Obsessive-compulsive disorder (OCD) is characterized by anxiety-provoking ideas, images or impulses (obsessions) and by urges (compulsions) to do something that will lessen the anxiety.
Symptoms
The dominant theme of the obsessive thoughts may be harm, risk, danger, contamination, doubt, loss, or aggression. Typically, affected people feel compelled to perform repetitive, purposeful rituals to balance their obsessions, as in the following:
• Washing to balance contamination. Checking to balance doubt. Hoarding to balance loss.
• Avoiding people who may provoke them to balance fear of behaving aggressively.
Most rituals, such as hand washing or checking locks, are observable, but some mental rituals, such as silent repetitive counting or statements muttered under the breath, are not.
At some point, people with OCD recognize that their obsessions do not reflect real risks and that the behaviors they perform to relieve their concern are unrealistic and excessive. Preservation of insight, although sometimes slight, differentiates OCD from psychotic disorders, in which contact with reality is lost.
Because people with this disorder fear embarrassment or stigmatization, they often conceal their obsessions and rituals, on which they may spend several hours each day. Relationships often deteriorate, and performance in school or at work may decline. Depression is a common secondary feature.
Diagnosis
Obsessions:
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recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
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the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
Compulsions:
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repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession
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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 designed to neutralize or prevent or are clearly excessive.
Treatment:
• Exposure and ritual prevention therapy
• Often antidepressants
Exposure and ritual prevention therapy is effective; its essential element is exposure to situations or people that trigger the anxiety-provoking obsessions and rituals. After exposure, patients forgo rituals, allowing the anxiety triggered by exposure to diminish through habituation. Improvement often continues for years, especially in patients who master the approach and use it even after formal treatment has ended. However, most patients have incomplete responses as they also do to drugs.
Many experts believe that combining exposure and ritual prevention and drug therapy is best, especially for severe cases. SSRIs and clomipramine (a tricyclic antidepressant with potent serotonergic effects) are effective. For most SSRIs, low doses (eg, fluoxetine 20 mg po once/day, fluvoxamine 100 mg po once/day, sertraline 50 mg po once/day, paroxetine 40 mg po once/day) are often as effective as larger ones.
CLINICAL VIGNETTES
Which one of the following is most consistent with obsessive-compulsive disorder in adults?
A. Impulses related to excessive worry about real-life problems
B. A belief by the patient that obsessions are not produced by his or her own mind, but are “inserted” thoughts
C. Recognition by the patient that the obsessions or compulsions are excessive or
unreasonable
D. Compulsions that bring relief to the patient rather than causing distress
E. Full remission with treatment
ANSWER: C. The criteria for obsessive-compulsive disorder (OCD) indicate that the patient at some point recognizes that the obsessions or compulsions are excessive or unreasonable. The impulses of OCD are not related to excessive worry about one’s problems, and the patient recognizes that they are the product of his or her own mind. In addition, the patient experiences marked distress because of the impulses. Full remission is rare, but treatment can provide significant relief.
A 28-year-old female complains to her doctor that she is in danger of losing her job. She states that she is late to work almost everyday because, before she leaves for work, she must check all of the faucets to make sure the water is turned off. She also needs to repeatedly check to make sure that her stove is off. When she is finally ready to leave, she returns from her car several times to ensure that her doors and windows are locked. Which of the following drugs will her physician most likely prescribe?
A. Buspirone
B. Chlorpromazine
C. Clomipramine
D. Imipramine
E. Phenelzine
The correct answer is C. This patient is suffering from obsessive-compulsive disorder. Clomipramine, a tricyclic antidepressant, and the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, are effective in this disorder. None of the other answer choices listed constitute effective therapy for this disorder.
Buspirone (choice A) is a non-benzodiazepine anxiolytic that does not have marked sedative or euphoric effects. Unlike the benzodiazepines, buspirone is devoid of hypnotic, anticonvulsant, and muscle relaxant properties.
Chlorpromazine (choice B) is an antipsychotic (phenothiazine) drug.
Imipramine (choice D) is a tricyclic antidepressant.
Phenelzine (choice E) is a monoamine oxidase inhibitor type of antidepressant.
Zolpidem (choice F) is a non-benzodiazepine hypnotic agent