Obsessive-compulsive disorder (OCD) is a condition in which a person has obsessions and/or compulsions that cause significant distress or impairment in social, occupational, or other important areas of functioning. The obsessions or compulsions are time-consuming, occupying more than 1 hour of attention per day. The obsessive-compulsive symptoms are not attributable to the effects of a substance (drug of abuse or medication) or another mental disorder or medical condition.
Epidemiology
Comorbidity
Obsessions are recurrent and persistent thoughts, urges or images that are experienced as intrusive and unwanted, causing most individuals to feel anxiety or distress. An individual who has obsessions will try to ignore or suppress the thoughts, urges or images, or to neutralize them with some other thought or action, including a compulsive act.
Compulsions are repetitive behaviors that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The behaviors or thoughts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation. However, the behaviors or thoughts are not connected in a realistic way to what they are designed to neutralize or prevent, or are clearly excessive. Examples of compulsions include hand washing, checking things, praying, counting, repeating words silently.
Genetic studies indicate that relatives of persons with OCD have a threefold to fivefold higher probability of having OCD or obsessive-compulsive features. Studies of twins have consistently found a much higher rate of OCD among both identical twins than among both fraternal twins. However, it’s not yet clear if the higher probability of OCD among relatives is always due to genetics versusthe influence of cultural and behavioral factors.
The most common pattern of OCD is an obsession of contamination, followed by washing or accompanied by compulsive avoidance of the presumably contaminated object. Patients may literally rub the skin off their hands by excessive hand washing or may be unable to leave their home due to fear of germs.
The second most common pattern in OCD is obsession of doubt, followed by a compulsion of checking. The obsession often implies some danger of violence, such as forgetting to turn off the stove or not locking a door. The checking may involve multiple trips back into the house to check the stove, for example.
The third most common pattern of OCD involves intrusive obsession thoughts without a compulsion. Such obsessions are usually repetitious thoughts of a sexual or aggressive act that is reprehensible to the patient. Patients obsessed with thoughts of aggressive or sexual acts may report themselves to police or confess to a priest.
The fourth most common pattern of OCD is the need for symmetry or precision, which can lead to a compulsion of slowness. For example, individuals with this form of OCD can take hours to eat a meal or shave their faces.
Body dysmorphic disorder is a preoccupation that a person has with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. The individual also performs repetitive behaviors, such as excessive grooming, mirror checking or reassurance seeking, or mental acts, such as appearing one’s appearance to others, in response to the concern.
The preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning. The preoccupation with one’s appearance is not better explained by symptoms of an eating disorder. The diagnosis will include” muscle dysmorphia” if the individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular.
A hoarding disorder is defined as a persistent difficult discarding or parting with possessions, regardless of their actual value. The difficulty is due to a perceived need to save the items, resulting in the accumulation of possessions that congest and clutter active living areas. The hoarding causes significant distress or impairment in social, occupational, or other important areas of functioning, including maintaining a safe environment for one’s self and others. The hoarding is not better explained by the symptoms of another mental disorder or medical condition.
Trichotillomania, or hair-pulling disorder, is recurrent pulling out of one’s hair, resulting in hair loss. The hair pulling causes significant distress or impairment in social, occupational, or other important areas of functioning. The hair pulling or hair loss is not attributable to another medical issue, such as a dermatological condition, or another mental disorder.
Excoriation is recurrent skin picking, resulting in skin lesions. The skin picking causes significant distress or impairment in social, occupational, or other important areas of functioning. The skin picking is not attributable to the effects of a substance (e.g., cocaine), another medical condition (e.g., scabies), or another mental disorder.
A substance/medication-induced obsessive-compulsive disorder or related disorder is:
Yes. Obsessions, compulsions, preoccupations with appearance, hoarding, skin picking, hair pulling, other body-focused repetitive behaviors can be caused by other medical conditions, such as a stroke or brain injury.
Yes. Other types of obsessive-compulsive and related disorders that do not include all the typical symptoms include:
Yes. OCD is closely related to Tourette syndrome, and the two conditions often occur together. Tourette syndrome is a disorder that involves repetitive movements of unwanted sounds (tics) that cannot be easily controlled. About 90 percent of people with Tourette syndrome have compulsive symptoms and as many as two-thirds meet the diagnostic criteria for OCD. Besides Tourette syndrome, psychosis often leads to obsessive thoughts and compulsive behaviors that can be difficult to distinguish from OCD. In addition, OCD can be difficult to differentiate from depression because the two disorders often occur together, and major depression is often associated with obsessive thoughts. About one-third of patients with OCD have major depressive disorder.
Studies have found that pharmacotherapy, behavior therapy, or a combination of both is effective is significantly reducing the symptoms of patients with OCD.
The standard medication approach is to start with an SSRI or clomipramine and then move to other drug strategies if the serotonin-specific drugs are not effective. If treatment with clomipramine or an SSRI is unsuccessful, many therapists add valproate (Depakene), lithium (Eskalith), or carbamazepine (Tegretol). Other drugs that can be tried in the treatment of OCD are venlafaxine (Effexor), pindolol (Visken) and the monoamine oxidase inhibitors (MAOIs), especially phenelzine (Nardil). Other treatments for unresponsive patients include buspirone (BuSpar), 5-hydroxytrptamine (5-HT), L-triptophan, and clonazepam (Klonopin).
