Symptoms:
OCD is characterized by recurrent intrusive thoughts, images, or urges (obsessions) that typically cause anxiety or distress, and by repetitive mental or behavioral acts (compulsions) that the individual feels driven to perform, either in relation to an obsession or according to rules that he or she believes must be applied rigidly or to achieve a sense of completeness. People with obsessive-compulsive disorder (OCD) experience obsessions, compulsions, or both.
Compulsions (or rituals) are repetitive behaviors (eg, washing, checking) or mental acts (eg, praying, counting, repeating words silently) that the individual feels driven to perform in relation to an obsession or according to rules that must be applied rigidly or to achieve a sense of “completeness.”
Obsessions are repetitive and persistent thoughts (eg, of contamination), images (eg, of violent or horrific scenes), or urges (eg, to stab someone). Obsessions are not pleasurable or experienced as voluntary. They are intrusive, unwanted, and cause marked distress or anxiety in most individuals. A person suffering from OCD attempts to ignore, avoid, or suppress obsessions or to neutralize them with another thought or action (eg, performing a compulsion).
Compulsions (or rituals) are repetitive behaviors (eg, washing, checking) or mental acts (eg, counting, repeating words silently) that the individual feels driven to perform and are typically thematically related to an obsession (eg, washing rituals occur with obsessive fears of contamination) or according to rules that must be applied rigidly. The aim can be to reduce the distress triggered by obsessions or to prevent a feared event (eg, becoming ill). However, these compulsions are either not connected in a realistic way to the feared event (eg, arranging items symmetrically to prevent harm to a loved one) or are clearly excessive (eg, showering for hours each day). Compulsions may also be performed in response to a sense of “incompleteness” (eg, a need to perform actions until “just right”). Compulsions are not done for pleasure, although some individuals experience relief from anxiety or distress.
Treatment
Patients with obsessive-compulsive disorder (OCD) be treated with cognitive-behavioral therapy (CBT) consisting of exposure and response prevention, a selective serotonin reuptake inhibitor (SSRI) medication, or both. For most patients with OCD, first-line treatment should be with exposure and response prevention (a type of CBT).
SSRI medication is a reasonable alternative if CBT is unavailable, not indicated, or if the patient prefers medication. Higher doses of SSRIs or clomipramine have generally been found to be more effective for OCD. As an example, fluoxetine can be gradually titrated to 40 to 80 mg/day. The medication should be continued within the therapeutic range for at least six weeks before concluding that the drug is ineffective. Some patients may respond to doses that are higher than the maximum approved by the FDA, although at the risk of greater side effects. Doses of citalopram above 40 mg/day are no longer recommended by the FDA due to the risk of QTc interval prolongation.
If an adequate trial of the SSRI results in no response, we suggest treatment with a different SSRI, clomipramine, or venlafaxine if the patient prefers medication or progressing to a trial of exposure and response prevention if the patient is willing.
If a trial of an SSRI or SNRI results in a partial response, but the patient continues to experience clinically significant symptoms, we suggest augmenting the antidepressant with CBT consisting of exposure and response prevention before trying an antipsychotic medication. (eg, risperidone 0.5 to 3 mg/day). Other approaches with less supporting evidence are increasing the SSRI dose above the maximum approved by the FDA or adding clomipramine (≤75 mg/day).SSRIs and clomipramine generally lead to improvement in 40 to 60 percent of people with OCD. When patients have an adequate response, practice guidelines recommend that they be maintained on the medication for at least one to two years.