil) 45–60 90 … … $0.84/15 mg $151.20 Selegiline transdermal (Emsam) 6 (skin patch) 12 … … $70.27/6 mg patch $2018.10 Tranylcypromine (Parnate) 20–30 50 … … $3.60/10 mg $540.00 Other Compounds Bupropion SR (Wellbutrin SR) 300 4003 < 1 < 1 $3.38/200 mg $202.80 Bupropion XL (Wellbutrin XL) 3004 4504 < 1 < 1 $0.55/300 mg $32.10 Mirtazapine (Remeron) 15–45 45 4 2 $2.77/30 mg $84.90 Nefazodone (Serzone) 150–600 600 3 1 $4.98/200 mg $448.20 Trazodone (Desyrel) 100–300 400 4 < 1 $0.21/100 mg $25.60 Vilazodone (Viibryd) 10–40 40 1 1 $11.43/40 mg $342,90 Vortioxetine (Brintellix) 10 20 < 1 < 1 $16.11/20 mg $483.30 11, weak effect; 4, strong effect.2Average wholesale price (AWP, for AB-rated generic when available) for quantity listed. Source: IBM Micromedex Red Book (electronic version) IBM Watson Health, Greenwood, CO, USA. Available at https://www.micromedexsolutions.com (cited April 10, 2020). AWP may not accurately represent the actual pharmacy cost because wide contractual variations exist among institutions.3200 mg twice daily.4Wellbutrin XL is a once-daily form of bupropion. Bupropion is still available as immediate release, and, if used, no single dose should exceed 150 mg.SNRIs, serotonin norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors.