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Obsessive Compulsive DisorderAka: OCD

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  1. Epidemiology
    1. Lifetime Prevalence: as high as 2.5%
    2. Onset: late adolescent or early adulthood
    3. Occurs equally in men and women
  2. Risk factors in childhood suggestive of OCD Development
    1. Separation anxiety
    2. Resistance to change or novelty
    3. Risk aversion
    4. Submissiveness
    5. Sensitivity
    6. Perfectionism
    7. Hyper-morality
    8. Ambivalence
    9. Excessive devotion to work
  3. Symptoms
    1. Obsessions
      1. Intrusive distressing thoughts, impulses, or images
        1. Contamination (50%)
        2. Pathologic doubt (42%)
        3. Somatic (33%)
        4. Need for symmetry (32%)
        5. Aggressive (31%)
        6. Sexual (24%)
      2. Obsessions are not related to real-life problems
      3. Attempts to ignore, suppress or neutralize obsessions
      4. Recognition that obsessions are product of own mind
    2. Compulsions
      1. Repetitive behaviors as a response to obsessions
        1. Checking (61%)
        2. Washing (50%)
        3. Counting (36%)
        4. Need to ask or confess (34%)
        5. Symmetry and precision (28%)
        6. Hoarding (18%)
        7. Praying
        8. Repeating words silently
      2. Compulsions are intended to reduce distress
        1. Not connected realistically to preventing obsession
        2. Excessive measures
  4. History: Sample Questions
    1. Do certain thoughts keep coming into your head?
      1. Is this despite your trying to keep the thoughts out?
      2. Do the thoughts make sense or do they seem absurd?
      3. What do you do to try to counteract these thoughts?
    2. Do you feel a need to do something over and over again?
      1. Is this despite your not wanting to do these things?
      2. Do these actions seem reasonable or excessive?
  5. Signs
    1. Raw chapped hands (constant hand washing)
    2. Unproductive hours spent on homework
    3. Erasure holes in test papers and school work
    4. Repeatedly asking the same question
    5. Persistent fear of illness
    6. Persistent fear that someone else will experience harm
    7. Difficulty leaving the house
    8. Recurrent tardiness
    9. Significant increase in laundry
    10. Unusually long time to get ready for bed or dressing
    11. Hoarding useless objects
    12. Peculiar patterns of walking or sitting
  6. Diagnosis
    1. Obsessions or Compulsions as described above
    2. Insight that obsessions or compulsions are excessive
    3. Impaired function
      1. Marked distress
      2. Time consuming (more than an hour per day)
      3. Interfere with patient's normal routine
      4. Interfere with occupation, education, relationships
    4. Not limited to an Axis I Diagnosis (examples follow)
      1. Eating disorder and preoccupation with food
      2. Substance Abuse and preoccupation with drugs
    5. Obsessions or Compulsions not due to secondary cause
      1. Not due to Substance Abuse
      2. Not due to underlying medical condition
  7. Differential Diagnosis
    1. Major Depression
    2. Generalized Anxiety Disorder
    3. Panic Disorder
    4. Hypochondriasis
    5. Tourette's Syndrome
    6. Schizophrenia
  8. Management: Medications
    1. Tricyclic Antidepressants (most effective)
      1. Clomipramine (Anafranil) 150 to 250 mg/day
    2. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. Fluoxetine (Prozac) 40 to 80 mg per day
      2. Fluvoxamine (Luvox) 200 to 300 mg per day
      3. Paroxetine (Paxil) 20 to 60 mg per day
      4. Sertraline (Zoloft) 50 to 200 mg per day
  9. Management: Behavioral Therapy (80-90% effective)
    1. Exposure and Desensitization over 10 week period
      1. Increasingly expose patient to avoided stimulus
    2. Response prevention
      1. Prevented from performing associated rituals
    3. Thought stopping
  10. Resources
    1. Obsessive-Compulsive Foundation, Inc
      1. Address: 90 Depot St. PO Box 70, Milford, CT 06460
      2. Phone: (203) 878-5669
  11. References
    1. APA (1994) DSM IV, APA, p. 417-23
    2. Black (1997) Resident Staff Physician 43(3):64-76
    3. Bagheri (1999) Am Fam Physician 59(8):2263
    4. Eddy (1998) Am Fam Physician 57(7):1623
    5. Rasmussen (1992) Psychiatr Clin North Am 15:743

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