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Depression and Anxiety Resource Center Depression and Anxiety Resource Center View all Depression and Anxiety Articles You are in: eMedicine Specialties > Pediatrics > Developmental And Behavioral Rate this Article Email to a Colleague Anxiety Disorder: Obsessive-Compulsive Disorder Get CME/CE for article Last Updated: May 15, 2006 Synonyms and related keywords: obsessive-compulsive disorder, OCD, compulsive behavior, obsessive thinking, handwashing, repeating, checking, touching, counting, arranging, hoarding, praying, obsessive-compulsive neurosis, compulsive neurosis Depression and Anxiety CME Depression and Anxiety Multimedia Library

AUTHOR INFORMATION Section 1 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

Author: W Douglas Tynan, PhD , Clinical Associate Professor of Pediatrics, Thomas Jefferson University of Philadelphia; Director, Primary Care Mental Health, Division of Behavioral Health, Alfred I duPont Hospital for Children W Douglas Tynan, PhD, is a member of the following medical societies: American Psychological Association, and Society for Research in Child Development Editor(s): Carol Diane Berkowitz, MD , Executive Vice Chair, Professor, Department of Pediatrics, Harbor-University of California at Los Angeles

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Medical Center; Mary L Windle, PharmD , Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Caroly Pataki, MD , Associate Program Director, Clinical Associate Professor, Department of Psychiatry and Biobehavioral Sciences, Division of Child and Adolescent Psychiatry, Neuropsychiatric Institute and Hospital, UCLA; Carrie Sylvester, MD, MPH , Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School; and Murray M Kappelman, MD , Professor, Departments of Pediatrics and Psychiatry, University of Maryland School of Medicine Disclosure

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INTRODUCTION Section 2 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

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Obsessive-compulsive disorder (OCD) is a significant neurobiological disorder that severely can disrupt academic, social, and vocational functioning. The major feature of this disorder is recurring obsessions and compulsions that interfere with a person's life. Once believed to be relatively rare in children and adolescents, OCD now is believed to affect as many as 2% of children. Among adolescents with OCD, the literature indicates that very few receive an appropriate and correct diagnosis, and even fewer receive proper treatment. This finding is unfortunate because effective cognitive, behavioral, and pharmacologic treatments are now available. PATHOPHYSIOLOGY Section 3 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

Diagnosis of obsessive-compulsive disorder (OCD) is not exclusionary. Other anxiety disorders, tic disorders, and disruptive behavior disorders, as well as learning disabilities, are common comorbidities with OCD. Other obsessivecompulsive type disorders, such as body dysmorphic disorder, trichotillomania, and habit problems (eg, nail biting) are less common, but certainly not rare. OCD is considered a neuropsychiatric disorder. In the history of treatment, insight-oriented psychotherapy did not appear to improve OCD, and psychodynamic understanding was not helpful. OCD symptoms do not appear to represent intrapsychic conflicts within individuals. Indeed, relatively few OCD behaviors exist, and they are experienced in much the same manner by patients, regardless of their interpersonal histories. FREQUENCY Section 4 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

In the United States, obsessive-compulsive disorder (OCD) is substantially more common in children and adolescents than once believed and has a 6month prevalence of approximately 1 in 200 children and adolescents, while the prevalence of OCD occurring at any time during childhood is assumed to be 2-3 per 100 children. Among adults with OCD, interview data indicate that one third to one half developed the disorder during childhood. Unfortunately, this disorder often goes unrecognized in children and adolescents. In one epidemiologic survey, 18 children were found to have OCD, and only 4 were receiving any professional mental health care. Not one of these 4 was diagnosed properly. Reasons advanced for the underdiagnosis and lack of treatment include some factors specific to OCD, including the secretiveness of the disorder and lack of insight by the patients. Also, many of the symptoms of

OCD are found in other disorders, leading to misdiagnosis. OCD has been studied most comprehensively at the National Institute of Mental Health with referred patients, who likely represent more severe cases. In those studies, the modal age of onset was 7 years; the mean age was 10.2 years. These figures imply the possible existence of an early-onset group and a second group with onset in adolescence. Boys are more likely to have a prepubertal onset and a family member with OCD or Tourette syndrome. Girls are more likely to have onset of OCD during adolescence. OCD is more common in whites than African American children in clinical samples. However, epidemiologic data suggest no differences in prevalence as a function of ethnic group or geographic region.

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CLINICAL COURSE Section 5 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

Recurring obsessions and/or compulsions causing distress or interfering with a person's life characterize obsessive-compulsive disorder (OCD). Obsessions are defined as recurrent and persistent thoughts, images, or impulses that are egodystonic, intrusive, and, for the most part, acknowledged as senseless. Obsessions usually are accompanied by dysphoric affect, such as fear, doubts, and disgust. Children and adolescents with OCD typically first try to ignore, suppress, or deny obsessive thoughts and may not report the symptoms as egodystonic or senseless. However, by trying to neutralize excessive thoughts, individuals with OCD very quickly change their behaviors by performing some type of compulsive actions, which are repetitive purposeful behaviors performed in response to the obsession. Usually, these repetitive actions follow certain rules or are quite stereotyped. Some compulsions observed include behaviors such as washing, counting, or lining up of objects. Other compulsions are covert mental acts such as counting or reading a passage again and again. These compulsions also serve to reduce the anxiety produced by the obsessive thoughts. If something interferes with or blocks the compulsive behavior, the child feels heightened anxiety or fear and can become quite upset and oppositional. The diagnostic criteria for OCD specify that a child or adolescent may have either obsessions or compulsions, although nearly all children with this disorder have both. The symptoms must cause some distress, consume more than 1 hour per day, or must significantly interfere with school, social activities, or important relationships. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is quite clear that at some point, patients affected with OCD need to recognize that their obsessions come from within their own minds and are not worries about genuine problems. In a similar way, compulsions must be observed as excessive or unreasonable. Thus, the clinician does not include nightly bedtime rituals or other typical normative daily patterns as suggestive of this disorder. Although most adolescents and some children with OCD recognize the senselessness of the disorder, the requirement of insight into the disorder is not required for the diagnosis of OCD in children. As with many neuropsychiatric disorders, a chronic waxing and waning of symptoms occurs in the chronic disorder of OCD. Thus, many families choose not to seek treatment because the symptoms have decreased independent of treatment in the past. Another requirement to make the diagnosis is that specific content of obsessions cannot be related to another psychiatric diagnosis (eg, obsessive thoughts about food may be the result of an eating disorder, paranoid thoughts may be related to a psychotic thought disorder). Not confusing OCD with normal ritualistic behavior of childhood is important. Most children exhibit typical, age-dependent, compulsive behaviors. Frequently, young children prefer that events occur in a particular way, they insist on specific bedtime or mealtime rituals, and they become distressed if these rituals are

disrupted. Cross-sectional research of ritualistic behavior in children demonstrates that these behaviors appear when the individual is aged approximately 18 months, peak when the individual is aged approximately 2-3 years, and decline afterward. Presence of these behaviors appears to be related to mental age; thus, children who are mentally retarded and have cognitive levels at a developmental age of 2-3 years may have higher rates of compulsive behaviors, which are appropriate to their cognitive levels of development. These behaviors are best understood by acknowledging that they involve mastery and control of their environment, and, usually, they decrease to low levels by middle childhood. As a child ages, compulsive behaviors are replaced by hobbies or focused interests. Normative compulsive behaviors can be discriminated from OCD on the basis of content, timing, and severity. Normative compulsive behaviors do not interfere with daily functioning. One of the leading causes of death of patients with OCD is suicide. Estimates reflect as many as 10% of patients with OCD make suicide attempts in adolescent and adult years. USUAL BEHAVIORAL FEATURES Section 6 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

Sets of common obsessions and compulsions are observed in pediatric individuals with obsessivecompulsive disorder (OCD). Typically, these sets are described best as just so behaviors, in which certain things have to be arranged or performed in a particular way to relieve the anxiety. The most clinically useful and detailed symptoms checklist is included in the Yale-Brown ObsessiveCompulsive Scale. The most common theme of obsessions are contamination themes, and the related compulsive behavior is washing, usually compulsive handwashing. Along with contamination themes, problems with aggressive obsessions, sexual obsessions, the need for symmetry and order, obsessions about harm to oneself or others, and the need to confess exist. These excessive thoughts result in the common compulsive behaviors of washing, repeating, checking, touching, counting, arranging, hoarding, or praying. When overt, observable compulsive behaviors are relatively easy to observe to make the diagnosis (eg, washing, repeating, checking, touching); covert behaviors (eg, counting, praying, reading something again and again) are harder to assess and evaluate. If OCD is suspected and if a child is taking an extremely long time to complete some tasks, a high likelihood exists that the child may be engaged in one of these covert rituals. EVALUATION Section 7 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

Differentials Childhood Habits and Stereotypic Movement Disorder Anxiety Disorder: Trichotillomania Attention Deficit Hyperactivity Disorder Pervasive Developmental Disorder: Asperger Syndrome Child Abuse and Neglect: Posttraumatic Stress Disorder Tourette Syndrome Other Problems to be Considered Major depressive disorder Diagnostic tests If obsessive-compulsive disorder (OCD) is suspected, referral to a mental health professional is indicated. A complete family history is essential, especially any history of relatives who may have OCD or Tourette syndrome, as is a history of any infection that may have preceded the onset of symptoms. Accurate assessment is essential. Of structured interviews and psychological tests used, the Yale-Brown Obsessive-Compulsive Scale is considered the instrument of choice in making the definitive diagnosis. Often the nature of the excessive thoughts leads to misdiagnosis. Common misdiagnoses for OCD include posttraumatic stress disorder (PTSD) and attention deficit/hyperactivity disorder (ADHD). For example, if a child has obsessive sexual thoughts, clinicians commonly assume that some type of sexual abuse is underlying these thoughts, leading to a diagnosis of PTSD. Unfortunately, treatment then takes the form of further exploration and discussion of these thoughts, which may make them more frequent and prominent. In general, a psychodynamic approach (ie, discussing these problems at length to get at underlying causes) may reinforce and worsen the symptoms. Thus, for a child presenting with anxiety symptoms and compulsive behaviors that are worsening or not responding to talk therapy, the clinician should consider the possibility of OCD.

OCD also can be confused with ADHD. At first, seeing how these 2 disorders overlap may be difficult; however, in the classroom situation, these disorders may present in a similar fashion. When children with OCD are preoccupied with their obsessive thoughts and covert counting or rereading rituals in school, the teacher perceives the children as being inattentive. Children engaged in the compulsively driven behaviors often have a very high level of energy and activity. According to the DSM-IV criteria for ADHD, most children with OCD are inattentive and often hyperactive and/or impulsive. Also, in an attempt to maintain focus and control, children with ADHD can become compulsively rigid and perseverative. Because the behaviors observed in persons with OCD often are stereotypical and repetitive, 2 other disorders, both in the developmental disability spectrum, commonly are confused with OCD. First, children with mild autism or Asperger disorder also may have repetitive thoughts and specific stereotypic compulsive behaviors. While disorders in the autistic spectrum are considered to be pervasive developmental disorders (PDD) and quite different than OCD, at times the differential diagnosis between the 2 sets of disorders is somewhat difficult to make. In individuals with OCD, the behaviors are usually included in those described in Usual Behavioral Features; however, they may change form. Thus, a child with OCD may have a handwashing compulsive behavior, which may change later to a need for order. However, a child with OCD, when not preoccupied with obsessive thoughts, does not have social difficulties of relatedness or communication problems. In persons with autism or Asperger disorder, the compulsive behaviors do not tend to change over time. Often, a child with autism may have the same preoccupation for years. In addition, autistic stereotypic behaviors tend to be unique to the child; in persons with OCD, stereotypic behaviors are almost always those discussed in Usual Behavioral Features. Social difficulties and communication problems are key intrinsic features of Asperger disorder on the PDD spectrum. CAUSES Section 8 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

Obsessive-compulsive disorder (OCD) is considered a neuropsychiatric disorder. OCD symptoms do not appear to represent intrapsychic conflicts within individuals. Indeed, relatively few OCD behaviors exist, and they are experienced in much the same manner by patients, regardless of their interpersonal histories. Initial successes in treatment of OCD with selective serotonin reuptake inhibitors (SSRIs) have led to a neuropsychiatric explanation of a serotonin-mediated "grooming behavior" that has been disrupted. In addition, clear family genetic studies demonstrate that, in some cases, both OCD and Tourette syndrome may represent expressions of the same gene. Tic disorders occur more frequently in individuals who have OCD, and first-degree relatives of patients with OCD have higher rates of tic disorders, a full Tourette syndrome, and OCD. Neuroimaging studies suggest abnormalities in neurologic circuits that link cortical areas to the basal ganglia. These circuits appear to change in response to successful treatment with either SSRI medication or cognitive behavior therapies (CBTs). Also, neurotransmitter and neuroendocrine abnormalities have been documented in childhood-onset OCD. Thus, as increasing genetic, neural imagery, and neurotransmitter data are accumulating, the data strongly suggest a neuropsychiatric origin for this disorder. Most recently, investigators have found OCD symptoms that arise from, or are strongly exacerbated in, the context of group A beta hemolytic streptococcal (GABHS) infection, which has been given the eponym pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAs). Sudden exacerbation of OCD symptoms in the presence of upper respiratory tract illness marks these cases. The mechanism is believed to be caused by antineuronal antibodies formed against group beta-hemolytic streptococcal cell wall antigens, which cross-react with caudate neural tissue and initiate OCD symptoms. Reactions against other infections, including viral agents, are also being considered. Current research is evaluating this particular factor in the development of OCD. These cases are believed to comprise a fairly small percentage (ie, <5%) of all persons with OCD, but this may be an important mechanism in children who may have had some tendencies or subclinical OCD symptoms prior to infection.

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TREATMENT Section 9 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

Medical care Successful treatment of this chronic disorder involves both the judicious use of SSRIs and structured psychotherapy designed to provide the patient with the skills to master the obsessive thoughts and accompanying compulsive behaviors. Management of infectious etiologies remains uncertain and may include strategies similar to those for Sydenham chorea. SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder. Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population. In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of depressive illness. After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive riskbenefit ratio in the treatment of depressive illness in patients younger than 18 years. In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment. However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue. Currently, evidence does not support an increased risk of suicide in obsessive-compulsive disorder (OCD) or other anxiety disorders treated with SSRIs. Psychotherapy CBT routinely is described as the psychotherapeutic treatment of choice for adults, children, and adolescents who have been diagnosed with OCD. Unlike psychodynamic or insight-oriented psychotherapy, CBT helps the child understand the disorder and develop strategies to identify problem situations and resist giving in to the obsessive thoughts and compulsive behaviors. Treatment relies heavily on exposing the individual to the problem situations and then preventing the compulsive response. The resulting anxiety then is managed by training children to use strategies that help them work with their anxiety in a more effective and less disruptive way. However, exposure to the anxiety-producing object is the key to success in treatment. Thus, for children who compulsively wash their hands because they feel that the hands are dirty or contaminated, the therapist may have them intentionally touch things that are dirty and then have

patients wait several hours before washing their hands. This results in very high anxiety after the initial contamination, followed by a gradual reduction in anxiety over time, until hand washing is allowed some hours later. In pediatric patients, this exposure is presented gradually, under the patients' control, after patients have been taught other ways of managing their anxiety and fear. Anxiety management techniques may include relaxation training, distraction, or imagery. Often, the OCD is personified as something that makes the child perform an action. Thus, children learn to assess situations and ask themselves if they really want to do something, as opposed to the perception that the OCD is making them do something. For school-aged children, the development of mastery and control is a critical issue in their overall psychological growth; therefore, learning to overcome an irrational drive, such as one experienced with OCD, has a certain appeal to their own sense of mastery. With CBT, the initial goals are specific to 1 or 2 behaviors; however, as the patient becomes successful in coping with these situations, generalization usually occurs to other symptoms that have not been targeted. Usually, the patient reports an overall reduction in obsessive thoughts, general anxiety, and the need to perform certain actions. Pharmacotherapy Treatment of OCD in adults has demonstrated that medications are effective, and the existing studies of children with OCD using medications also tend to suggest some benefit. At this time, the SSRIs (ie, fluoxetine, fluvoxamine, paroxetine, sertraline) have been demonstrated to be effective treatments of OCD, and they have a lower rate of adverse effects compared to previously used medications. These SSRIs are considered to be the first-line medications for treatment of OCD. Fluoxetine and paroxetine have been demonstrated to be effective in controlled studies, while the others have demonstrated effectiveness in open trials. A number of controlled studies are being conducted currently. Anecdotal reports suggest that the adverse effect profile for these medicines is similar for children as adults, except that children and adolescents appear to be more prone to agitation if started at usual adult doses. An expert consensus panel recommends trials with 2 or 3 of the SSRI medicines before switching to a different class of medication. Clomipramine, the second-line medication, is the most extensively studied medication in the pediatric population. The FDA has approved clomipramine for the treatment of OCD in children aged 10 years and older. However, clomipramine results in a higher rate and severity of adverse effects in children. These are the same as those observed in adults (eg, anticholinergic, antihistaminic, alpha blocking). No unexpected long-term adverse reactions have been observed; however, tachycardia and slightly increased PR-, QRS-, and QT-corrected intervals on the ECG were noted. Given the potential for tricyclic antidepressant-related cardiotoxic effects, pretreatment and periodic ECG and therapeutic drug monitoring is warranted. With all of these medicines, a large number of persons with OCD do not respond until 8-12 weeks of treatment (dissimilar to the shorter time noted in the treatment of depression); thus, waiting at least 8 (preferably 10) weeks before changing medicines or dramatically raising dosages is important. Approximately one third of patients do not respond to a particular SSRI, and the likelihood of responding drops significantly after 3 SSRI trials. Because properly executed CBT can be a very effective treatment on its own, complex medication strategies are not recommended until the patient has a trial of CBT, along with an SSRI. Combination treatment CBT and pharmacotherapy work well together clinically. Many clinicians believe that most children with OCD benefit from the combined treatment. Controlled studies are being conducted; at least 1 open trial demonstrated that CBT in combination with SSRI was far superior to either therapy alone. While CBT requires a skilled therapist and 10-20 sessions to complete, its advantage is that once the skills are learned, the patient can use them in the future. No specific predictors of treatment outcome have been identified for pediatric OCD. Children who can identify their obsessions as senseless and their rituals as useless and distressing are more motivated and better candidates for CBT. Comorbidity with other disorders, specifically oppositional disorders and/or ADHD, makes compliance with treatment more difficult. A calm supportive family environment in which parents and/or caregivers actively can support the child's coping strategies also should improve outcome. Patient education For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles, Anxiety, Panic Attacks, and Hyperventilation. BIBLIOGRAPHY Section 10 of 10 Author Information Introduction Pathophysiology Frequency Clinical Course Usual Behavioral Features Evaluation Causes Treatment Bibliography

American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 1998 Oct; 37(10 Suppl): 27S-45S[Medline].

Benazon NR, Moore GJ, Rosenberg DR: Neurochemical analyses in pediatric obsessivecompulsive disorder in patients treated with cognitive-behavioral therapy. J Am Acad Child Adolesc Psychiatry 2003 Nov; 42(11): 1279-85[Medline]. Georgiou-Karistianis N, Howells D, Bradshaw J: Orienting attention in obsessive-compulsive disorder. Cogn Behav Neurol 2003 Mar; 16(1): 68-74[Medline]. March JS, Leonard HL: Obsessive-compulsive disorder in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996 Oct; 35(10): 1265-73[Medline]. March JS, Frances A, Carpenter D: Treatment of obsessive-compulsive disorder. The Expert Consensus Panel for obsessive-compulsive disorder. J Clin Psychiatry 1997; 58 Suppl 4: 272[Medline]. March JS, Mulle K: OCD in Children and Adolescents: A Treatment Manual. 1998. Pediatric OCD Treatment Study (POTS) Team: Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 2004 Oct 27; 292(16): 196976[Medline]. Rossi A, Barraco A, Donda P: Fluoxetine: a review on evidence based medicine. Ann Gen Hosp Psychiatry 2004 Feb 12; 3(1): 2[Medline]. Simon GE, Savarino J, Operskalski B, Wang PS: Suicide risk during antidepressant treatment. Am J Psychiatry 2006 Jan; 163(1): 41-7[Medline][Full Text]. Stewart SE, Geller DA, Jenike M, et al: Long-term outcome of pediatric obsessive-compulsive disorder: a meta-analysis and qualitative review of the literature. Acta Psychiatr Scand 2004 Jul; 110(1): 4-13[Medline]. NOTE: Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER Anxiety Disorder: Obsessive-Compulsive Disorder excerpt

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Obsessive-Compulsive Disorder
Article Last Updated: Aug 29, 2007 AUTHOR AND EDITOR INFORMATION Section 1 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous References Author: William M Greenberg, MD, Associate Director, Clinical Development, Forest Research Institute, Forest Laboratories, Inc; Clinical Associate Professor of Psychiatry, New York University School of Medicine; Visiting Scientist, Nathan S Kline Institute for Psychiatric Research; Consulting Staff, Bergen Regional Medical Center; Private Practice William M Greenberg is a member of the following medical societies: American Orthopsychiatric Association and American Psychiatric Association Coauthor(s): Sarah C Aronson, MD, Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland Editors: Mohammed A Memon, MD, Medical Director of Geriatric Psychiatry, Department of Psychiatry, Spartanburg Regional Hospital System; Francisco Talavera, PharmD, PhD , Senior Pharmacy Editor, eMedicine; David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine; Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin; Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA Author and Editor Disclosure Synonyms and related keywords: OCD, obsessive-compulsive disorder, obsessions, cognitivebehavioral therapy, CBT, anxiety, behavior therapy, exposure and response prevention

INTRODUCTION Section 2 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment

Medication Follow-up Miscellaneous References

Background
Obsessive-compulsive disorder (OCD) is a relatively common, if not always recognized disorder, 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. 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 Obsessions Fear of contamination Commonly Associated Compulsions Washing, cleaning Ordering, arranging, balancing, Need for symmetry, precise arranging straightening until "just right" Unwanted sexual or aggressive thoughts Checking, praying, undoing actions, or images asking for reassurance Doubts (eg, gas jets off, doors locked) Repeated checking behaviors Concerns about throwing away Hoarding something valuable

Individuals often have obsessions and compulsions in several categories, and may have other obsessions (eg, scrupulosity, somatic obsessions, physical or mental repeating rituals). Often, the first pathological obsession that an individual may experience is fear of contamination. OCD should not be confused with obsessive-compulsive personality disorder (OCPD). The diagnosis of OCPD refers to an individual who has "a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood." They often display perfectionism, excessive devotion to work, rigidity, and/or miserliness (for further details, see DSM-IV-TR ).1 Lay individuals may often describe an individual with such a personality as having OCD, but, just as lay individuals may describe someone who appears to have characteristics of multiple personalities as schizophrenic, this is also quite inaccurate. In fact, despite the unfortunate similarities in labels, relatively few individuals with OCD also meet criteria for OCPD, and the converse is also true. 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 disorders2, 3, although this remains a controversial proposal4.

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. However, these agents (eg, memantine, Nacetylcysteine, 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.10 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 Section 3 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous References

History
OCD is diagnosed primarily by presentation and history. Once the diagnosis is suspected, the YaleBrown Obsessive Compulsive Scale (Y-BOCS)11 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:12 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 diagnoses Current or past substance abuse or dependence Antecedent infections, especially streptococcal and herpetic infections 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 thoughts 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 4565% in studies in children, and 27-47% in adults.13 Monozygotic twins may be strikingly concordant for OCD (80-87%), compared with 47-50% concordance in dizygotic twins.14 Several genetic studies have supported linkages to a variety of serotonergic, dopaminergic, and glutamatergic genes.15, 16, 17, 18, 19 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, etc. 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.

DIFFERENTIALS Section 4 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous References Acute Respiratory Distress Syndrome Anorexia Nervosa Anxiety Disorders Attention Deficit Hyperactivity Disorder Body Dysmorphic Disorder Bulimia Cocaine-Related Psychiatric Disorders Dementia Due to Head Trauma Depression Hallucinogens Huntington Disease Dementia Mental Retardation Panic Disorder Phobic Disorders Posttraumatic Stress Disorder Rheumatic Fever Schizophrenia Social Phobia Somatoform Disorders Tourette Syndrome Other Problems to be Considered

Bipolar disorder (Manic-depressive illness)

WORKUP Section 5 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous References

Imaging Studies
Functional MRI and 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 CBT.8 These imaging modalities, however, are of value for research, and not indicated for normal workups.

TREATMENT Section 6 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous References

Medical Care
The mainstays of treatment of OCD include pharmacotherapy, particular forms of behavior therapy (exposure and response prevention and some forms of CBT), education and family interventions, and neurosurgical treatment in extremely refractory cases. A practice guideline for the treatment of OCD has recently been published by the American Psychiatric Association.20 Pharmacotherapy First-line pharmacologic treatments are potent 5-HT reuptake inhibitors, such as the SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, escitalopram) and clomipramine (Anafranil), with possible alternatives including venlafaxine, a serotonin norepinephrine reuptake inhibitor (SNRI). All of these are commonly used to treat OCD, although not all have received an FDA indication for this disorder. Unlike in the case of major depression, complete or near-complete remission of OCD symptoms is rare with only serotonergic antidepressant treatment. More typically, perhaps half of patients may experience symptom reductions of 30-50%, as measured by the Y-BOCS, with many others failing to even achieve this degree of relief. Doses above those needed for treatment of depression may be more effective for some patients. A therapeutic dose for 6-10 weeks may be required to observe a clinical response (see Medication). Response tends to be slow and continue for at least 12 weeks (the common duration of OCD pharmacologic clinical trials), unlike the use of these same antidepressants in the treatment of major depressive episodes, where responses are more often seen somewhat earlier. Several treatment studies suggest a possible role for norepinephrine (NE) in cases of

OCD. A subset of patients reportedly show greater clinical improvement with a combination of 5-HT and NE reuptake inhibition as compared to treatment with SSRIs alone. These have included patients treated with clomipramine (a tricyclic antidepressant [TCA] with both 5-HT and NE reuptake inhibition) and those whose SSRI treatment was augmented with an NE reuptake inhibitor such as desipramine. Behavior therapy This is a first-line treatment that should be undertaken with a psychotherapist who has specific training and experience in behavior therapy (most commonly behaviorally-trained psychologists). Some patients will not undertake this therapy, with perhaps 25% rejecting it and 25% dropping out of behavioral therapy, but it should definitely be encouraged if a competent behavioral therapist is available. Exposure and response (or ritual) prevention (ERP) is the important and specific core element in behavior therapy for OCD. The patient rank orders OCD situations he or she perceives as threatening, and then the patient is systematically exposed to symptom triggers of gradually increasing intensity, while the patient is to suppress his or her usual ritualized response. This is generally challenging and often quite distressing for the patient, but when effectively done, promotes unlearning of the strong link that has existed between having an urge and giving into the urge. When a patient does not respond in the face of a potent trigger, extinction of the response can take place. Significant others should be involved when possible, and they may have to be willing to change their responses to the patient (eg, not provide requested reassurance to irrational doubts). ERP is now usually administered as part of a broader program of CBT, specifically designed for OCD. Other elements of CBT that are used include identifying and challenging the cognitive distortions of OCD symptoms (eg, intolerance of uncertainty, black and white thinking, focusing on unlikely extreme possibilities instead of viewing the future in a balanced manner, ascribing overimportance to thoughts, excessive concern about the importance of one's thoughts, inflated sense of responsibility). After making the patient aware of his or her irrational thoughts, the therapist works to have the patient counter them with more rational thoughts and do cost/benefit analyses regarding performing his or her rituals. Meditation and relaxation techniques may be useful, but not during active ERP, as the effectiveness of these exercises requires that the patient experience a significant level of discomfort and then not respond with his or her characteristic rituals. A patient may benefit from a self-help book in conducting ERP (eg, Foa and Reid, 200121), and workbooks are available for CBT as well. When recommending such a book, the treating physician should be familiar with its content. Another related approach described by Dr. Jonathan Grayson focuses on getting the patient to accept living with uncertainty, as it relates to his or her obsessional ideas, and prepare an individualized script to reinforce this attitude.22 Psychodynamic psychotherapy alone has generally not been found helpful in ameliorating OCD symptoms. It may, however, be useful in working on a patient's resistance to accepting recommended treatments, or in appreciating the interpersonal effects that a patient's OCD symptoms are having on others.20 Strategies for treatment resistance Strategies should always include an assessment of complicating diagnoses, medication compliance, drug dose, and duration of therapy. The presence of a comorbid diagnosis that has not been addressed, such as depression or panic disorder, can interfere with clinical recovery and identification may guide the choice of interventions. Targeted interventions might include, for example, lithium or antipsychotic augmentation or ECT for depression. Interventions for patients with treatment resistance include the following: Change or increase in medication (eg, increase dose or prescribe different SSRI or clomipramine) More intensive CBT Other interventions, which have not received an FDA indication for OCD include the following: Addition of an NE reuptake inhibitor, such as desipramine, to an SSRI, or a trail of venlafaxine Addition of a typical or atypical antipsychotic, especially in patients with a history of tics Augmentation with buspirone Addition of inositol Sole or augmented use of selected glutamatergic agents Deep brain stimulation (DBS)23 or cingulotomy neurosurgery24 for severe and intractable cases Some clinicians feel that individuals with comorbid Tourette disorder or with hoarding as their principal OCD symptom may be more likely to be treatment resistant, although there is significant variation in treatment response, regardless of the particular presenting symptomatology.

Surgical Care

Neurosurgical treatment of OCD is performed at a limited number of centers and is reserved for patients with severe and refractory symptoms. The most common small series use a specific small lesion (eg, cingulotomy) or deep brain stimulation. Current clinical trials are also exploring the application of transcranial magnetic stimulation (TMS) for OCD, a noninvasive treatment approach. One surgical technique involves the stereotactic placement of bilateral lesions in the anterior cingulate cortex. A case series of 18 patients showed a 28% response rate, with an additional 17% showing a partial response. No significant adverse neurologic or cognitive sequelae were noted.

Consultations
While treatment approaches for OCD are now well described in the literature, many clinicians remain unfamiliar with the features and management of this disorder. Consultation should be sought if the treating physician is unfamiliar or uncomfortable with the diagnosis, or if they feel they have exhausted the interventions with which they feel comfortable. Neurosurgical treatment of OCD is available at only a limited number of medical centers. The Obsessive Compulsive Foundation can provide a listing of centers with experience in this area.

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MEDICATION Section 7 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous References

Only antidepressants that potently inhibit presynaptic reuptake of serotonin appear to be effective in treating OCD. Clomipramine (Anafranil) is the only TCA with this quality. The SSRIs are also effective. SSRIs have the advantages of ease of dosing and low toxicity in overdose. Available SSRIs include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft). The dual serotonin-norepinephrine reuptake inhibitor antidepressants (SNRIs) venlafaxine (Effexor) and duloxetine (Cymbalta) may also have efficacy in OCD, and they have safety and tolerability profiles comparable to those of the SSRIs, but neither has yet been FDA-approved specifically for treatment of OCD. SSRIs are generally preferred over clomipramine in treating OCD. The adverse effect profiles of SSRIs are less prominent, so improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with TCAs. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population. In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweighed the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appeared to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years. In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment. Upon further analysis of pooled clinical trial data suicidality was reportedly increased in children and adolescents being treated with SSRIs for depression (approximately 2% for those treated with placebo vs 4% for those on SSRIs, although no actual suicides occurred in either group). These clinical trials were unfortunately not designed to specifically and clearly assess suicidal thoughts and behaviors, and therefore included events not readily classified. The FDA issued a public health advisory in October of 200425, mandating a black box warning for antidepressants. Antidepressant treatment of children and adolescents with depression then significantly decreased over the next 2 years, although apparently so did suicides for this population. In 2007, the FDA extended its warning to young adults.26 Currently, evidence does not exist to associate an increased risk of suicide in patients with OCD and/or other anxiety disorders being treated with SSRIs. However, physicians should closely attend to whether treated patients have unusual uncomfortable adverse reactions (eg, akathisia), or if they might have comorbid bipolar disorder (which may involve only subtle hypomanic episodes), as occasionally antidepressant use seems to be associated with triggering dysphoria and sometimes manic episodes in such individuals. Children, adolescents, and young adults being treated with antidepressants should be closely and frequently monitored, particularly early in treatment, for any suicidal ideation or actions. Drug Category: Antidepressants SSRIs are used commonly. The tricyclic antidepressant clomipramine is also used, although often attended by more uncomfortable adverse effects. Fluoxetine (Prozac) Enhances serotonin activity due to selective Description reuptake inhibition at neuronal membrane. Highly protein-bound and metabolized by CYP450 2D6. 20-80 mg/d PO; not to exceed 80 mg/d PO; divide Adult Dose into 2 or more doses when >40 mg/d <12 years: 1 mg/kg/d PO; not to exceed 40 mg/d Pediatric Dose >12 years: 1 mg/kg/d PO; not to exceed 60-80 mg/d Documented hypersensitivity; concurrent MAOI Contraindications therapy May potentiate medications such as TCAs, SSRIs, phenothiazines, carbamazepine, flecainide, class 1C antiarrhythmics, and quinidine; serotonergic Interactions agents (eg, MAOI, tryptophan, sibutramine, other appetite suppressants) may induce serotonin syndrome C - Fetal risk revealed in studies in animals but not Pregnancy established or not studied in humans; may use if benefits outweigh risk to fetus Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before initiating fluoxetine therapy; common Precautions adverse effects include restlessness, sexual dysfunction, GI upset, sleep disturbance, and headache Drug Name

Drug Name Description Adult Dose

Paroxetine (Paxil) Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. 20-80 mg/d PO

Not established Documented hypersensitivity; concurrent MAOI Contraindications therapy; seizure disorder Phenobarbital and phenytoin decrease effects of paroxetine; alcohol, cimetidine, sertraline, Interactions phenothiazines, and warfarin increase toxicity of paroxetine D - Fetal risk shown in humans; use only if benefits Pregnancy outweigh risk to fetus Cirrhosis; suicide attempt; SIADH; DM; breastfeeding; taper over 1-2 wk to avoid SSRI withdrawal syndrome; common adverse effects Precautions include fatigue, sexual dysfunction, and weight gain; caution in history of seizures, mania, renal disease, and cardiac disease

Pediatric Dose

Sertraline (Zoloft) Enhances serotonin activity due to selective Description reuptake inhibition at the neuronal membrane. Adult Dose 50-200 mg/d PO <6 years: Not established 6-12 years: 25 mg/d PO; if tolerated, may increase Pediatric Dose by 50 mg/wk; not to exceed 200 mg/d PO >12 years: Administer as in adults Documented hypersensitivity; concurrent MAOI Contraindications therapy; seizure disorder Increases toxicity of MAOIs, diazepam, tolbutamide, Interactions and warfarin C - Fetal risk revealed in studies in animals but not Pregnancy established or not studied in humans; may use if benefits outweigh risk to fetus Cirrhosis; suicide attempt; SIADH; DM; breastfeeding; common adverse effects include fatigue, sexual dysfunction, GI upset, and sleep disturbance; caution in preexisting seizure Precautions disorders; caution in those who have experienced a recent myocardial infarction and those who have unstable heart disease, hepatic impairment, or renal impairment

Drug Name

Citalopram (Celexa) Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. Also Description has the advantage of fewer potential drug interactions. Citalopram is a 50:50 racemate of rand s-citalopram. Adult Dose 20-60 mg/d PO Pediatric Dose Not established Documented hypersensitivity; concurrent MAOI Contraindications therapy May be potentiated by azole antifungals, omeprazole, and macrolides; serotonin syndrome Interactions may be induced by buspirone, tramadol, MAOIs, and nefazodone C - Fetal risk revealed in studies in animals but not Pregnancy established or not studied in humans; may use if benefits outweigh risk to fetus Cirrhosis; suicidal tendencies; SIADH; DM; Precautions breastfeeding; common adverse effects include fatigue and sexual dysfunction

Drug Name

Drug Name Description

Fluvoxamine (Luvox) Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane.

100-300 mg/d PO divided bid/tid <8 years: Not established 8-17 years: 25 mg PO qhs; if tolerated, increase by Pediatric Dose 25 mg PO q4-7d; not to exceed 200 mg/d PO; if total daily dose >50 mg, administer in divided doses Documented hypersensitivity; concurrent MAOI Contraindications therapy Potentiates triazolam, alprazolam, theophylline, warfarin, carbamazepine, methadone, beta-blockers, Interactions and diltiazem effects; smoking may increase serum levels C - Fetal risk revealed in studies in animals but not Pregnancy established or not studied in humans; may use if benefits outweigh risk to fetus Cirrhosis; suicide attempt; SIADH; DM; breastfeeding; history of seizures; common adverse Precautions effects include fatigue, drowsiness, sexual dysfunction, sleep disturbance, and GI distress

Adult Dose

Clomipramine (Anafranil) Tricyclic antidepressant with potent NE and 5-HT Description reuptake inhibition. Adult Dose 75-250 mg PO qhs or in divided doses <10 years: Not established >10 years: 25 mg/d PO, advancing over 2 wk to 3 mg/kg/d or 100 mg/d PO in divided doses, Pediatric Dose whichever is smaller; if tolerated, advance to maximum dose of 3 mg/kg/d or 200 mg/d PO, whichever is smaller; after titration to a therapeutic dose, may administer hs Documented hypersensitivity; concurrent use of Contraindications MAOI or other TCA Potentiates CNS depressants, anticholinergics, Interactions sympathomimetics, and other protein-bound drugs; potentiated by CYP2D6 inhibitors; SSRIs C - Fetal risk revealed in studies in animals but not Pregnancy established or not studied in humans; may use if benefits outweigh risk to fetus Suicidal tendencies or risk of overdose; seizure Precautions disorder; cardiac disease; glaucoma; urinary retention

Drug Name

Escitalopram SSRI and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in Description CNS resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants. 10 mg PO qd initially; if needed, may increase to 20 Adult Dose mg/d after 1 wk Pediatric Dose Not established Documented hypersensitivity; administration within Contraindications 14 d of receiving MAOI Primarily metabolized by CYP450 3A4 and 2C19; coadministration with alcohol or other centrally acting drugs increases CNS depression; cimetidine Interactions increases AUC and maximum serum concentration; coadministration with sumatriptan and SSRIs has caused weakness and hyperreflexia C - Fetal risk revealed in studies in animals but not Pregnancy established or not studied in humans; may use if benefits outweigh risk to fetus Caution with history of seizures, mania, suicide; common adverse effects include insomnia, Precautions ejaculation disorder (primarily ejaculatory delay),

Drug Name

nausea, sweating, fatigue, and somnolence

FOLLOW-UP Section 8 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous References

Further Inpatient Care

OCD typically is treated in an outpatient setting. Consider hospitalization if symptoms are sufficiently severe to impair a patient's ability to care for himself/herself safely at home or if a risk of suicide exists. If admission is necessary, admitting the patient to an inpatient unit whose staff is familiar with OCD and behavioral therapy is preferable.

Further Outpatient Care

OCD is a chronic illness that usually can be treated in an outpatient setting. The mainstays of treatment are behavior therapy and use of serotoninergic antidepressant medications. Patients who have achieved remission of symptoms with behavior therapy alone may never require medication and may only need to return to therapy if they have an exacerbation of their illness. Also, a subset of patients has been treated with a combined approach; these patients can discontinue medication, maintaining a remission with behavioral interventions alone. However, many patients require ongoing medication to prevent relapse.

In/Out Patient Meds

SSRIs or clomipramine should be advanced as tolerated to a therapeutic dose. Clinical response may take 6-10 weeks to become apparent. The clinician should review adequacy of dose, duration of therapy, and compliance before deciding that a medication is ineffective. Antipsychotics, such as haloperidol, olanzapine, and risperidone, have been used with some success in augmenting SSRIs in patients with OCD, particularly in those with comorbid Tourette disorder or other tic disorders.7

Transfer
If a patient has symptoms of sufficient severity to warrant hospitalization, consider transfer to a psychiatric unit with expertise in treating OCD.

Prognosis
OCD is an illness with a wide range of potential severity. Overall, close to 70% of patients entering treatment experience a significant improvement in their symptoms. However, OCD remains a chronic illness, with symptoms that may wax and wane during the life of the patient. Roughly 15% of patients can show a progressive worsening of symptoms or deterioration in functioning over time. Approximately 5% of patients have a complete remission of symptoms between episodes of exacerbation. Pharmacological treatment is often prescribed on a continuing basis; if a successfully treated individual discontinues their medication regimen, relapse is not uncommon. However, patients who successfully complete a course of CBT (perhaps as few as 12-20 sessions) may experience enduring relief even after the treatment, although some evidence shows that having CBT continue in some extended but less frequent fashion may further decrease the risk of relapse. A certain percentage of patients may have disabling, treatment-resistant symptoms. These patients may require multiple medication trials and/or referral to a research center. A small subgroup of these patients may be candidates for neurosurgical intervention.

Patient Education
Education about the nature and treatment of OCD is essential. As with many psychiatric disorders, patients and their families often have misconceptions about the illness and its management. Information should be provided about the neuropsychiatric source of the symptoms, as opposed to having families unnecessarily blame themselves for causing the disorder. Some of the limited experience the public has with modestly accurate portrayals of OCD come from the visual media (eg, Jack Nicholson in As Good As It Gets, Nicolas Cage in Matchstick Men, Leonardo DiCaprio in The Aviatorthe screen saga of Howard Hughes' life, and Tony Shalhoub in the television series Monk). A more helpful and very well-written book for the public, which became a national best-seller, is Dr. Judith Rapoport's The Boy Who Couldn't Stop Washing27, telling the story of the recognition and identification of effective treatments for individuals with OCD. More usefully, patients and their families should be provided information on support groups and have opportunities to discuss the impact the illness has had on their self-experience and on their relationships. The Obsessive-Compulsive Foundation (203-401-2070) is a self-help and family organization founded in 1986 that offers information and resources regarding OCD and related disorders (including contact information for various types of affiliated support groups, contact information listing psychiatrists and therapists who are experienced in the treatment of OCD, research opportunities, book reviews, etc). Some other organizations offer more specialized resources, (eg, San Francisco Bay Area Internet Guide for Extreme Hoarding Behavior), the Madison Institute of Medicine's Obsessive Compulsive Information Center, which provides information and a monthly newsletter for individuals with OCD symptoms of scrupulosity about religious/moral issues. A more complete listing of OCD resources appears as an appendix in the APA Practice Guideline for OCD.20 Several self-help books are also available, including Drs. Edna Foa and Reid Wilson's book21, which can add CBT-style self-treatment to the educational experience they provide.

MISCELLANEOUS Section 9 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous References

Medical/Legal Pitfalls
The most common medical pitfall in the treatment of OCD is the failure to make the diagnosis. Clinicians should be familiar with the diagnostic criteria and consider OCD in their differential when evaluating tics, mood and anxiety disorders, or other compulsive behaviors such as trichotillomania or neurodermatitis. Another common pitfall is the failure to identify the comorbid diagnoses frequently encountered in patients with OCD. These can include the following: Major depressive disorder (30-70%) Panic disorder (14%, 35% lifetime incidence) Body dysmorphic disorder (14.5%) Generalized anxiety disorder (20%) Social phobia and simple phobia (24%) ADHD Tourette syndrome (5-7%) Other tic disorders (20-30%) Trichotillomania Neurodermatitis Idiopathic torticollis Substance abuse Eating disorders Identification of these diagnoses guides treatment interventions as well as identifies those patients who are at higher risk for suicide or self-harm. Not surprisingly, patients with OCD have

a significant risk for suicide, which increases with the severity of symptoms and the number of concurrent psychiatric diagnoses.

REFERENCES Section 10 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous References

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Obsessive-Compulsive Disorder excerpt Article Last Updated: Aug 29, 2007