Obsessive-compulsive disorder

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
  • Opposite of ego-syntonic
    • Behavior patterns are in agreement with one's sense of self
    • Seen in obsessive-compulsive personality disorder
• 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

• Anxiety disorders
• Depressive disorders
• Bipolar disorders
• Tic disorders
• Tourette syndrome
• Personality disorders
• Schizophrenia or schizoaffective disorder

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)

Hoarding disorder

• Epidemiology
  • Point prevalence: ∼ 2–6%
  • ♂ > ♀
• 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
  • Cognitive behavioral therapy
  • If CBT fails: trial of SSRI (off-label use)

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)

• Definition: an irresistible compulsion to pull out one's hair
• Epidemiology
  • Lifetime prevalence: ∼ 2%
  • ♀ >> ♂
  • Onset is usually in adolescence following a stressful event, but can happen at any age.
  • ↑ Incidence of comorbid major depressive disorder, OCD, and excoriation disorder
• Clinical features
  • Hair loss, most commonly involving the scalp, eyebrows, or eyelashes
  • The pattern of hair loss is usually patchy, with hair of different lengths.
• Diagnostic criteria (DSM-5)
  • Hair loss due to recurrent pulling out of one's hair
  • Repeated attempts to stop this behavior
  • Results in significant distress/impairment (e.g., difficulty performing in school or at work)
  • Not due to another medical or mental disorder (e.g., skin disease, body dysmorphic disorder)
• Differential diagnosis: alopecia
• Treatment
  • Cognitive behavioral therapy
  • SSRIs

The differential diagnoses listed here are not exhaustive.

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

• Cognitive-behavioral therapy (CBT)
  • Cognitive therapy techniques
  • Exposure and response prevention
• Pharmacotherapy
  • Antidepressants
    • SSRIs are the preferred treatment (e.g., sertraline, paroxetine, fluoxetine, fluvoxamine).
    • Alternatively:
      • Tricyclic antidepressants with serotonergic action (e.g., clomipramine)
      • SNRIs (e.g., venlafaxine)
  • Atypical antipsychotics (e.g., risperidone, aripiprazole, quetiapine)

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.

• Diagnosis: See “Diagnostics” above.
• Management
  • First-line: CBT ^[9]
  • Alternatively; : pharmacologic treatment with selective serotonin reuptake inhibitors (SSRIs)
  • A combination of CBT and pharmacotherapy (e.g., SSRI) should be initiated in patients with severe symptoms (e.g., functional decline) or in patients with comorbidity (e.g., major depressive disorder, generalized anxiety disorder). ^[10]