Obsessive-Compulsive Disorder (OCD) & Related Disorders

KEY FEATURES

• 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

• The prevalence in the general population is 2–3%

• Major depression will develop in two-thirds of patients with OCD

• 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, that can mimic schizophrenia

DIAGNOSIS

• Clinical

TREATMENT

Medications

• Selective serotonin reuptake inhibitors (SSRIs) and clomipramine (Table 27–6)

  • Fluoxetine in doses higher than those used in depression (up to 60–80 mg orally daily)

  • Sertraline, paroxetine, and fluvoxamine are used with comparable efficacy, each with its own side-effect profile

  • Usually requires a longer time to response than depression (up to 12 weeks)

  • Clomipramine

    • Use in doses equivalent to those used for depression

    • Check plasma levels 2–3 weeks after achieving a dose of 50 mg/d; keep levels < 500 ng/mL

• Medications that may be helpful as adjuncts to SSRIs in treatment-resistant cases include

  • Antipsychotics

  • Topiramate

  • Memantine

  • Riluzole

  • N-acetylcysteine

  • Lamotrigine

  • Ondansetron

  • Anti-inflammatory medication (minocycline, celecoxib)

• Studies have shown mixed evidence for one-time infusions of ketamine and esketamine; further studies are required to confirm efficacy and optimal dosing

Psychological

• Patients may respond to cognitive-behavioral therapy (CBT); the patient learns to identify maladaptive cognitions associated with obsessive thoughts and to challenge them

• Exposure and response prevention therapy

  • A form of CBT

  • Patients work through 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

  • CBT or exposure and response prevention therapy combined with medications may be more effective than a single intervention alone

Social

• It is important to set appropriate expectations by educating the patient and family about the course of illness and treatment options

• Severe OCD is commonly associated with vocational disability

  • Patient may need a ...