Obsessive-compulsive disorder

Last updated: November 21, 2022

Summarytoggle arrow icon

Obsessive-compulsive disorder (OCD) is characterized by persistent and recurring thoughts, urges, or images (obsessions) that lead to repetitive behaviors or mental acts (compulsions). Since obsessions are experienced as intrusive and involuntary as well as undesirable and unpleasurable, they generally cause anxiety or distress. While compulsive actions are generally not experienced as pleasurable, their performance may provide relief from the distress and anxiety caused by an obsession. At the same time, however, compulsions are, like the obsessions that trigger them, uncontrollable as well as time-consuming and therefore cause distress and impairment of function. Comorbidity with anxiety, mood, and tic disorders is common. Therapy typically involves cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs).

  • Sex: (female individuals slightly more affected in adulthood, male individuals slightly more affected in childhood)
  • Age of onset: average is 20 years of age [1]
  • Lifetime prevalence: approx. 2% [2]

Epidemiological data refers to the US, unless otherwise specified.

The etiology of OCD is multifactorial. Factors that have been associated with OCD development include:

  • Genetic: familial transmission
  • Neurobiological: abnormalities in the orbitofrontal cortex, anterior cingulate cortex, and striatum
  • Serotonin level imbalance may play a role.
  • Infection: pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)
  • Psychological trauma

Symptoms

  • Ego-dystonic: behavior or thought patterns that are inconsistent with or repulsive to one's sense of self
  • Obsessions: distressing thoughts, emotions, and/or sensations that are recurring and intrusive
  • Compulsions: repetitive actions to provide relief from anxiety caused by obsessions (can take up a substantial amount of time)

Comorbidities

References:[3]

Diagnostic criteria (DSM-5)

  • Obsessions and/or compulsions
    • Obsessions (e.g., thoughts about contamination, harm, or symmetry) defined by both:
      • Recurrent/persistent, intrusive thoughts, or urges that cause anxiety or distress
      • Attempts to suppress these thoughts or urges
    • Compulsions (e.g., repeatedly washing hands, opening and closing a door multiple times, or rearranging objects on a desk) defined by both:
      • Repetitive behaviors or mental exercises; (e.g., counting, repeating words) that the individual feels compelled to perform in order to relieve anxiety brought upon by the obsessions.
      • These behaviors or mental actions may be performed in an attempt to prevent some perceived dreaded event, though they tend to be excessive and not connected in any realistic way to the event.
  • Time-consuming (e.g., ≥ 1 hour/day), or result in significant distress/impairment (school, work)
  • Not due to substance-use disorders or another medical condition
  • Not due to another mental disorder (e.g., anxiety disorders, eating disorders)
Differential diagnoses of obsessive compulsive disorder
Type of disorder Characteristics
Obsessive compulsive disorder
  • Intrusive thoughts, images, and urges that trigger repetitive, compulsive behavior
  • Ego-dystonic: behavior patterns are not in agreement with ideal self-image
Obsessive-compulsive personality disorder
  • Excessive perfectionism and rigid control regarding real-life concerns
  • Behavior is ego-syntonic, meaning that the affected individual's thought and behavior patterns are congruent with their self-image and therefore they do not perceive them as wrong.
Generalized anxiety disorder
  • Recurrent thoughts revolve around real-life concerns, e.g., work, as opposed to the obsessions in OCD, which tend to be of an irrational nature.
Hoarding disorder
  • Difficulty discarding belongings
Tic disorder
Body dysmorphic disorder
Trichotillomania
  • Compulsive behavior is limited to hair pulling in the absence of obsessions.

Hoarding disorder

  • Epidemiology
  • Diagnostic criteria (DSM-5)
    • Persistent urge to keep items and distress associated with getting rid of items
    • Difficulty discarding belongings
    • Accumulation of belongings → intended use of belongings is compromised and living areas are cluttered
    • Clinically relevant impairment in functioning and/or clinically relevant distress
    • Not explained by other medical conditions (e.g., brain injuries) or mental illness (e.g., OCD)
  • Treatment

Body dysmorphic disorder (BDD)[4][5]

  • Definition: an excessive preoccupation with perceived flaws or defects in appearance
  • Epidemiology
    • Prevalence: estimated to affect about 1 in 50 people in the general population [6]
    • [7]
    • Mean age of onset: ∼ 17 years
  • Diagnostic criteria (DSM-5)
    • Persistent preoccupation with one or more perceived flaws in physical appearance that are mild or imperceivable to others.
    • Repetitive behaviors (e.g., constantly checking the mirror, skin picking, excessive grooming) or thoughts about one's appearance (e.g., comparing oneself to others)
    • Clinically relevant impairments in functioning and/or clinically relevant distress
    • In order to conclusively diagnose BDD, an eating disorder that might also explain the symptoms must be excluded
  • Subtype: muscle dysmorphia
    • Patients may use anabolic steroids or other potentially dangerous substances to increase muscle mass.
    • Occurs almost exclusively in men
    • A preoccupation with one's body not being muscular, large, or lean enough
  • Treatment
    • Initial approach
      • Educate patients about BDD and available treatment options.
      • Evaluate the patients' distress, level of insight, and impairment in function
        • Good insight: patients perceive their beliefs as definitely/probably false
        • Poor insight: patients perceive their beliefs as probably true
        • Absent insight or delusional beliefs: patient perceive their beliefs as true
      • Avoid making (positive or negative) remarks on the patient's appearance, challenging their beliefs, or dismissing their perceived flaw as minor/imagined.
      • Consider involving family members, if appropriate.
      • Cosmetic interventions are not recommended in patients with BDD.
    • First-line treatment: selective serotonin reuptake inhibitors (SSRIs) and/or CBT

Trichotillomania (hair-pulling disorder)

The differential diagnoses listed here are not exhaustive.

A combination of pharmacotherapy and psychotherapy has been proven effective in the treatment of OCD.

OCD in pregnant individuals and parents postpartum

  • Epidemiology: new-onset OCD in ∼ 4 % of pregnant patients [8]
  • Clinical features: For general information, see “Clinical features” above.
Clinical features of OCD in pregnant individuals and parents postpartum
Examples of obsessions Example of resulting compulsions
During pregnancy
  • Repeated provocation of fetal movement (e.g., poking the belly) to ensure the fetus is still alive
  • Contamination of the fetus (e.g., by bacteria)
  • Excessive washing and cleaning
  • Aggressive obsession symptoms relating to the fetus (i.e., persistent thoughts of being responsible for harm to the fetus, whether intentional or not)
  • Hiding all objects that might be used to harm the fetus
  • Avoiding driving for fear of an accident
Postpartum
  • Repeated checking on the infant (esp. at night)
  • Fear of malpositioning the baby
  • Excessive washing and cleaning of the infant
  • Aggressive obsession symptoms relating to the fetus (i.e., persistent thoughts of being responsible for harm to the infant, whether intentional or not; incl. intrusive sexual thoughts)
  • Avoidance of being alone with the infant or changing diapers
  • Poor parenting skills or criticism of parenting skills from others
  • Excessive research on the topic of parenting
  • Avoiding parenting groups due to fear of criticism
  1. Schofield CA, Battle CL, Howard M, Ortiz-Hernandez S. Symptoms of the anxiety disorders in a perinatal psychiatric sample: a chart review.. J Nerv Ment Dis. 2014; 202 (2): p.154-60. doi: 10.1097/NMD.0000000000000086 . | Open in Read by QxMD
  2. Öst LG, Havnen A, Hansen B, Kvale G. Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993-2014.. Clin Psychol Rev. 2015; 40 : p.156-69. doi: 10.1016/j.cpr.2015.06.003 . | Open in Read by QxMD
  3. Simpson HB, Foa EB, Liebowitz MR, et al. Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial.. JAMA psychiatry. 2013; 70 (11): p.1190-9. doi: 10.1001/jamapsychiatry.2013.1932 . | Open in Read by QxMD
  4. Seibell PJ, Hollander E. Management of obsessive-compulsive disorder.. F1000prime reports. 2014; 6 : p.68. doi: 10.12703/P6-68 . | Open in Read by QxMD
  5. Zohar AH. The Epidemiology of Obsessive-Compulsive Disorder in Children and Adolescents. Child Adolesc Psychiatr Clin N Am. 1999; 8 (3): p.445-460. doi: 10.1016/s1056-4993(18)30163-9 . | Open in Read by QxMD
  6. Brady CF. Presentation and treatment of complicated obsessive-compulsive disorder. J Clin Psychiatry. 2014; 75 (3): p.e07. doi: 10.4088/JCP.13023tx2c . | Open in Read by QxMD
  7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. undefined. 2013 . doi: 10.1176/appi.books.9780890425596 . | Open in Read by QxMD
  8. Veale D, Singh A. Understanding and treating body dysmorphic disorder. Indian J Psychiatry. 2019; 61 (7): p.131. doi: 10.4103/psychiatry.indianjpsychiatry_528_18 . | Open in Read by QxMD
  9. Prevalence of BDD. https://bdd.iocdf.org/professionals/prevalence/. . Accessed: October 27, 2022.
  10. Koran LM, Abujaoude E, Large MD, Serpe RT. The Prevalence of Body Dysmorphic Disorder in the United States Adult Population. CNS Spectr. 2008; 13 (4): p.316-322. doi: 10.1017/s1092852900016436 . | Open in Read by QxMD

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