Obsessive-compulsive Disorder (OCD)

Overview

Definition

Obsessive-compulsive disorder (OCD) is a heterogeneous disorder characterized by obsessions and compulsions that impair daily function. 

• Obsessions:
  • Recurrent thoughts, images, or urges that are intrusive and recognized as unwanted, causing significant anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and distress 
  • Some common obsessive concerns include fear of contamination or germs, obsessions with symmetry/order, and thoughts of harm to self or others.
•  Compulsions:
  • Repetitive behaviors or mental acts that the individual is driven to perform in relation to an obsession
  • Some common compulsive behaviors include repeating words silently, constant checking on something, hoarding, and extreme washing/cleaning.

Epidemiology

• Lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of 2%–3% worldwide 
• Women have a slightly higher prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency than men
• More males are affected in childhood.
• Mean Mean Mean is the sum of all measurements in a data set divided by the number of measurements in that data set. Measures of Central Tendency and Dispersion age of onset is 19.5 years.
• Onset in childhood or adolescence is frequently associated with a stressful event.
• Most of those diagnosed with OCD also meet the criteria for other psychiatric disorder(s):
  • ⅔ have a history of another anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder (e.g., panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder).
  • Up to 30% have a lifetime history of tic disorder.
  • High comorbidity with major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder

Etiology

Genetic

• Accounts for more of the variance in childhood-onset cases
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who have 1st-degree relatives with OCD are 3–5 times more likely to suffer from OCD themselves.
• Exact genes Genes A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. DNA Types and Structure involved are still unknown.

Environment

• Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease (PANDAS):
  • Syndrome associated with OCD brought on by group A streptococcal infection
  • Believed to be an autoimmune reaction to the infection, leading to damage in the basal ganglia Basal Ganglia Basal ganglia are a group of subcortical nuclear agglomerations involved in movement, and are located deep to the cerebral hemispheres. Basal ganglia include the striatum (caudate nucleus and putamen), globus pallidus, substantia nigra, and subthalamic nucleus. Basal Ganglia: Anatomy
• Traumatic events (stress)

Biological

• Dysfunction in the cortico-striatal-thalamo-cortical (CSTC) pathway:
  • Deep-brain stimulation in certain areas reduces symptoms of those with therapy-refractory OCD
  • Disruption creates OCD behavior in animal models.
  • New-onset OCD found in those with neurologic lesions (e.g., stroke, traumatic brain injury Traumatic brain injury A form of acquired brain injury which occurs when a sudden trauma causes damage to the brain. Le Fort Fractures)
• Hormonal effects can exacerbate or produce OCD, as seen in premenstrual and/or postpartum periods.
• Abnormalities in serotonergic, dopamine Dopamine One of the catecholamine neurotransmitters in the brain. It is derived from tyrosine and is the precursor to norepinephrine and epinephrine. Dopamine is a major transmitter in the extrapyramidal system of the brain, and important in regulating movement. Receptors and Neurotransmitters of the CNS, and glutamatergic neurotransmission Neurotransmission The communication from a neuron to a target (neuron, muscle, or secretory cell) across a synapse. In chemical synaptic transmission, the presynaptic neuron releases a neurotransmitter that diffuses across the synaptic cleft and binds to specific synaptic receptors, activating them. The activated receptors modulate specific ion channels and/or second-messenger systems in the postsynaptic cell. In electrical synaptic transmission, electrical signals are communicated as an ionic current flow across electrical synapses. Synapses and Neurotransmission are suspected, though findings are still inconclusive.

Clinical Presentation and Diagnosis

Clinical features

• Obsessions and compulsions impair activities of daily living because they are time-consuming, intrusive, and cause displeasure.
• Majority of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have both obsessions and compulsions.
• Obsessions may have specific identifiable themes, with related compulsion(s):
  • Fear of contamination (obsession) and resultant behavior of repetitive handwashing (compulsion)
  • Need for order or symmetry (obsession) and arranging items again and again (compulsion)
  • Fear of harm on self or others (obsession), and the compulsion of repeated checking (e.g, making sure doors are locked)
  • Religious obsessions (too much focus Focus Area of enhancement measuring < 5 mm in diameter Imaging of the Breast on religion) and related compulsion (excessive praying)
  • Sexual obsession (thoughts of improper or disturbing sexual acts) and avoiding interaction with people due to fear of acting on those thoughts
• Compulsions:
  • Performed to alleviate the stress of the obsession (e.g., wash hands repeatedly to reduce contamination)
  • Acts are often out of proportion or unrealistic, however (e.g., showering for hours to reduce contamination or rearranging items to prevent harm).
• Course and associated manifestations:
  • Onset is gradual.
  • Strongly associated with suicidal thoughts
  • In the extreme, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship display avoidant behavior (e.g., restricting exposure Exposure ABCDE Assessment outside for fear of contamination).
  • Many patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have beliefs of:
    • Grand responsibility and overinflation of threat
    • Perfectionism Perfectionism A personality trait characterized by a person’s striving for flawlessness and setting excessively high performance standards, accompanied by overly critical self-evaluations and concerns regarding others’ evaluations. Cluster C Personality Disorders
  • Patient insight Insight Psychiatric Assessment varies as well, with ≤ 4% having no insight Insight Psychiatric Assessment (patient is convinced that OCD beliefs are real and true).
• The Yale-Brown Obsessive Compulsive Scale Scale Dermatologic Examination (Y-BOCS) is a clinician-rated scale Scale Dermatologic Examination for assessing the severity of obsessive and compulsive symptoms.

DSM-V diagnostic criteria for OCD

• Presence of obsessions, compulsions, or both: 
  • Definition of obsessions:
    • Recurrent thoughts, images, or urges that are intrusive and recognized as unwanted, causing significant anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and distress
    • Attempts are made by the individual to avoid, ignore, or suppress such thoughts, images, or urges, or to offset them with another thought or through an action (compulsion).
  • Definition of compulsions:
    • Repetitive behaviors or mental acts that the individual is compelled to perform in response to an obsession or rigid personal rules
    • The behaviors or mental acts are aimed at preventing or reducing anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, or preventing an event/situation; however, behaviors are not realistically or proportionately connected to the event/situation.
• The obsessions and/or compulsions are time-consuming and impair daily activities of life (social or occupational impairment).
• Drug use or other medical conditions must be ruled out as causes.
• Symptoms are not better explained by any other psychiatric disorder.

Management

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

• CBT: 
  • Uses the technique of exposure Exposure ABCDE Assessment and response prevention:
    • Repeated and prolonged exposure Exposure ABCDE Assessment to feared situation
    • Abstaining from compulsive behavior
  • Obsessive thoughts without compulsions are more difficult to treat; habituation training or thought stopping is used instead.
  • Thought stopping:
    • A distraction technique in which a sudden sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology stimulus is applied to distract the patient from obsessional thought
    • Patient is taught to identify the obsession (e.g., fear of severe illness from handshakes) and derail it (e.g., patient is instructed to say “stop” when the thought occurs).
• Group therapy Group therapy A form of therapy in which two or more patients participate under the guidance of one or more psychotherapists for the purpose of treating emotional disturbances, social maladjustments, and psychotic states. Psychotherapy has shown some efficacy.
• Family education and support are important.

Pharmacotherapy

• SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants:
  • Mainstays of drug treatment
  • Higher dosages are often required for treatment of OCD than depression.
• Tricyclic antidepressants Tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants ( TCAs TCAs Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants) specifically clomipramine Clomipramine A tricyclic antidepressant similar to imipramine that selectively inhibits the uptake of serotonin in the brain. It is readily absorbed from the gastrointestinal tract and demethylated in the liver to form its primary active metabolite, desmethylclomipramine. Tricyclic Antidepressants, are also good initial treatment options. 
• Augmentation with antipsychotic Antipsychotic Antipsychotics, also called neuroleptics, are used to treat psychotic disorders and alleviate agitation, mania, and aggression. Antipsychotics are notable for their use in treating schizophrenia and bipolar disorder and are divided into 1st-generation antipsychotics (FGAs) and atypical or 2nd-generation antipsychotics. First-Generation Antipsychotics medication (e.g., risperidone Risperidone A selective blocker of dopamine D2 receptors and serotonin 5-HT2 receptors that acts as an atypical antipsychotic agent. It has been shown to improve both positive and negative symptoms in the treatment of schizophrenia. Second-Generation Antipsychotics) has shown efficacy in cases where SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants or clomipramine Clomipramine A tricyclic antidepressant similar to imipramine that selectively inhibits the uptake of serotonin in the brain. It is readily absorbed from the gastrointestinal tract and demethylated in the liver to form its primary active metabolite, desmethylclomipramine. Tricyclic Antidepressants are unsuccessful.
• Best clinical outcome is combination of SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants with behavioral therapy.

Other therapies

• Deep-brain stimulation: 
  • For treatment-refractory OCD
  • Surgical technique where electrodes Electrodes Electric conductors through which electric currents enter or leave a medium, whether it be an electrolytic solution, solid, molten mass, gas, or vacuum. Electrocardiogram (ECG) are implanted in specific brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification locations
  • May improve the efficacy of pharmacotherapy and psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy following successful procedures
  • Adverse effects include development of seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures, infection, and bleeding.
• Other invasive interventions (experimental):
  • Neurosurgical ablation
  • Transcranial magnetic stimulation Transcranial magnetic stimulation A technique that involves the use of electrical coils on the head to generate a brief magnetic field which reaches the cerebral cortex. It is coupled with electromyography response detection to assess cortical excitability by the threshold required to induce motor evoked potentials. This method is also used for brain mapping, to study neurophysiology, and as a substitute for electroconvulsive therapy for treating depression. Induction of seizures limits its clinical usage. Major Depressive Disorder

Differential Diagnosis

• Obsessive-compulsive personality disorder Obsessive-Compulsive Personality Disorder Cluster C Personality Disorders: a preoccupation Preoccupation Body Dysmorphic Disorder with orderliness, perfectionism Perfectionism A personality trait characterized by a person’s striving for flawlessness and setting excessively high performance standards, accompanied by overly critical self-evaluations and concerns regarding others’ evaluations. Cluster C Personality Disorders, and mental and interpersonal control at the expense of flexibility and efficiency. The patient follows rigid rules and often has extreme devotion to work at the expense of relationships. The excessive preoccupation Preoccupation Body Dysmorphic Disorder is considered to be maladaptive. While the obsessive component is similar to OCD, there are no unwanted urges or thoughts, or irrational recurrent behaviors. 
• Hoarding disorder: persistent difficulty parting with possessions because of a perceived need to save them. The patient is distressed at the thought of discarding their possessions. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship can have obsessions (e.g., concerns of harm or feeling of being incomplete) that make hoarding become a compulsive behavior (collecting old newspapers for fear that the information is needed to prevent harm). In these cases, OCD is the diagnosis.
• Specific phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder: anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder characterized by significant fear of a particular situation or object. This fear leads to avoidance behavior Avoidance behavior Specific Phobias. Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder occurs upon exposure Exposure ABCDE Assessment to stimulus but is also triggered even when hearing the name of the stimulus and in anticipation Anticipation The apparent tendency of certain diseases to appear at earlier age of onset and with increasing severity in successive generations. Huntington Disease of the stimulus. Compared with OCD, specific phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder is not associated with rituals or repetitive acts.
• Tourette syndrome Tourette Syndrome A neuropsychological disorder related to alterations in dopamine metabolism and neurotransmission involving frontal-subcortical neuronal circuits. Both multiple motor and one or more vocal tics need to be present with tics occurring many times a day, nearly daily, over a period of more than one year. The onset is before age 18 and the disturbance is not due to direct physiological effects of a substance or another medical condition. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning. Tics and Tourette Syndrome: tics Tics Habitual, repeated, rapid contraction of certain muscles, resulting in stereotyped individualized actions that can be voluntarily suppressed for only brief periods. They often involve the face, vocal cords, neck, and less often the extremities. Examples include repetitive throat clearing, vocalizations, sniffing, pursing the lips, and excessive blinking. Tics tend to be aggravated by emotional stress. When frequent they may interfere with speech and interpersonal relations. Conditions which feature frequent and prominent tics as a primary manifestation of disease are referred to as tic disorders. Tics and Tourette Syndrome and related diseases represent a set of neurobehavioral disorders of childhood that are characterized by sudden and repeated muscle movements sometimes accompanied by sounds or vocalizations. Tourette syndrome Tourette Syndrome A neuropsychological disorder related to alterations in dopamine metabolism and neurotransmission involving frontal-subcortical neuronal circuits. Both multiple motor and one or more vocal tics need to be present with tics occurring many times a day, nearly daily, over a period of more than one year. The onset is before age 18 and the disturbance is not due to direct physiological effects of a substance or another medical condition. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning. Tics and Tourette Syndrome is a severe form with symptoms lasting more than 1 year and involving both motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and vocal tics Tics Habitual, repeated, rapid contraction of certain muscles, resulting in stereotyped individualized actions that can be voluntarily suppressed for only brief periods. They often involve the face, vocal cords, neck, and less often the extremities. Examples include repetitive throat clearing, vocalizations, sniffing, pursing the lips, and excessive blinking. Tics tend to be aggravated by emotional stress. When frequent they may interfere with speech and interpersonal relations. Conditions which feature frequent and prominent tics as a primary manifestation of disease are referred to as tic disorders. Tics and Tourette Syndrome. These repetitive behaviors are not compulsions as they are not aimed at neutralizing obsessions. Obsessive-compulsive disorder and Tourette syndrome Tourette Syndrome A neuropsychological disorder related to alterations in dopamine metabolism and neurotransmission involving frontal-subcortical neuronal circuits. Both multiple motor and one or more vocal tics need to be present with tics occurring many times a day, nearly daily, over a period of more than one year. The onset is before age 18 and the disturbance is not due to direct physiological effects of a substance or another medical condition. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning. Tics and Tourette Syndrome frequently co-occur.