Obsessive-Compulsive Disorder (OCD) & Related Disorders

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

• 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