Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is characterized by recurrent thoughts or urges (i.e., obsessions) that often lead to repetitive behaviors or mental acts (i.e., compulsions). Obsessions are experienced as intrusive, involuntary, and undesirable, and they generally cause anxiety and/or distress. While compulsions are not generally experienced as pleasurable, their performance may provide relief from the distress and anxiety caused by an obsession. Compulsions and obsessions are uncontrollable and time-consuming, leading to significant function impairment. Comorbidity with other psychiatric disorders (e.g., anxiety disorders, mood disorders, tic disorders) is common. Treatment includes cognitive behavioral therapy (CBT) and/or selective serotonin reuptake inhibitors (SSRIs).

• Sex: ♀ > ♂ (female individuals slightly more affected in adulthood, male individuals slightly more affected in childhood) ^[1][2]
• Age of onset: average ∼ 20 years of age ^[1]
• Lifetime prevalence: ∼ 2% ^[1]

Epidemiological data refers to the US, unless otherwise specified.

The etiology of OCD is multifactorial. Factors that have been associated with OCD development include:

• Genetic: familial transmission
• Neurobiological: abnormalities in the cortico-striato-thalamo-cortical (CSTC) circuit, including the orbitofrontal cortex, anterior cingulate cortex, and striatum
• Serotonin level imbalance may play a role.
• Infection: pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)
• Psychological trauma

Symptoms ^[1][3]

Behavior and thought patterns of OCD are egodystonic (i.e., inconsistent with or repulsive to one's sense of self).

• Obsessions (recurrent, intrusive, and distressing thoughts or urges), e.g.:
  • Fears around contamination of self and/or others
  • Worries about immorality
  • Fixation on symmetry and order
  • Fear of harming self and/or others
• Compulsions (repetitive behaviors or mental acts to provide relief from anxiety caused by obsessions; can be substantially time-consuming), e.g.:
  • Excessive cleaning or hand-washing
  • Repetitive “neutralizing” thoughts or prayers
  • Ordering and rearranging objects
  • Checking that tasks have been done correctly, e.g., opening and closing a door multiple times to confirm it is locked
• Obsessions and compulsions can lead to severe anxiety and avoidance behaviors (e.g., avoiding situations that may trigger symptoms).

Unlike individuals with obsessive-compulsive disorder, individuals with obsessive-compulsive personality disorder show egosyntonic behavior.

Comorbidities ^[4]

Most individuals with OCD have comorbid psychiatric disorders, e.g.:

• Anxiety disorders
• Mood disorders, e.g., depressive disorders, bipolar disorder
• Impulse control disorders
• Tic disorders, e.g., Tourette syndrome
• Personality disorders
• Schizophrenia or schizoaffective disorder

Approach ^[3]

• Consider screening tools, e.g., the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) in patients with symptoms of OCD. ^[3]
• Rule out differential diagnoses of OCD and assess for comorbidites (e.g., anxiety and mood disorders).
• Confirm the diagnosis using the DSM-5 TR diagnostic criteria for OCD.
• Evaluate suicide risk.

DSM-5 TR diagnostic criteria for OCD ^[2][3][5]

Diagnostic criteria

Diagnosis is confirmed in individuals who meet all of the following criteria.

• Presence of obsessions and/or compulsions
  • Obsessions are defined by both of the following:
    • Recurrent, intrusive, and distressing thoughts or urges
    • Attempts to suppress or neutralize these thoughts or urges
  • Compulsions are defined by both of the following:
    • Repetitive behaviors or mental acts that the individual feels compelled to do to relieve anxiety brought upon by obsessions
    • When behaviors or mental actions are performed to prevent an unwanted event, they are excessive or cannot be realistically connected to the event.
• Symptoms are time-consuming (e.g., ≥ 1 hour/day) and/or result in significant distress or impairment; in key areas of functioning (e.g., school, work, social life).
• Symptoms are not attributable to:
  • The effects of a substance or medication
  • Another medical or psychiatric condition (See “Differential diagnoses of obsessive-compulsive disorder.”)

Specifiers

Specifiers provide additional information on the diagnosis, which can be used to support management decisions.

• Level of insight: the patient's degree of understanding that their thoughts are not true ^[3][5]
• Tic-related OCD: current or past diagnosis of a tic disorder ^[3]

The differential diagnoses listed here are not exhaustive.

Excoriation disorder ^[1][2]

• Epidemiology
  • ♀ > ♂
  • Onset: adolescence
  • Comorbidities: OCD, trichotillomania, MDD, BDD
• Diagnostic criteria (DSM-5 TR) ^[2]
  • Recurrent skin picking resulting in lesions
  • Repeated attempts to decrease or stop picking
  • Symptoms cause significant distress or impairment in daily functioning
  • Not due to any substance disorder or another medical or psychiatric disorder (e.g., tactile hallucinations, intentional self-harm, BDD, eczema, psoriasis, scabies)
• Treatment
  • Habit reversal therapy
  • Evidence for pharmacological treatment is limited. ^[1]

Hoarding disorder ^[6]

• Epidemiology
  • Point prevalence: ∼ 2–6%
  • ♂ > ♀ ^[6]
• Diagnostic criteria (DSM-5 TR) ^[6]
  • Persistent urge to keep belongings
  • Difficulty discarding belongings, regardless of their value
  • Accumulation of belongings, which causes the intended use of belongings to be compromised and living areas to be cluttered.
  • Not explained by other medical conditions (e.g., brain injuries) or mental illness (e.g., OCD)
  • Results in significant distress/impairment in key areas of functioning (work, social life)
  • Not due to another medical condition (e.g., brain injury) or psychiatric disorder (e.g., OCD)
• Treatment ^[1]
  • CBT
  • There is currently no evidence of pharmacological treatment efficacy.

Body dysmorphic disorder (BDD) ^[2]

• Definition: an excessive preoccupation with perceived flaws or defects in appearance
• Epidemiology
  • Prevalence: ∼ 2.5% ^[2]
  • ♂ ≈ ♀ ^[2]
  • Mean age of onset: 17 years ^[2]
• Diagnostic criteria (DSM-5 TR) ^[2]
  • Persistent preoccupation with one or more perceived flaws in physical appearance that are mild or imperceivable to others
  • Repetitive behaviors (e.g., constantly checking the mirror, skin picking, excessive grooming) or thoughts about one's appearance (e.g., comparing oneself to others)
  • Results in significant distress and impairment in key areas of functioning (e.g., school, work, social life)
  • Symptoms are not due to an eating disorder.
• Specifiers
  • Muscle dysmorphia: a preoccupation with one's body not being muscular, large, or lean enough
    • Occurs almost exclusively in men
    • Affected individuals may use anabolic steroids or other potentially dangerous substances to increase muscle mass.
  • Level of insight
    • Absent insight or delusional beliefs: Patients perceive their beliefs as true.
    • Poor insight: Patients perceive their beliefs as probably true.
    • Good insight: Patients perceive their beliefs as definitely/probably false.
• Treatment ^[7]
  • First-line treatment: SSRIs and/or CBT ^[1]
  • General measures
    • Educate patients about BDD and available treatment options.
    • Avoid making remarks (positive or negative) on the patient's appearance, challenging their beliefs, or dismissing their perceived flaw as minor and/or imagined. ^[7]
    • Consider involving family members, if appropriate.
    • Cosmetic interventions are not recommended in patients with BDD. ^[7]

Trichotillomania (hair-pulling disorder) ^[6]

• Definition: an irresistible compulsion to pull out one's hair
• Epidemiology
  • Prevalence: ∼ 2% ^[6]
  • ♀ 10:1 ♂ ^[6]
  • Onset is usually in adolescence following a stressful event but can happen at any age.
  • Comorbidities (e.g., MDD, excoriation disorder) are common.
• Clinical features
  • Hair loss, most commonly involving the scalp, eyebrows, or eyelashes
  • The pattern of hair loss is usually patchy, with hair of different lengths.
• Diagnostic criteria (DSM-5 TR) ^[6]
  • Hair loss due to recurrent pulling out of one's hair
  • Repeated attempts to ; decrease or stop this behavior
  • Results in significant distress/impairment in key areas of functioning (e.g., school, work, social life)
  • Not due to another medical condition (e.g., skin disease) or psychiatric disorder (e.g., body dysmorphic disorder)
• Differential diagnosis: alopecia
• Treatment ^[1]
  • CBT: habit reversal therapy
  • Limited evidence for SSRIs

Approach ^[3][5]

• First-line treatments: CBT and/or SSRIs
• Consider psychiatry referral for patients with any of the following: ^[3]
  • Severe OCD symptoms
  • Poor insight
  • Significant comorbidities (e.g., tic disorders, hoarding disorders, MDD)
  • Inadequate response to SSRIs
• Treat comorbidities (e.g., MDD, anxiety disorders).
• Consider hospitalization for patients with suicidal ideation or who are unable to adequately care for themselves. ^[5]
• See “Special patient groups” for OCD in children and OCD in pregnant and postpartum individuals.

Cognitive behavioral therapy ^[3][4]

• Monotherapy: patients with mild to moderate symptoms or when SSRIs are contraindicated (e.g., comorbid bipolar disorder, pregnancy)
• CBT with SSRIs: patients with inadequate response to CBT or SSRI as monotherapy or for severe symptoms ^[4]
• Recommended therapy modalities include cognitive therapy and exposure and response prevention.

Pharmacological treatment ^[4]

• SSRIs, e.g., sertraline , paroxetine , fluoxetine , fluvoxamine
  • In combination with CBT, e.g., in patients with severe symptoms
  • As monotherapy, e.g., if CBT is not available or declined
• Refractory OCD
  • Combination of CBT and an SSRI if initial treatment was monotherapy
  • Consider switching to one of the following:
    • A different SSRI
    • A tricyclic antidepressant with serotonergic action, e.g., clomipramine ^[3]
    • An SNRI, e.g., venlafaxine (off-label) ^[5]
  • A combination of an antipsychotic agent (off-label), e.g., risperidone, quetiapine, and an SSRI may be considered. ^[3]

OCD in children ^[1]

• Epidemiology
  • Prevalence 1–2 % ^[1]
  • Psychiatric comorbidities are common.
• Diagnostics
  • See “Diagnostics for OCD.”
  • In patients with abrupt onset, PANDAS may be considered.
• Management
  • Mild or moderate symptoms: CBT with exposure and response prevention therapy
  • Severe symptoms: CBT and SSRIs, e.g., sertraline , fluvoxamine

OCD in pregnant and postpartum individuals

• Epidemiology: New-onset OCD occurs in up to 22% of pregnant individuals. ^[8]
• Clinical features
  • See “Clinical features of OCD.”
  • Pregnant and postpartum individuals may show particular obsessions and compulsions.

Intrusive thoughts of infant harm in postpartum OCD are egodystonic and often shocking to the parent, whereas egosyntonic thoughts about harming an infant may indicate postpartum psychosis. ^[8]

Patients with perinatal OCD are not at risk of intentionally harming their child, but patients with postpartum psychosis may be because of delusional beliefs. ^[8]

• Diagnostics
  • See “Diagnostics for obsessive-compulsive disorder.”
  • Rule out other perinatal psychiatric disorders, especially postpartum psychosis.
• Management ^[8]
  • Consult psychiatry. ^[9]
  • Management is similar to non-pregnant individuals. See also “Treatment for obsessive-compulsive disorder” above.
    • First-line treatment: CBT: exposure and response prevention therapy ^[1]
    • SSRIs (e.g., sertraline) may be considered with or without CBT in moderate or severe symptoms, or if response to CBT monotherapy is inadequate.
  • Offer other supportive measures, e.g., family therapy.

Pharmacotherapy during pregnancy and breastfeeding should only be given after weighing risks and benefits under specialist guidance. ^[1][4]