OBSESSIVE COMPULSIVE DISORDER

OBSESSIVE COMPULSIVE DISORDER - Anna K. Morin, PharmD
BASICS
DESCRIPTION
• Obsessive compulsive disorder (OCD) is a psychiatric condition classified as an anxiety disorder in DSM-IV-R and characterized by obsessions (recurrent, intrusive thoughts, ideas, or images) and compulsions (repetitive, ritualistic behaviors or mental acts).
• System(s) Affected: Nervous
• Synonym(s): Obsessive compulsive neurosis
ALERT
Not to be confused with obsessive compulsive personality disorder
Geriatric Considerations
• Diagnosis rarely is made after age 50 years.
• Consider neurologic disorders in new-onset OCD in elderly patients.
Pregnancy Considerations
• Onset of OCD has been noted during postpartum period.
• Safety of medications has not been established during pregnancy or lactation.
Pediatric Considerations
• Child/adolescent onset in 33% of cases
• At this age, Males > Females (3:1)
• Insidious onset; consider brain insult in acute presentation of childhood OCD
EPIDEMIOLOGY
• Predominant age
- Mean age 22-36 years
- 1/3 of cases present by age 15 years
- 85% of cases present before age 35 years
- New cases rare after age 50 years
• Predominant sex
- Male = Female (males present at younger age)
Incidence
• 1.5-2.1% 1-year prevalence in adults
• 0.7% 1-year prevalence in children and adolescents
Prevalence
• 2.5% lifetime prevalence in adults
• 1-2.3% prevalence in children and adolescents
RISK FACTORS
Genetics
• Greater concordance in monozygotic twins
• Positive family history in ~20% of cases
• Evidence of a dominant or codominant mode of transmission
PATHOPHYSIOLOGY
See "Etiology."
ETIOLOGY
• Dysregulation of neurotransmitter, serotonin
• Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections
ASSOCIATED CONDITIONS
• Depression
• Panic disorder
• Social phobia
• Phobia
• Tourette syndrome
• Substance abuse
• Eating disorder
• Body dysmorphic disorder


DIAGNOSIS
(1,3,4) [A]
SIGNS AND SYMPTOMS
• Obsessions and compulsions cause marked distress, are time consuming (>1 hour per day) and cause significant occupational/social impairment.
• Patients know obsessions come from their own minds and are not imposed from outside (as in thought insertion).
• Compulsions are designed to relieve the anxiety of obsessions; they are not inherently enjoyable ("ego dynastic") and do not result in completion of a useful task.
• Common obsessive themes
- Harm (i.e., being responsible for an accident)
- Doubt (i.e., whether doors or windows locked or iron turned off)
- Blasphemous thoughts (i.e., in a devoutly religious person)
- Contamination, dirt, or disease
- Symmetry or orderliness
• Common rituals or compulsions
- Hand washing, cleaning
- Checking
- Counting
- Hoarding
- Ordering, arranging
- Repeating
• Neither obsessions nor compulsions are related to another mental disorder (i.e., thoughts of food in presence of eating disorder).
• 80-90% of patients with OCD have obsessions and compulsions.
• 10-19% of patients are pure obsessional.
Physical Exam
Dermatologic problems caused by excessive washing may be observed.
TESTS
• Yale Brown obsessive-compulsive scale (Y-BOCS)
• Maudsley obsessive-compulsive inventory (MOCI)
• Children's Yale Brown obsessive-compulsive scale (CY-BOCS)
Lab
No diagnostic laboratory findings identified
Imaging
Positron emission tomography (PET) scan
• Abnormal metabolism in frontal cortex and caudate nuclei (not generally available other than in research centers)
Diagnostic Procedures/Surgery
Psychiatric interview
DIFFERENTIAL DIAGNOSIS
• Not to be confused with obsessive compulsive personality disorder (see "Differential Diagnosis")
• Impulse control disorders
- Compulsive gambling, sex, or substance abuse: The "compulsive" behavior is not in response to obsessive thoughts, and patient derives pleasure from the activity.
• Depression
• Brooding, but ideas not as senseless as OCD
• Schizophrenia
- Patient perceives thought to be true and coming from an external source.
• Obsessive compulsive personality disorder
- In personality disorder, traits are "ego syntonic." Traits include perfectionism, preoccupation with detail, trivia, or procedure and regulation. Patient tends to be rigid, moralistic, and stingy. Often rewarded in patient's job as desirable traits.
• Generalized anxiety, phobic disorders, separation anxiety
- Similar response of heightened anxiety, but presence of obsessions or rituals clarifies OCD diagnosis.
• Anxiety disorder due to general medical condition
- It may be that obsessions or compulsions are assessed to be a direct physiologic consequence of a general medical condition.
TREATMENT
(2,3,4)[A]
GENERAL MEASURES
• Combined medications and cognitive behavior therapy (CBT) is most effective
• Psychiatric referral for CBT (in vivo exposure and prevention of compulsions)
• Family psychoeducation
• Parent behavior management training if patient with OCD is a child or adolescent
MEDICATION (DRUGS) (2,3,4)[A]
First Line
• Adequate trial at least 10-12 weeks
• Optimal doses may exceed typical doses for depression
• Selective serotonin reuptake inhibitor (SSRI), fluoxetine (Prozac)
- Adults: Begin 20 mg/d every morning and increase every 4-6 weeks to obtain maximal response. Dose range: 20-80 mg/d.
- Children: Begin with 10 mg/d every morning and increase every 4-6 weeks to obtain maximal response. Dose range: 20-60 mg/d.
• SSRI, sertraline (Zoloft)
- Adults: Begin with 50 mg/d and increase every 4-7 days until response. Dose range: 50-200 mg/d; may divide if above 100 mg/d.
- Children: Begin with 25 mg/d; increase in 25-mg increments until clinical response. Dose range: 50-200 mg/d.
• SSRI, paroxetine (Paxil)
- Adults: Begin with 20 mg/d; increase every 4-7 days in 10-mg increments until maximal clinical response. Dose range: 40-60 mg/d.
- Children: Safety and efficacy have not been established for OCD.
• SSRI, fluvoxamine (Luvox)
- Adult: Begin with 100 mg/d and increase every 4-7 days in 50-mg increments until clinical response. Dose range: 200-300 mg/d.
- Children (8-17 years): Begin with 25 mg/d; increase every 4-7 days in 25-50 mg increments until clinical response. Dose range: 50-200 mg/d.
Second Line
• Try switch to another SSRI
• Tricyclic, clomipramine (Anafranil)
- Adults: Begin with 25 mg/d; increase gradually to 100 mg over 1st 2 weeks, then to 250 mg (maximum dose) over next several weeks, as tolerated.
- Children: Begin with 25 mg/d over 1st 2 weeks as in adults, then titrate, as tolerated, up to 3 mg/kg or 200 mg/d (whichever is smaller) over the next several weeks.
• Contraindications
- Suicidal ideation and behavior or worsening depression; increased risk, particularly in children and adolescents, during 1st few months of therapy with antidepressants
- Absolute SSRI contraindications
 Hypersensitivity to the selective serotonin reuptake inhibitors
 Within 14 days of monoamine oxidase (MAO) inhibitor
- Relative SSRI contraindications
 Severe liver impairment
 Seizure disorders (lowers seizure threshold)
- All SSRIs pregnancy category C, except paroxetine, which is pregnancy category D
- Clomipramine is a tricyclic antidepressant and carries the same contraindications as drugs in that class
 Tricyclic class of antidepressants dangerous in overdose.
- Absolute clomipramine contraindications
 Within 6 months of myocardial infarction
 Narrow-angle glaucoma
 3rd-degree atrioventricular (AV) block
 Within 14 days of MAO inhibitor
- Relative clomipramine contraindications
 Prostatic hypertrophy (urinary retention)
 Seizure disorder (lowers seizure threshold)
 1st- or 2nd-degree AV block, bundle branch block, and CHF (proarrhythmic effect)
 Pregnancy category C
• Precautions
- A drug should to be taken for a minimum of 10 weeks before considering it a treatment failure; could be several months before peak efficacy is seen.
- Because patients with OCD may have concomitant depression, suicide potential must be assessed.
- Long 1/2-life of fluoxetine (>7 days) may be troublesome if patient has an adverse reaction.
- May cause drowsiness and dizziness when therapy is initiated. Warn patients about driving and heavy-equipment hazards.
• Significant possible interactions
- Clomipramine
 Not yet fully elucidated
 May interfere with guanethidine, clonidine
 Serum level increased if used concomitantly with haloperidol
 Probable plasma increase if used with cimetidine, fluoxetine, methylphenidate
 Increases serum level of phenobarbital
- Fluoxetine and sertraline cause increased concentrations of warfarin, phenytoin, carbamazepine, diazepam, tricyclic antidepressants, and neuroleptics
SURGERY
Neurosurgery (last resort)
FOLLOW-UP
DISPOSITION
Outpatient care
PROGNOSIS
• Chronic waxing and waning course in majority
• 24-33% fluctuating course
• 11-14% phasic with periods of remission
• 54-61% chronic progressive course
• Early onset a poor outcome predictor
COMPLICATIONS
• Depression in 1/3 of patients with OCD
• Avoidant behavior (phobic avoidance)
- Children may drop out of education
- Adults may become home-bound
• Anxiety and paniclike episodes associated with obsessions
PATIENT MONITORING
• Y-BOCS
• MOCI
REFERENCES
1. Diagnostic and Statistical Manual of Mental Disorders DSM-IV (Text Revision), 4th ed. Washington, DC: American Psychiatric Association, 2000.
2. Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry, 8th ed. Baltimore: Williams  Wilkins, 2004.
3. Jenike MA. Clinical practice: Obsessive-compulsive disorder. N Engl J Med. 2004;350:259-265.
4. Heyman I, Mataix D, Fineberg NA. Clinical review: Obsessive-compulsive disorder. Br Med J. 2006; 333:424-429.
MISCELLANEOUS
See also: Anxiety, depression