Obsessive-Compulsive Disorder: Diagnosis and Management JILL N. FENSKE, MD, and THOMAS L. SCHWENK, MD, University of Michigan Medical School, Ann Arbor, Michigan Obsessive-compulsive disorder is an illness that can cause marked distress and disability. It often goes unrecognized and is undertreated. Primary care physicians should be familiar with the various ways obsessive-compulsive disorder can present and should be able to recognize clues to the presence of obsessions or compulsions. Proper diagnosis and education about the nature of the disorder are important first steps in recovery. Treatment is rarely curative, but patients can have significant improvement in symptoms. Recommended first-line therapy is cog- nitive behavior therapy with exposure and response prevention or a selective serotonin reuptake inhibitor. The medication doses required for treatment of obsessive-compulsive disorder are often higher than those for other indications, and the length of time to response is typi- cally longer. There are a variety of options for treatment-resistant obsessive-compulsive disorder, including augmentation of a selec- tive serotonin reuptake inhibitor with an atypical antipsychotic. ECK Obsessive-compulsive disorder is a chronic condition with a high rate B of relapse. Discontinuation of treatment should be undertaken with oan caution. Patients should be closely monitored for comorbid depression and suicidal ideation. (Am Fam Physician. 2009;80(3):239-245. Copy- right © 2009 American Academy of Family Physicians.) ILLUSTRATION BY J ▲ Patient information: bsessive-compulsive disorder from obsessions and compulsions.2 OCD A handout on obsessive- (OCD) is a neuropsychiatric dis- interferes with work performance, social compulsive disorder, written by the authors order characterized by recurrent interactions, and family relationships. It is of this article, is avail- distressing thoughts and repeti- a chronic disorder and is likely to persist if able at http://www.aafp. O tive behaviors or mental rituals performed to not treated effectively. Nearly 70 percent of org/afp/20090801/239- reduce anxiety. Symptoms are often accom- patients report a continuous course of symp- s1.html. panied by feelings of shame and secrecy toms, and 23 percent experience a waxing This article exempifies because patients realize the thoughts and and waning course.3 The average time to the AAFP 2009 Annual Clinical Focus on manage- behaviors are excessive or unreasonable. This treatment after meeting diagnostic criteria 3 ment of chronic illness. secrecy, along with a lack of recognition of for OCD is 11 years. This delay is attrib- OCD symptoms by health care professionals, uted to many factors, including reluctance often leads to a long delay in diagnosis and of patients to report symptoms and under- This clinical content con- treatment. OCD has a reputation of being recognition of OCD by physicians. forms to AAFP criteria for evidence-based continuing difficult to treat, but there are many effective medical education (EB treatments available. Pathogenesis CME). See CME Quiz on The current model for the pathogenesis page 225. Epidemiology of OCD is complex. Neuroimaging stud- The lifetime prevalence of OCD is 1.6 per- ies show involvement of the dorsolateral The online version 1 of this article cent. Symptoms usually begin during prefrontal cortex, basal ganglia, and thala- includes supple- adolescence, and more than 50 percent of mus.4 Because of the response to selective mental content at http:// affected persons have symptom onset before serotonin reuptake inhibitors (SSRIs), it www.aafp.org/afp. their mid-20s.1 OCD has substantial adverse is hypothesized that the serotonin system effects on well-being; more than one half of is heavily involved in the neurochemistry patients report moderate to severe distress of OCD. Family studies have shown that August 1, 2009 ◆ Volume 80, Number 3 www.aafp.org/afp American Family Physician 239 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2009 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Obsessive-Compulsive Disorder SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Patients with OCD should be monitored for psychiatric comorbidities and suicide risk. C 3, 19, 21 Cognitive behavior therapy with exposure and response prevention is an effective treatment A 21-23 for OCD. SSRIs are an effective treatment for OCD and are recommended as first-line pharmacologic therapy. A 21, 24, 25 A trial of SSRI therapy should continue for eight to 12 weeks, with at least four to six weeks at the C 21 maximal tolerable dosage. SSRIs should be taken for at least one to two years before attempting to discontinue. Exposure and C 21 response prevention “booster” sessions should be considered to prevent relapse. Augmentation of SSRI therapy with atypical antipsychotic agents is effective in some patients with B 16, 21, 30 treatment-resistant OCD. OCD = obsessive-compulsive disorder; SSRI = selective serotonin reuptake inhibitor. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort.xml. genetics have a role in the etiology of OCD, particularly Diagnosis in the early-onset form of the disorder.5 An immuno- Obsessions are recurrent intrusive thoughts or images logic component has also been proposed, based on the that cause marked distress. Patients usually recognize association of OCD with pediatric autoimmune neu- that the thoughts are self-generated and inappropri- ropsychiatric disorder associated with streptococcal ate. Some common obsessions involve contamination, infections (PANDAS), in which children develop an doubts about whether an important task has been per- abrupt onset of OCD symptoms or tics after infection formed, or worries that an action will harm another with group A Streptococcus. person (Table 1). Compulsions are repetitive activities or mental rituals designed to counteract the anxiety caused by obsessions. Common compulsions include handwashing, checking, ordering, praying, counting, Table 1. Common Obsessions and Compulsions and seeking reassurance (Table 1). The Diagnostic and Statistical Manual of Mental Disorders, 4th ed., states Type Examples that to meet the criteria for OCD, the obsessions cannot Obsessions be excessive worries about everyday problems, and they Aggressive Images of hurting a child or parent must cause marked distress (Table 2).6 impulses OCD is a heterogeneous disorder with several subtypes Contamination Becoming contaminated by shaking hands and a multitude of manifestations (Table 3).7-15 There are with another person several associated disorders (often referred to as OCD Need for order Intense distress when objects are disordered or asymmetric Religious Blasphemous thoughts, concerns about unknowingly sinning Table 2. Diagnostic Criteria for Obsessive- Repeated Wondering if a door was left unlocked Compulsive Disorder doubts Sexual imagery Recurrent pornographic images Recurrent obsessions or compulsions Compulsions Obsessions and compulsions are severe enough to be time consuming (more than one hour daily) or to cause marked Checking Repeatedly checking locks, alarms, distress or significant impairment appliances At some point during the course of the disorder, the person has Cleaning Handwashing recognized that the obsessions or compulsions are excessive or Hoarding Saving trash or unnecessary items unreasonable Mental acts Praying, counting, repeating words silently If another axis I disorder is present, the content of the Ordering Reordering objects to achieve symmetry obsessions or compulsions is not restricted to it Reassurance- Asking others for reassurance The disturbance is not a result of physiologic effects of a seeking substance or medical condition Repetitive Walking in and out of a doorway multiple actions times Information from reference 6. 240 American Family Physician www.aafp.org/afp Volume 80, Number 3 ◆ August 1, 2009 Obsessive-Compulsive Disorder Table 3. Subtypes of Obsessive-Compulsive Disorder Subtype Features 7,8 spectrum disorders), such as body dysmor- Early-onset Symptom onset before puberty phic disorder, trichotillomania, hypochon- Higher frequency of tics and other psychiatric comorbidities driasis, and eating disorders. These disorders Onset of compulsions often predates obsessions Compulsions often severe and frequent have similar features and respond to the Less responsive to first-line treatments same therapies used to treat OCD. Strong familial link (17 percent among first-degree relatives) Patients are often reluctant to report symp- Hoarding9 Less insight than in other OCD subtypes toms of OCD, which they may find embar- Symptoms often more severe rassing. Physicians should maintain a high Higher rates of psychiatric comorbidities, especially social awareness for the possibility of OCD in phobia patients with general complaints of anxiety Greater degree of global impairment or depression. Patients may offer clues by May be less responsive to psychological treatment alluding to intrusive thoughts or repetitive “Just right”10,11 Patients wish to have