++
++
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
++
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
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
++
++
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
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
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
++