17. Obsessive-Compulsive Disorders

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    7. OBSESSIVE-COMPULSIVE DISORD ERSRichard L. OSullivavt,M .D ., an d Michael A . lenike, M.D.

    1. Define obsessive compulsivedisorder.Obsessive-compulsive disorder (OCD) is classified in DSM-IV as an anxiety disorder mani-fested by either obsessions andlor compulsions that cause significant distress or dysfunction insocial or personal areas. Obsessions are thoughts and are defined as recurrent, persistent ideas,images, or impulses that are a significant source of distress or interfere with social or role function-ing. Compulsions are behaviors or mental acts that are repetitive, purposeful, and intentionaland performed in response to an obsession or according to certain rules or in a stereotypical fash-ion. The thoughts or behaviors cause distress, are resisted at least initially, do not form part of apsychosis, and are recognized as senseless. Anxiety is a central feature of OCD, and the repetitivebehaviors or mental acts are often a means to neutralize the distress associated with obsessions.2. Define obsessive compulsivepersonality disorder.Obsessive-compulsive personality disorder (OCPD) may be misdiagnosed as OCD or comorbidwith OCD. OCPD tends to be a chronic, pervasive condition embodying several traits, such as ob-sessive attention to detail, inflexibility, and perfectionism. Such characteristics differ from but maybe confused with the compulsive rituals found in OCD. Obsessive-compulsive personality disordercan be distinguished from OCD by the lack of obsessions, compulsions, rituals, and severe anxietythat are common to OCD. The cognitions and behaviors typical of OCD usually are very disturbing,or dystonic, to the patient, whereas the personality traits of OCPD generally are not dystonic. The

    symptoms of OCD frequently wax and wane in intensity; OCPD traits are relatively enduring.FEATURES OF OBSESSIVE-COMPULSIVE DISORDER*

    Either obsessions or compulsionsObsessionsRecurrent and persistent ideas, thoughts, impulses, or images that are experienced as intrusive and sense-Thoughts, impulses are not simply excessive worries about problems.Person attempts to ignore or suppress such thoughts or to neutralize them.Person recognizes that the obsessions are the product of his or her own mindCompulsionsRepetitive behaviors or mental acts performed in response to an obsession or rigidly applied rules.Behaviors are designed to neutralize or prevent distress or some dreaded event or situation, but are ex-Persons recognizes his or her behavior is excessive or unreasonable (except children).Obsessions/compulsionscause marked distress, are time-consuming (more than hr/day), or significantlyIf another axis I disorder is present, the content of the obsessions or compulsions is not restricted to it.Disturbanceis not due to the direct physiologic effects of a substance or general medical condition.

    less and cause marked anxiety or distress.

    cessive or not realistically connected with what they are meant to neutralize.

    interfere with the persons normal routine.

    FEATURES OF OBSESSIVE-COMPULSIVE PERSONALITY DISORDER.A pervasive pattern of perfectionism and inflexibility, beginning by early adulthood, present in variouscontexts

    plus85

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    86 Obsessive-Compulsive DisordersAt least 4 of the following:Preoccupations with details, rules, lists, order, organization, and schedules.Perfectionism that interferes with task completion.Excessive devotion to work and productivity to the exclusion of leisure activities and friendships.Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values.Unable to discard worn-out or worthless objects even when they have no sentimental value.Unreasonable insistence that others submit to his or her way of doing things.Miserly spending style toward self and others; money is viewed as something to be hoarded.Rigidity and stubbornness.

    DSM-IV criteria.Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Copyright1994American Psychiatric Association.3. How is obsessive compulsive personality disorder treated?Care should be taken to distinguish OCD from OCPD because treatments differ. Little evidence

    suggests that behavioral or pharmacologic treatments, which are effective for OCD, are useful in treat-ing OCPD. Traditional psychodynamic psychotherapy is often the treatment of choice for OCPD andmay be helpful over the long term, but controlled data about effective treatments for OCPD are lacking.4. When do everyday habitsor idiosyncrasies cross the linetobecome OCD or require treatment?Habits, idiosyncrasies, and compulsiveness are common human behaviors. Thoughts or behav-iors become maladaptive or may require treatment when they are sufficiently distressing or so time-consuming that they interfere with functioning.5. Is OCD a common problem?Yes. It affects 1-3 of populations in cross-cultural studies. It may begin at any age but mostcommonly becomes evident in early adulthood. Childhood cases are more common in boys thangirls, but overall in adults the disorder is more common in women.The clinical presentation in children and the elderly generally is similar to that in adults but mayrequire more diagnostic acumen for practitioners not familiar with OCD. For example, a child who is

    a slow learner because he or she has to keep rereading a sentence (a form of checking) may be misdi-agnosed as having a primary learning problem instead of OCD. Another example is a child who ap-pears to have a bladder problem because of frequent trips to the bathroom, when in fact contaminationobsessions drive the child to wash his hands compulsively. In older patients, anxious preoccupationswith physical symptoms, sometimes misinterpreted as ruminations, may actually be obsessions.6. When and how does OCD start?Obsessive-compulsive behaviors usually have existed for many years before they come to pro-fessional attention. Onset of symptoms generally is gradual but occasionally is abrupt. The mean ageof onset is approximately 22 years.OCD may start as intrusive thoughts that seem odd and frightening, such as violent images thatenter the mind. Such images are distressing and are resisted, at least initially. In addition, the thoughtsdo not feel as though they are voluntarily created, but are intruding into consciousness. OCD also maybegin as repetitive, ritualized behaviors that need to be done in the same way over and over.Frequently patients show more than one obsession or compulsion, and these may change over time.7. Describe some common OCD preoccupations and behaviors.Common obsessions include contamination, aggression, bodily fears, concerns about safety orharm, and need for exactness, completeness or symmetry. Compulsions frequently include checking,washing, repeating, counting, collecting, and hoarding. Compulsions usually are paired with obses-sions. Performance of a compulsion may temporarily relieve some of the anxiety generated by n ob-session. For example, after shaking hands or touching doorknobs, a person with contaminationobsessions may need to wash the hands repeatedly until he or she feels clean and the anxiety associatedwith the obsession lessens, at least temporarily. If a person has concerns about safety or harm to

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    Obsessive-Compulsive Disorders 87others, he or she may n eed to recheck that nothing terrible has happened; f or example, by repeatedlycalling people o r checking behind the car to see that no o ne has been run over. Su ch behaviors can beextremely time-consuming, sometimes taking up much of a persons day, and may have a severe,deleterious impact on functioning of the individual and family.8. When is misdiagnosis likely to occur in patients with OCD?A particularly important clinical problem is the d evelopment of postpartum OCD , which m ay beacute and severe in onset. It is easily confused with o r dismissed as normal anxieties of motherhoo d. Inaddition, severe or bizarre obsessions may be misdiagnosed as psychotic symp toms, particularly inpeople w ith a psychotic disorder. Attention should be paid to the potential for misdiagnosis in this pop-ulation as well. (See Question 14.)9. What are current theories about the pathophysiology of OCD?Whereas early literature referred first to dem ons, then to psychodynamic influences as the gene-sis of O CD , growing evidence suggests a neurobiologic basis. Family studies sugg est that at least

    some forms of OCD have a familial predisposition. Neuropsychological assessments of groups ofpatients with OCD demonstrate abnormalities. Structural and functional neuroimaging studies im-plicate basal ganglia struc tures, especially the striatum, as w ell as orbitofrontal hyperactivity in thepathophysiology of OCD. A failure of brain development has been suggested by the finding s of in-creased gray matter and decreased white matter in OC D patients compared w ith normal controls.The role of environmental influences in the development and expression of OC D is not clear.10. What disorders possibly are related to OCD?trum of OC D disorders:Several disorders bear some similarities to OCD and are commonly considered within a spec-Trichotillomania (compulsive or repetitive hair pulling)

    Bod y dy smorphic disorder (obsession with an imagined o r exaggerated defect in appearance)Tourettes syndrome (motor and vocal tics)Globu s hystericus (episodic fear of choking an d inability to breathe, often with sensation of aCom pulsive skin picking or nail bitingBowel an d bladder obsessionsOlfactory reference sy ndrom e (belief that on e is emitting an offensive odor)

    lump in the throat)

    11. How do 1 screen for OCD and related disorders?Patients frequently are secretive about sym ptoms because of shame about their obsessions and com -pulsions. They consider their though ts and behaviors to be disturbed and em barrassing, and therefore arereluctant to disclose them. The degree of sham e, coupled with a reluctance to discuss symptoms, oftenresults in misdiagnosis or undertreatment of the full range of suffering. Thus the first step is to askscreening questions in every initial evaluation. Patients may have symp toms of more than on e disorder,such as both O CD and trichotillomania, or body dysmorphic disorder and skin picking. They m ay n otrealize that the conditions are treatable.

    Screening Questions or Obsessive Compulsive and Related DisordersDo you have thoughts, ideas, or mental images that come into your mind that you cannot seem to get rid of?Are these thoughts troubling to you in some w a y d o they make you anxious or upset?Are there any behaviors or habits that you do over and over that seem excessive or unusual?Is your life negatively affected by an inflexible need to do things just right or in a ritualized, repetitive way?Do you find that you tend to co llect things excessively or have trouble throwing things out so that yourhome becomes cluttered?Do you find yourself touching, rubbing, or picking at parts of your body repeatedly?Do you ever pull ou t your hair?Are there any aspects of your appearance that you find yourself troubled by or preoccupied with?Have others commented on behaviors or actions you perform that seem unusual or excessive to them or

    to yourself?

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    88 Obsessive-Compulsive Disorders12. How often is psychosis associated with OCD?Although patients frequently report that they feel crazy as a result of symptoms, frank psy-chosis, delusions, and hallucinations are relatively uncommon in patients with OC D. If psychosis ispresent, it generally should not b e considered as part of OC D, an d other diagnoses or comorhid con-ditions should be considered. How ever, som e people with body dysmorphic disorder are preoccu-pied with the perception of a defect to delusional proportions, and most patients w ith olfactoryreference syndrome have delusional perceptions of odor.13. Do patients with OCD act on their obsessions?sure them that this is extremely rare.Although patients often are fearful that they may act on their obsessions, it is important to reas-

    14. How is OCD misdiagnosed?OC D may be misdiagnosed as a psychotic disorder, depression, o r oth er anxiety disorder (seeQuestion 8).OCD also may be underdiagnosed w hen it occurs in people with developmental disorders,men tal retardation, or Tourettes syndrome. Th e differential diagnos is shou ld include such disorders.Neuroleptic m edications have been used incorrectly to treat OC D when obsessions are misdiag-nosed as psychotic sym ptom s or schizophrenia. M isdiagnosis generally o ccurs because the clinicianhas not inquired about the full range of symptoms, has considered spectrum disorders to be typicalOCD , or has mistaken OCD symptoms as indicative of another disorder. Diagnosis m ay be com pli-cated by the reluctance of so m e patients to disclose fully their range o f sy mptom s, particularly w ithobsessions that are sexual or violent in nature, related to bodily function, or blasphemous.15. Does routine brain imaging have a role in OCD?Although research applications of neuroimaging have show n structural and functional brain ab-normalities in people with OC D, clinical brain im aging generally is no t indicated, w ith a few excep-tions. Because obsessive-compulsive sy mptom s may o ccur as a result of various illnesses, new onsetof OC D symptoms in patients over age may be an indication for a magnetic resonance imaging orcomputed tomography scan of the brain to assist in the differential diagnosis and to rule out otherpathology. In atypical patients; patients with system ic autoimmun e, inflammatory, vascular, or neo-plastic diseases in which brain lesions also may arise; and patients with cognitive difficulties or focalneurologic abnormalities, neurologic consultation and brain imag ing m ay be indicated.16. How does one begin treatment for OCD?After the diagnosis is made, the patient shou ld be educated about the disorder. Options fo r be-havioral and medication treatment should be reviewed. Social suppo rts, such as self-help groups forpatients and families, should be cons idered . Education m ay inc lude several excellent patient-ori-ented books. Decisions about pharmacologic and behavioral interventions typically are made on acase-by-case basis.The severity and types of symptoms as well as the resources and motivation ofthe patient are important factors in treatment planning.17. What are effective treatments for OCD?Clinical experience and research suppo rt two primary modes of treatment fo r OCD: behavioraland pharmacologic. T he majority of patients report a significant improv ement in sym ptoms withthese treatment m odalities. Inadequate em pirical support justifies the use of psychodynamic psy-chotherapy as treatment for OC D. However, patients with OC D may have other problems that re-spond to psychotherapy. In addition, patients with early-onset OCD may benefit frompsychotherapy, b ecause they ar e likely to have missed a num ber of develop mental milestones.Psychoeducational support groups may be helpful for patients with O CD and also for their families.Excellent sources of inform ation about local resources include the following:Obsessive Compulsive Foundation, 9 Depot Rd., Milford, CT 064 60 (203-878-5669).Trichotillomania Learning Center (TL C), 1215 Mission St., Suite 2, Santa Cruz, CA (831-457-

    1004).

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    Obsessive-Compulsive Disorders 9Tourette Sy ndro me Association, Inc., 42-4 0 Bell Blvd., Bayside, NY 11361-2874 (718-224-2999).Anxiety Diso rders Association of America, 60 00 Executive Blvd., Suite 51 3 Rockville, MD20852 (301-231-8368).

    18. What are the components of behavioral treatmentfor OCD?Behavioral therapy generally is effective for checking and washing rituals. It is symptom-fo-cused and go al-directed and may be accomplished in as few as a dozen session s, depending o nsym ptom severity. Motivation and comp liance are important factors in success. Results vary, butmany patients m aintain their respon se over extended periods. Virtually all patients with O CD shouldbe offered a cou rse of behavior therapy.Treatm ent typically begins with a behavioral analysis, identifying the various target behaviorsand associated cognitions that are problematic. The environmental context for the behaviors is iden-tified, with recognition of internal and external cues and reinforcers important in symptoms mainte-nance. Primary treatment fo r compulsive rituals consists of exposure and response prevention. Suc htechniques involve a graded progressive exposure to the anxiety-inducing stimulus, with preventionof the associated ritualistic response.Behav ioral therapy is less effective for patients with obsessions and no rituals. Thou ght-stop-ping has been used with limited success.19. What are the first line medications for OCD treatment?A num ber of medications have demonstrated efficacy in treating OC Ds. All are potent sero-tonin reuptake inhibitors (SRIs) and effective antidepressants: clomipramine (Anafranil), fluoxe-tine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Although chemicallydistinct, they have similar efficacy in treating patien ts with OCD. Tolerance and respo nse to eachagent may vary with individuals. The m edications also differ in pharm acokinetics, side effects,and interactions. It is believed that their antiobsessional effects result in part from blocking sero-tonin reuptake. It is still unclear, however, exactly how se rotonin fits into the pathophy siology ofOCD.Initial drug choice sh ould be an SR I, and if the first choice is not successful or if side effectslimit use, the other agents, including clomipramine, should be tried. Patients who do not respond toon e medication m ay benefit from another in the same class. Dosage may be increased as tolerated tothe upper end of recomm ended doses, and a trial usually should last for 10 days before medication ischanged or augmentation strategies are begun. Response times vary. Rare p atients report a quick re-duction in sym ptoms, but maximal response may take several months.Note that tolerance and side effects are important factors in choice of agent, because pharma-cotherapy for OC D m ay be long-term for some patients.20. Should behavioral therapy or medications be started first? Should they be started together?Absolute guidelines for when to begin which type of treatment are lacking, but so me generalprinciples m ay help to guide clinical decision making. In general, medications should be avoided asa first-line treatment in children or pregnant women, until the patient has not responded to behav-ioral therapy and the severity of the illness dictates pharmacotherapy. M edications have been su c-cessfully used in the elderly as well as in patien ts with o ther serio us medical pro blem s, but careshould be exercised about side effects and interactions. Many patients receive combined medicationand behavioral therapy. The two treatments co mp lement each other. Some patients have g reat suc-cess with medications or behavioral therapy alone. Patients with significant comorbid D SM-IV axisI or I1 illnesses, poor motivation or compliance, chaotic social situations, or only obsessions tend todo poorly in behavioral therapy alone. Behavioral therapy for compulsive rituals yields improvementin about two-thirds of patients, with lasting gains ov er several years of follow-u p. Treatment withSRIs alone generally results in m oderate improvement.

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    90 Obsessive-Comp ulsive Disorders21. How does one gauge response to OCD treatment?The Yale-Brown Obsessive Compulsive Scale (Y BOC S) is a qu ick and simple clinician-adminis-tered scale that gives reliable ratings of symp tom severity for obsessions and compulsions. In add ition,assessment of anxiety and depressive sym ptoms with self-report instruments is useful. Clinical globalassessments of severity and improvem ent also are frequently used. Treatmen t refractoriness may be de-fined as less than 25 decrease in O CD symptoms on the YBOCS or persistent significant symptomsdespite adequate trials of first-line behavioral therapy or m edications. Com plete resolution of sy mptomsis rare, but the great majority of patients get considerable relief. Strategies for pharm acologic approachesto the approximately 20 of patients who are refractory to standard treatments are shown below.

    Pharmacologic Strategies.for Refractory Obsessive CompulsiveDisorderAGENT DOSE DURATION

    First-line: SRIsClomipramineFluoxetineFluvoxamineSertralineParoxetineAugmentationClonazepamNeurolepticsPimozideBuspirone

    ClonazeparnPhenelzineTranylcy promineBuspirone

    Alternative M onotherapy

    Up to 250 mg/dUp to 80 mg/dUp to 300 mg/dUp to 2 mg/d40 to 6 mg/dUp to mg/dUp to 3 mg/dUp to 6 mgldUp to mg/dUp to 90 mg/dUp to 6 mg/dUp to 6 mg/d

    10wkIOwk10w k10wk10wk

    > 4 w k> 4 wk> 8 w k> 4 w k

    10wk10w k> 6 w kAdapted from Jenike M A Rauch SL: Managing the patient with treatment-resistant obsessive compulsive disor-der: Current strategies. J Clin Psychiatry 55(Suppl): 1-17, 1994.22. What conditions frequently coexist with OCD? How does this affect treatment planningand response?Com mon com orbid cond itions include major depression, simple and social phobia, eating disor-ders, substance abuse , panic disorder, and Tourettes syndro me . Co mo rbid axis I conditions mayneed to be treated first, concomitantly, or after treatment o f O CD , depending on the relative clinicalseverity of the comor bid condition . Avoidant and dep ende nt personality disord ers are am ong themost comm on in O CD probands. Schizotypal, borderline, and avoidant personality disorders maynegatively affect response to pharm acotherapy. Conversely, patients w ho appear to have a personal-ity disorder while they have significant OCD sym ptoms m ay no lon ger meet criteria for a personal-ity disorder once their OCD is effectively treated.23. What is the relationship between OCD and Tourettes syndrome?Symptom s in O CD and Tourettes syndrome may overlap: Tourettes patients frequently haveOC D sym ptom s, and tics are com mo n in OC D patients. Family and genetic studies and other currentevidence suggest a comm on pathophysiology with a different phenotypic expression in so m e formsof Tourettes syndro me and O CD . Treatment of O CD com orbid w ith Tourettes syndrom e generallyrequires neuroleptics (o r clonidine) and an SRI. Behavioral therapy for tics is not highly successfuloverall, but may be useful fo r compulsive rituals. The clinical and phenom enologic overlap betweenOCD and spectrum disorders is an exciting area of current research.24. What is the role of neurosurgery in treatment of OCD?Severe, disabling, treatment-refractory OC D sym ptom s have been successfully treated w ith var-ious neurosurgical procedures, including frontal leucotomy, lim bic leucotomy, anterior capsulotomy,

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    Obsessive-Compulsive Disorders 91and cingulotomy. Such procedures are reserved for patients who hav e failed extensive trials of behav-ioral and pharmaco logic interventions and are literally disabled and dys functional as a result of OC D.Risks are those associated with any neurosurgical procedure, including infection, seizure, and po tentialloss of norm al functioning. Neurosurgery should be considered only after everything else has failed.25. How long does OCD last? Is treatment lifelong?OCD tends to be a chronic disorder. There may be episodic or continuous forms, and in occa-sional patients acute episodes do not recur. Duration of active treatment varies. Som e patients havechronic low levels of symptoms by which they are not severely affected, except at times of increasedstress or when a concomitant axis I disorder, such as depression, occurs. Such patients may benefitfrom periodic use of medication or booster sessions of behavioral therapy.Development of behavioral skills is important in all patients with OCD , to help minimize symp -tom s and interfe rence . Som e patients req uire only relatively shor t-term use of mediations (6-12months), whereas others need medication for an extended period. Cu rrent research is attempting todetermine which patients need long-term treatment.

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