Obsessive-Compulsive Disorder (OCD) is a condition characterized by unwanted, intrusive, and recurrent thoughts, images, or urges (obsessions) that cause anxiety and distress. This leads to repetitive tasks (compulsions) performed in response to obsessions in an attempt to reduce the distress, even though these actions are often not realistically connected to the feared event. As a result, OCD significantly impairs daily functioning and negatively impacts the quality of life.
Common Obsessions and Compulsions
Obsessions:
- Fear of contamination
- Need for symmetry or exactness
- Fear of causing harm or making mistakes
- Sexual or religious obsessions
Compulsions (Rituals):
- Behavioral: Cleaning or handwashing, organizing or arranging, checking.
- Mental: Repeating words silently, praying, counting, ruminating.
These compulsions do not have to be directly connected to the obsession or feared event. Around one in three people with OCD also experience some form of tics, and up to 60% report sensory phenomena preceding compulsions.
Causes of OCD
The cause of OCD likely involves a combination of factors, including genetic influences. Some evidence suggests it may be transmitted in an autosomal dominant fashion, with genes related to serotonin, dopamine, and glutamate neurotransmitters being implicated. Compulsions may also be self-reinforcing, temporarily reducing the anxiety brought on by obsessions.
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections):
- Autoimmune antibodies generated during a strep infection may cross-react with those in the basal ganglia.
- Childhood Acute Neuropsychiatric Symptoms (CANS) is a preferred term encompassing other causes such as toxins or metabolites.
Prevalence and Demographics
Between 1 and 4% of the population is affected by OCD, typically with onset in late adolescence to the early 20s. Females are slightly more commonly affected, but males tend to have a more chronic course, earlier onset, and greater likelihood of treatment resistance. Coexisting conditions are common, with 75% having an anxiety disorder, 63% having mood disorders (most commonly major depressive disorder), and 10% attempting suicide.
Diagnosis
A diagnosis of OCD is based on the DSM-5 criteria:
- Presence of obsessions, compulsions, or both.
- Symptoms are time-consuming (e.g., over an hour per day) and cause significant distress or impairment in functioning.
- Symptoms are not attributable to substances or another medical condition.
- Symptoms cannot be better explained by another mental disorder.
Insight Levels:
- Good: Recognizes that OCD beliefs are probably not true.
- Poor: Believes OCD beliefs are true.
- Absent/Delusional: Completely convinced OCD beliefs are true (without diagnosing psychotic disorder based on this alone).
The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) is commonly used to measure OCD symptoms, with scores ranging from 0 to 40 (40 being the most severe). It features five questions each on obsessions and compulsions and can track treatment progress.
Treatment
OCD treatment is divided into pharmacological and cognitive behavioral therapy (CBT). However, 40% of patients may not see a benefit from either approach.
Pharmacological Therapy:
- First-line: Selective Serotonin Reuptake Inhibitors (SSRIs) like fluoxetine or paroxetine. Clomipramine, a serotonin-specific tricyclic antidepressant, is another option.
- Second-line: Addition of antipsychotics for nonresponders.
Cognitive Behavioral Therapy (CBT):
- Typically in the form of Exposure and Response Prevention (ERP), where triggers are identified and graded. The patient is then encouraged to expose themselves to these triggers and refrain from compulsive rituals. As symptoms improve, more severe triggers are targeted.
Patients are considered nonresponders when there is no response to two SSRIs and clomipramine taken for 12 weeks each, alongside CBT.