Obsessive-Compulsive Disorder (OCD)

Obsessions are unwanted, intrusive thoughts, urges, or mental images, the presence of which usually causes marked distress or anxiety. The dominant themes of the obsessions include harm (eg, fears of harm to self or others), cleaning or contamination (eg, patients may obsess about becoming contaminated with dirt or germs), forbidden or taboo thoughts (eg, aggressive or sexual obsessions), and the need for symmetry. The obsessions are not pleasurable. Thus, patients usually try to ignore and/or suppress them, or they try to neutralize them by performing a compulsion.

Compulsions (often called rituals) are excessive, repetitive, purposeful behaviors that people feel they must do to prevent or reduce the anxiety caused by their obsessive thoughts or to neutralize their obsessions. Examples are

• Washing (eg, handwashing, showering)

• Checking (eg, that the stove is turned off, that doors are locked)

• Counting (eg, repeating a behavior a certain number of times)

• Ordering (eg, arranging tableware or workspace items in a specific pattern)

Most rituals, such as handwashing or checking locks, are observable, but some mental rituals, such as silent repetitive counting or statements muttered under the breath, are not. Typically, the compulsive rituals must be done in a precise way according to rigid rules. The rituals may or may not be connected realistically to the feared event. When connected realistically (eg, showering to avoid being dirty, checking the stove to prevent fire), the compulsions are clearly excessive—eg, showering for hours each day or always checking the stove 30 times before leaving the house. In all cases, the obsessions and/or compulsions must be time-consuming (ie, they take up an 1 hour a day or often much more) or cause patients significant distress or impairment in functioning; at their extreme, obsessions and compulsions may be incapacitating.

The degree of insight varies. Most people with obsessive-compulsive disorder (OCD) recognize to at least some degree that the beliefs underlying their obsessions are not realistic (eg, that they really will not get cancer if they touch an ashtray). However, occasionally, insight is completely lacking (ie, patients are convinced that the beliefs underlying their obsessions are true and that their compulsions are reasonable).

Because people with this disorder may fear embarrassment or stigmatization, they often conceal their obsessions and rituals. The time, distress, or poor functioning associated with the obsessions and compulsions may cause relationships to be disrupted and performance in school or at work to decline.

Many people with OCD have coexisting past or current psychologic disorders, including

• Anxiety disorders (76%) (1)

• Mood disorders (63%; the most common is major depressive disorder [41%] (2))

• Obsessive-compulsive personality disorder (23 to 32%) (3)

Almost 50% of people with OCD have suicidal thoughts at some point, and about 10% attempt suicide (see Suicidal Behavior) (4, 5). Risk of an attempt is increased if people also have major depressive disorder.

• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria

Diagnosis of obsessive-compulsive disorder is clinical, based on the 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 or distress.

• The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (ie, by performing a compulsion).

Compulsions are defined by both of the following:

• Repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) 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 either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

The obsessions or compulsions must be time-consuming (eg, > 1 hour a day) or cause clinically significant distress or impairment of functioning. In addition, they must not be attributable to the physiologic effects of a substance (eg, medication, illicit drug) or another medical condition.

• Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy, which encompasses exposure and ritual prevention therapy, has been shown to be effective for in patients with obsessive-compulsive disorder (1). The essential element of exposure and ritual prevention therapy is gradually exposing patients to situations or people that trigger the anxiety-provoking obsessions and rituals while asking them not to perform their rituals. For example, a patient with contamination obsessions and washing compulsions may be asked to touch a toilet seat without washing her hands. This approach allows the anxiety triggered by exposure to diminish through habituation and learning. Improvement often continues for years, especially in patients who master the approach and use it even after formal treatment has ended. However, some patients have incomplete responses (as some also do to medications).

Cognitive therapy techniques (eg, cognitive restructuring) may also be useful in targeting some symptoms of obsessive-compulsive disorder.

SSRIs

2N3). However, there are more supporting data for atypical neuroleptics as SSRI-augmenting agents than for other medications.

Many experts believe that combining exposure and ritual prevention with medications is best, especially for severe cases.