Obsessive-compulsive disorder (OCD) is characterized by recurrent, intrusive, undesired thoughts (known as obsessions) and/or uncontrollable repetitive acts (known as compulsions). Obsessions and compulsions are time-consuming (> 1 hour in a day), and cause significant distress in a patient’s daily life. The prevalence is 2-3%, with a mean onset in the second decade. | Obsessive-Compulsive Disorder
BY Jorge Muniz, PA-C
Contents
Before we begin,
Neil Hilborn is an American slam poet who writes and performs poetry. His poems often detail personal experiences and battles with mental illness. | Wikipedia
Mental disorder characterized by the presence of obsessions and/or compulsions.
#4 M/C psychiatric illness and a leading cause of disability.
Obsessive-compulsive disorder cycle:
Obsessions are unwanted ideas, images, or impulses that repeatedly enter a person’s mind. Although recognised as being self generated, they are experienced as “egodystonic” (out of character, unwanted, and distressing). Compulsions are repetitive stereotyped behaviours or mental acts driven by rules that must be applied rigidly. They are often intended to neutralise anxiety provoked by the obsessions,
The obsessive-compulsive disorder cycle. Obsessions are intrusive thoughts (ideas, images, or impulses) that repeatedly enter a person’s mind against his or her will. These generate considerable anxiety and are difficult to dismiss. Compulsions or rituals are repetitive acts that are performed in an attempt to reduce the anxiety caused by the obsessions, but the relief is only temporary. Later in the course of obsessive-compulsive disorder, rituals can become more automatic and increase, rather than reduce, the anxiety. Psychological theories of obsessive-compulsive disorder suggest that ritualising maintains the problem as it prevents habituation to the anxiety and disconfirmation of the patient’s fears. Psychological therapies aim to break this cycle by persuading patients to expose themselves to the feared situations while refraining from performing any rituals; this is known as exposure and response prevention | Heyman, I., Mataix-Cols, D., & Fineberg, N. A. (2006). Obsessive-compulsive disorder. BMJ (Clinical research ed.), 333(7565), 424–429. https://doi.org/10.1136/bmj.333.7565.424
Classification
Obsessive–compulsive and related disorders (OCRDs):
OCRDs are often prevalent but under-recognized conditions that are characterized by repetitive and unwanted thoughts or behaviours. Some OCRDs include preoccupations and compulsive behaviours (such as body dysmorphic disorder), but others have predominantly motoric or behavioural symptoms (such as trichotillomania).
Obsessive–compulsive and related disorders (OCRDs) chapter in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes obsessive–compulsive disorder (OCD; previously classified as an anxiety disorder), body dysmorphic disorder (previously classified as a somatoform disorder) and trichotillomania (previously classified as an impulse control disorder), as well as hoarding disorder and excoriation (skin-picking) disorder (both of which are new to the classification system). In the International Classification of Diseases, 11th Revision (ICD-11), this chapter also includes Tourette syndrome (also classified as a neurodevelopmental disorder), hypochondriasis (also classified as an anxiety disorder) and olfactory reference syndrome (which is new to the classification system). Similar to OCD, the OCRDs are often prevalent but under-recognized conditions that are characterized by repetitive and unwanted thoughts or behaviours. Some OCRDs include preoccupations and compulsive behaviours (such as body dysmorphic disorder), but others have predominantly motoric or behavioural symptoms (such as trichotillomania). Sensory phenomena, including premonitory urges and ‘just right’ perceptions (where a patient continues their compulsions until there is a feeling that things are ‘just right’ and they can stop), can be present in some OCRDs, including OCD and Tourette syndrome | Stein, D.J., Costa, D.L.C., Lochner, C. et al. Obsessive–compulsive disorder. Nat Rev Dis Primers 5, 52 (2019). https://doi.org/10.1038/s41572-019-0102-3
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):
Obsessive-compulsive disorder (OCD)
Body dysmorphic disorder (BDD)
Trichotillomania
Hoarding disorder
Excoriation (skin-picking) disorder
Substance/medication-induced OCRD
OCRD as a result of another medical condition
Other specified OCRD
Unspecified OCRD
International Classification of Diseases, 11th Revision (ICD-11):
Tourette syndrome (also classified as a neurodevelopmental disorder)
Hypochondriasis (also classified as an anxiety disorder)
Olfactory reference syndrome
Etiology
Genetic, psychological, and external circumstances all play a role.
Individuals with obsessive–compulsive disorder (OCD) may be genetically vulnerable to the impact of environmental factors that may trigger modification of the expression of glutamate-, serotonin- and dopamine-system-related genes through epigenetic mechanisms. In turn, neuroanatomical expression of these modifications results in an OCD-specific imbalance between the direct and indirect loops of the cortico–striato–thalamo–cortical (CSTC) circuit. Aberrant activation along the CSTC loop is associated with phenotypic presentation of OCD phenomenology. Although OCD is clinically heterogeneous, it is generally and universally characterized by obsessive concerns about threats or danger and subsequent engagement in rituals to neutralize the threats and/or distress that accompany obsessions. This negative reinforcement cycle, when left untreated, perpetuates OCD psychopathology | Pauls DL, Abramovitch A, Rauch SL, Geller DA. Obsessive–compulsive disorder: an integrative genetic and neurobiological perspective. Nat Rev Neurosci [Internet]. 2014 May 20 [cited 2017 Mar 24];15(6):410–24. Available from: http://www.nature.com/doifinder/10.1038/nrn3746
Comorbidities:
OCD is characterized by substantial comorbidity (~90%)
Comorbidities of OCD | Ruscio AM, Stein DJ, Chiu WT & Kessler RC The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol. Psychiatry 15, 53–63 (2008).
Pathophysiology
Cortico–striato–thalamo–cortical (CSTC) circuits:
Involved in sensorimotor, cognitive, affective and motivational processes in OCD
Circuits involved in OCD: OCD is mediated by parallel, partly segregated, cortico–striato–thalamo–cortical (CSTC) circuits that are involved in sensorimotor, cognitive, affective and motivational processes. | dCaud, dorsal part of caudate nucleus; dlPFC, dorsolateral prefrontal cortex; dmPFC, dorsomedial prefrontal cortex; IFG, inferior frontal gyrus; NAcc, nucleus accumbens; OFC, orbitofrontal cortex; pPut, posterior part of putamen; pre-SMA, pre-supplementary motor area; SMA, supplementary motor area; Tham, Thalamus; vCaud, ventral part of caudate nucleus; vlPFC, ventrolateral prefrontal cortex; vmPFC, ventromedial prefrontal cortex. | van den Heuvel OA et al. Brain circuitry of compulsivity. Eur. Neuropsychopharmacol 26, 810–827 (2016)
Defence mechanisms involved:
Uncoding
Reaction formation
Isolation
Presentation
Hallmarks of OCD are presence of obsessions and compulsions.
Obsessive thoughts: Constant and repetitive thoughts that are very hard to shake off. Although someone with OCD feels that the thoughts are illogical and unpleasant, it is hard to simply stop them using will power alone.
Compulsive behaviors: Certain rituals that are repeated over and over. For people with OCD, this is a way to try to get frightening thoughts out of their head and feel safe again.
Common sets of obsessions and compulsions in patients with OCD include concerns about contamination together with washing or cleaning, concerns about harm to self or others together with checking, intrusive aggressive or sexual thoughts together with mental rituals, and concerns about symmetry together with ordering or counting.
OCD symptom dimensions: Studies using a factor-analytic approach have consistently supported a four-factor or five-factor model of obsessive-compulsive disorder (OCD) symptoms, including a ‘contamination’ dimension (contamination or cleanliness obsessions and cleaning compulsions), a ‘harmful thoughts’ dimension (thoughts of harm to self and others and checking compulsions), a ‘forbidden thoughts’ dimension (aggressive, sexual, religious obsessions with mental rituals or praying), a ‘symmetry’ factor (symmetry obsessions, and repeating, ordering and counting compulsions), and a ‘hoarding’ factor (hoarding or saving obsessions and related compulsions). Hoarding disorder is considered as a separate entity in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, although hoarding symptoms can also be found in patients with OCD in some cases. | Stein, D.J., Costa, D.L.C., Lochner, C. et al. Obsessive–compulsive disorder. Nat Rev Dis Primers 5, 52 (2019). https://doi.org/10.1038/s41572-019-0102-3
Case study:
Diagnosis
Screening tests:
Short OCD screener: 6 questions long simple and effective way to screen patients for symptoms of OCD
Commonly used instruments to assess OCD (optional) | Janardhan Reddy, Y. C., Sundar, A. S., Narayanaswamy, J. C., & Math, S. B. (2017). Clinical practice guidelines for Obsessive-Compulsive Disorder. Indian journal of psychiatry, 59(Suppl 1), S74–S90. https://doi.org/10.4103/0019-5545.196976
DSM-5 diagnostic criteria:
To receive a formal diagnosis, the DSM 5 requires > 1 hour/day to be consumed by the obsession or compulsions or that they cause significant daily stress.
Obsessions, compulsions or both
Time-consuming (distress to daily life)
Not physiologic effects of substance or medication condition
Not better explained by another disorder
Management
Treatment of OCD comprises several components, starting with building a therapeutic alliance with the patient and psychoeducation, followed by psychological and/or pharmacological approaches, and, for patients with treatment-resistant OCD, neuromodulation and neurosurgery.
OCD treatment algorithm: Cognitive–behavioural therapy (CBT) or selective serotonin reuptake inhibitors (SSRIs) are the first-line treatments for obsessive–compulsive disorder (OCD). Unresponsive patients can receive augmentation with other treatment modalities. Neurosurgery is only considered in highly refractory and severe cases. AAP, atypical antipsychotics; DBS, deep brain stimulation; rTMS, repetitive transcranial magnetic stimulation; SNRI, serotonin-noradrenaline reuptake inhibitor ; SRI, serotonin reuptake inhibitor. aThe presence of specific comorbidities may change the algorithm (for example, focus on mood stabilizers plus CBT in the presence of bipolar disorder, and the addition of antipsychotics in those with psychotic symptoms or tics). bEffect sizes are similar for different SSRIs. cMonthly booster sessions for 3 to 6 months. d12–24 months. | Stein, D.J., Costa, D.L.C., Lochner, C. et al. Obsessive–compulsive disorder. Nat Rev Dis Primers 5, 52 (2019). https://doi.org/10.1038/s41572-019-0102-3
