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A common, chronic condition, often associated with marked anxiety and depression,
characterized by obsessions & compulsions.
Obsessions/compulsions must cause distress or interfere with the person's social or
individual functioning (usually by wasting time), and should not be the result of another
psychiatric disorder.
At some point in the disorder, the person recognizes the symptoms to be excessive or
unreasonable.
Epidemiology
LTP: 2-3%
M:F = 1:1
Age: Adolescence/ Early adulthood, 70% before 25 Y
FH: 35% 1st Degree
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DSM IV Diagnostic Criteria
A: Obsessions: Thoughts, Images, Impulses that are:
Recurrent, persistent, regarded by ptn as intrusive & inappropriate, cause marked anxiety
Not simply excessive worries about real life problems.
Ptn recognizes them as product of his own mind & senseless & attempts to resist them.
Compulsions: Repetitive behaviors (hand washing, ordering), mental acts (praying, count)
Clinical Features
Checking (63%),
Washing (50%),
Contamination (45%),
Doubting (42%),
Bodily fears (36%),
Counting (36%),
Insistence on symmetry (31%),
Aggressive thoughts (28%).
Comorbidity
Depressive disorder (70%),
Alcohol- and drug-related disorders,
Social phobia,
Specific phobia,
Panic disorder,
Eating disorder,
Tic disorder
Associations
Avoidant, dependent, histrionic traits (40% of cases),
Anankastic/obsessive-compulsive traits (15%) prior to disorder.
In schizophrenia, 45% of patients may present with symptoms of OCD (schizo-obsessive
poorer prognosis).
Differential Diagnosis
Normal (but recurrent) thoughts, worries, or habits;
Anankastic PD/ OCDPD,
Schizophrenia;
Phobias;
Depressive disorder;
Hypochondriasis;
Body dysmorphic disorder;
Trichotillomania.
Aetiology
Neurochemical:
Dysregulation of the 5HT system, or 5HT/DA interaction.
Immunological:
Cell-mediated autoimmune factors may be associated (e.g. against basal ganglia peptides).
Imaging CT and MRI:
bilateral reduction in caudate size. PET/SPECT: hyper metabolism in orbitofrontal gyrus and
basal ganglia (caudate nuclei) that normalizes following successful treatment (either
pharmacological or psychological).
Genetic:
Suggested by family and twin studies (35% of first-degree relatives affected, MZ: 50-80% DZ:
25%.).
Psychological:
Defective arousal system and/or inability to control unpleasant internal states.
Obsessions are conditioned (neutral) stimuli, associated with an anxiety-provoking event.
Compulsions are learned (and reinforced) as they are a form of anxiety reducing avoidance.
Psychoanalytical:
Regression from Oedipal stage to pre-genital anal-erotic stage of development as a defense
against aggressive or sexual (unconscious) impulses.
Associated defenses:
Isolation,
Undoing,
Reaction formation.
Management
Drugs better > PT
Psychotherapy
Supportive: valuable (including family members, use of groups);
Psychoanalytical: no unequivocal evidence of effectiveness (insight-orientated
psychotherapy may be useful in some patients).
Behavioral therapy: Response prevention useful in ritualistic behavior; thought stopping
may help in ruminations; exposure techniques for obsessions.
Cognitive therapy so far not proven effective.
Pharmacological:
Antidepressants:
o SSRIs: fluoxetine, fluvoxamine, sertraline, or paroxetine should be considered first-
line (no clear superiority of any one agent, high doses usually needed e.g. 40-60 mg
fluoxetine, Allow at least 4-12 wks for treatment response, Regard as a long-term).
o Clomipramine: (e.g. 200-300 mg) has specific anti-obsessional action (first-or
second-line choice).
Augmentative strategies:
o Buspirone if marked anxiety;
o Antipsychotic (risperidone, haloperidol, pimozide) if psychotic features, tics, or
schizotypal traits.
o Lithium if marked depression.
Physical:
o ECT consider if patient suicidal or severely incapacitated.