The essential feature is recurrent obsessional thoughts or compulsive acts. Obsessional thoughts are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist. Anxiety is almost invariably present. If compulsive acts are resisted the anxiety gets worse.
An individual diagnosed with obsessive-compulsive disorder needs to meet all of the following criteria:
Presence of obsessions, compulsions, or both:
Obsessions are defined by both of the following:
Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety and distress.
The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by both of the following:
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silentl) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note. Young children may not bbe able to articulate the aims of these behaviors or mental acts.
The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause significant distress or impairment in social, occupational, or other important areas of functioning.
The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania (hair-pulling disorder); skin picking, as in excoriation [skin picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupations with substances or gambling, as in substance-related and addictive disorders; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Obsessive-compulsive disorder (OCD) is often a severe anxiety disorder that affects approximately 2% of the population. This disorder is characterized by: (a) obsessions (unwanted, disturbing, and intrusive thoughts, images, or impulses that are generally seen by the patient as excessive, irrational, and ego-alien), and (b) compulsions (repetitive behaviors and mental acts that neutralize obsessions and reduce emotional distress). These obsessions and/or compulsions are time consuming (take more than 1 hour per day), or cause marked distress or life impairment.
First-line treatments for this disorder are: (1) cognitive behavioral therapy (exposure and response prevention), and/or (2) SSRI/SNRI antidepressant medication. All first-line treatments are equally effective. Second-line treatments are: (1) adding an atypical antipsychotic, and (2) possibly repetitive transcranial magnetic stimulation. The average amount of time that lapses between onset of symptoms and appropriate treatment is 17 years. Up to 40% to 60% of patients do not have a satisfactory outcome.
Vitamins and dietary supplements are ineffective for this disorder.
Compulsive, repetitive behavior is seen throughout nature (e.g., birds have repetitive songs and mating rituals). Animals can be quickly taught "superstitious behavior" (e.g., only giving a bird food when it lifts one wing results in the bird learning to walk around with one wing always elevated). Humans also have a high propensity to acquire unwanted, repetitive, "superstitious" thoughts (obsessions) and behaviors (compulsions). Individuals with obsessions try desperately to suppress them by performing a compulsion (e.g., contamination obsessions lead to hand-washing compulsions). The obsession is unwanted and unpleasant, and the compulsion is performed to reduce the unpleasantness associated with the obsession. Compulsions are not done for pleasure. Some individuals with this disorder compulsively hoard objects, and fill their homes with objects they can not discard. When confronted with situations that trigger obsessions and compulsions, individuals with this disorder experience marked anxiety, disgust, or even panic attacks. Situations that trigger obsessions and compulsions are avoided (e.g., restaurants, public restrooms, public transportation, social gatherings).
There is a striking similarity in the presentation of OCD throughout the world. It usually involves cleaning, symmetry (putting everything in its proper place), hoarding, taboo thoughts, or fear of harm. OCD can cause severe social and occupational impairment.
The majority (76%) of individuals with this disorder had an anxiety disorder (e.g., panic disorder, social anxiety disorder, generalized anxiety disorder, specific phobia), and 63% had a depressive or bipolar disorder. Up to one-third of individuals with obsessive-compulsive disorder (OCD) also had obsessive-compulsive personality disorder. Surprisingly, up to 30% of individuals with obsessive-compulsive disorder had a tic disorder. The combination of obsessive-compulsive disorder, tic disorder, and attention-deficit/hyperactivity disorder occurs in children. Tourette's disorder, trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder are also comorbid with obsessive-compulsive disorder. Rates of obsessive-compulsive disorder are elevated in schizophrenia or schizoaffective disorder (12%), eating disorders, body dysmorphic disorder, and oppositional defiant disorder.
Associated Laboratory Findings
No laboratory test has been found to be diagnostic of this disorder.
The 1-year prevalence rate of OCD is 1.2%, with women in adulthood slightly more likely to develop this disorder than men.
One-quarter of cases start by age 14, and the mean age at onset in America is 19.5 years. Onset after 35 is unusual. OCD develops earlier in males than females. Nearly 25% of males have onset before age 10. Onset is usually gradual (but sudden onset does occur, especially after infections). In adulthood, untreated OCD has a chronic course with only a 20% recovery rate after 40 years. However, 40% of individuals with onset of OCD in childhood or adolescence recover by early adulthood.
First-degree relatives of adults with OCD are twice as likely than normal to have OCD. However, first-degree relatives of individuals with onset of OCD in childhood or adolescence are 10-times more likely than normal to have OCD. Research is showing that dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum is strongly implicated in OCD.
The nature, assessment, and treatment of obsessive-compulsive disorder. (2012) Obsessive-compulsive disorder (OCD) is an anxiety disorder that affects between 1% to 2% of individuals and causes considerable impairment and disability. Although > 50% of individuals experience symptom onset in childhood, symptoms can continue to develop throughout adulthood. Accurate and timely assessment of clinical presentation is critical to limit impairment and improve prognosis. Presently, there are 2 empirically supported treatments available for OCD in children and adults, namely cognitive-behavioral therapy and pharmacotherapy with serotonin reuptake inhibitors.
Deep brain stimulation for intractable psychiatric disorders. (2012) Deep brain stimulation (DBS) has virtually replaced ablative neurosurgery for use in medication-refractory movement disorders. DBS is now being studied in severe psychiatric conditions, such as treatment-resistant depression (TRD) and intractable obsessive-compulsive disorder (OCD). Effects of DBS have been reported in ~100 cases of OCD and ~50 cases of TRD for seven (five common) anatomic targets. Although these published reports differ with respect to study design and methodology, the overall response rate appears to exceed 50% in OCD for some DBS targets. DBS was generally well tolerated in both OCD and TRD, but some unique, target- and stimulation-specific adverse effects were observed (e.g., hypomania).
Evidence-based pharmacotherapy and other somatic treatment approaches for obsessive-compulsive disorder: state of the art (2011)Meta-analyses of the randomized controlled trials (RCT) in obsessive-compulsive disorder (OCD) have clearly demonstrated that selective serotonin reuptake inhibitors (SSRIs) are the medication treatment of choice, while cognitive behavioural therapy (CBT) with exposure and response prevention is the psychotherapy of choice in OCD. Several guidelines emphasized that SSRIs are the first choice of medication in OCD. It has been noted that these agents may need to be given at a higher dose, and for a longer duration, than is usually the case in disorders such as depression. In the management of refractory patients, medication history should be carefully reviewed and adherence to the recommendations of the guideline established. Antipsychotics (risperidone, quetiapine, haloperidol) are currently the pharmacotherapy augmentation strategy of choice. In those OCD patients who fail to respond to a range of SSRIs and augmentation strategies combined with CBT, more unusual interventions (including deep brain stimulation) can be considered.
Diversity of obsessive-compulsive disorder and pharmacotherapy associated with obsessive-compulsive spectrum disorders (2011) Serotonin reuptake inhibitors (SRI) are effective in the treatment of obsessive-compulsive disorder (OCD). The response rate for SRI is approximately 50% and refractory OCD may exist. The effect of antipsychotics augmentation therapy has been established for this kind of patients. However, OCD is clinically and biologically heterogeneous neuropsychiatric disease and it will affect the response of pharmacotherapy. Several subtypes of OCD have been identified. Early onset OCD and hoarding symptoms dominant patients with OCD tend to resist SRI treatment. Antipsychotics augmentation with SRI is much effective for OCD with tic disorders. SRI is effective for patients with body dysmorphic disorder (BDD) in preoccupation with body appearance or sensation subgroup.
Efficacy of antipsychotic augmentation therapy in treatment-resistant obsessive-compulsive disorder: a meta-analysis of double-blind, randomised, placebo-controlled trials (2011)Only 40 - 60 % of all patients with obsessive-compulsive disorder (OCD) respond to serotonin reuptake inhibitors (SRIs). Therefore, the evaluation of additive treatment in the presence of treatment resistance has high clinical relevance. All double-blind, randomised, placebo-controlled trials that evaluated the efficacy of a combination therapy of SRIs and antipsychotics in treatment-resistant OCD were identified by systematic literature searches and combined in a meta-analysis. After the augmentation, significantly more subjects in the intervention groups (SRI + antipsychotic) fulfilled the response criterion (reduction in the Yale-Brown obsessive compulsive scale [Y-BOCS] = 35 %) than in the control groups (SRI + placebo) (relative risk = 2.16). The subgroup analysis showed significant efficacy only for risperidone.
Obsessive-compulsive disorder in children and adolescents. (2011) Early-onset obsessive-compulsive disorder (OCD) is one of the more common mental illnesses of children and adolescents, with prevalence of 1% to 3%. Its manifestations often lead to severe impairment and to conflict in the family. Obsessive-compulsive manifestations are of many types and cause severe impairment. Comorbid mental disturbances are present in as many as 70% of patients. The disease takes a chronic course in more than 40% of patients. Cognitive behavioral therapy is the treatment of first choice, followed by combination pharmacotherapy including selective serotonin reuptake inhibitors (SSRI) and then by SSRI alone.
Pharmacotherapy of compulsive hoarding. (2011) SRIs appear to be as effective for compulsive hoarders as for nonhoarding OCD patients. Symptom improvement from pharmacotherapy of compulsive hoarding appears to be at least as great as that resulting from cognitive-behavioral therapy (CBT). However, the combination of pharmacotherapy and CBT for compulsive hoarding is likely more effective than either treatment alone.
Psychotherapy for obsessive-compulsive disorder: what is evidence based?. (2011)Cognitive behavioural therapy with exposure and response prevention (CBT) is the most thoroughly investigated and most effective intervention, leading to a clinically significant symptom reduction in 60-70% of the patients. Correctly applied, this treatment can be equally effective as its combination with pharmacological management.