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An irrational idea or impulse repeatedly and unwantedly intrudes into awareness
Obsessions (recurring distressing thoughts such as fears of exposure to germs) and compulsions (repetitive actions such as washing one's hands many times)
Are recognized by the individual as unwanted or unwarranted and are resisted
However, anxiety is alleviated only by ritualistic performance of the compulsion or by deliberate contemplation of the intruding idea or emotion
Some patients only experience obsessions, while some experience both obsessions and compulsions
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
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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, that can mimic schizophrenia
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Selective serotonin reuptake inhibitors (SSRIs) and clomipramine (Table 25–6)
Fluoxetine (up to 60–80 mg orally daily)
Sertraline, paroxetine, and fluvoxamine are used with comparable efficacy, each with its own side-effect profile
Medications that may be helpful as adjuncts to SSRIs in treatment-resistant cases include
Antipsychotics
Topiramate
Memantine
Riluzole
Transcranial magnetic stimulation is FDA-approved for OCD
Deep brain stimulation is FDA approved on a humanitarian device exemption basis for patients with refractory OCD
Psychosurgery (eg, cingulotomy) has a limited place in selected cases of severe unremitting OCD
Patients may respond to cognitive-behavioral therapy (CBT) in which the patient learns to identify maladaptive cognitions associated with obsessive thoughts and to challenge them
Exposure and response prevention (ERP) therapy
A form of CBT
Patients work through a list of their obsessions and compulsions with their therapist, first exposing themselves to the trigger, then working to prevent the habitual thought or compulsion that accompanies it
There is evidence that both CBT or ERP combined with medications can be more effective than a single intervention alone
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