eMedicine Specialties > Psychiatry > Adult

Obsessive-Compulsive Disorder

Author: William M Greenberg, MD, Associate Director, Clinical Development, Forest Research Institute, Forest Laboratories, Inc; Visiting Scientist, Nathan S Kline Institute for Psychiatric Research; Private Practice
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Updated: May 31, 2009

Introduction

Background

Obsessive-compulsive disorder (OCD) is a relatively common, if not always recognized, disorder that is often associated with significant distress and impairment in functioning. Due to stigma and lack of recognition, individuals with OCD often must wait many years before they receive a correct diagnosis and indicated treatment. In severe presentations, this disorder is quite disabling and is appropriately characterized as an example of severe and persistent mental illness.

OCD is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as an anxiety disorder.¹ It is characterized by distressing intrusive obsessive thoughts and/or repetitive compulsive actions (which may be physical or mental acts) that are clinically significant. The specific DSM-IV-TR criteria for OCD are as follows:

• The individual expresses either obsessions or compulsions. Obsessions are defined by the following 4 criteria.
  • Recurrent and persistent thoughts, impulses, or images are experienced at some time during the disturbance as intrusive and inappropriate and cause marked anxiety and distress. Those with this disorder recognize the craziness of these unwanted thoughts (such as fears of hurting their children) and would not act on them, but the thoughts are very disturbing and difficult to tell others about.
  • The thoughts, impulses, or images are not simply excessive worries about real-life problems.
  • The person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action.
  • The person recognizes that the obsessional thoughts, impulses, or images are a product of his/her own mind (not imposed from without, as in thought insertion).
• Compulsions are defined by the following 2 criteria:
  • The person performs repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) in response to an obsession or according to rules that must be applied rigidly.
  • The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are meant to neutralize or prevent or they are clearly excessive.
• At some point during the course of the disorder, the person recognizes that the obsessions or compulsions are excessive or unreasonable. This does not apply to children.
• The obsessions or compulsions cause marked distress; are time consuming (take >1 h/d); or significantly interfere with the person's normal routine, occupational or academic functioning, or usual social activities or relationships.
• If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it, such as preoccupation with food and weight in the presence of an eating disorder, hair pulling in the presence of trichotillomania, concern with appearance in body dysmorphic disorder, preoccupation with drugs in substance use disorder, preoccupation with having a serious illness in hypochondriasis, preoccupation with sexual urges in paraphilia, or guilty ruminations in the presence of major depressive disorder.
• The disorder is not due to the direct physiologic effects of a substance or a general medical condition.
• The additional specification of "with poor insight" is made if, for most of the current episode, the person does not recognize that the symptoms are excessive or unreasonable.

Obsessions and their related compulsions (the latter also referred to as rituals) often fall into 1 or more of several common categories.

Table. Categorizing Obsessions and Compulsions 

Open table in new window

Although OCD is categorized as an anxiety disorder in DSM-IV-TR, Dr. Eric Hollander has proposed that it should instead be considered an impulse control disorder along with other disorders such as trichotillomania, kleptomania, and pathological gambling, which would comprise an O-C spectrum of disorders^2,3 , although this remains a controversial proposal⁴ .

Case vignette

Ms. A is a 32-year old married mother of 2, living with her family in a suburban community. She comes to a psychiatrist’s office seeking help, with the strong encouragement of her husband, stating that she “just can’t cope anymore.”

In recent years, she has been spending increasing amounts of time, now at least 4 hours per day, in cleaning rituals. She will not allow anyone in the house to wear shoes, has declared the upstairs bathroom off limits, and will not let anyone else in the kitchen. She washes her hands with hot water and soap for at least 5 minutes after any occasion when she feels they have been contaminated and always wears gloves when outside. The skin on her hands is reddened and irritated. She spends up to an hour a day keeping items in the house in perfect placement (symmetrical and balanced), and she can become extremely angry if someone disturbs their placement. She spends approximately an hour every day arranging and rearranging her clothes in her closets, ordering each item on hangers in placement by size and color and correcting anything that is not hanging exactly symmetrically.

Over the last year she has also become phobic when seeing or hearing words pertaining to death, fearing that this could somehow lead to an untimely death for one of her children. If she reads such words or hears them on the radio or television, she will repeat the Lord’s Prayer in her own mind 100 times; if she loses count she will start again. This has led to her general avoidance of reading and listening to radio or television, except at times when she feels the content will be “safe.”

Initially rather clean, neat, fastidious, and cautious, these potentially adaptive tendencies have grown very trying for her husband and 2 young children, and an inordinate amount of time and attention is taken up related to her perceived needs for rules for cleaning and household items to be arranged “just so.” She recognizes the craziness of her fears of the word "death," but feels she cannot control her responses. She has become frustrated and unhappy coping with her fears and her burdensome responses, and although very reluctant to give up any of her protective rituals, she has agreed to seek professional advice, with the urging of an aunt who has confided her own successful struggles with similar problems.

Pathophysiology

The exact pathophysiologic process that underlies OCD has not been established. Research and treatment trials suggest that abnormalities in serotonin (5-HT) neurotransmission in the brain are meaningfully involved in this disorder. This is strongly supported by the efficacy of serotonin reuptake inhibitors (SRIs) in the treatment of OCD.^5,6

Evidence also suggests abnormalities in dopaminergic transmission in at least some cases of OCD. In some cohorts, Tourette disorder (also known as Tourette syndrome) and multiple chronic tics genetically co-vary with OCD in an autosomal dominant pattern. OCD symptoms in this group of patients show a preferential response to a combination of serotonin specific reuptake inhibitors (SSRIs) and antipsychotics.⁷

Functional imaging studies in OCD have demonstrated some reproducible patterns of abnormality. Specifically, MRI and positron emission tomography (PET) scanning have shown increases in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus, with a trend toward right-sided predominance. In some studies, these areas of overactivity have been shown to normalize following successful treatment with either SSRIs or cognitive-behavioral therapy (CBT).⁸ These findings suggest the hypothesis that the symptoms of OCD are driven by impaired intracortical inhibition of specific orbitofrontal-subcortical circuitry that mediates strong emotions and the autonomic responses to those emotions. Cingulotomy, a neurosurgical intervention sometimes used for severe and treatment-resistant OCD, interrupts this circuit (see Treatment).

Similar abnormalities of inhibition are observed in Tourette disorder, with a postulated abnormal modulation of basal ganglia activation.

More recently, attention has focused on glutamatergic abnormalities and possible glutamatergic treatments for OCD.⁹ Although modulated by serotonin and other neurotransmitters, the synapses in the cortico-striato-thalamo-cortical circuits thought to be centrally involved in the pathology of OCD principally employ the neurotransmitters glutamate and gamma-aminobutyric acid (GABA). Preclinical studies and several case reports and small clinical trials have provided some preliminary support for the therapeutic use of specific glutamatergic agents.^10,11 However, these agents (eg, memantine, N-acetylcysteine, riluzole, topiramate, glycine) have varied glutamatergic and other pharmacological effects, so if they are demonstrated to be effective, clarifying any therapeutic mechanism of action will be important.

The fact that obsessive-compulsive symptoms seem to often take very stereotypic forms has led some to hypothesize that the pathological disturbance causing OCD may be disinhibiting and exaggerating some built-in behavioral potential that we have, which under other circumstances might have an adaptive function (eg, primate grooming rituals).

Frequency

United States

Once believed to be rare, OCD was found to have a lifetime prevalence of 2.5% in the Epidemiological Catchment Area study.¹² Current estimates of lifetime prevalence are generally in the range of 1.7-4%. Discovery of effective treatments and education of patients and health care providers have significantly increased the identification of individuals with OCD over the past decade.

International

International studies have shown a similar incidence and prevalence of OCD worldwide.

Mortality/Morbidity

• OCD is a chronic disorder. Without treatment, symptoms may wax and wane in intensity but rarely remit spontaneously. While many patients experience moderate symptoms, OCD can be a severe and disabling illness.
• Those with OCD often do not seek treatment. Many individuals with OCD delay for years before obtaining an evaluation for obsessive-compulsive (OC) symptoms. Patients with OCD often feel shame regarding their symptoms and put great effort into concealing them from family, friends, and health care providers.

Race

OCD appears to have a similar prevalence in different races and ethnicities, although specific pathological preoccupations may vary with culture and religion (eg, concerns about blaspheming are more common in religious Catholics and Orthodox Jews).

Sex

The overall prevalence of OCD is equal in males and females, although the disorder more commonly presents in males in childhood or adolescence, and in females in their twenties. Childhood-onset OCD is more common in males and more likely to be comorbid with attention deficit hyperactivity disorder (ADHD) and Tourette disorder.

It is not uncommon for women to experience the onset of OCD during a pregnancy, although those who already have OCD will not necessarily experience worsening of their symptoms during pregnancy. However, women commonly experience worsening of their OCD symptoms during the premenstrual time of their periods. Women who are pregnant or breastfeeding should collaborate with their physicians in making decisions about starting or continuing OCD medications.

Age

Symptoms usually begin in individuals aged 10-24 years. Childhood-onset OCD may have a higher rate of comorbidity with Tourette Disorder and ADHD.

Clinical

History

OCD is diagnosed primarily by presentation and history. Once the diagnosis is suspected, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS)¹³ is an important tool in defining the range and severity of symptoms and monitoring the response to treatment. The Y-BOCS is comprised of 10 items, 5 for obsessions and 5 for compulsions, each scored 0-4 (total score 0-40). For both obsessions and compulsions, these items rate the time spent, interference with functioning, distress, resistance, and control. Elements that should be covered when obtaining the history, including suggestions for typical interview questions, include the following:¹⁴

• Nature and severity of obsessive symptoms
  • Have you ever been bothered by thoughts that do not make any sense and keep coming back to you even when you try not to have them?
  • When you had these thoughts, did you try to get them out of your head? What would you try to do?
  • Where do you think these thoughts were coming from?
• Nature and severity of compulsive symptoms
  • Has there ever been anything that you had to do over and over again and could not resist doing, such as repeatedly washing your hands, counting up to a certain number, or checking something several times to make sure you have done it right?
  • What behavior did you have to do?
  • Why did you have to do the repetitive behavior?
  • How many times would you do it and how long would it take?
  • Do these thoughts or actions take more time than you think makes sense?
  • What effect do they have on your life?

Information appropriate for a full evaluation is as follows: 

• Age of onset
• History of tics, either current or past
• Psychiatric review of systems and comorbidities
  • OCD is frequently attended by other psychiatric comorbid diagnoses, prominently including major depressive disorder, alcohol and/or substance use disorders, other anxiety disorders, impulse control disorders (eg, trichotillomania, skin-picking), and Tourette and tic disorders (perhaps 40% of individuals with Tourette disorder will have OCD). Therefore, in taking a psychiatric history, the focus should be on identifying such comorbidities, seeking to elicit the following:
    • Mood and anxiety symptoms
    • Somatoform disorders, especially hypochondriasis and body dysmorphic disorder
    • Eating disorders
    • Impulse control disorders, especially kleptomania and trichotillomania
    • ADHD
  • The co-occurrence of schizophrenia and OCD is more problematic for a variety of reasons. Not infrequently, individuals with schizophrenia do seem to have significant OC symptoms (sometimes, ironically, caused or exacerbated by the use of the very effective antipsychotic clozapine, whereas adjunctive antipsychotics may lessen treatment-resistant OC symptoms in those who do not have schizophrenia). When OC symptoms are present in someone who has schizophrenia, they may meet criteria for a diagnosis of OCD, but such patients often respond poorly to the usual OCD treatments, and perhaps OCD in schizophrenia has a different pathophysiology.
  • Family history of OCD, Tourette disorder, tics, ADHD, and other psychiatric diagnose
  • Current or past substance abuse or dependence
  • Antecedent infections, especially streptococcal and herpetic infection
  • Common obsessions include the following:
    • Contamination
    • Safety
    • Doubting one's memory or perception
    • Scrupulosity (need to do the right thing, fear of committing a transgression, often religious)
    • Need for order or symmetry
    • Unwanted, intrusive sexual/aggressive thought
  • Common compulsions include the following:
    • Cleaning/washing
    • Checking (checking locks, stove, iron, safety of children)
    • Counting/repeating actions a certain number of times or until it "feels right"
    • Arranging objects
    • Touching/tapping objects
    • Hoarding
    • Confessing/seeking reassurance
    • List making

Physical

• A complete Mental Status Examination should be performed. The patient should be evaluated for orientation, memory, disturbances of mood and affect, presence of hallucinations, delusions, suicidal and homicidal risk, and judgment (including whether insight into the irrational nature of their symptoms is still present).
• Evaluate all patients with OCD for the presence of Tourette disorder or other tic disorders, as these comorbid diagnoses may influence treatment strategy. The findings on neurologic and cognitive examination should otherwise be normal. Focal neurologic signs or evidence of cognitive impairment should prompt evaluation for other diagnoses.
• Skin findings in OCD may include the following:
  • Eczematous eruptions related to excessive washing
  • Hair loss related to trichotillomania or compulsive hair pulling
  • Excoriations related to neurodermatitis or compulsive skin picking

Causes

The cause of OCD is not known; however, the following factors are relevant:

• Genetic: Twin studies have supported strong heritability for OCD, with a genetic influence of 45-65% in studies in children, and 27-47% in adults.¹⁵ Monozygotic twins may be strikingly concordant for OCD (80-87%), compared with 47-50% concordance in dizygotic twins.¹⁶ Several genetic studies have supported linkages to a variety of serotonergic, dopaminergic, and glutamatergic genes.^{17,18,19,20,21} Other genes putatively linked to OCD have included those coding for catechol-O-methyltransferase (COMT), monoamine oxidase-A (MAO-A), brain-derived neurotrophic factor (BDNF), myelin oligodendrocyte glycoprotein (MOG), GABA-type B-receptor 1, and the mu opioid receptor, but these must be considered provisional associations at this time. In some cohorts, OCD, ADHD, and Tourette disorder/tic disorders co-vary in an autosomal dominant fashion with variable penetrance.
• Infectious: Case reports have been published of OCD with and without tics arising in children and young adults following acute group A streptococcal infections. Fewer reports cite herpes simplex virus as the apparent precipitating infectious event. It has been hypothesized that these infections trigger a CNS autoimmune response that results in neuropsychiatric symptoms (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections [PANDAS]). A number of the poststreptococcal cases have reportedly improved following treatment with antibiotics.
• Other neurological conditions: Rare reports exist of OCD presenting as a manifestation of neurologic insults such as brain trauma, stimulant abuse, carbon monoxide poisoning.
• Stress: OCD symptoms can worsen with stress; however, stress does not appear to be an etiologic factor.
• Interpersonal relationships
  • OCD symptoms can interact negatively with interpersonal relationships, and families can become involved with the illness in a counterproductive way (eg, a patient with severe doubting obsessions may constantly ask reassurance for irrational fears from family members or significant others; constantly providing this can inhibit the patient from making attempts to work on their behavioral disturbances).
  • Parenting style or upbringing does not appear to be a causative factor in OCD.

• Search for CME/CE on This Topic »

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